Guideline
Complications of ERCP

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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.

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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.

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