How to manage a patient with hypotension, haematemesis, and melena after a failed Endoscopic Retrograde Cholangiopancreatography (ERCP) due to perforation?

Management of Hypotension, Haematemesis, and Melena After Failed ERCP with Perforation

For a patient with hypotension (BP 80/50), haematemesis, melena, and mild tenderness following ERCP perforation, immediate laparotomy (option D) is the most appropriate management.

Clinical Assessment and Rationale

• Patients with perforations who are hemodynamically unstable (as indicated by BP 80/50) should be surgically managed without any attempt at endoscopic closure 1
• The combination of hypotension, haematemesis, and melena indicates active bleeding, which requires immediate intervention 1
• In patients with ongoing resuscitative needs and hemodynamic instability following perforation, conservative or endoscopic management is contraindicated 1

Management Algorithm

Initial Stabilization

• Immediate fluid resuscitation and blood product administration should be initiated while preparing for definitive intervention 1
• Hemodynamic stability is the key factor in determining management strategy, and this patient is clearly unstable 1

Definitive Management Options Analysis

1. Repeat Endoscopy (Option A)

   • Not appropriate in this scenario as:
     • The patient is hemodynamically unstable 1
     • There is evidence of perforation with peritoneal signs 1
     • Attempting endoscopic intervention could worsen the perforation and delay definitive treatment 1

2. Laparoscopy (Option B)

   • Not the first choice because:
     • In hemodynamically unstable patients with perforation, open surgery provides better exposure and faster control 1
     • The patient has signs of active bleeding that may be difficult to control laparoscopically 1

3. Coeliac Angiography Embolization (Option C)

   • While angioembolization can be considered for isolated bleeding, it is not appropriate when:
     • There is a known perforation that requires surgical repair 1
     • The patient is hemodynamically unstable with signs of peritonitis 1
     • Delaying surgical management could lead to worsening sepsis 2

4. Laparotomy (Option D)

   • Most appropriate because:
     • It allows direct visualization and repair of the perforation 1
     • Provides immediate control of bleeding source 1
     • Enables thorough abdominal lavage to reduce risk of sepsis 1
     • Mortality from ERCP-related perforations can be as high as 20%, and immediate surgical intervention is critical in unstable patients 3

Important Considerations

• ERCP-related perforations have a high mortality rate (up to 20%) and require prompt management 3
• Delayed diagnosis or referral for intervention can significantly worsen outcomes, with mean delays of 6.6 days reported in some studies 2
• Risk factors for mortality after ERCP perforation include malignancy, age over 80 years, and sphincterotomy in the pancreatic duct 3

Pitfalls to Avoid

• Do not attempt conservative management in hemodynamically unstable patients with perforation 1
• Avoid delaying surgical intervention when signs of active bleeding and perforation coexist 2
• Do not rely on endoscopic closure techniques in patients with hemodynamic instability, even though these techniques (such as endoclips or purse-string sutures) may be successful in stable patients 4, 5
• Recognize that the incidence of ERCP-related perforations is low (0.72%) but carries significant morbidity and mortality when they occur 3