Update in ERCP Complication

By Sirithanaphol W.

ERCP
Endoscopic Retrograde Cholangio-Pancreatography Radiologic imaging of the Hepatobiliary tree and Pancreatic duct Specialized side viewing upper endoscope Minimally invasive management of biliary and pancreatic disorders Long learning curve to develop proficiency Therapeutic and diagnostic ERCP

ERCP Complication
Acute complication
Post ERCP pancreatitis Post ERCP cholangitis Post ERCP bleeding Post ERCP perforation Biliarry and pancreatic stent related complication Unusual complication

Long term complication

Iatrogenic ampullary stenosis

Acute Complication
Mild Pancreatitis
Clinical pancreatitis
Amylase > 3X at 24 hr after procedure Prolong admit 2-3 d

Moderate
Pancreatitis requiring hospitalization 4-10 d

Severe
Hospitalization more than 10 days Pseudocysts Intervention Septic shock Surgery

Cholangitis

> 38 c for 24-48 hr

Febrile or septic illness requiring treatment more than 3 d Percutaneous interven

Bleeding

clinical evidence of bleeding Hct drop > 3% No transfusion

Possible or very slight leak Tx by fluids and suction 3 d

Transfusion 4 units No angiographic intervention or surgery

Tx medically 4-10 d

Transfusion 5 units Intervention

Perforation

Tx medical > 10 d Intervention

1. Post ERCP pancreatitis

Young Koog Cheon et al : 14,331 pt
Acute pancreatitis : 4 %
Mild 2.9 % Moderate 0.8 % Severe 0.3 %

High risk in
Contrast into pancreatic duct Calcification in pancreatic duct

Definition of severe pancreatitis : Atlanta Symposium 1992

1. Post ERCP pancreatitis

Etiology
Mechanical trauma to papilla / pancreatic sphincter Obstruction of pancreatic duct

Risk factor for Post-ERCP pancreatitis

Scott T. et al Multiple prospective randomized controlled trial

1. Post ERCP pancreatitis : Management

Pancreatic duct stent
Fazel A. et al
Prophylactic transpapillary pancreatic duct (PD) stent in patients at high risk for post ERCP pancreatitis

74 patients

PD stent

No PD stent

38 pts

36 pts

Pancreatitis
2 pts

Pancreatitis
10 pts

1. Post ERCP pancreatitis : Management

Pancreatic duct stent
Meta-analysis : 5 trials
481 patients

PD stent

No PD stent

206 pts
Mild to Moderate Pancreatitis

275 pts

12 pts

Mild to Moderate Pancreatitis

Severe Pancreatitis

36 pts

36 pts

Saad AM. et al

1. Post ERCP pancreatitis : Management

Drugs prophylaxis for post ERCP pancreatitis
1. Octreotide : Meta-analysis : 10 clinical trials
Patients

Octreotide

Placebo

Pancreatitis
7.6 %

Pancreatitis
5.5 %

Not Significant N-acetylcysteine , Pentoxifylline , diclofenac , allopurinol

1. Post ERCP pancreatitis : Management

Drugs prophylaxis for post ERCP pancreatitis
2. Ceftazidime 2 gm (30 min before ERCP) : Prospective study
321 Patients

Ceftazidime

Control

Pancreatitis
2.6 %

Pancreatitis
9.4 %

Significant ATB + contrast media : Not significant

2. Post ERCP Cholangitis

Antibiotic prophylaxis : Controversy Peter B. cotton et al
ERCP 11,484 pts

1994-1996 ERCP 3387 pts ATB 95% infection 0.48%

1997 ERCP 1066 pts ATB 92% infection 0.28%

1998-2001 ERCP 4092 pts ATB 46% infection 0.24%

2002-2005 ERCP 4039 pts ATB 26% infection 0.23%

2. Post ERCP Cholangitis

Antibiotic prophylaxis : in high risk
Endoscopic drainage : incomplete Pancreatic pseudocyst GB stone or hilar tumor Immunocompression

3. Post ERCP Bleeding

Hemorrhage is a serious complication 1-2 % of cases Freeman et al
Risk factors for hemorrhage after sphincterotomy

Freeman et al

3. Post ERCP Bleeding

Sedef K. et al
Endoscopic Sphincterotomy

Re-ES

ES

Bleeding 2.8 %

Pancreatitis 2.2 %

Not Significant

3. Post ERCP Bleeding

Sedef K. et al
Endoscopic Sphincterotomy

Duodenal diverticulum
Bleeding 6.3 %

Without diverticulum
Pancreatitis 1.9 %

Not Significant

3. Post ERCP Bleeding

Dharmendra V. et al
Endoscopic Sphincterotomy

Pure current

Mixed current

Bleeding 37.3 %

Pancreatitis 12.2 %

Significant

3. Post ERCP Bleeding : Management

Endoscopic intervention
Adrenaline injection Electrocautery Endoclip

Failed Endoscopic intervention

Surgical treatment Angiography with embolization

4. Post ERCP Perforation

R. Enns et al
ERCP 9314 pts ERCP related perforation 33 pts

Difficult esophageal intubation---hypopharyngeal tear

Billroth II gastrectomy---anastomosis with afferent limb Duodenal stricture , periampullary diverticulum

Difficult cannulations or proximal to an obstructing lesion

R.Enn et al

4. Post ERCP Perforation : Management

Location of perforation Clinical of patients

Large diameter instrument + free rupture --- Surgery

Small diameter instrument + retroperitoneum --- Conservative TX

5. Biliary and pancreatic stent related complication

Biliary
Fail or inadequate positioning --- early cholangitis Perforation Migration Stent occlusion --- late cholangitis
Ingrowth of tumor / hyperplastic inflammatory tissue

Pancreas
Exacerbation of pancreatitis Pancreatic infection Pancreatic duct disruption Stent occlusion --- 50% in 6 weeks , 100% in 9 weeks Stricture --- chronic pancreatitis

Unusual complication
Subcapsular hepatic hematoma (4 cases)
guidewire trauma

Long term complication

Iatrogenic ampullary stenosis Long term complication of Endoscopic sphincterotomy 0.5-3.9%

Marie IIe C. et al
Cause of Iatrogenic ampullary stenosis

Marie IIe et al

Long term complication

Iatrogenic ampullary stenosis Type 1
Is confined to the intraduodenal part of the sphincter complex Range 28-5,156 d (538 d) Hallmark there is room to extend the sphincterotomy

Type 2
When the stenosis lesion extends beyond the intraduodenal part of the sphincter complex into CBD Range 24-1728 d (111 d) Hallmark need of dilatation therapy

Thank You