Prevention and Management ofAdverse Events of EndoscopicRetrogradeCholangiopancreatographyBryan Balmadrid, MD, Richard Kozarek, MD*KEYWORDS
ERCP Endoscopic retrograde cholangiopancreatography Prevention Management Adverse events Complications Pancreatitis Perforation
Recognize preprocedure and intraprocedure risks for post-ERCP pancreatitis to performeffective risk-reducing modalities, which include prophylactic pancreatic stent placementand rectal indomethacin.
Endoscopic options for the management of luminal and pancreaticobiliary duct perfora-tions exist, so it is important to recognize these adverse events early.
Intraprocedural bleeding occurs commonly, but most cases spontaneously resolve. Forunresolved bleeding, standard endoscopic therapy modalities can be used through theduodenoscope with good efficacy.
With increased knowledge about adverse events and the different modalities of treatment,endoscopists practicing ERCP should have the necessary volume and experience tomaintain these skills.INTRODUCTION
Endoscopic retrograde cholangiopancreatography (ERCP) has been a classicmodality to evaluate the biliary and pancreatic ducts. Because of its invasive natureand significant rate of complication, ERCP is no longer used as an initial diagnosticprocedure but instead has become a therapeutic option. In general, endoscopiesshare similar complications, such as perforation, bleeding, and issues with sedation.However, ERCP adds other unique complications, such as acute pancreatitis, cholan-gitis, and cholecystitis, in addition to increased risk of bleeding and perforation,depending on the initial goal and indication of the ERCP. To compare, colonoscopieshave a 0.1% rate of perforation and 1% to 4% postpolypectomy rate of bleeding 1,2Virginia Mason Medical Center Digestive Disease Institute, 3rd Floor Buck Pavillion, 1100 9thStreet, Seattle, WA 98101, USA* Corresponding author.E-mail address: email@example.com
Gastrointest Endoscopy Clin N Am 23 (2013) 385403http://dx.doi.org/10.1016/j.giec.2012.12.007 giendo.theclinics.com1052-5157/13/$ see front matter 2013 Elsevier Inc. All rights reserved.
Balmadrid & Kozarek386compared with ERCPs with 0.34% rate of perforation and 2% postsphincterotomyrate of bleeding.3 Other noninvasive modalities used in evaluating the pancreaticobili-ary ducts, such as cross-sectional imaging and transabdominal ultrasound (US), areusually readily available and should be the primary diagnostic modalities. Diagnosticendoscopic ultrasound (EUS) has a lower rate of complications than ERCP and canbe considered among the primary diagnostic approaches. However, EUS requiressedation and is more invasive in nature than the other imaging modalities. ERCPshould now be considered a therapeutic option and, with the exception of a patientwith potential sphincter of Oddi dysfunction (SOD), is not a diagnostic option. ERCPshould be performed if there is a reasonable probability that therapy (ie, stone extrac-tion) is required, and as always, the benefits of the procedure need to be weighedagainst the risks and potential complications.The most common complication and untoward event when performing ERCP is
post-ERCP pancreatitis (PEP). Other complications to consider are perforations,including those of the duodenal wall, as well as the biliary and pancreatic ducts.Sphincterotomies are often performed simultaneously and thus postsphincterotomybleeding is also of concern. Overall, there may be a 5% to 10% risk of short-termcomplications after ERCP, but this varies greatly depending on the patients riskfactors.4 For example, patients with SOD have up to a 40% risk of developing PEPin some studies.INDICATIONS
An effective way to reduce complications is to limit or avoid ERCP, and as noted above,there has been more focus placed on the indications to perform an ERCP as it hasmoved away from the realm of diagnostic procedures. Classic indications include chol-edocholithiasis and cholangitis. Clinical criteria are available to estimate the likelihoodof these diagnoses and the suggested management protocols based on their likeli-hood. Thus, even with classic indications, ERCP may not necessarily be the firstmodality of choice.5 For example, the American Society of Gastrointestinal Endoscopyrecommends that only patients meeting the criteria for high suspicion undergo anERCP for choledocholithiasis. The high suspicion group includes a common bileduct (CBD) stone on visible on US, total bilirubin greater than 4 mg/dL, or clinicalascending cholangitis.6 In addition, a dilated CBD greater than 6 mm on US and totalbilirubin 1.8 to 4.0 mg/dL are also highly suspicious (Table 1). Otherwise, EUS ormagnetic resonance cholangiopancreatography is recommended for the initial evalu-ation, or simply proceeding with a cholecystectomy with intraoperative cholangio-gram.5 There are many reasonable indications for an ERCP that may fall outside ofthe classic indications. It is then important to have a detailed patient discussion, pref-erably with patients friends and family participating, and that this be clearlydocumented.
