Endoscopic retrograde cholangiopancreatography (ERCP)

Role

ERCP combines endoscopy with fluoroscopic contrast imaging of the biliary and pancreatic ductal systems, and - unlike MRCP - allows immediate therapeutic intervention (stone extraction, sphincterotomy, stenting) in the same procedure
Reserved for cases where a therapeutic intervention is anticipated, given its invasiveness and complication profile compared with the purely diagnostic MRCP - diagnostic-only ERCP has been largely replaced by MRCP given the lower risk of the non-invasive alternative

A duodenoscope is passed to the ampulla of Vater, the bile/pancreatic duct is cannulated, and contrast is injected under fluoroscopy to visualise the ductal anatomy - sphincterotomy (cutting the sphincter of Oddi) then allows instrument passage for stone extraction, stricture dilatation, or stent placement

Primary indications: choledocholithiasis with obstruction/cholangitis (stone extraction), malignant or benign biliary strictures (stenting for palliation or bridging to surgery), and pancreatic duct pathology in selected cases
Pre-procedure imaging (MRCP or ultrasound) is generally used first to confirm a treatable finding exists, given ERCP's own risk profile - proceeding directly to ERCP without this confirmation increases the rate of a purely diagnostic (and therefore avoidable-risk) procedure

Post-ERCP pancreatitis is the most common significant complication (occurring in a meaningful minority of procedures) - risk factors include a difficult cannulation, sphincter of Oddi dysfunction as the indication, and younger patient age; rectal NSAID administration (e.g. indometacin) peri-procedurally reduces this risk in higher-risk patients and is now standard practice where not contraindicated
Other complications: bleeding (particularly post-sphincterotomy), perforation, and cholangitis (if biliary drainage is incomplete after the procedure)

Choledocholithiasis, cholangitis, biliary strictures (malignant and benign), chronic/acute pancreatitis with a ductal complication, post-ERCP pancreatitis

The shift toward MRCP-first diagnostic imaging (reserving ERCP for confirmed, treatable findings) reflects a broader trend of using ERCP as a targeted therapeutic tool rather than a diagnostic-and-therapeutic procedure performed on suspicion alone

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