What is the management for bilious vomiting post Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Management of Bilious Vomiting Post-ERCP

Bilious vomiting after ERCP requires immediate assessment for post-ERCP complications, particularly pancreatitis, cholangitis, or perforation, with CT imaging as the first-line diagnostic tool and management directed at the specific complication identified. 1

Initial Assessment and Recognition

The first priority is to determine which post-ERCP complication is causing the bilious vomiting:

• Obtain CT imaging immediately to diagnose complications and rule out perforation, fluid collections, or pancreatitis in adults 1
• Assess for alarm symptoms including fever, severe abdominal pain, distention, and signs of sepsis, as these indicate serious complications requiring urgent intervention 2
• Check laboratory markers including liver function tests (bilirubin, AST, ALT, ALP, GGT), inflammatory markers (CRP, PCT), and lactate to evaluate severity of inflammation and sepsis 2

Management Based on Specific Complications

Post-ERCP Pancreatitis (Most Common)

Post-ERCP pancreatitis is the most frequent complication, occurring in approximately 3.5-3.7% of cases 2, 3:

• Conservative management with IV fluids, pain control, and bowel rest for mild cases 1
• Do NOT attempt salvage pancreatic stenting once pancreatitis has developed 4
• Continue supportive care until symptoms resolve, as most cases are self-limited 1

Post-ERCP Cholangitis/Biliary Sepsis

If bilious vomiting is accompanied by fever and signs of infection:

• Initiate antimicrobial therapy immediately: within 1 hour if sepsis is present, within 6 hours for less severe cases 2, 1
• Use broad-spectrum antibiotics: 4th-generation cephalosporins, piperacillin/tazobactam, imipenem/cilastatin, or meropenem 2
• Perform urgent biliary decompression if incomplete drainage is suspected 2, 1
• ERCP with stent placement is the procedure of choice for biliary decompression, as it has lower risk than percutaneous or surgical approaches 2, 1
• Evaluate with ultrasound or CT if no improvement with conservative therapy, and consider repeat ERCP with bile culture 4

Perforation or Bile Leak

If imaging reveals perforation or bile leak:

• Percutaneous drainage of any fluid collections identified on CT 2
• Broad-spectrum antibiotics immediately (within 1 hour) 2
• Surgical consultation for retroperitoneal perforation or diffuse biliary peritonitis requiring urgent abdominal lavage and drainage 2

Conservative Management Protocol

For uncomplicated bilious vomiting without evidence of serious complications:

• NPO status with nasogastric decompression if vomiting is persistent 5
• IV fluid resuscitation to correct dehydration and electrolyte abnormalities 5
• Antiemetic therapy: ondansetron 0.15 mg/kg IV (maximum 4 mg) for persistent vomiting 5
• Serial clinical assessment with repeat imaging if symptoms worsen or fail to improve within 24-48 hours 1

Critical Pitfalls to Avoid

• Do not delay imaging in patients with bilious vomiting post-ERCP, as this may represent serious complications requiring urgent intervention 1
• Do not inject contrast under pressure during repeat ERCP in suspected cholangitis, as this may cause cholangio-venous reflux and worsen septicemia 2
• Do not withhold antibiotics while awaiting imaging if sepsis is suspected—start within 1 hour 2, 1
• Do not assume simple gastritis—bilious vomiting specifically suggests biliary or pancreatic complications rather than routine post-procedure nausea 5

When to Escalate Care

Immediate escalation is required for:

• Hemodynamic instability or signs of septic shock 6
• Evidence of perforation on imaging 2
• Failure to improve with conservative management within 24 hours 4
• Development of diffuse peritonitis 2