Ccomplications of ERCP

Best Practice & Research Clinical Gastroenterology 30 (2016) 793e805
Contents lists available at ScienceDirect
Best Practice & Research Clinical

Gastroenterology
10
Complications of ERCP
Rupjyoti Talukdar, MD, Clinical Pancreatologist, Clinician
Scientist (Wellcome-DBT Fellow) a, b, *
a
Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India
b
Asian Healthcare Foundation, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India
a b s t r a c t
Keywords:
Pancreatitis Even though considered safe, endoscopic retrograde chol-
Bleeding angiopancreatography (ERCP) is among the endoscopic procedures
Perforation associated with the highest rate of complications. Post ERCP
Infection pancreatitis (PEP) is the most common complication of ERCP.
Prophylactic stenting Several independent risk factors have been associated with PEP.
Prevention
Prophylactic PD stenting has been shown to be highly effective in
Coagulopathy
preventing PEP. More recent studies have suggested that NSAIDs,
especially rectal indomethacin, could by itself be effective in pre-
venting PEP. However, head to head RCTs comparing PD stents
with NSAIDs would be required to confirm this. Other complica-
tions include ERCP induced bleeding, perforation, and cholangitis.
Bleeding is related to morphological, procedural, and patient
related factors. Early identification and correction of the risk fac-
tors are of paramount importance in preventing bleeding. Risk of
infection is particularly high during ERCP. It is important to ensure
complete drainage of obstructed biliary system in order to reduce
the risk of post-ERCP cholangitis.
© 2016 Elsevier Ltd. All rights reserved.
Introduction
With technological advances and better operator experience, endoscopic procedures are increas-
ingly becoming safer. However, in spite of being considered safe, endoscopic retrograde chol-
angiopancreatography (ERCP) is still associated with high potential for complications. The first study
* Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, 500082, Telangana, India. Fax: þ91 40 23324255.
E-mail addresses: rup_talukdar@yahoo.com, rupppp@gmail.com.
http://dx.doi.org/10.1016/j.bpg.2016.10.007
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794 R. Talukdar / Best Practice & Research Clinical Gastroenterology 30 (2016) 793e805
that evaluated the prevalence of ERCP related complications was conducted during the latter half of
1974, nearly 6 years after the inception of the procedure [1]. This was a questionnaire based multi-
center survey in the United States that included data from 10,435 ERCP procedures. At that time, when
ERCP procedures were largely diagnostic, complications included ‘injection pancreatitis’ in 1%, ‘chol-
angitic abscess’ in 0.8%, drug reactions in 0.6%, ‘pancreatic sepsis pseudocyst’ in 0.3%, ‘instrumental
injury’ in 0.2%, and aspiration pneumonia in 0.1%. There were a total of 15 deaths. Currently, when ERCP
is mostly therapeutic, the incidence of overall post-ERCP complications is higher, but variable across
different studies. Nevertheless, pancreatitis and bleeding retains their position of being the two most
common complications. A systematic survey of 21 prospective studies between 1977 to 2006 involving
16,885 subjects reported an overall post-ERCP complication rate of 6.85% [95% confidence interval (CI)
6.46e7.24] with a 0.33% [95% CI: 0.24, 0.42] mortality [2]. While few of the patients in these studies
received only diagnostic ERCP, another recent single center retrospective study involving only thera-
peutic procedures (n ¼ 2715) by a single endoscopist reported a post ERCP complication rate of 4.9% [3].
This chapter addresses the major post-ERCP complications, their prevention and management.
Furthermore, complications after ERCP under special circumstances such as PSC, cirrhosis, ampullec-
tomy, pregnancy, and surgically altered anatomy have also been discussed.
Post-ERCP pancreatitis
The overall incidence of post-ERCP pancreatitis (PEP) has been estimated to be 3.47% (95% CI
3.19e3.75), with an associated mortality of 3.08% (95% CI 1.65e4.51) [2]. However, the incidence
may be as high as 15% among high risk patients [4]. PEP is defined as new-onset or worsening
abdominal pain with the elevation of serum amylase to greater than thrice the upper limit of
normal at 24 h after the procedure and need for greater than 2 days of pancreatitis related hos-
pitalization [5]. In terms of severity, post-ERCP pancreatitis can be classified into mild, moderate
and severe (Table 1) [5]. PEP is usually associated with both patient and procedure related factors.
Traditionally, based on multivariate analyses the risk factors for PEP had been classified into def-
inite, possible and non risk factors [6]. Among the definite or high risk factors are female gender,
young age, suspected sphincter of Oddi dysfunction, absence of chronic pancreatitis, and history of
prior PEP. A more recent systematic review and meta-analysis [7] of studies after 2002 with sample
size greater than 100 (173-11497) (N ¼ 13, 32381 ERCP procedures) reported the following
statistically significant risk factors (odd's ratio [OR] 95% CI): female gender (1.40 [1.24e1.58]);
