post ERCP complication summary

Expanded Discussion

This patient presents to the ER with abdominal symptoms less than one week since ERCP guided biliary stricture stenting. These symptoms likely may be related to well-described complications of ERCP, and I would like to review them here. It is helpful to think of the ERCP complications from three perspectives; severity, timing, and etiology.

First, consider the severity of a potential complication. They are normally classified as mild, moderate, or severe. This classification is assigned depending on the need for hospitalization. Normally mild complications result in hospitalizations of less than 3 nights. Moderate severity complications normally require between 4 to 10 nights of hospitalization, and severe complications usually require ICU admissions or hospitalizations greater than 10 nights. Unfortunately, fatalities have been attributed to post-ERCP complications as well. In terms of etiology, there are complications arising directly from the procedure, so called “focal”, and those related generally to all procedures themselves, called “nonspecific”. The four most common focal complications of ERCP are pancreatitis, bleeding, perforation, and infection. Common nonspecific complications include medication adverse events, contrast allergies, cardiopulmonary complications, and electrosurgical hazards. One must next consider the timing of the complication. These are subdivided into immediate, early, delayed, and late. Immediate complications are those that are said to have happened during the procedure itself. Early complications normally arise within the recovery period, normally a day. Delayed complications manifest themselves within 30 days in the case of focal complications and within 3 days in the case of nonspecific complications. Finally late complications manifest themselves months to years later.

Given this perspective into the classification of ERCP complications let us now more fully described both focal and non-specific complications. Pancreatitis, the most frequent adverse event ranges from 2 -5% but it is important to remember that post procedure hyperamylasemia is seen in 75% of patients. Several treatments are currently being investigated including NSAIDs, glucocorticoids, allopurinol, IL-10, pentoxifylline, PAF, octreotide, anti-oxidants, and anti-metabolites, however none are currently recommended. With respect to bleeding, half of all cases have been found to follow sphincterotomy with an overall incidence ranging from 1 to 5% depending on the study. Of all cases of bleeding (226) in a review of 16,855 patients, severe bleeding (defined as transfusion of 5 or great units of blood or surgical/angiography intervention) was described in 66 episodes (29%). Post ERCP infection normally results from instrumentation of obstructed biliary or pancreatic systems. The recommended way to maximally reduce the incidence of infection/sepsis/cholangitis (currently estimated at ~1.5%) is a complete drainage of an obstruction. Finally, GI perforations during ERCP are subdivided into retroperitoneal, bowel wall, or bile duct perforations. Bowel wall perforations normally occur in the esophagus, stomach, duodenum, or jejunum with an estimated of incidence of between 0.5 to 2% and require surgical intervention in their management or stenting. Biliary perforations can be effectively treated with transhepatic drains to nasobiliary tube and are preferable to internal biliary stents because they do not permit adequate bile drainage.

References:

1. Loperfido S, Costamagna G. 2010. “Overview of indications for and complications of ERCP and endoscopic biliary sphincterotomy.” www.uptodate.com

2. Loperfido S, Costamagna G. 2010. “Post ERCP bleeding.” www.uptodate.com

3. Loperfido S, Costamagna G. 2010. “Post ERCP perforation.” www.uptodate.com

4. Loperfido S, Costamagna G. 2010. “Post ERCP pancreatitis.” www.uptodate.com

5. Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo. “Chapter 285: Gastrointestinal Endoscopy”. Harrison’s Principles of Internal Medicine 17^th Edition. McGraw Hill 2008.