Perforation is a rare but serious adverse event of ercp. Duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Perforation of the duodenum is a recognized complication of endoscopic retrograde cholangiopancreatography ercp. Evidencebased strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography ercp combined with endoscopic sphincterotomy es. Duodenal perforation post ercp is rare, occurring in 1% range 0. Endoscopic retrograde cholangiopancreatography ercp is an invasive. Infection cholangitis the rate of postercp cholangitis is. Diagnosis and management of ercpinduced complications are performed with clinical, laboratory, and radiologic procedures.
In stable patients, conservative management of duodenal perforation post ercp is preferred. The most common complication is post ercp pancreatitis, which occurs in approximately 5% to 15% of patients and is the subject of a significant amount of research, including identifying risk factors for and developing drugs to prevent the. Perforation related to endoscopic retrograde cholangiopancreatography ercp is a rare complication associated with significant morbidity and mortality. Perforation is one of the rare but most feared complications of endoscopic retrograde cholangiopancreatography. Endoscopy shows a high sensitivity and specificity for diagnosis of iatrogenic perforation 11. Methods we experienced perforations associated with ercp. Endoscopic retrograde cholangiopancreatography singla. Post ercp antibiotics are not mandatory for all patients if complete biliary drainage is achieved. Absence of free air does not always rule out perforation, since it is mostly retroperitoneal. Post ercp migration of biliary stent through common bile. Acute iatrogenic perforation during endoscopy is defined as the presence of gas or luminal contents outside the gastrointestinal tract 7. Postercp biliary complications in patients with biliary.
Two patients presented within 2436 h after the pro cedure to the emergency room with abdominal pain and fever and were found to have free air on ct scan and. Mar 05, 2015 a middle aged man with cbd stones, ercp done. The group demonstrated that, of the 2874 patients 48% who had a sphincterotomy, 40 patients 0. Endoscopic retrograde cholangiopancreatography ercp is a specialized endoscopic procedure for the management of pancreatic and biliary diseases, in which the common bile duct and or the. Patients with severe pancreatitis after ercp should undergo pancreatitis management and monitoring in an intensive care hospital environment or. Free air collection in the retroperitoneum after endoscopic sphincterotomy. Ercp is a diagnostic procedure designed to examine diseases of the liver, bile ducts and pancreas. Your bile ducts are tubes that carry bile from your liver to your. The incidence of perforation reported by recent series ranges from 0. In 5 patients, duodenal perforation was immediately noticed during the ercp procedure, and in 1 patient the diagnosis was made after routine postercp abdominal radiography. An elevation in the serum amylase concentration is common after endoscopic retrograde cholangiopancreatography ercp, occurring in up to 75 percent of patients.
Management of endoscopic retrograde cholangiopancreatography. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. The overall post ercp cholangitis rate was 10% 660 mild 3, moderate 3. It is generally agreed that some ercprelated perforations can be successfully managed without surgery 8,9,10,11. Early management experience of perforation after ercp. We evaluated our experience of managing post ercp perforations to help define the role of surgery with percutaneous drainage pcd. Management of duodenopancreatobiliary perforations after.
Treatment results of gastrointestinal perforation after. The incidence of perforation post ercp has been investigated by howard et al, who performed a retrospective analysis of 6040 ercps. The most common complication is postercp pancreatitis, which occurs in. This study evaluated the management and outcomes of these perforations. Since infection after ercp is caused by bacteria, antibiotics are the primary form of treatment. Saunders6, antonios vezakis7, jean michel gonzalez3, stine ydegaard turino4, zacharias p. Management of perforation after endoscopic retrograde.
Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography ercp are an uncommon adverse event, occurring in 0. Severe pancreatitis is estimated to occur in roughly twotothree percent of patients who develop pancreatitis after ercp. If you do not have a driver with you at check in, we will reschedule your appointment. Radiological studies performed after the procedure showed a large area. This study evaluated the early management experience of these perforations. Infection cholangitis the rate of post ercp cholangitis is 1% or less. During an ercp, an endoscope is inserted into the mouth and through the esophagus to the biliary tract. Surgical management of duodenal perforations after ercp. We evaluated our experience of managing postercp perforations to help define the role of surgery with percutaneous drainage pcd. Managing risks related to ercp in elderly patients with. Abdominal ultrasound scan was requested in a single occasion, in which free. Chest and abdominal radiographs are useful in assessing post ercp complications.