previous PEP (3.66 [2.76e4.82]); history of previous pancreatitis (1.66 [1.38e2.00]); endoscopic
sphincterotomy (1.42 [1.14e1.78]); precut sphincterotomy (2.11 [1.72e2.59]); and SOD (2.11
[1.72e2.59]). Other significant risk factors that could increase the incidence of PEP include absence
of bile duct dilatation, difficult or failed canulation, failed clearance of biliary stones, number of
pancreatic duct injections and trainee involvement [6]. Even though difficult canulation is
considered a significant risk factor for PEP (incidence of 4.3e14%) [8,9], the definition of difficult
canulation could be variable depending on factors such as expertise and patient volume. Never-
theless, in general, canulation attempt for 10e30 minutes before abandoning or upto eight
canulation attempts has been defined as difficult canulation in different studies [4]. It was also
shown in a study involving 225 high risk patients undergoing therapeutic ERCP that failed
prophylactic stenting was associated with a 16.1 fold increase (95% CI 1.3e200) in the development
of PEP [10]. This observation was supported by another subsequent study where multivariate
analysis showed the odd's of developing PEP after failed PD stenting to be 8.3 (95% CI 2.3e30) [11].
Table 1
Classification of severity of post-ERCP pancreatitis.
Mild Moderate Severe
Clinical pancreatitis, amylase at least 3 X Pancreatitis requiring Hospitalization for more than 10days,
ULN at more than 24 h after ERCP, hospitalization for 4e10 days or hemorrhagic pancreatitis, necrosis,
requiring admission or prolongation or pseudocyst, or need for intervention
of planned admission by 2e3 days. (percutaneous drainage or surgery)
R. Talukdar / Best Practice & Research Clinical Gastroenterology 30 (2016) 793e805 795
Other factors that may be associated with PEP include absent CBD stones, absence of chronic
pancreatitis, trainee participation, low-endoscopy volume and pancreatic brush cytology [6]. The
role of extent of pancreatic duct opacification as a risk factor is however controversial, and the type
of current used (blended versus pure) and the contrast osmolality are unlikely risk factors [6].
A recent retrospective study of 544 patients suggested that the risk of post-ERCP pancreatitis could
be higher with self-expanding metal stenting (SEMS) of the bile duct, compared to plastic stenting
[12]. However, the risk was similar with covered and uncovered SEMS. Another recent retrospective
matched-control study involving 2628 individuals from the National Inpatient Sample demon-
strated pregnancy as an independent risk factor for PEP [13]. Furthermore, insulin resistance has
also emerged as a new risk factor for PEP in a prospective pilot study on 141 patients, but will
require further validation in multiple cohort involving substantially higher sample size [14].
Prevention
With the development of pharmacologic agents, endoscopic accessories and improved techniques,
the risk of post-ERCP pancreatitis have considerable come down.
Pharmacologic modalities
Over the past several years, a number of pharmacological agents including anti-inflammatory
drugs [NSAIDS (indomethacin, diclofenac; corticosteroids), protease inhibitors (ulinastatin, gabaxate
mesilate), hormones (somatostatin/ octreotide, secretin), drugs that relax the sphincter of Oddi
(nitrates, epinephrine, botulinum toxin, nifedipine, lidocaine)], and intravenous fluids have been put to
trial for preventing post-ERCP pancreatitis. Out of these, steroids ulinastatin, botulinum toxin, lido-
caine, and nifedipine have not been found to be useful in either metaanalyses or RCTs [4].
The possible efficacy of secretin in preventing PEP was demonstrated in a study by Jowell et al. in a
double blind RCT including 869 patients, in which immediate pre-procedural IV synthetic secretin
(16 mcg) reduced the frequency of PEP from 15.1% to 8.7% (p ¼ 0.004) [15]. Interestingly, efficacy in PEP
reduction was best for patients who underwent biliary spincterotomy. This promising data needs to be
validated in other populations prior to recommending secretin for PEP prophylaxis in routine practice.
Furthermore, a potential hurdle in the use of synthetic secretin would be its cost and availability.
A meta-analysis of 5 RCTs (1660 patients) showed that sublingual glyceryl trinitrate was capable in
reducing the relative risk of developing PEP (RR reduction of 0.61 [95% CI 0.44e0.86]) in low risk
patients [16]. However, the number needed to treat was high and there were substantial adverse
events, thereby precluding it routine use in the prophylaxis of PEP.
Studies evaluating the effect of somatostatin and gabaxate in reducing the incidence of PEP have
yielded heterogeneous results. A recent metaanalysis of seven randomized placebo-controlled trials
with over 3000 patients showed that a continuous 12-hr infusion of somatostatin and gabaxate
mesilate pre-procedure resulted in PEP risk difference of 7.7% (95% CI 3.4e12.0, p < 0.001) and 5.2%
(95% CI 1.1 to 9.4, p ¼ 0.01) respectively. In the same meta-analysis, it was also shown that a bolus dose
of somatostatin pre-procedure was associated with a PEP risk difference of 8.2% (95% CI 4.4 to 12.0,
