General surgery biliary surgery

1. Endoscopic
retrograde
cholangiopancrea
tography (ERCP)
complications
Modhi A Alhussinan
AlFaisal University
Supervised by: Dr.Khalid. –Care hospital.

2. ERCP indications:
(a) biliary tract disorders;
(b) pancreatic disorders; and
(c) ampullary disorders
It is used for diagnosis of jaundice, evaluation of
known or suspected pancreatic disease, and pre- or
postoperative assessment of the biliary tree in
patients undergoing laparoscopic cholecystectomy.
In addition to detection of strictures and tumors, it is
used to localize the site of duct leakage in pancreatic
ascites, check for pancreas divisum, and collect
secretions for cytologic and chemical analysis.
Applications of therapeutic ERCP include
sphincterotomy, removal of common bile duct
stones, lithotripsy, biliary drainage, and stricture
dilation.
The contraindications are few and include severe
cardiopulmonary disease and acute pancreatitis not
due to gallstone disease.

3. therapeutic options.
(ERCP) is an invasive procedure that is performed to diagnose and
treat pancreatic and biliary disease.
In approximately 5%–10% of cases, the procedure itself causes
adverse events.
Diagnosis and management of ERCP-induced complications are
performed with clinical, laboratory, and radiologic procedures.
Evaluation of the type and severity of the complication is necessary
and is successfully performed with computed tomography (CT).
The most common causes of post-ERCP pain are acute pancreatitis
and duodenal perforation.
In severe pancreatitis, the pancreas is enlarged and enhances
heterogeneously at CT. Pancreatic enhancement is diminished in
areas of glandular necrosis.
In duodenal perforation, CT may reveal extraluminal air or fluid.
CT findings of acute duodenal hemorrhage are duodenal wall
thickening and a high-attenuation mass in the duodenal wall.
In infection, the bile ducts can be dilated and the attenuation of the
bile can be increased at CT. Abscesses appear as hypoattenuating
masses with enhancing capsules. CT findings of stent migration are
an atypical location of the stent and bowel impaction. Other
complications of ERCP are those related to endoscopy and include
esophageal, liver, and splenic injury.

4. 4
ERCP:
overview of
complications
Avoidance of unnecessary ERCP is the best way to
reduce ERCP-related complications.
Cardiopulmonary depression is the most common
complication associated with endoscopy (up to
50% of overall complications; 1% of events
considered to be severe) and is usually associated
with the use of sedation [1,6]. Hypoxia (incidence
of 7-40%) and aspiration (incidence of 0.3-1.0%)
are associated with increasing age, chronic
illness, depressed mental status, supine
positioning, and sedation
In general, complications are classified as mild if the
length of hospital stay is less than or equal to 3 nights;
moderate if the length of hospital stay is between 4
and 10 nights
severe if the patient is hospitalized for 10 or more
nights, is admitted to an intensive care unit, or
requires surgery
As regards timing,
immediate if they occur during or shortly
after the procedure;
early if they occur within a few hours;
delayed if they occur within 30 days

5. The definition of post-ERCP
pancreatitis includes:
(a) new-onset or worsening
abdominal pain;
(b) elevation of serum amylase
three times above normal at 24
hours post procedure; and
(c) requirement for >2 days of
pancreatitis related hospitalization
Pancreatitis (inflammation of the pancreas) is the most frequent complication, occurring in
about 3 to 5 percent of people undergoing ERCP. When it occurs, it is usually mild, causing
abdominal pain and nausea, which resolve after a few days in the hospital

6. Placement of a pancreatic
duct stent allows the free
flow of pancreatic exocrine
secretions, preventing
ductal hypertension and
reducing the risk of
pancreatitis.
pancreatic duct stenting reduces
the incidence of PEP in high-risk patients.

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Cholangitis
• Patients typically present with fever, jaundice, and abdominal pain, but
hypotension and altered mental status can ensue in severe cases.
• The risk of post-ERCP cholangitis is highest in patients with incomplete biliary
drainage (ie, hilar cholangiocarcinoma and primary sclerosing cholangitis) and
prior history of liver transplantation.
• Current guidelines recommend antibiotic prophylaxis before ERCP in patients
who have had liver transplantation or when patients with known or suspected
biliary obstruction may be incompletely drained, and these guidelines
discourage the routine use of antibiotic prophylaxis before ERCP when
complete biliary drainage is anticipated or for cases in which biliary
obstruction is not suspected.

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Cholecystitis
• Post-ERCP cholecystitis is an uncommon adverse event but should be recognized
early and not be mistaken for acute cholangitis.
• Patients may present with fever, abdominal pain, leukocytosis, and a positive
Murphy’s sign. Diagnosis should be confirmed by imaging findings. Pathogenesis is
believed to be related to gallbladder contamination by nonsterile contrast material in
the context of gallbladder dyskinesia or outflow (cystic duct) obstruction.
• The role of prophylactic periprocedural intravenous antibiotics to prevent
cholecystitis has not been studied. Treatment of post-ERCP cholecystitis traditionally
includes surgery or percutaneous cholecystostomy. However, transpapillary and EUS-
guided gallbladder drainage may be considered, especially in patients who are not
surgical candidates (eg, inoperable periampullary carcinoma).

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Liver cirrhosis, dilated common
bile ducts, periampullary diverticulum, precut
sphincterotomy, and common bile duct stones appear to
increase
the risk of postsphincterotomy bleeding
Most episodes of bleeding cease spontaneously; thus, treatment
should be reserved for patients who have clinically significant
bleeding.
Treatment options for postsphincterotomy bleeding
include balloon tamponade, injection of dilute epinephrine
solution through a sclerotherapy needle, heater probe
or bipolar coagulation, and/or the placement of endoscopic clips.

11. Perforation of the bile duct, pancreatic duct, or duodenum
is reported in less than 1% of patients undergoing ERCP.
Bile duct perforation can be a result of guidewire or
sphincterotome manipulation and, if significant, leads to
development of an encapsulated collection of bile (a
biloma).
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The most common presumed causes
were guidewire manipulation (32%),
sphincterotomy
(15%), endoscope manipulation (11%),
cannulation
(11%), stent placement (9%), or stricture dilation

12. ERCP-related perforation include the performance of
sphincterotomy, the presence of Billroth II anatomy,
intramural injection of contrast, performance of
biliary stricture dilatation, presence of sphincter of
Oddi dysfunction, long duration of the procedure
Retroperitoneal perforation rarely
requires surgery; however, free duodenal perforations
usually require open surgical toilet and repair.49
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