What are the complications of Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Complications of Endoscopic Retrograde Cholangiopancreatography (ERCP)

ERCP carries an increased risk for complications, particularly pancreatitis, cholangitis, and bleeding, with overall complication rates ranging from 1.8% to 18.4%, which is higher than for other endoscopic procedures. 1

Major Complications

Post-ERCP Pancreatitis (PEP)

• Most common serious complication of ERCP, occurring in approximately 3.5% of cases (range 1.6%-15.7%) 2
• Risk factors include:
  • Female sex (OR: 2.6) 1
  • Guidewire manipulation in the pancreatic duct (OR: 8.2) 1
  • Sphincter of Oddi dysfunction (21.7% risk) 2
  • Previous ERCP-related pancreatitis (19% risk) 2
  • History of recurrent pancreatitis (16.2% risk) 2
  • Pain during the procedure (27% risk) 2
  • Multiple cannulation attempts (14.9% risk) 2
  • Precut sphincterotomy (20% risk) 2
• Prevention strategies:
  • Routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP 1, 3
  • Prophylactic pancreatic stent placement (5-Fr) in high-risk patients 1, 3
  • Minimally traumatic cannulation techniques 4

Bleeding

• Occurs in approximately 0.8-1.3% of procedures 1, 2
• Almost exclusively associated with therapeutic procedures, particularly sphincterotomy 2
• Risk factors include:
  • Coagulopathy 5
  • Initiation of anticoagulant therapy within 3 days after procedure 5
  • Active cholangitis 5
  • Low endoscopist case volume 5
• Management:
  • Delay anticoagulation for at least 48 hours after ERCP, especially if sphincterotomy was performed 5
  • For high thrombotic risk patients, consider bridging with low molecular weight heparin 5

Cholangitis

• Occurs in less than 1% of procedures 2
• Most cases are secondary to incomplete drainage of obstructed bile ducts 2
• Risk is particularly high during ERCP with manipulation of an obstructed biliary system 6
• Prevention requires ensuring complete drainage of obstructed biliary systems 6

Perforation

• Rare but serious complication (0.08-0.4% of procedures) 2, 1
• Types include:
  • Guidewire perforation
  • Periampullary perforation during sphincterotomy
  • Duodenal perforation remote from papilla
  • Bile duct perforation during stricture dilation

Technical Challenges and Considerations

Cannulation Difficulties

• Primary cannulation success rate is approximately 88.2% 1
• Challenges in PSC patients include:
  • Retraction of the papilla 1
  • Altered endoscope position due to hypertrophy of the left liver lobe 1
• Failure rates of 0-6% have been reported 1

Stent-Related Complications

• Stent migration 1
• Stent occlusion 1
• Injury to the bile duct 1

Special Patient Populations

Primary Sclerosing Cholangitis (PSC)

• Higher overall risk of adverse events compared to other indications 1
• Increased risk of contrast extravasation 1
• ERCP in PSC patients should be undertaken by experienced pancreaticobiliary endoscopists 1

Mortality Risk

• Procedure-related mortality is approximately 0.4% 1, 7

Prevention Strategies

Operator Experience

• ERCP should be performed by experienced pancreaticobiliary endoscopists, particularly in high-risk cases 1

Patient Selection

• Proper patient selection is critical to avoid unnecessary risk 4
• Consider non-invasive alternatives (MRCP, EUS) when appropriate 1

Pharmacological Prevention

• Routine rectal administration of NSAIDs (diclofenac or indomethacin 100 mg) immediately before or after ERCP 1, 3
• The rectal route provides higher bioavailability by bypassing first-pass hepatic metabolism 3

Technical Considerations

• Minimize pancreatic duct manipulation and contrast injections 2
• Consider pre-emptive endoscopic papillotomy in patients where repeat procedures are anticipated 1
• Prophylactic pancreatic stenting in high-risk patients 1, 3

By understanding these complications and implementing appropriate prevention strategies, the risk of adverse events following ERCP can be minimized, though not eliminated entirely.