How Best to Avoid and Manage ERCP-related Complications

ERCP is the key procedure in pancreatobiliary intervention mainly stone and stricture. Although, this is the minimally invasive procedure comparing with surgical intervention, some serious adverse events can be occurred including mortality (0.1-0.2%). Endoscopist should select proper indication in term of risk-benefit, avoid marginal indication and keep in mind “ Failure without complication is better than success with severe complication”. This presentation will focus on ERCP procedure-related apart from sedation- related and reprocessing-related complication. There are 4 major complications, perforation, bleeding, pancreatitis and cholangitis.

Risk Factors How to prevent and avoid Management

Perforation (0.08-0.8%) (antibiotic coverage)
type 1: Scope insertion: too quick D1 to D2 Gentle manipulation Closure with TTS/OTS clip
forceful manipulation, Use end-viewing scope Surgery with definitive Rx.
surgically altered anatomy in altered anatomy

type 2: Sphincterotomy (EST), Keep safety margin for EST Biliary stent insertion
needle knife papillotomy
balloon dilation (EPLBD), basket insertion Avoid EPLBD in small CBD/stricture (prefer FCMS)

type 3: Forceful insertion (wire, basket, Need to see fluoroscopy and avoid Biliary stent insertion
biopsy), forceful insertion (no resistant)
Laser/EHL,
Stent malposition

type 4: too much air insufflation Use Co2 and minimize insufflation Observation

Bleeding (1.1-2.0%)

Coagulopathy, cirrhosis, ESRD Proper prepare in antiplatelet/anticoagulant user Diluted
antiplatelet, anticoagulant use Proper and adequate EST, adrenalin injection
Cholangitis (inflamed ampulla) Consider balloon dilation in very high risk situation Secured
with coagrasper, bipolar,
FCMS (fully covered metal stent)

Pancreatitis (1.8-7%/32%)

Patient-related
Prior Hx. Of post ERCP pancreatitis OR Vigorous IV fluid Intensive care
Suspected SOD Rectal NSAID suppository Close monitoring
Female gender Pancreatic duct stent placement
Normal serum bilirubin (small bile duct)
Procedure -related
Biliary balloon sphincter dilation
Moderate-to –difficult cannulation
Pancreatic sphincterotomy
Pancreatic contrast injection
Avoid: Repeated contrast injection wire insertion in PD

Cholangitis 0.5%-18%) (antibiotic coverage)

Hilar stricture Prior antibiotic coverage Biliary drainage (if needed)
(contrast injection in undrained MRCP guided wire insertion (PTBD/EUS guided)
segment) Air cholangiography
Wire insertion before injection
Per oral cholangioscopy avoid forceful NSS irrigation