Background: Adequate sedation and amnesia are important in the performance of ERCP's. In the ill or uncooperative patient the decision to involve anesthesiology for administrating monitored anesthesia care (MAC) or general anesthesia (GA) is often important for patient safety and procedural success. We evaluated characteristics, indications, and complications in patients undergoing ERCP with anesthesiology assistance at our tertiary referral center. Results: From 7/1/02 to 6/30/04 2077 ERCP's were performed. A total of 192 procedures were performed in 111 patients with anesthesiology assistance. One hundred eighty-nine patients received GA and 3 received MAC. Sixty patients were female. The average procedural age was 43.9 years. Indications for GA or MAC included age of 18 or less (34%), ASA class IV (10.4 %), inability to sedate during an earlier procedure (11.4 %), chronic narcotic use (14.1 %), age 85 or greater (6 %), and sepsis (4.6 %). Thirty-four percent were ASA II and 40.6 % were ASA class III. Eight had PSC, 11 had choledochoceles, and 2 were pregnant. Ninety-one percent of procedures were therapeutic. Findings: 6 normal exams, pancreatic duct dilation in 75, common bile duct (CBD) dilation in 57, CDB stone in 30, benign CBD stricture in 35, benign pancreatic duct stricture 39, malignant biliary stricture in 11, pseudocyst 16, anastomotic stricture after liver transplantation in 9, pancreatic divisum in 5, and pancreatic mass in 5 patients. Procedural success was 98%. Anesthesia complications occurred in 2 patients (1%) (prolonged paralysis and uncomplicated ventricular tachycardia). Thirty- four patients were discharged the same day. Seventy-two were discharged within 24 hours of the procedure. Thirty-six of the 72 had sphincterotomies necessitating a 24 hour observational stay at our institution. Fifteen patients were discharged within 48 hours. Eight patients were admitted for an average of 6.9 days. The remaining 57 procedures were performed on hospitalized patients. Conclusion: Anesthesia support is employed in a variety of conditions and not limited to those with multiple comorbidities. The involvement of anesthesiology increases the procedural success and can be accomplished with low morbidity.