Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized technique combining X-ray and endoscopy  to study the bile ducts, pancreatic duct and gallbladder. Ducts are drainage routes; the drainage channels from the liver are called bile or biliary ducts. The pancreatic duct is the drainage channel from the pancreas.

The most common reason for ERCP is a type of jaundice caused by obstruction of the bile duct.

This is an x-ray (fluoroscopy) image taken during an ERCP. The large tube seen in the middle of the field is the ERCP-endoscope. To the left is x-ray dye outlining the bile ducts and to the right is the pancreas duct.

The procedure is technically demanding and requires a high degree of skill, training and experience. Complications such as pancreatitis or perforation can be serious. Studies have shown again and again that the results with ERCP are better when the gastroenterologist has special training in the procedure and experience.

There are fewer and fewer cases that require ERCP because EUS (endoscopic ultrasound) is safer and often more informative than ERCP (see below). That means, fewer gastroenterologists have received sufficient training in ERCP.  However, sometimes ERCP is the only way to get the job done. When this is the case, choosing the right person for the job is crucial.

Dr. Klaus Gottlieb is the only gastroenterologist in San Luis Obispo County who dedicated a full year of training to ERCP. He was selected from many applicants to do a specialized ERCP fellowship at Indiana University where he trained under some of the leading pioneers of ERCP in the United States, Dr. Glen Lehman and Dr. Stuart Sherman.

Before this, he spent a month at the Technical University of Munich Department of Medicine in the department of Professor Meinhard Classen who ‘invented’ ERCP. He wrote two ERCP papers with Classen that summarize the cutting-edge research then conducted in the department. Dr. Gottlieb has authored many more papers on topics related to ERCP and has conducted some important research about the prevention of post-ERCP pancreatitis. For an ERCP related publication list follow this link.



EUS, the acronym for endoscopic ultrasound, sometimes also called endosonography, is a specialized procedure that combines endoscopy (use of a scope to look at the inside lining of the gastrointestinal tract) with ultrasound which is the use of high frequency sound waves to see detailed images of the bowel wall and nearby organs or structures.

During this EUS a fine needle is directed under ultrasound guidance through the endoscope into a suspicious mass adjacent to the stomach to obtain a sample.

Suspected pancreatic cancer is the most common reason to perform an EUS.

An EUS is performed by a gastroenterologist who has advanced training. In addition to receiving specialized training in ERCP (ERCP fellowship) Dr. Klaus Gottlieb was fellowship-trained in EUS. He is the only EUS- fellowship-trained gastroenterologist in San Luis Obispo County.

An EUS scope is a thin, flexible tube with a camera and a light on the end. A tiny ultrasound probe is also attached to the end of the scope. An upper EUS looks at the upper GI system: Walls of the upper GI tract — esophagus (the tube that links your mouth and stomach), stomach and small intestine, nearby organs — pancreas, gallbladder and bile ducts, and nearby structures — lymph nodes, tumors, cysts and blood vessels

A lower EUS looks at the lower GI system: Bowel wall of your rectum and lower colon and nearby organs — bladder, prostate and uterus, and nearby structures — lymph nodes and tumors — and detailed images of the anal sphincter (muscles around the anus).

Fine needle aspiration (FNA): If a tissue sample is needed, Dr. Klaus Gottlieb will use the ultrasound image to guide a thin needle through the endoscope to take a biopsy. You won’t be able to feel this.

An EUS is often performed as an outpatient procedure, like other endoscopic exams.  Most EUS cases are performed with sedation (medication that helps blocks pain and makes you feel sleepy).  Dr. Gottlieb will talk with you about the type of sedation used for your exam.

Dr. Klaus Gottlieb established a EUS practice in Spokane, WA, in 1999. He quickly became very busy attracting referrals from a tri-state area (Eastern Washington, Northern Idaho, Western Montana). The 11 years of experience in Spokane are summarized in a popular textbook he authored: “Diagnostic Endosonography – A case based approach”: 

His YouTube video “Endoscopic Ultrasound – A Survey of typical Applications” – aimed at a professional audience – has attracted more than 14, 000 viewers. 

See his research articles, reporting many fascinating and rare cases, here .