Background <p>Common bile duct stones (CBDS) can rapidly lead to cholangitis or biliary pancreatitis, making timely and accurate diagnosis essential. Although EUS provides high diagnostic accuracy, its value in emergency settings remains unclear. This study aimed to evaluate the clinical value of emergency EUS-guided ERCP.</p> Methods <p>A retrospective analysis was performed on the clinical data of 215 patients diagnosed with CBDS at the First Affiliated Hospital of Anhui Medical University between June 2018 and June 2024. Patients were assigned to either the emergency EUS group or the elective EUS group according to the timing of symptom onset after admission and the timing of EUS examination. Clinical efficacy, primary endpoints, and secondary endpoints were compared between the two groups.</p> Results <p>Both the emergency and elective EUS groups achieved a 100% technical success rate for EUS and ERCP. The clinical success rates of ERCP were 96.3 and 94.8%, respectively, with no significant difference (<i>P</i> &gt; 0.05). The emergency EUS group had significantly shorter hospital stays and lower hospitalization costs (<i>P</i> &lt; 0.05). Post-ERCP complications were also significantly fewer in the emergency group (<i>P</i> &lt; 0.05). There were no ICU admissions occurred in either group, and long-term complication rates were comparable (<i>P</i> &gt; 0.05).</p> Conclusion <p>In this real-world retrospective study, an emergency EUS-guided ERCP strategy was associated with reduced short-term complications, shorter hospitalization, and lower healthcare costs compared with an elective approach, without affecting long-term biliary outcomes. Therefore, emergency EUS-guided ERCP may represent a feasible and potentially beneficial strategy for patients presenting with CBDS, primarily by improving short-term clinical outcomes, although prospective studies are required to confirm these findings.</p>