GuidelineComplications of ERCP
Section snippets
Incidence
Pancreatitis is the most common serious ERCP complication.7, 8, 9, 10, 11, 12, 13, 14, 15 Although transient increase in serum pancreatic enzymes may occur in as many as 75% of patients,16 such an increase does not necessarily constitute pancreatitis. A widely used consensus definition for post-ERCP pancreatitis (PEP) is (1) new or worsened abdominal pain, (2) new or prolongation of hospitalization for at least 2 days, and (3) serum amylase 3 times or more the upper limit of normal, measured
Hemorrhage
Most ERCP-associated bleeding is intraluminal, although intraductal bleeding can occur and hematomas (hepatic, splenic, and intra-abdominal) have been reported.56, 57, 58 Hemorrhage is primarily a complication related to sphincterotomy rather than diagnostic ERCP. In a meta-analysis of 21 prospective trials, the rate of hemorrhage as a complication of ERCP was 1.3% (95% CI, 1.2%-1.5%) with 70% of the bleeding episodes classified as mild.18 Hemorrhagic complications may be immediate or delayed,
Perforation
Perforation rates with ERCP range from 0.1% to 0.6%.7, 8, 10, 15, 63 Three distinct types of perforation have been described: guidewire-induced perforation, periampullary perforation during sphincterotomy, and luminal perforation at a site remote from the papilla.63 Risk factors for perforation determined in a large retrospective study included the performance of a sphincterotomy, Billroth II anatomy, the intramural injection of contrast, prolonged duration of procedure, biliary stricture
Cholangitis
The rate of post-ERCP cholangitis is 1% or less.7, 8, 10 Risk factors identified as significant include the use of combined percutaneous-endoscopic procedures, stent placement in malignant strictures, the presence of jaundice, primary sclerosing cholangitis, low case volume, and incomplete or failed biliary drainage.7 In the case of malignant hilar obstruction (ie, Klatskin tumor), it is suggested that endoscopists avoid filling all intrahepatic segments and drain all intrahepatic segments that
Cardiopulmonary complications
Significant cardiopulmonary complications are rare, occurring in 1% of cases with an associated fatality rate of 0.07% based on a meta-analysis of 12,973 patients enrolled in 14 prospective studies.18 Complications include cardiac arrhythmia, hypoxemia, and aspiration. In 1 study comparing patients older than 65 years of age with younger patients, standard cardiac risk factors and hemodynamic and electrocardiographic changes during the procedure were reported as more common in the group older
Mortality
The overall mortality rate after diagnostic ERCP is approximately 0.2%.10 Death rates after therapeutic ERCP are twice as high (0.4%-0.5% in 2 large prospective studies).7, 10 In a large meta-analysis, overall ERCP-specific mortality was 0.33% (95% CI, 0.24%-0.42%).18 Death may occur from any of the complications described previously. The mortality rate must be considered in the light of the underlying indication for ERCP and patient comorbidity.
Miscellaneous complications
A wide variety of additional complications have been reported. These include ileus, antibiotic-related diarrhea, hepatic abscess formation, pneumothorax/pneumomediastinum, perforation of colonic diverticula, duodenal hematoma, portal venous air, and impaction of therapeutic devices, such as stone retrieval baskets.8, 10 Pseudocysts may become infected, and filling of pseudocysts in the absence of subsequent drainage should be avoided, if possible.
Numerous complications of ERCP-placed stents
Conclusion
Complications are inherent in the performance of endoscopic procedures and more so for ERCP. Knowledge of potential ERCP complications, their expected frequency, and the risk factors for their occurrence may help to recognize and to minimize the incidence and severity of complications. Endoscopists are expected to carefully select patients for the appropriate intervention, be familiar with the planned procedure and available technology, and be prepared to manage any adverse events that may
Disclosure
The following authors disclosed financial relationships relevant to this publication: Dr Evans: consultant to Cook Medical; Dr Decker: consultant to Facet Biotechnology. All other authors disclosed no financial relationships relevant to this publicaton.
References (92)
- et al.
Complications of ERCP
Gastrointest Endosc
(2003) - et al.
The role of endoscopy in the evaluation of suspected choledocholithiasis
Gastrointest Endosc
(2010) - et al.
