Ercp complications copy

General surgery biliary surgery

1. Endoscopic retrograde cholangiopancreatography (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. Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most commonly performed endoscopic procedures. It provides the treating physician with both diagnostic and 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. ERCP: overview of complications

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.

7. 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.

8. 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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10. 10 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). 11 The most common presumed causes were guidewire manipulation (32%), sphincterotomy (15%), endoscope manipulation (11%), cannulation (11%), stent placement (9%), or stricture dilation (7%).

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 12