In patient b the laparoscopic procedure had to be converted to open and ttube inserted via the perforation site. Only two patients required operation and the results of surgery are presented in table iv. Postendoscopic retrograde cholangiopancreatography ercp perforation usually resolves conservatively. Sepsis may occur in patients with partial obstruction of common bile duct. With this, the complexity of the procedure and risk of complication including duodenal perforation have increased.
Introduction after successful medical management of a patient with a clinical picture suggestive of post sphincterotomy duodenal perforation, and in which the computed axial tomography ct scan of the abdomen revealed the presence of subcutaneous emphysema and retroperitoneal air, there was concern about the frequency of post ercp with sphincterotomy pneumoretroperitoneum. Endoscopic retrograde cholangiopancreatography ercp related perforations are a rare but serious complication. Paspatis1, jeanmarc dumonceau2, marc barthet3, soren meisner4, alessandro repici5, brian p. Endoscopic retrograde cholangiopancreatography ercp niddk. European society of gastrointestinal endoscopy esge position statement authors gregorios a. An overview of the complications of ercp and detailed discussions of other individual complications are presented separately. Diagnosis and management of ercp induced complications are performed with clinical, laboratory, and radiologic procedures. The other six perforations were diagnosed by plain xray of the abdomen or ct scan for postercp abdominal pain. Management of ercprelated small bowel perforations. A recent retrospective analysis of nearly 1500 patients with pancreas divisum who underwent ercp reported an overall post ercp complication rate of 7. In both cases the ttube was clamped on day 5 followed by cholangiogram to confirm no bile leakage prior to taking out the drains.
Managing perforations related to endoscopic retrograde. Post ercp, cbd perforations are relatively rare with the incidence ranging from 0. During balloon sweepings the scope snapped and hit the duodenal wall opposite to the ampullary area. Retrospective study of duodenal perforations after ercp diagnosed at a tertiary. The most common causes of post ercp pain are acute pancreatitis and duodenal perforation. Treatment is to leave suspend oral feeding, feed the patient. Perforation is one of the most feared complications of endoscopic retrograde cholangiopancreatography ercp. Ercp is usually best performed under general anesthesia. Ercprelated perforations were identified in this study. The patient remained hospitalized with a diagnosis of postercp and sphincterotomy duodenal perforation.
Ercprelated perforations in the new millennium sage journals. Algorithm for the management of ercprelated perforations. The abdominal radiographs of 4 patients 36% showed intraabdominal free air. Common bile duct perforation by biliary stents postercp. The incidence of perforation during ercp ranges from 0. Endoscopic retrograde cholangiopancreatography ercp is a commonly used method in the diagnosis and treatment of biliary and pancreatic channel diseases. Perforation, endoscopic retrograde cholangiopancreatography, ercp. It is remarkable to note that 18 patients 62% were older than 70 years of age at the time of ercprelated perforation diagnosis. There is no consensus to guide the clinician on the management of ercprelated perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. Pancreatitis and bleeding are the most common complication. Two perforations were incidentally diagnosed in an asymptomatic patient in. It is generally agreed that some ercp related perforations can be successfully managed without surgery 8,9,10,11. Pdf management of duodenal perforation postendoscopic. Endoscopic retrograde cholangiopancreatography ercprelated perforations are a rare but serious complication.
Vs there are 5 complications that are seen in an endoscopic retrograde cholangiopancreatography ercp. The complication rate is 510% with a mortality rate between 0. Due to the discrete nature of the symptoms and the absence of signs of peri. Pdf endoscopic retrograde cholangiopancreatography ercp has. Prompt recognition and management with endoscopic therapy if possible, antibiotics, and early collaboration with surgeons can help. Some advocate a nonsurgical approach to management in certain select patients. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare complication, but it is associated with significant mortality. The diagnosis of duodenal perforation after ercp is gener ally based on. The basic characteristics of patients with biliarytype sod group and control group are shown in table 1. Introduction after successful medical management of a patient with a clinical picture suggestive of post sphincterotomy duodenal perforation, and in which the computed axial tomography ct scan of the abdomen revealed the presence of subcutaneous emphysema and retroperitoneal air, there was concern about the frequency of post ercp with sphincterotomy pneumoretroperitoneum and if any procedure. Post endoscopic retrograde cholangiopancreatography ercp perforation usually resolves conservatively. The incidence of perforation postercp has been investigated by howard et al, who performed a retrospective analysis of 6040 ercps. Ercp prep instructions endoscopic retrograde cholangiopancreatography planning for your ercp you must have a driver with you at the procedure. Free air below diaphragm arrow after extraction of the calculus.