p < 0.0001 [17]. However, there was no effect of somatostatin and gabaxate infusions in PEP risk
reduction when administered for less than 12 h. Another subsequent metaanalysis involving 17 trials
(n ¼ 3818) further confirmed that bolus doses of somatostatin could reduce the incidence of PEP; and
also suggested that high doses of octreotide also has a preventive role [18].
Beneficial effect of epinephrine in the prevention of PEP has been inconsistent. Even though it was
not found to be effective in a previous randomized trial, a subsequent network metaanalysis of 99 RCTs
(25,313 patients) that evaluated 16 agents reported that topical epinephrine could reduce the risk of
PEP by 75% compared to controls on sensitivity analyses (OR 0.25 [95% CI 0.06e0.66)] [19]. Currently, a
large multicenter international study to evaluate the effect of topical epinephrine spray in preventing
PEP is nearing completion and the results are expected soon (www.clinicaltrials.gov; NCT02116309).
Other than epinephrine, rectal NSAIDS also emerged as the other effective pharmacologic modality
that could prevent PEP in this network metaanalyses.
Among the NSAIDs, indomethacin has been recently in the limelight as one of the most efficient
yet low cost pharmacologic agent for PEP prohpylaxis. Even though efficacy of NSAIDs for PEP
prevention has been reported in small scale studies since 2003, the landmark study that appeared
to have changed practice was published in 2012. In this double blind RCT involving 602 patients
where 100 mg of rectal indomethacin/placebo was administered as suppositories just after ERCP,
there was a reduction of PEP from 16.9% to 9.2% (p ¼ 0.005) [20]. However, the major criticism of
this study was the inclusion of only high risk patients of which a substantial majority had SOD.
Furthermore, over 80% of patients in this trial received pancreatic stents, thereby leaving a room to
think of a potential contribution of the stenting. However, a subsequent post-hoc analyses by the
same group suggested that the efficacy was likely to be due to rectal indomethacin alone [21]. This
was further substantiated by a more recent network meta-analysis which suggested that NSAIDs
may be more effective than prophylactic PD stenting [22]. Nevertheless, the jury is still out and the
issue could be best resolved by a head to head RCT comparing prophylactic PD stenting versus
rectal indomethacin. The efficacy of rectal indomethacin in reducing PEP was further supported by
two subsequent metaanalysis [23,24] and a large multicenter randomized trial [25]. However, two
very recent studies with conflicting results has again placed rectal indomethacin into discussion.
Lavenik et al. reported that rectal indomethacin does not prevent PEP in a prospective double blind
placebo controlled trial involving 449 consecutive patients undergoing ERCP [26]. The study was
from a single center and 70% patients had average risk of developing PEP, which the authors
emphasizes to be representative of unenhanced patients encountered in typical gastroenterology
practice. Based on the results of this study, the authors suggested reconsideration of recent
guidelines which recommend prophylactic rectal indomethacin for all patients undergoing ERCP. Of
note, this study was terminated early (after just about one-third recruitment), which reduced the
statistical power and substantially increased the probability of a Type II error. On the other hand, a
retrospective study involving 4017 patients with both high and low risk of PEP (including 803 with
malignant biliary obstruction, a group often not included in previous PEP prevention studies),
showed a 65% risk reduction (OR 0.35; 95% CI, 0.24e0.51; p < 0.001) in the development PEP after
use of rectal indomethacin [27]. The study population represented a real life scenario encountered
in clinical practise and the authors demonstrated a reduction of PEP with use of indomethacin in
subgroups of patients with different levels of risk (including malignant biliary obstruction), unlike
the previous study where patients were not sub-analyzed according to low/average and high risk.
However, like the previous study, this was also conducted in a single center thereby limiting its
generalizability in the absence of external validation. Furthermore, the retrospective nature of the
study keeps room for the inherent problems associated with these type of studies. Therefore, the
need to design the ‘perfect’ study that could provide all inclusive and generalizable conclusions still
remain.
Several studies have reported the role of IV hydration in acute pancreatitis. The first study on
aggressive hydration in the prevention of PEP was reported in a pilot randomized trial. In this
study, aggressive hydration (ringer lactate; 3 mL/kg/h during the procedure, a 20-mL/kg bolus
after the procedure, and 3 mL/kg/h for 8 hours after the procedure) was compared with standard
hydration (ringer lactate; 1.5 mL/kg/h during and for 8 hours after procedure) [28]. The study
demonstrated that PEP developed in no patients in the aggressive hydration arm compared to
17% in the standard arm. Role of aggressive hydration was also supported in a cohort of 6505
