Surgical Endoscopy

, Volume 33, Issue 1, pp 169–178 | Cite as

National trends of endoscopic retrograde cholangiopancreatography utilization and outcomes in decompensated cirrhosis

  • Dhruv MehtaEmail author
  • Priti Poojary
  • Aparna Saha
  • Supreet Kaur
  • Shanti Patel
  • Lavneet Chawla
  • Arun Kumar
  • Priya Simoes
  • Deepthi Busayavalasa
  • Girish Nadkarni
  • Madhusudhan Sanaka



Endoscopic retrograde cholangiopancreatography (ERCP) can be challenging in patients with decompensated cirrhosis (DC) due to increased risk of adverse events related to liver dysfunction. Limited data exist regarding its national utilization in patients with DC. We aim to determine the trends in utilization and outcomes of ERCP among patients with DC in US hospitalizations.


We identified hospitalizations undergoing ERCP (diagnostic and therapeutic) between 2000 and 2013 from the National Inpatient Sample (NIS) database and used validated ICD9-CM codes to identify DC hospitalizations. We utilized Cochrane–Armitage test to identify changes in trends and multivariable survey regression modeling for adjusted odds ratios (aOR) for adverse outcomes and mortality predictors.


There were 43782 cases of ERCPs performed in DC patients during the study period. Absolute number of ERCPs performed in this population from 2000 to 2013 showed an upward trend; however, the proportion of DC patients undergoing ERCP remained stable. We noted significant decrease in utilization of diagnostic ERCP and an increase of therapeutic ERCPs (P < 0.01). There was a significant decrease in the mean length of stay for DC patients undergoing ERCP from 8.2 days in 2000 to 7.2 days in 2013 (P < 0.01) with an increase in the mean cost of hospitalization from $17053 to $19825 (P < 0.001). Mortality rates showed a downward trend from 2000 to 2013 from 13.6 to 9.6% (P < 0.01). Increasing age, Hispanic race, diagnosis of hypertension and diabetes mellitus, and private insurance were related to adverse discharges(P < 0.01). Increasing age, presence of hepatic encephalopathy, and sepsis were associated with higher mortality (P < 0.01).


There is an increasing trend in therapeutic ERCP utilization in DC hospitalizations nationally. There is an overall decrease in mortality in DC hospitalizations undergoing ERCP. This improvement in mortality suggests improvement in both procedural technique and peri-procedural care as well as overall decreasing mortality in cirrhosis.


ERCP Cirrhosis Epidemiology Trends Healthcare utilization 


Compliance with ethical standards


Drs. Dhruv Mehta, Priti Poojari, Aparna Saha, Supreet Kaur, Shanti Patel, Lavneet Chawla, Arun Kumar, Priya Simoes, Deepthi Busayavalasa, Girish Nadkarni, and Madhusudhan Sanaka have no conflicts of interest or financial ties to disclose.


