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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 Moderate Severe
Pancreatitis • Clinical pancreatitis
• Amylase > 3X
at 24 hr after procedure
• Prolong admit 2-3 d
• Pancreatitis requiring
hospitalization 4-10 d
• Hospitalization more
than 10 days
• Pseudocysts
• Intervention
Cholangitis • > 38 c for 24-48 hr • Febrile or septic illness
requiring treatment
more than 3 d
• Percutaneous interven
• Septic shock
• Surgery
Bleeding • clinical evidence of bleeding
• Hct drop > 3%
• No transfusion
• Transfusion ≤ 4 units
• No angiographic
intervention or surgery
• Transfusion≥ 5 units
• Intervention
Perforation • Possible or very slight leak
• Tx by fluids and suction 3 d
• Tx medically 4-10 d • 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
No PD stent
36 pts
PD stent
38 pts
Pancreatitis
2 pts
Pancreatitis
10 pts
1. Post ERCP pancreatitis : Management
481 patients
No PD stent
275 pts
PD stent
206 pts
Mild to Moderate Pancreatitis
12 pts
Mild to Moderate Pancreatitis
36 pts
Severe Pancreatitis
36 pts
• Pancreatic duct stent
– Meta-analysis : 5 trials
Saad AM. et al
1. Post ERCP pancreatitis : Management
• Drugs prophylaxis for post ERCP pancreatitis
1. Octreotide : Meta-analysis : 10 clinical trials
Patients
PlaceboOctreotide
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
ControlCeftazidime
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%
1997
ERCP 1066 pts
1998-2001
ERCP 4092 pts
2002-2005
ERCP 4039 pts
ATB
92%
ATB
46%
ATB
26%
infection
0.48%
infection
0.28%
infection
0.24%
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
ESRe-ES
Bleeding
2.8 %
Pancreatitis
2.2 %
Not Significant
3. Post ERCP Bleeding
• Sedef K. et al
Endoscopic Sphincterotomy
Without diverticulum
Duodenal diverticulum
Bleeding
6.3 %
Pancreatitis
1.9 %
Not Significant
3. Post ERCP Bleeding
• Dharmendra V. et al
Endoscopic Sphincterotomy
Mixed currentPure 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
R.Enn et al
Difficult esophageal intubation---hypopharyngeal tear
Billroth II gastrectomy---anastomosis with afferent limb
Duodenal stricture , periampullary diverticulum
Difficult cannulations or proximal to an obstructing lesion
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