patients undergoing ERCP; wherein it was hypothesized that large periprocedural fluid volume
could possibly reduce the rate of PEP [29]. Though sample size was large, the study was retro-
spective in nature. On the other hand, the sample size was very small in the previous study and
the incidence of PEP appeared to be higher than usual in the standard hydration arm. A better
answer to the use of prophylactic IV hydration was provided in a recent multicenter RCT that
compared vigorous lactated ringer's with standard ringer's infusion in an 1:1 design involving
510 patients [30]. That rate of PEP was significantly lower in patients who received vigorous
hydration (initial bolus of 10 mL/kg before the procedure, 3 mL/kg/h during the procedure, for 8
hours after the procedure, and a post-procedure bolus of 10 mL/kg) compared to standard
hydration (1.5 mL/kg/h during and for 8 hours after the procedure) (4.3% vs 9.8%; RR 0.41; 95% CI
0.20e0.86; p ¼ .016).
Endoscopic modalities
The benefits of prophylactic PD stenting to prevent PEP was earliest shown in the mid to late 90s’
[31]. Since then, there have been several reports that supported the protective effects of prophylactic
stenting in preventing PEP. A recent meta-analysis of 14 RCTs that included 1233 patients in the PD
stent group and 1277 in the no stent group demonstrated an odd's of developing PEP of 0.35 (95%
CI 0.25e0.49) in favor of prophylactic PD stenting [32]. This risk reduction was similar to an earlier
meta-analysis which included 18 studies (8 RCTs with 656 subjects and 10 non-RCTs with 4904 sub-
jects) [33]. This meta-analysis showed an odd's ratio of developing PEP of 0.22 (95% CI 0.12e0.38) in
favor of PD stenting with an absolute risk difference of 13.3% (95% CI 8.8e17.8%). Studies that had
addressed the issue of the stent size for PEP prevention were evaluated in a recent systematic review
and network meta-analysis [34]. The results suggested that both 5-Fr single pig-tailed unflanged and
straight flanged stents performed significantly better than 3-Fr single-pigtail unflanged stents. This
implies that stent diameter is more important than the type. Another retrospective study involving 346
prophylactic PD stenting that compared between 5-Fr and 4-Fr stents reported that both stent
sizes were equally effective in preventing PEP; while the rate of spontaneous migration was high with
the 4-Fr stent [35]. Therefore, it is plausible that short 5-Fr stents be used for the prevention of PEP.
Few other technical strategies that have been evaluated for the prevention of PEP include guidewire
canulation, early precut biliary papillotomy, and combined use of papillary ballon dilatation with
modest biliary sphincterotomy for large CBD stones. A Cochrane systematic review (12 RCTs, 2340
patients) that compared wire guided CBD canulation with canulation followed by contrast opacifica-
tion demonstrated that the risk of PEP was lower with the former based on intention-to-treat analysis
[relative risk of 0.51 (95% CI 0.32e0.82; p ¼ 0.005)] [36]. Another recent Cochrane systematic review
evaluated seven RCTs (577 patients) for effectiveness and safety of the pancreatic guidewire (PGW)
technique compared to persistent conventional biliary canulation (contrast- or guidewire-assisted
canulation) or other advanced techniques for difficult biliary canulation. The results showed that
PGW technique significantly increased PEP compared to other endoscopic techniques (RR 1.98, 95% CI
1.14 to 3.42). However, the quality of evidence was low [37].
Even though precut sphincterotomy has been considered a risk factor for PEP, the actual mechanism
as to whether the procedure itself or prior prolonged and multiple attempts to regular canulation is not
clear. This issue was addressed in six RCTs, which were meta-analyzed (sample size of 966); and the
results showed that early precut biliary sphincterotomy was associated with a lower risk of developing
PEP compared to conventional method requiring repeated canulation attempts (OR 0.47; 95% CI
0.24e0.91) [38]. Similar results were obtained in another metaanalysis which yielded a OR (95% CI) of
0.46 (0.23e0.92) for PEP in favor of precut sphincterotomy [39].
Pooled analysis of studies comparing large papillary balloon dilatation (LPBD) versus biliary
sphincterotomy for removal of large CBD stones showed a marginal increase in PEP in the LPBD group
[40]. However, the trade-off associated with a modest to complete biliary sphinctertomy is the higher
risk of bleeding. On the other hand, biliary sphinctertomy followed LBPD has been shown to be asso-
ciated with a lower incidence of PEP [41]. Nevertheless, this needs to be addressed further since few
other studies have failed to show increased rates of PEP with LPBD without prior biliary sphincterotomy.
Post-ERCP bleeding
Bleeding after ERCP occurs in upto 2% of patients (severe bleed in 0.1e0.5%) and is specifically
related to sphincterotomy [42]. It can be immediate (seen in up to 30% of all cases with post-ERCP
bleeding) or delayed (any time after the procedure to the end 2 weeks) [43]. Post-ERCP bleeding is
associated with a 3.54% (95% CI 1.08e6.00) bleeding related mortality. Severity-wise, post-ERCP
