Clin Endosc.  2023 Jul;56(4):433-445. 10.5946/ce.2023.013.

Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management

• Wu CCH
• Lim SJM
• Khor CJL

• KMID: 2544564
• DOI: http://doi.org/10.5946/ce.2023.013

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient’s clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.

Keyword

Bleeding; Endoscopic retrograde cholangiopancreatography; Infections; Pancreatitis; Perforation

Figure

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  Fig. 1. Stapfer type I perforation was seen in the duodenal wall opposite the major papilla.

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  Fig. 2. Contrast leak was noted after deployment of one over-the-scope clip, indicating that defect was not completely closed.

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  Fig. 3. No further contrast leak was noted after placement of the second over-the-scope clip.

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  Fig. 4. Nasojejunal tube was inserted for suctioning to reduce the secretions traversing the region of the repaired perforation, as well as to ensure continuation of enteral nutrition.

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  Fig. 5. Management algorithm of post-endoscopic retrograde cholangiopancreatography bleeding. FCSEMS, fully covered self-expanding metal stent; GDA, gastroduodenal artery; SPDA, superior pancreaticoduodenal artery; IPDA, inferior pancreaticoduodenal artery.

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