update in ercp complication

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


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


• 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


• 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


• Sedef K. et al

Endoscopic Sphincterotomy

ESRe-ES

Bleeding

2.8 %

Pancreatitis

2.2 %

Not Significant


• Sedef K. et al


Without diverticulum

Duodenal diverticulum

Bleeding

6.3 %

Pancreatitis

1.9 %

Not Significant


• Dharmendra V. et al


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

update in ercp complication

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