The role of endoscopy in the evaluation and treatment of patients with pancreaticobiliary malignancy
Gastrointest Endosc
(2003) - et al.
Current management of postoperative complications and benign biliary strictures
Gastrointest Endosc Clin N Am
(2003) - et al.
Informed consent for GI endoscopy
Gastrointest Endosc
(2007) - et al.
Complications of diagnostic and therapeutic ERCP: a prospective multicenter study
Am J Gastroenterol
(2001) - et al.
Risk factors for post-ERCP pancreatitis: a prospective, multicenter study
Gastrointest Endosc
(2001) - et al.
Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study
Gastrointest Endosc
(1998) - et al.
Risk factors for complications after performance of ERCP
Gastrointest Endosc
(2002) - et al.
Complications of ERCP: a prospective study
Gastrointest Endosc
(2004)
Quality indicators, including complications, of ERCP in a community setting: a prospective study
Gastrointest Endosc
Prevention of post-ERCP pancreatitis: a comprehensive review
Gastrointest Endosc
Endoscopic sphincterotomy complications and their management: an attempt at consensus
Gastrointest Endosc
Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years
Gastrointest Endosc
Adverse outcomes of ERCP
Gastrointest Endosc
Precut papillotomy via fine-needle knife papillotome: a safe and effective technique
Gastrointest Endosc
Papillary roof incision using the Erlangen-type pre-cut papillotome to achieve selective bile duct cannulation
Gastrointest Endosc
Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video)
Gastrointest Endosc
Timing of precut procedure does not influence success rate and complications of ERCP procedure: a prospective randomized comparative study
Gastrointest Endosc
Sphincter of Oddi manometry: decreased risk of clinical pancreatitis with use of a modified aspirating catheter
Gastrointest Endosc
Evidence-based imaging of pancreatic malignancies
Surg Clin North Am
Efficacy of diclofenac in the prevention of post-ERCP pancreatitis in predominantly high-risk patients: a randomized double-blind prospective trial
Gastrointest Endosc
Prophylactic corticosteroids do not prevent post-ERCP pancreatitis: a meta-analysis of randomized controlled trials
Pancreatology
Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis
Clin Gastroenterol Hepatol
Pancreatic-stent placement for prevention of post-ERCP pancreatitis: a cost-effectiveness analysis
Gastrointest Endosc
Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes
Gastrointest Endosc
Subcapsular hepatic hematoma after ERCP
Gastrointest Endosc
Adverse outcomes of endoscopic retrograde cholangiopancreatography: avoidance and management
Gastrointest Endosc Clin N Am
Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference?
Gastrointest Endosc
Management of antithrombotic agents for endoscopic procedures
Gastrointest Endosc
Management of endoscopic retrograde cholangiopancreatography-related perforation
Surgeon
Endoscopic drainage of malignant hilar obstruction: is one biliary stent enough or should we work to place two?
Gastrointest Endosc
Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study
Gastrointest Endosc
Magnetic resonance cholangiopancreatography-guided unilateral endoscopic stent placement for Klatskin tumors
Gastrointest Endosc
Placement of a metallic stent across the main duodenal papilla may predispose to cholangitis
Gastrointest Endosc
Risk factors for cholecystitis after metal stent placement in malignant biliary obstruction
Gastrointest Endosc
Antibiotic prophylaxis for GI endoscopy
Gastrointest Endosc
Infection after ERCP, and antibiotic prophylaxis: a sequential quality-improvement approach over 11 years
Gastrointest Endosc
Cardiopulmonary complications of ERCP in older patients
Gastrointest Endosc
Efficacy and safety of intravenous propofol sedation during routine ERCP: a prospective, controlled study
Gastrointest Endosc
Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial
Gastroenterology
Incidence of sedation-related complications with propofol use during advanced endoscopic procedures
Clin Gastroenterol Hepatol
Sedation and anesthesia in GI endoscopy
Gastrointest Endosc
Capnographic monitoring of respiratory activity improves safety of sedation for endoscopic cholangiopancreatography and ultrasonography
Gastroenterology
Pancreatic stents can induce ductal changes consistent with chronic pancreatitis
Gastrointest Endosc
Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy
Gastrointest Endosc
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This document is a product of the ASGE Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.