Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are invaluable tools in the diagnostic and therapeutic evaluation and management of a variety of pancreatobiliary disorders. Along with a significant refinement in the equipment and techniques used has come a recent trend toward aggressive therapeutic interventions. Because of the technical nature of these procedures and the characteristics of the patients, postprocedural complications may occur, ranging from minor (requiring brief hospitalization) to severe (causing permanent disability or death). This review summarizes these complications and outlines strategies to minimize them.
Similar content being viewed by others
References and Recommended Reading
Andriulli A, Loperfido S, Napolitano G, et al.: Incidence rates of post-ERCP complications: a systematic review of prospective studies. Am J Gastroenterol 2007, 102:1781–1788.
Loperfido S, Angelini G, Benedetti G, et al.: Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998, 48:1–10.
Freeman ML, Nelson DB, Sherman S, et al.: Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996, 335:909–918.
Williams EJ, Taylor S, Fairclough P, et al.: Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007, 39:793–801.
Cheng CL, Sherman S, Watkins JL, et al.: Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006, 101:139–147.
Freeman ML, DiSario JA, Nelson DB, et al.: Risk factors for post ERCP pancreatitis: a prospective multicenter study. Gastrointest Endosc 2001, 54:425–434.
Cotton PB, Lehman G, Vennes JA, et al.: Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991, 37:383–391.
Masci E, Mariani A, Curioni S, Testoni PA: Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy 2003, 35:830–834.
Fogel EL, Eversman D, Jamidar P, et al.: Sphincter of Oddi dysfunction: pancreaticobiliary sphincterotomy with pancreatic stent placement has a lower rate of pancreatitis than biliary sphincterotomy alone. Endoscopy 2002, 34:280–285.
Sherman S, Rufallo TA, Hawes RH, et al.: Complications of endoscopic sphincterotomy. A prospective series with emphasis on the increased risk associated with sphincter of Oddi dysfunction and nondilated bile ducts. Gastroenterology 1991, 101:1068–1075.
Mehta SN, Pavone E, Barkun JS, et al.: Predictors of post-ERCP complications in patients with suspected choledocholithiasis. Endoscopy 1998, 30:457–463.
Christensen M, Matzen P, Schulze S, et al.: Complications of ERCP: a prospective study. Gastrointest Endosc 2004, 60:721–731.
Cheon YK, Cho KB, Watkins JL, et al.: Frequency and severity of post-ERCP pancreatitis correlated with extent of pancreatic ductal opacification. Gastrointest Endosc 2007, 65:385–393.
Sherman S, Troiano FP, Hawes RH, et al.: Sphincter of Oddi manometry: decreased risk of clinical pancreatitis with use of a modified aspirating catheter. Gastrointest Endosc 1990, 36:462–466.
Cohen S, Bacon BR, Berlin JA, et al.: National Institutes of Health state-of-the-science conference statement: ERCP for diagnosis and therapy. Gastrointest Endosc 2002, 56:803–809.
Andriulli A, Leandro G, Niro G, et al.: Pharmacologic treatment can prevent pancreatic injury after ERCP: a metaanalysis. Gastrointest Endosc 2000, 51:1–7.
Andriulli A, Leandro G, Federici T, et al.: Prophylactic administration of somatostatin or gabexate does not prevent pancreatitis after ERCP: an updated meta-analysis. Gastrointest Endosc 2007, 65:624–632.
Choudhary A, Bechtold M, Puli S, et al.: Gabexate for prevention of post-ERCP pancreatitis: a meta-analysis [abstract]. Am J Gastroenterol 2008, 103:S82.
Omata F, Tokuda Y, Takahashi M, et al.: Meta-analysis: somatostatin or its long-acting analogue, octreotide for prophylaxis against post-ERCP pancreatitis [abstract]. Am J Gastroenterol 2008, 103:S90.
Elmunzer B, Waljee A, Elta G, et al.: A meta-analysis of rectal NSAIDs in the prevention of post-ERCP pancreatitis. Gut 2008, 57:1262–1267.
Abdel Aziz AM, Lehman GA: Pancreatitis after endoscopic retrograde cholangio-pancreatography. World J Gastroenterol 2007, 13:2655–2668.
Verma D, Kapadia A, Adler DG: Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes. Gastrointest Endosc 2007, 66:283–290.
Freeman ML: Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2007, 5:1354–1365.
Singh P, Das A, Isenberg G, et al.: Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 2004, 60:544–550.
Tarnasky PR, Palesch YY, Cunningham JT, et al.: Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction. Gastroenterology 1998, 115:1518–1524.
Patel R, Tarnasky PR, Hennessy WS, et al.: Does stenting after pancreatic sphincterotomy reduce post-ERCP pancreatitis in patients with prior biliary sphincterotomy? Preliminary results of a prospective, randomized trial [abstract]. Gastrointest Endosc 1999, 49:AB80.
Saad AM, Fogel EL, McHenry L, et al.: Pancreatic duct stent placement prevents post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction but normal manometry results. Gastrointest Endosc 2008, 67:255–261.
Sherman S, Hawes R, Earle D, et al.: Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy (ES)-induced pancreatitis? A final analysis of a randomized prospective study [abstract]. Gastrointest Endosc 1996, 43:413.
Aizawa T, Ueno N: Stent placement in the pancreatic duct prevents pancreatitis after endoscopic sphincter dilation for removal of bile duct stones. Gastrointest Endosc 2001, 54:209–213.
