What separates a grade 3 from a grade 4 ERCP?

Grade 3 covers procedures such as pancreatic therapy, removal of large or impacted stones, and stricture dilation in an intact stomach. Grade 4 is reserved for cases where access itself is the problem, including Roux-en-Y or Billroth II anatomy, hilar stricture requiring cholangioscopy, and pancreatic sphincterotomy in chronic pancreatitis.

Does the grade predict complications?

Higher grades track with longer procedures, more cannulation attempts, and a greater chance of post-ERCP pancreatitis, bleeding, and perforation. The grade is a planning tool rather than a validated risk score, so it should be combined with patient-specific factors such as sphincter of Oddi dysfunction and prior pancreatitis.

Who should perform grade 3 and 4 cases?

ASGE recommends that complex cases be handled by endoscopists who perform more than 200 ERCPs a year and have advanced fellowship training. Low-volume operators attempting grade 4 cases have measurably worse technical success and higher complication rates.

ERCP Complexity Grade (ASGE Four-Tier System)

Assign an ERCP to one of four ASGE complexity grades using the intended procedure, the patient's anatomy, and any comorbidity that raises sedation or access risk. Grade 3 and 4 cases belong in high-volume advanced endoscopy units.

Select every procedure performed. The highest-weighted element determines the overall grade (I–IV).

Grade	Expected difficulty
I	Basic: standard diagnostic and therapeutic procedures.
II	Intermediate: procedures requiring additional skill.
III	Advanced: complex therapeutic procedures.
IV	Very advanced: highly specialized procedures.

Clinical Guidance

The Schutz/ASGE grading system classifies ERCP procedures from Grade I (basic diagnostic and simple therapeutic work) to Grade IV (highly advanced interventions such as cholangioscopy, lithotripsy, and pseudocyst drainage). The grade reflects the technical difficulty and the level of training and resources required, and is used for credentialing, outcome reporting, and case-mix adjustment.

When more than one procedure is performed, the overall grade is set by the most advanced element. Grade III–IV procedures are typically reserved for experienced endoscopists at high-volume centers.

How It Works

Each component has a specific meaning:

Intended procedure — The intended procedure recorded for the scenario being assessed.
Patient's anatomy — The patient's anatomy recorded for the scenario being assessed.
Any comorbidity that raises sedation or access risk — The any comorbidity that raises sedation or access risk recorded for the scenario being assessed.

Note: Interpret the ercp complexity grade result against the thresholds and context described above.

How to Use

Enter the intended procedure, patient's anatomy, any comorbidity that raises sedation or access risk for the scenario you are assessing. Assign an ERCP to one of four ASGE complexity grades using the intended procedure, the patient's anatomy, and any comorbidity that raises sedation or access risk. Grade 3 and 4 cases belong in high-volume advanced endoscopy units. Use the ercp complexity grade result to inform your calculation.

ERCP Complexity Grade (ASGE Four-Tier System)

How It Works

How to Use

Formula Sources

Frequently Asked Questions