Increased operator experience also seems to reduce the risk of overall complicationsslightly, but more importantly, reduces risk of major complications.4 The role of expe-rience is difficult to quantify because the more experienced centers tend to performmore complicated procedures and thus may have an increased risk for complications.The patients may also be in poorer health or have more difficult anatomy. For example,community gastrointestinal groups often refer patients who have had unsuccessfulERCP cannulations or patients with altered anatomy to tertiary centers. It is intuitivelyobvious that the number and frequency of ERCPs performed by the endoscopist
Table 1Predictors of likelihood of ongoing choledocholithiasis
Very Strong Strong Moderate
CBD stone on US Dilated CBD on US >6 mm(with gallbladder in situ)
Other abnormal liverbiochemical levels
Clinical ascending cholangitis Bilirubin 1.84 mg/dL Age >55 y
Bilirubin >4 mg/dL Clinical gallstone pancreatitis
Likelihood based onpredictors
Presence of any very strongpredictor
High Preoperative ERCP
Presence of both strongpredictors
High Preoperative ERCP
No predictors present Low Laparoscopiccholecystectomy(no cholangiography)
All other patients Intermediate Laparoscopic IOC orpreoperative EUS or MRCP
Abbreviations: IOC, intraoperative cholangiogram; MRCP, magnetic resonancecholangiopancreatography.
Prevention and Management of Adverse Events of ERCP 387correlates inversely with rates of complication. However, determining the number ofcompleted procedures that are required to achieve proficiency is difficult becauseof all the variables involved. The British Society of Gastroenterology has recommen-ded a minimum of 75 ERCPs performed yearly.6 There is also evidence that thenumber of ERCP sphincterotomies performed in a week makes a difference in therate of bleeding complications.4 Finally, undertaking a dedicated ERCP/EUS(advanced endoscopy) fellowship reduces the risk, but controversy remains and it isstill unclear how many procedures need to be performed to gain even the basiccompetencies. Less than 200 cases does not seem to be adequate,7 but how manyremains a question.
PEP is the most common complication of ERCP with an average rate of 5%, but theincidence varies widely depending on risk factors.8 For example, SOD carries with ita 10% to 40% chance of PEP (Table 2).4 The diagnosis of PEP is similar to other acutepancreatitis: the combination of new onset abdominal pain along with an amylase andlipase elevation at least 3 times the upper limits of normal. The onset is usually within24 hours of the procedure, often occurring within 2 to 4 hours. Because of the varyingrates of PEP, it is important to risk stratify patients based on their preprocedure andintraprocedure risk.
Preprocedure Risk Factors
Patients with SOD carry the highest risk for PEP, ranging from 10% to 40%, and,therefore, it is important to assess this special population of patients carefully (seeTable 2).4,8 SOD is often suspected in younger women with abdominal pain and itseems women, in general, have a higher likelihood of PEP (odds ratio [OR], 2.23).Simply being evaluated for SOD dysfunction can raise the PEP likelihood to 10% to30%.4 It was initially thought that biliary and pancreatic sphincter manometry added
Table 2Preprocedure and intraprocedure risk factors to develop post-ERCP pancreatitis
Increased Risk (Pre-ERCP) Protective for PEP (Pre-ERCP) Intraprocedure Risk for PEP
Evaluation for SOD Chronic pancreatitis Pancreatic sphincterotomy
Female Pancreatic malignancy Repeated cannulation(>8 cannulation attempts)
Age 80 y Pneumatic dilation of biliarysphincter
Normal caliber bile duct Increased bilirubin levels Precut sphincterotomy(depending on context)
History of alcohol use Ampullectomy
Pancreas divisum(usually associated withdorsal duct cannulation)
Multiple or excessive injectionsinto the pancreatic duct(ie, injection to the tail,pancreatic acini opacification)
Previous history of PEP Cytologic brushing of thepancreatic duct
Balmadrid & Kozarek388to this risk factor. Cotton and colleagues8 retrospectively analyzed 11,497 ERCPs andfound biliary and pancreatic manometry to have ORs of 1.16 and 1.43, respectively,neither of which were statistically significant. Other risk factors usually attributed,but not exclusive, to this population, include an age less than 60 to 70 years andnormal c