What are the types of perforation that can occur post Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Types of Post-ERCP Perforation

Post-ERCP perforations are classified into four distinct types based on mechanism and location, with Type 1 (lateral duodenal wall) and Type 2 (periampullary) being the most clinically significant due to their high morbidity and mortality rates. 1

Classification System

Type 1: Lateral Duodenal Wall Perforation

• Caused by excessive shearing force or angle-related trauma from the duodenoscope shaft or tip, resulting in intraperitoneal or retroperitoneal leakage of bowel contents 1
• Occurs most commonly during forceful scope advancement where the duodenoscope shaft exerts excessive force on the duodenal wall or periampullary diverticulum 1
• Can also result from forceful retraction during difficult stone extraction 1
• Characterized by sudden bleeding, lumen deflation, and difficulty maintaining lumen insufflation 1
• These perforations commonly require surgical intervention unless early endoscopic closure is successfully achieved 1
• Large Type 1 perforations (>3 cm) are particularly difficult to close endoscopically and warrant urgent surgical consultation 1

Type 2: Periampullary (Retroperitoneal) Perforation

• Caused by overextension of a sphincterotomy beyond the intraduodenal portion of the ampulla 1
• These perforations are subtle and easily missed, requiring careful assessment of gas patterns on fluoroscopy 1
• Pre-cut sphincterotomy is a significant risk factor for this type 2
• CT scan should be obtained if there is concern, as delayed recognition beyond 6 hours dramatically increases mortality 1, 3
• Can be managed with through-the-scope clips (TTSCs) if feasible and/or by placing a fully covered self-expanding metal stent (SEMS) across the ampulla 1

Type 3: Guidewire or Instrumentation-Related Perforation

• Occurs secondary to guidewire insertion or stone extraction from the common bile duct 4
• All guidewire perforations in one series were recognized during ERCP 2
• Most Type 3 injuries can be successfully managed conservatively without delayed sepsis 4
• These perforations typically have lower morbidity compared to Type 1 and Type 2 4, 2

Type 4: Microperforation

• Probably represents microperforations noted on excessive insufflation during and after ERCP withdrawal 4
• Can be managed conservatively in most cases 4
• Generally have favorable outcomes with medical management 4

Clinical Significance and Outcomes

Overall Incidence and Mortality

• The overall perforation rate during ERCP is less than 1%, with reported rates of 0.45-1.6% 1, 5, 4, 2
• Mortality from ERCP-related perforation ranges from 7.8% to 9.9% 1, 3
• Delayed recognition beyond 6 hours is associated with increased hospital stay, mortality, and more complicated surgical intervention 1, 3

Risk Factors

• Older age, longer procedure duration, sphincter of Oddi dysfunction 1
• Non-dilated bile duct 1
• Performance of sphincterotomy or precut sphincterotomy 1
• Access papillotomy 1
• Altered anatomy (e.g., Billroth II partial gastrectomy) 1

Management Principles by Type

• Type 1 and Type 2 perforations require early diagnosis and aggressive management (surgical for Type 1 unless early endoscopic closure achieved; Type 2 can often be managed medically if recognized early) 6, 4
• Type 3 and Type 4 injuries may be managed conservatively 4
• Retroperitoneal perforations can often recover with medical conservative treatment if recognized early 5
• Most peritoneal perforations need surgery unless the lesion can be closed endoscopically in the early phase 5