Contraindications of ERCP
While no absolute contraindications to ERCP are explicitly defined in current guidelines, suspected duodenal perforation represents the clearest situation where ERCP should not be performed, and uncorrectable severe coagulopathy is a contraindication specifically to sphincterotomy. 1
Absolute Contraindications
Suspected Duodenal Perforation
- ERCP is not recommended when duodenal perforation is suspected, as instrumentation and insufflation can worsen peritoneal contamination and clinical outcomes 1
- This represents the most clearly defined contraindication in the trauma literature 1
Patient Inability to Cooperate or Provide Consent
- Patients who cannot tolerate the procedure position or cooperate with procedural requirements should not undergo ERCP 2, 3
- Hemodynamically unstable patients requiring immediate resuscitation are not candidates for elective ERCP 3
Relative Contraindications (Situations Requiring Modification or Deferral)
Coagulopathy and Thrombocytopenia
- Severe uncorrectable coagulopathy is a contraindication to biliary sphincterotomy specifically, though not to ERCP with stenting alone 1
- All patients should have FBC and INR/PT checked prior to ERCP 1
- When coagulopathy cannot be corrected, initial therapy should involve endoscopic stenting (lower bleeding risk) rather than sphincterotomy 1
- For patients on anticoagulation: 1
- Warfarin can be continued for low-risk procedures (stenting alone) 1
- For sphincterotomy, warfarin should be discontinued 5 days before, with bridging only for high-risk cardiac conditions 1
- DOACs should be withheld 2 days before high-risk procedures without bridging 1
- Clopidogrel requires cardiology consultation before discontinuation in high-risk cardiac patients 1
Pregnancy-Related Considerations
- First trimester ERCP should be deferred whenever possible due to poor fetal outcomes including 73.3% term pregnancy rate, 21.4% low birth weight, and 20% preterm delivery 1
- Second trimester is the preferred timing for urgent indications (choledocholithiasis, cholangitis, gallstone pancreatitis) 1
- Pregnancy increases post-ERCP pancreatitis risk (12% vs 5% in non-pregnant patients) 1
- Procedures should be performed at tertiary centers with multidisciplinary teams including advanced endoscopist, maternal-fetal medicine, neonatology, and anesthesiology 1
Contraindications to Rectal NSAIDs
- Rectal diclofenac or indomethacin 100mg is recommended for all ERCP patients to prevent post-ERCP pancreatitis unless contraindicated 1
- Contraindications to NSAIDs represent a relative contraindication requiring alternative prophylactic strategies 1
Acute Severe Pancreatitis Without Specific Indications
- Routine ERCP is not indicated in acute gallstone pancreatitis without cholangitis or common bile duct obstruction 1
- ERCP is indicated only when: 1
- Cholangitis is present (strong indication)
- Common bile duct obstruction is documented
- Not indicated for predicted severe pancreatitis alone without these features
Important Clinical Caveats
Risk Stratification
- Patient-related high-risk factors include: 4, 5
- Suspected sphincter of Oddi dysfunction (highest risk)
- Female sex
- Normal serum bilirubin
- Previous post-ERCP pancreatitis
- Multiple risk factors confer especially high risk 4
Procedure-Related Risk Factors
- Difficult cannulation, repeated pancreatic duct injection, and precut sphincterotomy by inexperienced operators increase complication risk 3, 4, 5
- Failed biliary drainage after contrast injection dramatically increases cholangitis risk and represents a procedural failure requiring urgent intervention 1, 3
Common Pitfall
- The most dangerous scenario is performing ERCP for marginal indications in high-risk patients—instances where ERCP is least clearly indicated are most likely to cause complications 4, 5
- Overall complication rates range 5-10%, with post-ERCP pancreatitis (2-5%), bleeding, perforation, and cholangitis being most common 1, 3, 5