Duodenal perforation, damage to common bile duct or ampulla of vater. Within 12 hours after the event, the patients underwent endoscopic or surgical approach. The other six perforations were diagnosed by plain xray of the abdomen or ct scan for post ercp abdominal pain. Experience in the management of the complication surgical team 4. The timing of diagnosis is critical for management and patient outcome 810. Ercprelated perforations may occur during sphincterotomy and. Postercp biliary complications in patients with biliary type. Endoscopic approach included closure of the perforation with endoclips and sems. Diagnosis and management of iatrogenic endoscopic perforations. The overall postercp cholangitis rate was 10% 660 mild 3, moderate 3. The expected rate of ercp induced pancreatitis is generally between 1% and 7%. A case report of nonsurgical duodenal perforation following ercp. A 90yearold male patient was admitted to the emergency department with dyspnea. Evaluation of the type and severity of the complication is necessary and is successfully performed with computed tomography ct.
The overall incidence rate of post ercp complications was. Advanced endoscopic technology should be considered early diagnosis of postercp perforation, when performed during ercp, or in the recovery room. Surgical or endoscopic management for postercp large. Dorsal duct canulation and minor papilla sphincterotomy were associated with a significantly higher incidence of post ercp pancreatitis 8. In the unknown group, only one perforation was identified during ercp. The diagnosis of postercp perforations are difficult and localization of the. Between november 2003 and december 2011, a total of 8504 ercps were performed at our regional endoscopy center. Free fluid which is within the retroperitoneum with very little intraperitoneal. Purpose the purpose of this study is to analyze the treatment strategies of patients with endoscopic retrograde cholangiopancreatography ercprelated perforations. The most common complication is postercp pancreatitis, which occurs in approximately 5% to 15% of patients and is the subject of a significant amount of research, including identifying risk. Yet, bleeding and cardiopulmonary events dominated, with a twofold increase in mortality in octogenarians and nearly a. Radiology ruled out the presence of subphrenic air, however, a cat scan of the abdomen revealed retroperitoneal air, but not collections or free fluid.
Most are minor perforations that settle with conservative management. Endoscopic retrograde cholangiopancreatographyrelated. Npo status is usually maintained for 24 hours and then a clear. Ercp hemorrhage, more than half of the patients had delay bleeding and required more than two times of endoscopic procedure. In total, 15 of 29 patients with ercp perforation were operated on. Safety of endoscopic retrograde cholangiopancreatography. The most common complication is postercp pancreatitis, which occurs in approximately 5% to 15% of patients and is the subject of a significant amount of research, including identifying risk factors for and developing drugs to prevent the. The most common causes of postercp pain are acute pancreatitis and duodenal perforation. A few perforations however result in lifethreatening retroperitoneal necrosis and require surgical intervention. Nehemiah samuel, mr, alex wheeler, dr, muhammad h shiwani, mr, ahmed masri. Postendoscopic retrograde cholangiopancreatography.
Management of duodenal perforation postendoscopic retrograde. Postercp complications are usually apparent within three days of the procedure, and rarely present after the 12 day. Endoscopic retrograde cholangiopancreatography ercp. Pancreatitis introduction post ercp pancreatitis pep is the most common serious adverse event attributed to the procedure, resulting in annual estimated costs exceeding 150 million dollars in the united states. Advanced endoscopic technology should be considered early diagnosis of post ercp perforation, when performed during ercp, or in the recovery room. Endoscopic retrograde cholangiopancreatography ercp is a procedure that combines upper gastrointestinal gi endoscopy and xrays to treat problems of the bile and pancreatic ducts. If the endoscope is unsanitized, the bacteria may spread and grow.
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