Complications of ERCP in patients with primary sclerosing cholangitis (PSC)

Patients with PSC can have intrahepatic or extrahepatic biliary strictures, or both, resulting in cholestasis and cholangitis. ERCP is commonly performed in the hope of locating a dominant extrahepatic or hilar stricture amenable to endoscopic therapy. These procedures are thought to carry an increased risk of complications, especially cholangitis, due to manipulation of a chronically obstructed biliary tree. Objective: To review complications of diagnostic and therapeutic ERCP in patients with PSC. Methods: We used a computerized database to identify consecutive patients with PSC between 1987 and 1997. ERCPs were classified as diagnostic or therapeutic, and procedure-related complications noted. The complication classification proposed by Cotton was used: i.e. mild (<4d in hospital), moderate (4-10 days in hospital) and severe (>10d in hospital). Results: 104 patients underwent 204 ERCPs. 35 complications (17%) were noted; all required hospitalization for at least 24 hours. Despite prophylactic antibiotic administration cholangitis was the most common complication occurring in 15 patients (7.5%). The majority of cases were mild but 2 patients with severe sepsis and liver abscess had prolonged hospitalizations. Pancreatitis occurred in 5.3% of patients with almost one-half of these being severe. Two patients suffered iatrogenic bile duct perforations, one requiring a 10 day hospital stay. Other complications included protracted nausea and vomiting (3), fractured rib (1), hemobilia (1) and myocardial infarction (1). Although the majority (79%) of the complications were seen in the therapeutic ERCP group, this was not significantly different from the diagnostic group (p = 0.695). All 10 severe complications, however, occurred in the therapeutic group. No deaths were recorded in either group. Conclusions: 1. ERCP in patients with PSC carries significant risk of morbidity. 2. Therapeutic ERCP in PSC patients accounted for most of the complications, and all of the severe ones, in this study. 3. ERCP-related complications were probably under-represented due to the retrospective nature of the study.

Duke Scholars

Author Malcolm Stanley Branch Medicine, Gastroenterology

Author Paul Simon Jowell Medicine, Gastroenterology