bleeding has been divided into three groups (Table 2). As shown by multivariate analysis, definitive risk
factors for post-ERCP bleeding includes coagulopathy, anti-coagulation within 3 days of sphincter-
otomy, cholangitis before ERCP, bleeding during initial sphincterotomy and lower ERCP volume [44].
Other possible risk factors include cirrhosis, dilated common bile duct, periampullary diverticulum,
precut sphincterotomy and common bile duct stone. Interestingly, use of aspirin, clopidogrel or NSAIDs
has shown divergent results in studies evaluating their role in increasing bleeding risk. Among the
various risk factors for bleeding, coagulopathy, impacted CBD stone and ampullary cancer are the ones
Table 2
Classification of severity of post-ERCP bleeding.
Mild Moderate Severe
Clinical evidence of bleeding with a Blood transfusion of four units or Blood transfusion of five or more units
hemoglobin drop of <3 g/dl and less with no surgical or angiographic or intervention (endoscopic, angiographic
no need for transfusion. intervention required. or surgical) required.
associated with profuse bleeding. The red-flag signs that signal major bleed and potential need for
interventions include hematemesis/melaena, hematochezia that is associated with a hemoglobin drop
of 2 gm/dl and need for blood transfusion [45].
Prevention
Prevention of post-ERCP bleeding mandates careful patient assessment for risk factors and their
correction whenever possible. If a patient has coagulopathy, this should be corrected and platelet count
and INR should be maintained at >50,000/cumm and less than 1.5, respectively. If the ERCP procedure
is not emergent, one could wait until correction of coagulopathy. Otherwise, emergent reversal of
anticoagulation can be achieved with fresh frozen plasma. Recommendations for anticoagulation
modification differ according to the risk of bleeding. The recently published BSG and ESGE guidelines
[46] strongly recommend continuation of clopidogrel and warfarin, though the quality of evidence is
weak. The guidelines also recommend discontinuation of the direct oral anticoagulants (DOAC) such as
dabigatran, rivaroxaban, apixaban, and endoxaban on the morning of the procedure (weak recom-
mendation). It should be ensured that the INR is maintained within the therapeutic range during the
week prior to the procedure. Aspirin may be continued for all ERCP procedures except ampullectomy
irrespective of the level of risk. In high risk procedure with low thrombotic risk, it is recommended
that clopidogrel and warfarin be stopped 5 days prior to the procedure (moderate to high quality
evidence; strong recommendation). For high-risk procedures with high thrombotic risk, aspirin may
be continued and use of clopidogrel should be done with the advise of a cardiologist based on the
risk/benefit equation (strong recommendation). Furthermore, warfarin in these patients should be
discontinued and replaced with low molecular heparin. The guidelines also recommend that high risk
patients who were on DOACs, the last dose of the drug should be taken 48 h prioir to the procedure
(strong recommendation). INR should be within 1.5 prior to the procedure. After the procedure, clo-
pidogrel and warfarin may be started by 48 h post procedure depending on the perceived risk of
bleeding and thrombosis.
In patients with renal impairment with coagulopathy, risk of post-ERCP bleeding can be reduced
by improving platelet function with 1-desamino-8d-arginine vasopressin (DDAVP) or estrogens, he-
modialysis and correction of anemia. Patients with advanced cirrhosis who require endoscopic
sphincterotomy should be treated with fresh frozen plasma and/or vitamin K to maintain the INR
between 1.4 and 1.7.
From a technical perspective, post-ERCP bleeding can be prevented in high risk patients if
sphincterotomy is performed in a high volume center with more experienced endoscopists. Other
factors that could aid in preventing post-ERCP bleed includes: sphincterotomy along the 11e1 o' clock
arc above the major papilla (has the least concentration of blood vessels) [47]; appropriate positioning,
avoidance of zipper cutting (long erratic cuts), and use of proper electrocautery techniques [48].
Post-ERCP bleeding in the context of the type of current used for sphincterotomy has been under
debate. It was shown in a meta-analyses that ‘pure cut’ current, which uses low voltage saw tooth
waveform with no major tissue heating, was associated with a higher episodes of mild, transient,
intraprocedural bleeding [49]. However, it is not clear if use of pure current at the beginning of the
procedure followed by blended current could reduce the risk of bleeding. Newer electrosurgical
generators that enable microprocessor-controlled sphincterotomy (endocut) has been shown to reduce
the incidence of endoscopically observed bleeding, though this does not change the incidence of
clinically significant bleeding [50]. Furthermore, use of balloon sphincteroplasty instead of sphinc-
terotomy in patients with coagulopathy reduces the risk of bleeding [51].
Treatment
Majority of post-ERCP bleeding stops spontaneously. In the event of endoscopically or clinically

