What are the considerations for Endoscopic Retrograde Cholangiopancreatography (ERCP) with Endoscopic Papillary Balloon Dilation (EPBD) in a patient with a history of coagulopathy, liver disease, or previous pancreatic surgery?

ERCP with Endoscopic Papillary Balloon Dilation (EPBD): Key Considerations

In patients with coagulopathy or liver disease, EPBD without prior sphincterotomy is the preferred approach over standard sphincterotomy to minimize bleeding risk, using an 8 mm diameter balloon with inflation maintained ≥1 minute. 1

Primary Indication for EPBD

EPBD is strongly recommended as an adjunct to biliary sphincterotomy for facilitating removal of large common bile duct stones. 1 This represents high-quality evidence with strong recommendation from the British Society of Gastroenterology (BSG) guidelines. 1

EPBD in High-Risk Patients

Coagulopathy and Liver Disease

EPBD without prior sphincterotomy should be considered as the primary alternative to biliary sphincterotomy in patients with uncorrected coagulopathy. 1 This approach significantly reduces hemorrhage risk compared to sphincterotomy:

• Meta-analysis data demonstrates EPBD is associated with lower incidence of hemorrhage versus sphincterotomy 1
• Network meta-analysis shows prolonged EPBD (>1 minute) has 90.3% probability of being the safest treatment regarding overall complications 1
• Clinically significant hemorrhage occurs in 0.1-2% of sphincterotomies, with coagulopathy being a major risk factor 1

Mandatory pre-procedure testing includes full blood count (FBC) and INR/PT prior to ERCP for ductal stones. 1 If deranged clotting or thrombocytopenia is identified, management should conform to local guidelines. 1

Patients on warfarin, antiplatelet therapy, or direct oral anticoagulants (DOACs) must be managed according to combined BSG/ESGE guidelines for endoscopy. 1

Altered Anatomy (Previous Pancreatic Surgery)

EPBD without sphincterotomy is specifically recommended for patients with difficult biliary access due to altered anatomy. 1 This includes patients with previous gastroenteric anastomoses where standard ERCP is technically challenging. 1

Critical Technical Requirements for EPBD

When performing EPBD without prior sphincterotomy, use an 8 mm diameter balloon and maintain inflation ≥1 minute following waist disappearance. 1 This prolonged inflation technique reduces post-ERCP pancreatitis risk to levels similar to sphincterotomy. 1

Trade-offs and Risk Profile

• Increased pancreatitis risk: EPBD without sphincterotomy carries higher risk of post-ERCP pancreatitis compared to sphincterotomy alone 1
• Lower bleeding risk: EPBD demonstrates significantly lower hemorrhage rates 1
• Stone clearance: EPBD shows slightly lower stone clearance rates compared to sphincterotomy 1

Contraindications to EPBD

Do not perform EPBD in patients with:

• Biliary strictures 1
• Ampullary, pancreatic, or biliary malignancies 1
• Prior biliary surgery (except cholecystectomy) 1
• Acute pancreatitis 1
• Large common bile duct stones (relative contraindication) 1
• Precut sphincterotomy already performed for biliary access 1

Pancreatitis Prophylaxis

Administer rectal NSAIDs (100 mg diclofenac or indomethacin) immediately before ERCP in all patients without contraindications. 2 This represents strong recommendation with moderate-quality evidence from ESGE guidelines. 2

In patients with high risk of post-ERCP pancreatitis from repeated pancreatic duct cannulation, insert a pancreatic stent in addition to rectal NSAIDs. 1, 2

Overall ERCP Risk Profile

The baseline complication rates for ERCP procedures are:

• Major complications: 4-5.2% (pancreatitis, cholangitis, hemorrhage, perforation) 1, 3, 4, 5
• Mortality: 0.4% 1, 3, 4, 5
• Iatrogenic pancreatitis with sphincterotomy: up to 10% 1, 4, 5

Clinical Algorithm for Decision-Making

For patients with coagulopathy:

1. Obtain FBC and INR/PT pre-procedure 1
2. If coagulopathy is uncorrectable, proceed with EPBD alone (no sphincterotomy) 1
3. Use 8 mm balloon with ≥1 minute inflation 1
4. Administer rectal NSAIDs for pancreatitis prophylaxis 2
5. Consider pancreatic stent if difficult cannulation occurs 1, 2

For patients with altered anatomy:

1. Assess technical feasibility of standard ERCP approach 1
2. If difficult biliary access anticipated, plan EPBD without sphincterotomy 1
3. Consider alternative approaches (EUS-guided drainage, percutaneous) if ERCP fails 3

For patients with large stones and normal coagulation:

1. Perform sphincterotomy first 1
2. Add EPBD as adjunct to facilitate stone removal 1
3. This combination achieves 80-95% stone clearance rates 1, 3, 4