ERCP grading scale


The ASGE ERCP (Endoscopic retrograde cholangiopancreatography) grading scale indicates the procedure complexity and predicts the chance of complictions.

The ERCP grading scale:

Grade 1
-Deep cannulation of duct of interest, main papilla, sampling
-Biliary stent removal/exchange

Grade 2
Biliary stone extraction < 10 mm
Treat biliary leaks
Treat extrahepatic benign and malignant strictures
-Place prophylactic pancreatic stents

Grade 3
-Biliary stone extraction > 10 mm
-Minor papilla cannulation in divisum, and therapy
-Removal of internally migrated biliary stents
-Intraductal imaging, biopsy, FNA
-Management of acute or recurrent pancreatitis
-Treat pancreatic strictures
-Remove pancreatic stones mobile and < 5 mm
-Treat hilar tumors
-Treat benign biliary strictures, hilum, and above
-Manage suspected sphincter of Oddi dysfunction (with or without manometry)

Grade 4
-Remove internally migrated pancreatic stents
-Intraductal image-guided therapy
-Pancreatic stones impacted and/or > 5 mm
-Intrahepatic stones
-Pseudocyst drainage, necrosectomy
-ERCP after Whipple or Roux-en-Y bariatric surgery

Increase 1 level (to a maximum of 4) when the patient has had Billroth II gastrectomy

ERCP adverse event rates

ERCP grading scale adverse event rate


Cotton PB, Eisen G, Romagnuolo J, et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. Gastrointest Endosc. 2011;73(5):868‐874. doi:10.1016/j.gie.2010.12.036

Sahar N, La Selva D, Gluck M, et al. The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital. Surg Endosc. 2019;33(2):448‐453. doi:10.1007/s00464-018-6317-7