significant bleeding, the first step of treatment is hemodynamic stabilization. Immediate post pro-
cedure bleeding is considered endoscopically significant if it obscures the endoscopic field or if the
bleeding persists after the intended therapeutic procedure. The simplest and the most commonly
employed way to treat immediate post-ERCP bleeding is to inject diluted epinephrine (0.5e30 ml) into
and around the sphincterotomy site. One study reported a 96% initial hemostasis with epinephrine
injection, with recurrence of bleeding in only 4e16% patients [52]. One potential risk with epinephrine
is the risk of cardiac arrhythmia in patients with coronary artery disease as a result of systemic ab-
sorption. Other modalities used for hemostasis after post sphincterotomy bleed include thermal
coaptive coagulation using bipolar or heater probe. It should be remembered that using the bipolar or
heater probe through the therapeutic channel of the duodenoscope could be technically more chal-
lenging compared to use with the gastroscope in case of ulcer bleed. It is essential that the operator
takes utmost care to avoid the pancreatic orifice and thereby prevent the development of pancreatitis.
Besides these commonly used methods for hemostasis, there are limited data on the use of argon
plasma coagulation and endoclip. This is very preliminary and should be used only under the setting of
clinical trials. In the event of refractory and recurrent post-ERCP bleeding not responding to endo-
therapy, other measures such as fully covered SEMS, angiographic embolization and even surgery
needs to be considered.
ERCP related perforation
ERCP related perforations are very rare (<1%), and are mostly seen with therapeutic procedures
(94%). These perforations have been classified by different manners by different authors, as tabulated in
Table 3 [53]. Risk factors for ERCP related perforations include sphincterotomy, intramural injections,
stricture dilatation, guidewire manipulation, prolonged procedure and difficult examination. Besides
these procedure related risk factors, patient related factor such as altered post-surgical anatomy
(eg. Billroth Type II) confers significant risk of developing perforation which usually occurs at the
anastomotic site or in the tortuous efferent limb. Perforations may occur in the esophagus, stomach
and duodenum from by endoscope manipulation, in the periampullary region from sphincterotomy
and the bile duct from instrumentation. In the majority of patients, perforations are easy to detect since
they are evidenced by extravasation of contrast from the biliary tree or the intestinal lumen during the
procedure itself. CT scans with contrast leak could be diagnostic of suspected perforations which do not
show up during the ERCP procedure. Rare perforations by a biliary stent through the opposite wall of
the duodenum are invariably detected late and are thus associated with profound morbidity.
Treatment
Perforations in the periampullary region and the bile duct usually have a complete recovery with
conservative treatment with parenteral antibiotics and nil by mouth. These may occasionally require
Table 3
Classification of ERCP related perforation according to different authors.
Stapfer et al. Howard et al. Kim et al.
Type I Lateral or medial Duodenal perforation Scope related perforation (associated with heavy
wall perforation remote from the papilla contamination)
Type II Perivaterian injury Periampullary retroperitoneal Perforation related to needle- knife used during the
perforation sphincterotomy, ERCP cannula or the sphincterotome
(associated with moderate contamination)
Type IIIDistal bile duct injury Guidewire related Guidewire related perforation (associated with
related to wire/basket perforation minimal contamination)
instrumentation
Type IV Retroperitoneal air alone - -
percutaneous drainage in case of large biliomas. Bile duct perforation can be additionally treated with
CBD stenting. Luminal perforation detected during the procedure should be immediately closed, which
can now be done using endoscopic clips in most cases [54,55]. Surgery is indicated in patients who do
not respond to conservative management, who have retained stones and large collections or who have
free intraperitoneal perforations.
Infection/Cholangitis
Endoscopy related infection is becoming a burgeoning risk over the past several years. Overall, it has
been reported to be 1.4%; however it is associated with a mortality of as high as 7.85%. Even though any
endocopsic procedure could be associated with infections, the risk is particularly high with ERCP due to
the inherent structural complexity of duodenoscopes, that could result in inadequate cleaning. Despite
adequate cleaning of duodenoscopes according to national guidelines, there could be duodenoscope
related infections as shown in a Canadian multicenter study that reported microbial growth in 7% of
duodenal samples [56]. Furthermore, rapid development of antibiotic resistance over the past few
years has added to the magnitude of existing risks of serious infections [57,58].
Table 4 shows the risk factors for post-ERCP infection [42].
Prevention and treatment
An easy way to prevent ERCP related infections is to restrict ERCP to therapeutic use as far as
possible. Use of air cholangiogram instead of contrast cholangiogram has been shown to be effective in
reduction of cholangitis in patients with malignant hilar obstruction in small retrospective studies and
prospective RCTs; but needs validation in larger multicenter studies [59,60]. Since incomplete biliary
drainage is associated with a substantial risk of developing cholangitis, it is prudent that complete
biliary drainage could reduce the risk. However, results of studies evaluating unilateral versus bilateral
duct system drainage in patients with malignant hilar obstruction has been divergent. While a
retrospective study of 141 patients with hilar obstruction showed significantly lower risk of cholangitis
with bilateral drainage, another subsequent RCT reported higher rate of early cholangitis in patients
with bilateral drainage compared to unilateral (16.6% vs. 8.8%, p ¼ 0.013) [61,62]. Stents used in these
studies were plastic; and recent studies have suggested that self-expandable metal stents (SEMS) could
be better in reducing the cholangitis rates. A recent meta-analysis that analyzed 19 studies that
compared 1045 SEMS versus 944 plastic stents demonstrated that the SEMS was associated with a
significantly lower incidence of cholangitis compared to plastic stents (8% vs 21%; OR 0.41; 95% CI
0.22e0.76). In the same meta-analyses, comparison of unilateral versus bilateral stenting in seven
studies involving 634 patients (346 unilateral, 268 bilateral) failed to show any significant difference in
the incidence of cholangitis [63].
Use of pre- and postprocedural antibiotics under relevant situations could reduce the incidence of
cholangitis. As shown in a Cochrane review involving nine RCTs (1573 patients), overall there was a
significant effect of pre-procedural antibiotics in preventing cholangitis (RR 0.54, 95% CI 0.33 to 0.91),
septicaemia (RR 0.35, 95% CI 0.11 to 1.11) and bacteraemia (RR 0.50, 95% CI 0.33 to 0.78) [64]. However,
prophylactic antibiotics did not appear to have any benefit to patients in whom the biliary obstruction
was resolved in the first ERCP procedure. This was based on the results of three studies, and probably
warrants generation of more data. Post ERCP antibiotics are not mandatory for all patients if complete
biliary drainage is achieved, except under situations of ERCP in patients with PSC or those with post
Table 4
Risk factors for post ERCP infections.
1. Combined percutaneous and endoscopic procedures

