ERCP and Its Complications

ERCP Basics - Scope & Purpose

• ERCP: Endoscopic Retrograde Cholangiopancreatography. Combines upper GI endoscopy & fluoroscopy.
• Purpose: Primarily therapeutic; diagnostic role diminishing with MRCP/EUS.
  • Diagnostic: Jaundice, suspected bile duct/pancreatic duct pathology.
  • Therapeutic: Stone extraction, stenting, sphincterotomy, biopsy, stricture dilation.
• Key Indications: Biliary obstruction (stones, strictures, tumors), pancreatitis (selected cases), sphincter of Oddi dysfunction.
• Contraindications (Absolute): Patient refusal, perforated viscus, medically unstable.

⭐ ERCP allows direct visualization and intervention in the biliary and pancreatic ducts, unlike MRCP which is purely diagnostic.

ERCP Technique - Duct Diving

• Prep: NPO 6-8 hrs, consent, IV. Antibiotics if high-risk (e.g., incomplete drainage).
• Position: Prone or left lateral.
• Sedation: Moderate sedation or MAC (propofol).
• Steps:
  • Side-viewing duodenoscope to major papilla in D2.
  • Selective guidewire-assisted cannulation of CBD/PD.
  • Contrast injection under fluoroscopy (cholangio/pancreatogram).
  • Therapeutic interventions: sphincterotomy, stone removal, dilation, stenting.

⭐ Guidewire-assisted cannulation is preferred; it reduces papillary trauma and significantly lowers post-ERCP pancreatitis (PEP) risk.

PEP - Fiery Aftermath

• Definition: Most common ERCP complication (1-10%); acute inflammation of pancreas post-procedure.
• Pathophysiology: Premature trypsinogen activation within pancreas → acinar cell injury.
• Diagnosis:
  • New/worsened epigastric pain (often radiating to back).
  • Serum amylase and/or lipase ≥3x ULN within 24 hours post-ERCP.
• Key Risk Factors:
  • Patient-related: Young female, suspected Sphincter of Oddi Dysfunction (SOD), prior PEP, normal bilirubin.
  • Procedure-related: Difficult/multiple cannulation attempts, pancreatic duct injection/acinarization, precut sphincterotomy.
• Prevention Strategies:

⭐ Prophylactic rectal NSAIDs (e.g., indomethacin 100mg) significantly reduce PEP risk, especially in high-risk patients.

• Management: Primarily supportive (NPO, IV fluids, analgesia). Severe cases require intensive care.
• 📌 PEP: Pain (abdominal), Elevated enzymes, Post-ERCP.

Other ERCP Risks - Beyond Pancreas

• Bleeding:
  • Incidence: 0.3-2%.
  • Risk factors: Sphincterotomy, coagulopathy, antiplatelet/anticoagulant use.
  • Management: Endoscopic (clips, adrenaline), angioembolization, surgery.
• Infection (Cholangitis/Cholecystitis):
  • Cholangitis: 0.5-3%; ↑ risk with incomplete drainage.
  • Prophylactic antibiotics if biliary obstruction or anticipated incomplete drainage.
• Perforation:
  • Incidence: 0.1-0.6%.
  • Types: Duodenal (scope/guidewire), bile duct (guidewire), retroperitoneal (sphincterotomy).

  ⭐ Perforation risk is notably increased with pre-cut sphincterotomy and in patients with Billroth II anatomy.

• Cardiopulmonary Events:
  • Aspiration, arrhythmias, MI, respiratory depression (often sedation-related).
• Sedation-Related Complications:
  • Hypoxemia, hypotension.

ERCP Safety - Smooth Scoping

• Pre-procedure: Careful patient selection; assess indications, contraindications, coagulation.
• Antibiotic prophylaxis: For high-risk patients (e.g., biliary obstruction, incomplete drainage).
• Technique: Experienced operator, guidewire cannulation, limit attempts, judicious contrast.
• PEP Prophylaxis: Pancreatic duct stent and/or rectal NSAIDs (indomethacin 100mg) for high-risk.

⭐ Routine pre-procedural rectal indomethacin or diclofenac significantly reduces Post-ERCP Pancreatitis (PEP) incidence.

High‑Yield Points - ⚡ Biggest Takeaways

• ERCP: Primarily therapeutic for biliary (e.g., CBD stones, strictures) & pancreatic duct issues.
• Post-ERCP Pancreatitis (PEP): Most common complication (~3-5% incidence).
• PEP Risk Factors: Young female, prior PEP, difficult cannulation, pancreatic sphincterotomy, SOD.
• PEP Prophylaxis: Rectal NSAIDs (indomethacin/diclofenac) are crucial.
• Other Major Complications: Bleeding (post-sphincterotomy), perforation (duodenal/ampullary), cholangitis.
• Technique: Guidewire cannulation preferred to reduce PEP.