Norton ID, Gostout CJ, Baron TH, et al.: Safety and outcome of endoscopic snare excision of the major duodenal papilla. Gastrointest Endosc 2002, 56:239–243.
Cheng CL, Sherman S, Fogel EL, et al.: Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 2004, 60:757–764.
Harewood GC, Pochron NL, Gostout CJ: Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005, 62:367–370.
Smithline A, Silverman W, Rogers D, et al.: Effect of prophylactic main pancreatic duct stenting on the incidence of biliary endoscopic sphincterotomy-induced pancreatitis in high-risk patients. Gastrointest Endosc 1993, 39:652–657.
Fazel A, Quadri A, Catalano MF, et al.: Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study. Gastrointest Endosc 2003, 57:291–294.
Freeman ML, Overby C, Qi D: Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success. Gastrointest Endosc 2004, 59:8–14.
Rashdan A, Fogel EL, McHenry L Jr, et al.: Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clin Gastroenterol Hepatol 2004, 2:322–329.
Howard TJ, Tan T, Lehman GA, et al.: Classification and management of perforations complicating endoscopic sphincterotomy. Surgery 1999, 126:658–663.
Fatima J, Baron TH, Topazian M, et al.: Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management. Arch Surg 2007, 142:448–454.
Freeman ML: Adverse outcomes of ERCP. Gastrointest Endosc 2002, 56:S273–S282.
Hoffman ML, Farrell MT, Yee YS: Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDs. Gastrointest Endosc 1994, 40:458–462.
Fogel EL, Alazmi W, Schmidt S, et al.: Clinical utility of peri-operative hemostatic screening tests (PHSTs) in patients undergoing outpatient ERCP [abstract]. Gastrointest Endosc 2006, 63:300A.
Banerjee S, Shen B, Baron TH, et al.; ASGE Standards of Practice Committee: Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008, 67:791–798.
Harris A, Chan AC, Torres-Viera C, et al.: Meta-analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1999, 31:718–724.
Draganov P, Pan JJ, Forsmark C: Prospective evaluation of adverse reactions to iodine-containing contrast media after ERCP [abstract]. Gastrointest Endosc 2008, 67:AB107.
Bournet B, Migueres I, Delacroix M, et al.: Early morbidity of endoscopic ultrasound: 13 years’ experience at a referral center. Endoscopy 2006, 38:349–354.
Lachter J: Fatal complications of endoscopic ultrasonography: a look at 18 cases. Endoscopy 2007, 39:747–750.
Das A, Sivak MV Jr, Chak A: Cervical esophageal perforation during EUS: a national survey. Gastrointest Endosc 2001, 53:599–602.
Barawi M, Gottlieb K, Cunha B, et al.: A prospective evaluation of the incidence of bacteremia associated with EUS-guided fine-needle aspiration. Gastrointest Endosc 2001, 53:189–192.
Janssen J, Konig K, Knop-Hammad V, et al.: Frequency of bacteremia after linear EUS of the upper GI tract with and without FNA. Gastrointest Endosc 2004, 59:339–344.
Eloubeidi MA, Tamhane A, Varadarajulu S, et al.: Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc 2006, 63:622–629.
Adler DG, Jacobson BC, Davila RE, et al.: ASGE guideline: complications of EUS. Gastrointest Endosc 2005, 61:8–12.
Wiersema MJ, Vilmann P, Giovannini M, et al.: Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology 1997, 112:1087–1095.
Lee LS, Saltzman JR, Bounds BC, et al.: EUS-guided fine needle aspiration of pancreatic cysts: a retrospective analysis of complications and their predictors. Clin Gastroenterol Hepatol 2005, 3:231–236.
Ryan AG, Zamvar V, Roberts SA: Iatrogenic candidal infection of a mediastinal foregut cyst following endoscopic ultrasound-guided fine-needle aspiration. Endoscopy 2002, 34:838–839.
Eloubeidi MA, Gress FG, Savides TJ, et al.: Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States. Gastrointest Endosc 2004, 60:385–389.
Al-Haddad M, Wallace MB, Woodward TA, et al.: The safety of fine-needle aspiration guided by endoscopic ultrasound: a prospective study. Endoscopy 2008, 40:204–208.
Gress F, Michael H, Gelrud D, et al.: EUS-guided fine-needle aspiration of the pancreas: evaluation of pancreatitis as a complication. Gastrointest Endosc 2002, 56:864–867.
Gress FG, Hawes RH, Savides TJ, et al.: Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography. Gastrointest Endosc 1997, 45:243–250.
Varadarajulu S, Eloubeidi MA: Frequency and significance of acute intracystic hemorrhage during EUS-FNA of cystic lesions of the pancreas. Gastrointest Endosc 2004, 60:631–635.
Jacobson BC, Waxman I, Parmar K, et al.: Endoscopic ultrasound-guided gallbladder bile aspiration in idiopathic pancreatitis carries a significant risk of bile peritonitis. Pancreatology 2002, 2:26–29.
Levy MJ, Wiersema MJ: EUS-guided celiac plexus neuroly sis and celiac plexus block. Gastrointest Endosc 2003, 57:923–930.
Hoffman BJ: EUS-guided celiac plexus block/neurolysis. Gastrointest Endosc 2002, 56:S26–S28.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Barkay, O., Khashab, M., Al-Haddad, M. et al. Minimizing complications in pancreaticobiliary endoscopy. Curr Gastroenterol Rep 11, 134–141 (2009). https://doi.org/10.1007/s11894-009-0021-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11894-009-0021-7