2. Stent placement in malignant strictures
3. Presence of jaundice
4. Low case volume
5. Incomplete or failed biliary drainage
liver transplant strictures, where 3e5 days course of oral antibiotics should be prescribed [65]. Even
though there are no recommendations on the ‘single best’ antibiotic for post ERCP infection prophy-
laxis, antibiotics that cover gram-negative organisms such as cephalosporin, fluoroquinolones and
aminoglycosides are reasonable choices [66,67]. Other intraprocedural measures that could reduce the
risk of ERCP related infections include minimizing or avoiding contrast injection in patients with
known biliary obstruction or cholangitis, ensuring complete drainage and putting a biliary stent or
naso-biliary drain in cases with incomplete drainage, and percutaneous drainage (PTBD) in case
endoscopic drainage is not feasible.
Delayed post-ERCP strictures
Though uncommon, sphincterotomy during ERCP could result in delayed biliary stricturing [68].
Strictures could develop either in the duodenal wall, referred to as Type 1 stenosis, treatment of which
include extension of the previous sphincterotomy. Stricture that occur deeper (Type 2 stenosis) may
require stricture dilatation as a definitive treatment. Other than extension of previous sphincterotomy
and dilatation, endotherapy for post-ERCP strictures also includes sequential insertion of increasing
number of biliary stents.
Besides biliary stenosis, obstruction to the pancreatic duct could result in recurrent episodes of
acute pancreatitis. Sphincterotomy with PD stenting (with or without stricture dilatation) is usually
ameliorative, though there may be a need for repeated procedures [69].
ERCP in special situations
Pancreas divisum is generally considered to be associated with a higher risk of developing com-
plications after ERCP. A recent retrospective analysis of nearly 1500 patients with pancreas divisum
who underwent ERCP reported an overall post-ERCP complication rate of 7.8%, and pancreatitis of 6.8%.
Dorsal duct canulation and minor papilla sphincterotomy were associated with a significantly higher
incidence of post-ERCP pancreatitis (8.2% and 10.6% respectively) [70].
In patients with primary sclerosing cholangitis, the overall incidence of post-ERCP complications is
not significantly different from that in general. However, the risk increases if ERCP is performed for
acute indications, as opposed to elective procedures [71].
Endoscopic ampullectomy is a situation that can be associated with a high rate of complications.
Studies have shown that it could be associated with a 3e25% incidence of acute pancreatitis, 2e30%
bleeding, 0e8% perforation, 0e5% cholangitis, and 0e8% delayed papillary stenosis [72]. Prophylactic PD
stenting is mandatory for prevention of PEP in these patients [73]. Bleeding could be both early and
delayed; and should be managed as any other ERCP related bleeding. A temporary biliary stent could be
helpful in preventing obstructive hemobilia and localize the ampullectomy bed in case brisk bleeding is
anticipated during the procedure. A high clinical suspicion is necessary for detecting perforation since
endoscopic features suggesting deep resection in ampullectomy is not as reliable as it is for other sites.
Ongoing pain should be used as a strong indicator for the need to conduct further radiological or surgical
evaluation. Absence of free air does not always rule out perforation, since it is mostly retroperitoneal [74].
ERCP could be challenging in cirrhotics. A recent retrospective matched study from patients in the
national inpatient database that compared 1308 compensated to 622 decompensated cirrhotics
demonstrated that the incidence of PEP and bleeding was significantly higher in the latter group (5.5%
vs 9.7% and 1.0% vs 4.3% respectively) [75]. Furthermore, cirrhotics who underwent ERCP had a
significantly higher rate of bacterial peritonitis compared to cirrhotics who underwent non-
pancreatobiliary endoscopy (2.2% vs 1.1%) [75].
Periampullary diverticula are observed in 8e32% of patients undergoing ERCP, of which the papilla
could be located within the diverticulum in up to 55% of patients. Canulation in the presence of per-
iampullary diverticulum often poses challenge, involves more time, requires greater expertise and
could be associated with higher rate of complications. Periampullary diverticulum are of two main
types, namely type I in which the papilla is located at the edge of the diverticulum or within a radius of
2 cm from the diverticular edge; and type II, in which the papilla is located inside the diverticulum or
lying between two adjacent diverticula (the latter also termed type III) [76]. The challenge during
canulation predominantly arises from the non-visualization of the papilla; and if the papilla could be
visualized the canulation success is similar to that in patients without periampullary diverticulum.
Technical details for canulation in the presence of periampullary diverticulum is out of the scope of this
article, and can be found in the recent review by Altonbary AY et al. [77].
Technical aspects of ERCP in surgically altered anatomy is also beyond the scope of this manuscript,
and can be accessed in the recent review by Gomez V et al. [78]. Suffice it to say, technical challenges
vary according to the primary surgical procedure, whether the papilla is intact (eg. Billroth I and II
gastrectomy with Roux-en-Y anastomosis, Roux-en-Y gastric bypass, gastroenteric anastomosis) or
whether new biliopancreatic anastomosis is created (eg. Whipple's operation, Roux-en-Y hep-
aticojejunostomy, cholecystojejunostomy, choledocoduodenostomy/jejunostomy). The major de-
terminants related to the overall success of ERCP in these altered anatomical situations are the length
and mobility/fixation of the bowel needed to be traversed. Besides these, the experience of the
endoscopist also has a substantial bearing in the technical success and prevention of complication.
Pediatric patients represents a specific subgroup in which data on ERCP complications are scant.
There is currently no specific consensus regarding ERCP in children in the context of types of scopes,
techniques etc. A recent retrospective chart review of 48 children with 65 ERCP procedures with an
adult duodenoscope reported a canulation success rate of 93.8%. Therapeutic procedures were per-
formed in 70.7% of patients and overall 9.2% developed PEP. There was no procedure related mortality
[79]. These data suggest that pediatric ERCPs done with standard duodenoscopes by experienced
endoscopists could be safe in children. However, more data from multicenter studies with larger
sample size would be required for definitive conclusions.
Post liver transplantation (LT) is another special situation which could pose challenges during the
ERCP procedure. However, one recent single center retrospective study showed that the rate of com-
plications in the LT rcepients were not significantly different from non-LT patients. The authors did
identify few independent risk factors that could increase the risk of post ERCP complications. These
included: use of mammalian target of rapamycin (mTOR) inhibitors (odds ratio [OR], 4.65; 95% CI,
1.01e21.81; p ¼ 0.049), serum creatinine level greater than 2 mg/dL (OR, 4.17; 95% CI, 1.07e16.26;
p ¼ 0.04), biliary sphincterotomy (OR, 3.03; 95% CI, 1.07e8.53; p ¼ 0.037), and more than two
pancreatic duct contrast injections (OR, 2.95; 95% CI, 1.10e7.91; p ¼ 0.032). Interestingly, steroid use
emerged as a protective factor [80].
Conflict of interest
None.
Practice points
Even though safe, ERCP confers substantial risk of complications.

