What are the management and treatment options for post-Endoscopic Retrograde Cholangiopancreatography (ERCP) complications?

Management and Treatment of Post-ERCP Complications

The management of post-ERCP complications requires prompt recognition, appropriate imaging, and targeted interventions based on the specific complication, with CT scan being the first-line imaging tool for new-onset symptoms in adults. 1

Common Post-ERCP Complications and Their Management

Post-ERCP Pancreatitis (PEP)

• PEP is the most common complication, occurring in approximately 7.2% of cases, with most instances (93%) being self-limiting 2
• Risk factors include female sex, sphincter of Oddi dysfunction, previous ERCP-related pancreatitis, multiple cannulation attempts, and pain during the procedure 2, 3
• Prevention strategies:
  • Routine rectal administration of 100 mg indomethacin or diclofenac immediately before or after ERCP in all patients without contraindications to NSAIDs 4, 5
  • Prophylactic pancreatic stent placement (5-Fr) in high-risk patients 5
• Management:
  • Conservative treatment with IV fluids, pain management, and bowel rest for mild cases 1
  • CT imaging for diagnosis and to rule out complications 1
  • MRI is preferred in pregnant patients and children 1

Bleeding

• Occurs in approximately 0.8-1.3% of procedures, almost exclusively associated with therapeutic interventions, particularly sphincterotomy 5, 2
• Risk factors include coagulopathy and therapeutic procedures 5
• Management:
  • Endoscopic hemostasis techniques (injection, thermal, or mechanical methods) 5
  • Delay anticoagulation for at least 48 hours after ERCP, especially if sphincterotomy was performed 5

Perforation

• Rare complication (0.08-0.69%) but potentially serious 2, 3
• Management:
  • Early detection is crucial for optimal outcomes 6
  • Conservative management with IV antibiotics, bowel rest, and serial abdominal exams for stable patients with contained perforations (Stapfer type 4) 6
  • Surgical intervention for signs of sepsis, peritonitis, or large perforations 6

Cholangitis and Other Infectious Complications

• Cholangitis occurs in approximately 1.21% of cases, often due to incomplete drainage 2, 3
• Abscess or intra-abdominal sepsis occurs in 7-25% of patients with pancreatic injuries 1
• Management:
  • Timely initiation of antimicrobial therapy (within 1 hour for sepsis, within 6 hours for less severe cases) 1
  • Biliary decompression is critical in treating biliary sepsis 1
  • ERCP with stent placement is the procedure of choice for biliary decompression 1
  • CT scan or MRI for diagnosis and to guide treatment 1

Pseudocyst Formation

• Most frequent complication following non-operative management of pancreatic injuries 1
• Management:
  • CT scan for evaluation and to guide percutaneous drainage 1
  • US and endoscopic US (EUS) can be used for follow-up and to guide percutaneous treatment 1
  • MRCP to document communication with main pancreatic duct 1
  • ERCP for treating the disease when appropriate 1

Pancreatic Fistula

• Occurs in 10-35% of major injuries of the pancreas after operative drainage or resection 1
• Management:
  • Preoperative cross-sectional imaging and pancreatogram during ERCP are essential for diagnosis 1
  • ERCP is the first step to treat persisting fistulas when feasible 1

Imaging Follow-Up for Post-ERCP Complications

• CT scan is the first-line imaging tool for assessment of complications in adults 1
• MRI is preferred in children and pregnant women 1
• US or contrast-enhanced US (CEUS) can be used as alternatives to CT for follow-up of fluid collections and pseudocysts, particularly in children 1
• ERCP is useful for diagnosis, management, and follow-up of complications such as pseudocysts, pancreatic fistulas, and main duct strictures 1

Special Considerations

• Patients with Primary Sclerosing Cholangitis (PSC) have a higher overall risk of adverse events and should be managed by experienced pancreaticobiliary endoscopists 5
• Long-term follow-up is suggested for patients who underwent pancreatic surgery due to the possibility of delayed onset of diabetes mellitus 1
• ERCP should be avoided if alternative diagnostic tests (CT, MRCP, or EUS) can provide similar diagnostic information 1
• Informed consent must provide patients with a realistic assessment of both risk and expected benefit 1

Common Pitfalls in Managing Post-ERCP Complications

• Failure to administer rectal NSAIDs at the optimal time (immediately before or after ERCP) 4
• Not screening for contraindications to NSAIDs before administration (allergy, significant renal impairment, active peptic ulcer disease, bleeding disorders) 4
• Delayed recognition of complications, particularly perforation and cholangitis 6
• Injection of contrast under pressure during PTBD, which may lead to cholangio-venous reflux and exacerbate septicemia 1