  1. 1.
    US Burden of Disease Collaborators (2013) The state of US health, 1990–2010: burden of diseases, injuries, and risk factors. JAMA 310:591–608. [PubMed: 23842577]CrossRefGoogle Scholar
  2. 2.
    Kanwal F, Gralnek IM, Hays RD, Zeringue A, Durazo F, Han SB et al (2009) Health-related quality of life predicts mortality in patients with advanced chronic liver disease. Clin Gastroenterol Hepatol 7:793–799CrossRefGoogle Scholar
  3. 3.
    Park DH, Kim MH, Lee SK et al (2004) Endoscopic sphinctero- tomy vs. endoscopic papillary balloon dilation for chole- docholithiasis in patients with liver cirrhosis and coagulopathy. Gastrointest Endosc 60:180–185CrossRefGoogle Scholar
  4. 4.
    Prat F, Tennenbaum R, Ponsot P et al (1996) Endoscopic sphincterotomy in patients with liver cirrhosis. Gastrointest Endosc 43:127–131CrossRefGoogle Scholar
  5. 5.
    Rakoski MO, McCammon RJ, Piette JD, Iwashyna TJ, Marrero JA, Lok AS et al (2012) Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study. Hepatology 55:184CrossRefGoogle Scholar
  6. 6.
    Del Olmo JA, Garcia F, Serra MA, Maldenodo L, Rodrigo JM (1997) Prevalence and incidence of gallstones in liver cirrhosis. Scand J Gastroenterol 32:1061–1065CrossRefGoogle Scholar
  7. 7.
    Conte D, Barisani D, Mandelli C, Bodini P, Borzio M, Pistoso S (1991) Cholelithiasis in cirrhosis: analysis of 500 cases. Am J Gastroenterol 86:1629–1632Google Scholar
  8. 8.
    Kuchipudi V, Chinoy M, Iber FL, Caruso G, Polepalle CH (1990) Increasing prevalence of gallstones in male veterans with alcoholic cirrhosis. Am J Gastroenterol 85:1593–1596Google Scholar
  9. 9.
    Acalovschi M, Badea R, Pasav M (1991) Incidence of gall- stones in liver cirrhosis. Am J Gastroenterol 86:1179–1181Google Scholar
  10. 10.
    Sheen I-S, Lian Y-F (1989) The prevalence and incidence of cholecystolithiasis in patients with chronic liver disease: a prospective study. Hepatology 9:538–540CrossRefGoogle Scholar
  11. 11.
    Friedman LS (1999) The risk of surgery in patients with liver disease. Hepatology 29:1617–1623CrossRefGoogle Scholar
  12. 12.
    O’Leary JG, Yachimski PS, Friedman LS (2009) Surgery in the patient with liver disease. Clin Liver Dis 13:211–231CrossRefGoogle Scholar
  13. 13.
    Montomoli J, Erichsen R, Christiansen CF et al (2013) Liver disease and 30- day mortality after colorectal cancer surgery: a Danish population-based cohort study. BMC Gastroenterol 13:66CrossRefGoogle Scholar
  14. 14.
    Inamdar S et al (2016) Decompensated cirrhosis may be a risk factor for adverse events in endoscopic retrograde cholangiopancreatography. Liver Int. Google Scholar
  15. 15.
    Navaneethan U, Njei B, Zhu X, Kommaraju K, Parsi MA, Varadarajulu S (2017) Safety of ERCP in patients with liver cirrhosis: a national database study. Endosc Int Open 5(4):E303–E314. CrossRefGoogle Scholar
  16. 16.
    Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. [Internet]. HCUP Qual. Control Proced. [cited 2014 Nov 2]; Available from Accessed 2 Nov 2014
  17. 17.
    Agency for Healthcare Policy and Research. Comparative analysis of HCUP and NHDS inpatient discharge data. [Internet]. Tech. Suppl. 13. NIS release 5 (1996) [cited 2014 Nov 2]; Available from: search/data/hcup/nhds/niscomp.html. Accessed 2 Nov 2014
  18. 18.
    Nehra MS, Ma Y, Clark C, Amarasingham R, Rockey DC, Singal AG (2013) Use of administrative claims data for identifying patients with cirrhosis. J Clin Gastroenterol 47:e50–e54CrossRefGoogle Scholar
  19. 19.
    Kramer JR, Davila JA, Miller ED, Richardson P, Giordano TP, El-Serag HB (2008) The validity of viral hepatitis and chronic liver disease diagnoses in Veterans Affairs administrative databases. Aliment Pharmacol Ther 27:274–282CrossRefGoogle Scholar
  20. 20.
    Nadkarni GN et al (2016) National trends of acute kidney injury requiring dialysis in decompensated cirrhosis hospitalizations in the United States. Hepatol Int 10:525–531CrossRefGoogle Scholar
  21. 21.
