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Overview of ERCP Complications: Prevention and Management

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ERCP and EUS

Abstract

Adverse events/complications are not uncommon with ERCP. Complications include post-ERCP pancreatitis, bleeding, perforation, cardiopulmonary complications, cholecystitis, and others. Diagnostic ERCP should be avoided. Prophylactic pancreatic duct stents reduce risk of post-ERCP pancreatitis of all degrees of severity in high-risk and mixed-risk patients. Rectal indomethacin independently reduces risk of post-ERCP pancreatitis and may have an additive effect to pancreatic stenting. Hemorrhage is largely a function of coagulation status and technique; perforation is almost entirely technique related. Recognition of risk factors and risk modification is key. Any adverse event should be recognized early and endoscopic management is central to management of hemorrhage and perforation. Appropriate supportive and interventional therapy should be initiated to minimize sequelae of complications.

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Author information

Authors and Affiliations

  1. Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 406 Harvard Street SE, Minneapolis, MN 55455, USA

    Martin L. Freeman MD, FACG, FASGE

  2. Gastroenterology, Aurora St. Luke’s Medical Center, Milwaukee, WI, USA

    Nalini M. Guda MD, FASGE, AGAF

Authors
  1. Nalini M. Guda MD, FASGE, AGAF
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  2. Martin L. Freeman MD, FACG, FASGE
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Corresponding author

Correspondence to Martin L. Freeman MD, FACG, FASGE .

Editor information

Editors and Affiliations

  1. Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Linda S. Lee

Electronic supplementary material

Video Caption

Video 3.1 Placement of prophylactic small caliber pancreatic stent in patient with tiny, tortuous pancreatic duct using 0.018-in. guidewire and 4F 2-cm inner-flanged soft stent

This young woman had recurrent abdominal pain associated with abnormal liver function tests (LFTs) suggestive of sphincter of Oddi dysfunction type II. MRCP showed a normal bile duct but a very tortuous small caliber ventral pancreatic duct. The plan was for ERCP with biliary sphincterotomy and a protective pancreatic stent . This type of pancreatic ductal anatomy leads to virtual impossibility of stent placement using conventional guidewires, as the wire will exit side branches and potentially lead to ductal perforation , while not allowing stability to place a protective stent. Therefore, the case was started with a 5-4-3 cannula (Boston Scientific) loaded with an 0.018″ Roadrunner wire (Cook Medical). The major papilla was very small, adding to technical challenge. The pancreatic duct was cannulated and a very limited amount of contrast injected, which showed the sharp angular turn in the main pancreatic duct. The 0.018″ wire was intentionally knuckled inside the duct, so that the platinum tip would remain intraductal and avoid entering side branches. Normally, we would leave a pancreatic wire and cannulate the bile duct with a second wire. However, the stability of this pancreatic wire was very precarious. As a result, we placed the pancreatic stent before attempting biliary access. With the wire pushed only as far as the first turn, a 4F 2-cm soft material, inner-flanged pancreatic stent (Hobbs Medical) was placed. The inner flange is critical to avoid immediate outward migration. Then, using the guidewire technique, an 0.025-in. wire was used to cannulate bile duct beside the pancreatic stent, and a biliary sphincterotomy performed.

This approach prioritizes early and safe placement of a protective pancreatic stent in a high-risk patient with a very tortuous, small-caliber pancreatic duct in whom conventional guidewire techniques are very risky for ductal perforation or failure to place a pancreatic stent. Additionally, this video demonstrates use of a soft material atraumatic stent to avoid pancreatic ductal injury [32, 53].

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Guda, N., Freeman, M. (2015). Overview of ERCP Complications: Prevention and Management. In: Lee, L. (eds) ERCP and EUS. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2320-5_3

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  • DOI: https://doi.org/10.1007/978-1-4939-2320-5_3

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