Pancreatitis, bleeding, perforation and infection/cholangitis are the usual complications after
ERCP.
Rectal NSAIDS and prophylactic pancreatic duct stenting has been shown to protect from
post ERCP pancreatitis.
The British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal
Endoscopy (ESGE) has recently published updated anticoagulation guidelines for patients
undergoing endoscopy.
It is important to ensure adequate biliary drainage in case of hilar obstructions in order to
prevent ERCP induced cholangitis.
ERCP with conventional instrument is generally safe in children when performed at experi-
enced center.
Pancreas divisum, primary sclerosing cholangitis, cirrhosis, periampullary diverticulum,
endoscopic ampullectomy and post-liver transplantation are special situations that are
associated with higher than usual risk of post ERCP complications.
Research agenda
Head to head comparison of prophylactic pancreatic duct stent with rectal NSAIDS needs to
be conducted.
The ideal canulation technique to prevent post ERCP complication needs to be evaluated
further in better quality clinical trials.
The ideal prophylactic antibiotic for post ERCP cholangitis needs to be evaluated.
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Mild Moderate Severe

Mild Moderate Severe

Majority of post-ERCP bleeding stops spontaneously. In the event of endoscopically or clinically

ERCP related perforation

Stapfer et al. Howard et al. Kim et al.

Prevention and treatment

1. Combined percutaneous and endoscopic procedures

Delayed post-ERCP strictures

ERCP in special situations

Even though safe, ERCP confers substantial risk of complications.

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