    Baram D, Daroowalla F, Garcia R, Zhang G, Chen JJ, Healy E et al (2008) Use of the all patient refined-diagnosis related group (APR-DRG) risk of mortality score as a severity adjustor in the medical ICU. Clin Med Circ Respir Pulm Med 2:19–25Google Scholar
  22. 22.
    Moffatt DC, Yu BN, Yie W, Bernstein CN (2014) Trends in utilization of diagnostic and therapeutic ERCP and cholecystectomy over the past 25 years: a population-based study. Gastrointest Endosc 79:615–622CrossRefGoogle Scholar
  23. 23.
    Moiz A et al (2017) Utilization trends in inpatient endoscopic retrograde cholangiopancreatography (ERCP): a cross-sectional US experience. Endosc Int Open 5(4):E261–E271. CrossRefGoogle Scholar
  24. 24.
    Del Olmo JA et al (1997) Prevalence and incidence of gallstones in liver cirrhosis. Scand J Gastroenterol 32(10):1061–1065CrossRefGoogle Scholar
  25. 25.
    Mercedes V et al (July 2013) Hospital mortality over time in patients with specific complications of cirrhosis. Liver Int 33(6):828–833. CrossRefGoogle Scholar
  26. 26.
    Schmidt ML et al (2015) Decreasing mortality among patients hospitalized with cirrhosis in the United States from 2002 through 2010. Gastroenterology 148(5):967–977, e2, CrossRefGoogle Scholar
  27. 27.
    Buxbaum J et al (2014) Aggressive hydration with lactated ringer’s solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 12(2):303–307, e1. CrossRefGoogle Scholar
  28. 28.
    Choi J-H et al (2017) Vigorous periprocedural hydration with lactated ringer’s solution reduces the risk of pancreatitis after retrograde cholangiopancreatography in hospitalized patients. Clin Gastroenterol Hepatol 15(1):86–92, e1. CrossRefGoogle Scholar
  29. 29.
    Shinju A et al (2010) Post-ERCP pancreatitis. J Hepato-Biliary-Pancreat Sci 17(1):70–78. CrossRefGoogle Scholar
  30. 30.
    Dumonceau J-M et al (2010) European society of gastrointestinal endoscopy (ESGE) guideline: prophylaxis of post-ERCP pancreatitis. Endoscopy 42(6):503–515. CrossRefGoogle Scholar
  31. 31.
    Artifon ELA et al (2011) Management of common bile duct stones in cirrhotic patients with coagulopathy: a comparison of supra-papillary puncture and standard cannulation technique. Dig Dis Sci 56(6):1904–1911. CrossRefGoogle Scholar
  32. 32.
    Mathur AK et al (2017) Hospital resource intensity and cirrhosis mortality in United States. World J Gastroenterol 23(10):1857–1865. CrossRefGoogle Scholar
  33. 33.
    Maurer KR et al (1989) Prevalence of gallstone disease in hispanic populations in the United States. Gastroenterology 96(2 Pt 1):487–492CrossRefGoogle Scholar
  34. 34.
    Everhart JE et al (1999) Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 117(3):632–639CrossRefGoogle Scholar
  35. 35.
    Friedman LS (1999) The risk of surgery in patients with liver disease. Hepatology 29(6):1617–1623. CrossRefGoogle Scholar
  36. 36.
    O’Leary JG, Yachimski PS, Friedman LS (2009) Surgery in the patient with liver disease. Clin Liver Dis 13(2):211–231. CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Dhruv Mehta
    • 1
    Email author
  • Priti Poojary
    • 2
  • Aparna Saha
    • 2
  • Supreet Kaur
    • 3
  • Shanti Patel
    • 4
  • Lavneet Chawla
    • 5
  • Arun Kumar
    • 5
  • Priya Simoes
    • 6
  • Deepthi Busayavalasa
    • 7
  • Girish Nadkarni
    • 2
  • Madhusudhan Sanaka
    • 8
  1. 1.Department of Gastroenterology and Hepatolobiliary DiseaseWestchester Medical Center at New York Medical CollegeValhallaUSA
  2. 2.Division of Nephrology, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA
  3. 3.Department of Hematology and OncologySt. Joseph’s Regional Medical CenterPatersonUSA
  4. 4.Department of Internal MedicineMaimonides Medical CenterBrooklynUSA
  5. 5.Department of Internal MedicineWestchester Medical Center at New York Medical CollegeValhallaUSA
  6. 6.Division of Gastroenterology, Hepatology and NutritionMemorial Sloan Kettering Cancer CenterNew YorkUSA
  7. 7.Department of Internal MedicineAdvocate Christ Medical Center Oak LawnOak LawnUSA
  8. 8.Division of Gastroenterology and Hepatobiliary DiseasesCleveland ClinicClevelandUSA

Personalised recommendations