What are the next steps for a 49-year-old patient experiencing vomiting a week after an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure?

Immediate Evaluation for Post-ERCP Complications

This 49-year-old patient with vomiting one week after ERCP requires urgent evaluation for delayed perforation, cholangitis, or post-procedure pancreatitis, with immediate CT imaging and laboratory assessment to guide management. 1

Critical Initial Assessment

Immediate Diagnostic Workup

• Obtain contrast-enhanced CT scan immediately to evaluate for:

  • Duodenal or periampullary perforation (Type 1 or Type 2) 1
  • Intra-abdominal fluid collections or bilomas 2
  • Retroperitoneal air or fluid 1
  • Pneumoperitoneum (occurs in <1% of post-ERCP cases) 3

• Laboratory evaluation should include:

  • Complete blood count (assess for leukocytosis suggesting infection) 1
  • Liver function tests and bilirubin (evaluate for cholangitis or biliary obstruction) 1
  • Lipase/amylase (rule out delayed pancreatitis) 4
  • Blood cultures if fever present 1

Key Clinical Features to Assess

• Fever and rigors: Suggests cholangitis or infected collection 1
• Peritoneal signs: Indicates possible perforation with peritonitis 1
• Jaundice or dark urine: Suggests biliary obstruction or cholangitis 1
• Timing and character of vomiting: Persistent vomiting one week post-procedure is abnormal and warrants investigation 5

Most Likely Complications at One Week Post-ERCP

Delayed Perforation

• Delayed recognition of perforation >6 hours after ERCP is associated with increased mortality and hospital stay 1
• Type 1 perforations (duodenal wall trauma) and Type 2 perforations (periampullary from sphincterotomy extension) can present in delayed fashion 1
• Mortality from ERCP-related perforation ranges 7.8%-9.9% 1

Cholangitis

• Post-ERCP cholangitis occurs when biliary drainage is inadequate 1
• Requires urgent biliary decompression via repeat ERCP or percutaneous drainage 1
• Key management: antimicrobial therapy plus biliary drainage 1

Delayed Pancreatitis

• While post-ERCP pancreatitis typically presents within 24-48 hours, delayed presentations can occur 5, 6
• Risk factors include difficult cannulation, pancreatic duct injection, and sphincter of Oddi dysfunction 6

Management Algorithm

If CT Shows Perforation:

1. Immediate surgical consultation 1
2. NPO status, IV fluids, broad-spectrum antibiotics 1
3. Consider endoscopic closure if perforation <1-3 cm and diagnosed early using through-the-scope clips or over-the-scope clips 1
4. Surgical intervention required if:
   • Large perforation (>3 cm) 1
   • Peritonitis present 1
   • Failed endoscopic closure 1

If CT Shows Collection/Biloma:

1. Repeat ERCP to assess for bile duct leak or retained stone 2
2. Biliary stent placement if leak identified 1, 2
3. Percutaneous drainage if collection is large or infected 1

If Cholangitis Suspected (fever, jaundice, elevated bilirubin):

1. Urgent ERCP for biliary decompression within 24 hours 1
2. Broad-spectrum antibiotics immediately 1
3. Endoscopic nasobiliary drainage or stent placement 1
4. If ERCP fails, proceed to percutaneous transhepatic biliary drainage 1

If No Acute Findings on CT:

1. Consider delayed gastric emptying or gastroparesis 7
2. Trial of metoclopramide 10 mg IV/IM for symptomatic relief 7
3. Close observation with serial examinations 5, 8
4. Low threshold for repeat imaging if symptoms persist or worsen 5

Critical Pitfalls to Avoid

• Do not dismiss vomiting as "routine post-procedure nausea" at one week post-ERCP—this timing suggests a complication 5, 8
• Delayed recognition of perforation significantly increases mortality—maintain high index of suspicion 1
• Free air on imaging post-ERCP does not always indicate bowel perforation—can result from pneumobilia or intrahepatic duct rupture in patients with hepatic masses 3, 2
• Inadequate biliary drainage in cholangitis is life-threatening—do not delay repeat ERCP if indicated 1
• One in six patients experience unplanned hospitalization after ERCP, emphasizing the importance of thorough evaluation 5

Immediate Next Steps

Admit the patient for observation, obtain urgent CT abdomen/pelvis with IV contrast, check complete metabolic panel with liver enzymes and lipase, and consult gastroenterology for potential repeat ERCP. 1, 5 The specific management pathway depends on imaging findings, but delayed complications at one week post-ERCP require aggressive investigation and treatment to prevent mortality. 1, 5, 8