ERCP Explained: Therapeutic Endoscopic Biliary and Pancreatic Intervention

ERCP combines side-viewing duodenoscopy with fluoroscopic contrast injection of the biliary and pancreatic ducts. Once the diagnostic and therapeutic mainstay of biliary disease, it is now almost exclusively therapeutic — diagnostic imaging is done with MRCP or EUS. Key therapeutic manoeuvres: biliary sphincterotomy, balloon or basket stone extraction, plastic or metal stent insertion, biliary dilation, tissue sampling (brushings). Indications: choledocholithiasis with cholangitis or persistent obstruction; biliary drainage in obstructive jaundice (benign or malignant strictures); tissue diagnosis of hilar or distal biliary strictures; management of post-cholecystectomy bile leaks; sphincter of Oddi dysfunction (controversial); pancreatic duct interventions in chronic pancreatitis. Complications: post-ERCP pancreatitis (3–5%, severe in ~10% of cases), bleeding (~1%), perforation (~0.5%), cholangitis (~1%). Rectal indomethacin 100 mg pre-procedure reduces post-ERCP pancreatitis by ~50% (INDOMETH-RCT). Prophylactic pancreatic duct stent reduces pancreatitis in high-risk cases. ERCP now competes with EUS-guided biliary drainage in surgically altered anatomy.