Complications
Pancreatitis following ERCP is the most common complication of the procedure, occuring in 3.5% of patients.[128] It is associated with female sex, age <65 years, a longer biliary cannulation time, and precut-sphincterotomy.[129] ERCP-associated pancreatitis is usually managed with bowel rest, analgesia, and intravenous hydration. Indometacin, given immediately after the ERCP, can help prevent this complication.[128][130]
Bile duct injury is defined as any damage to the bile duct, including leakage of bile, iatrogenic bile duct injury, and biliary strictures.[1] Bile leak occurs in 0.5% to 1.5% of patients undergoing laparoscopic cholecystectomy, and is associated with significant morbidity and higher 1-2 year mortality compared with patients who have uncomplicated surgery.[1][131][132] Major bile duct injuries are due to direct surgical trauma or from partial/complete transection of the bile duct caused by clips or ligation.[132] Bile duct injury is either detected intraoperatively, or patients typically present with persistent pain, fever, nausea and vomiting post cholecystectomy. Diagnosis is by laboratory testing (elevated white cell count, bilirubin, liver enzymes) and imaging (contrast CT or MRCP).[1][133] Risk factors for bile duct injury are Mirizzi syndrome, impacted cystic duct stones, and abnormal anatomy.[1][133] If detected during surgery, primary surgical repair can be performed; otherwise bile duct injuries are usually managed with endoscopic transpapillary biliary stent insertion.[1] If there is a concomitant biloma (a collection of bile outside of the biliary tree), percutaneous drainage may also be necessary, and antibiotics should be started immediately.[132]Acutely or perioperatively, bile duct injuries can lead to bleeding or perforation and biliary obstruction. Longer term bile duct strictures can develop. Biliary strictures are generally preventable. With the exception of complete transection, bile duct injury and strictures can be managed with endoscopic placement of bile duct stents.[133]
The frequency of bleeding as a complication of endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction varies from 1% to 48% depending on the definition applied (e.g., the magnitude of bleeding [limited vs. life-threatening] and if it occurred during the procedure).[134] Risk factors for post-sphincterotomy bleeding include a low endoscopist case volume, bleeding during initial sphincterotomy, cholangitis prior to ERCP, anticoagulation within 3 days of sphincterotomy, and coagulopathy.[135][136] This complication is commonly recognised at the time of the procedure and can be treated with endoscopic haemostatic techniques.[135]
If a gallstone erodes through the gallbladder wall, a cholecystoenteric fistula can develop and lead to duodenal obstruction (Bouveret syndrome). This usually presents with nausea and vomiting and abdominal pain, though can present with symptoms of upper gastrointestinal bleeding, such as haematemesis or melaena.[126] Diagnosis is made by demonstrating gastrointestinal tract obstruction on abdominal X-ray, ultrasound, or CT or MRI.[126] Treatment is with endoscopic extraction of the stone, lithotripsy, or surgery to relieve the obstruction, close the fistula, and prevent relapses. Select patients may require cholecystectomy.[126][127]
If a stone erodes through the gallbladder wall and creates a cholecystoenteric fistula, the stone can then pass into, and lead to obstruction of, the narrowest segment of healthy bowel, often the terminal ileum.[34] This presents with symptoms of bowel obstruction, with nausea, vomiting and crampy abdominal pain and distension.[34] CT is the most accurate imaging modality to confirm the diagnosis; treatment is usually with surgery.[34]
Acute cholecystitis occurs when obstruction of the cystic duct leads to gallbladder inflammation. Patients usually have intense, steady right upper quadrant pain (sometimes radiating to the back, right shoulder, or chest), a positive Murphy's sign, fever, nausea, vomiting, and leukocytosis.[1]
Continue investigation with cholescintigraphy (HIDA scan) if ultrasound and computed tomography are not diagnostic.
Absence of gallbladder filling is over 90% accurate, though false positives occur in fasting and intensive care unit patients.[1][120][121]
Treatment involves intravenous hydration, antibiotics, analgesia as needed, and early cholecystectomy. Evidence suggests that early cholecystectomy is associated with shorter hospital stay and fewer recurrent symptoms.[122] Patients unsuitable for surgery can be managed with percutaneous cholecystostomy tube placement.[1]
Acute cholangitis occurs when there is complete obstruction of the bile duct resulting in cholestasis and infected bile. The classic presentation is biliary pain, jaundice, and fever (Charcot's triad).[1] Hypotension and altered mental status may also be present (Reynolds' pentad). Leukocytosis and abnormal LFTs are typical.[1] Consider bacterial cholangitis a medical emergency.
Treatment involves intravenous hydration, antibiotics, analgesia, and biliary decompression within 24 to 48 hours. Severe cases may require urgent biliary decompression via ERCP with sphincterotomy and stone extraction.[123] Biliary stent placement, percutaneous drainage or surgical common bile duct exploration are alternative options if endoscopic decompression fails, or if there are contraindications to endoscopic procedures, such as coagulopathy.[1][124] If ERCP fails, percutaneous drainage or surgical common bile duct exploration may become necessary.
Occurs when there is pancreatic outflow obstruction or reflux of bile into the pancreatic duct. Patients usually present with severe epigastric abdominal pain with or without radiation into the back, nausea and vomiting, and elevated pancreatic enzymes.[1]
Diagnosis is confirmed on ultrasound, which demonstrates common bile duct dilation but is less accurate at detecting gallstones.[1]
Treatment involves aggressive intravenous hydration, analgesia, and ERCP with sphincterotomy and stone extraction within 72 hours of admission (for severe acute pancreatitis with evidence of biliary obstruction and/or cholangitis).[33][125] Mild acute pancreatitis requires only fluids and supportive care. Offer cholecystectomy before discharge from the hospital.
Mirizzi syndrome is when a large gallstone becomes lodged in the cystic duct and compresses or damages the common hepatic duct, resulting in biliary obstruction and jaundice.[33] It is an uncommon complication of cholelithiasis, occurring in 0.18% to 0.35% of cholecystectomy patients in the US.[33] There are several subtypes of Mirizzi syndrome, classified by the amount of the duct involved and whether a fistula is present.[33] Mirizzi syndrome is typically treated with laparoscopic cholecystectomy. The open procedure is preferred for certain subtypes.[1]
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