Managing perforations related to endoscopic retrograde. Alkawas, md keywords ercp, post ercp pancreatitis, post ercp hemorrhage, post ercp perforation, post ercp infection dr. According to data collected by the national confidential enquiry into patient outcome and death ncepod, roughly 37 percent of death after ercp occurs during the first week of ercp recovery. Since the introduction of endoscopic retrograde cholangiopancreatography ercp in 1968 1, it has become an indispensable endoscopic procedure in the practice of gastroenterology.
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. However, an increased risk of perforation is seen in patients with sphincter of oddi dysfunction, patients who are undergoing extensions of prior sphincterotomies, and. A long flexible tube, approximately the size of your little finger, is passed through the mouth and into the. We analyzed data pertaining to clinical details, management, and outcome. Surgical management of duodenal perforations after ercp. The incidence of biliary tract pathology is growing with an agerelated trend, and progresses as the population ages. Sepsis may occur in patients with partial obstruction of common bile duct. Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated. The primary outcome was the overall occurrence of successful cannulation, postercp complications. Early management experience of perforation after ercp. Perforation is one of the most feared complications of endoscopic retrograde cholangiopancreatography ercp. We retrospectively analyzed the clinical records of all patients aged. Endoscopic approach included closure of the perforation with endoclips and sems.
Most are minor perforations that settle with conservative management. Postercp perforation is burdened by a high risk of mortality. A few perforations however result in lifethreatening retroperitoneal necrosis and require surgical intervention. Common bile duct perforation by biliary stents postercp. Endoscopic retrograde cholangiopancreatography ercp represents the gold standard for treatment in these cases, but evidence about its safety in the elderly is still debated. We compared baseline characteristics and clinical data as well as ercp results in patients with and without periampullary diverticulum. Ercp can result in complications such as pancreatitis inflammation of the pancreas, perforation tear of the intestine, bile duct or pancreatic duct, bleeding, infection or reaction to medication.
Pancreatitis introduction postercp 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. An overview of the complications of ercp and detailed discussions of other individual complications are presented separately. Endoscopic retrograde cholangiopancreatography ercp. Original article influence of juxtampullary duodenal. Pdf management of duodenal perforation postendoscopic. Infection cholangitis the rate of postercp cholangitis is. Experience in the management of the complication surgical team 4. The management of this kind of perforation is controversial. 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. For safety reasons, you cant drive for 24 hours after ercp, as the sedatives or anesthesia used during the procedure needs time to wear off. This varying incidence is thought to relate to many factors. Of all the currently performed gastrointestinal endoscopic procedures it carries the highest complication rate.
Mild complications may require several nights in the hospital, a period of nil. Some advocate a nonsurgical approach to management in certain select patients. Influence of juxtampullary duodenal diverticula on endoscopic retrograde cholangiopancreatography. An elevation in the serum amylase concentration is common after endoscopic retrograde cholangiopancreatography ercp, occurring in up to 75 percent of patients.
The most common complications are postercp pancreatitis 1. Of these complications, postercp pancreatitis pep is the most. Clinical outcomes of ercprelated retroperitoneal perforations. Complications of endoscopic retrograde cholangiopancreatography. Perforation ercprelated perforation occurs in 0 3%related perforation occurs in 0. Clinical, laboratory, and ercp data of 780 patients referred to the taleghani hospital, as a great referral endoscopy center, in iran were prospectively.
Discussion iatrogenic perforation resulting from ercp is a rare but serious complication with high morbidity and mortal ity. If you have any further questions, please speak to a doctor or nurse caring for you. Conservative management of duodenal perforation following. Duodenal perforation, damage to common bile duct or ampulla of vater. Management of ercprelated small bowel perforations. Ercp is an endoscopic procedure that uses xrays to visualize the bile ducts and pancreas.
Iatrogenic duodenal injuries ercp was first introduced in 1968 by mccune et al and has evolved over the decades currently, it is a valuable, widely used diagnostic and therapeutic tool in hepatobiliarypancreas diseases ercp has a relatively high complication rate of nearly 10% and a. European society of gastrointestinal endoscopy esge. Between november 2003 and december 2011, a total of 8504 ercps were performed at our regional endoscopy center. Perforation is a rare but serious adverse event of ercp. The abdominal radiographs of 4 patients 36% showed intraabdominal free air. 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 condition. Post ercp cholecystitis, which is also a type of infection. Ducts are small tubes that let fluid pass from one place to another. Pdf early management experience of perforation after ercp. The timing of diagnosis is critical for management and patient outcome 810.
Stapfer type ii perforations have excellent outcomes when managed medically. Unfortunately, the risks of complications after ercp doesnt stop at pancreatitis. In both cases the ttube was clamped on day 5 followed by cholangiogram to confirm no bile leakage prior to taking out the drains. Both of the patients were managed conservatively with bowel rest, nasogastric suction, analgesia and intravenous antibiotics. Treatment results of gastrointestinal perforation after. Ercp complications and challenges in their diagnosis and. Evidencebased strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography ercp combined with endoscopic sphincterotomy es.
Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the. Acute iatrogenic perforation during endoscopy is defined as the presence of gas or luminal contents outside the gastrointestinal tract 7. Bowel perforations occurring an ercp do not, by themselves, show that the surgeon fell below the applicable standard of care. All of the patients 6591 years old were diagnosed during or immediately upon finishing the ercp procedures. Endoscopic retrograde cholangiopancreatography ercp is a procedure that should be performed by a skilled endoscopist to maximize the success rate and minimize complications, which occur in 5%10% of cases1,2. Two perforations were incidentally diagnosed in an asymptomatic patient in. Vivek kumbhari, md, from the department of medicine, division of gastroenterology and hepatology, johns hopkins medical institutions, in baltimore, maryland, usa discusses this original article algorithm for the management of ercprelated perforations. During balloon sweepings the scope snapped and hit the duodenal wall opposite to the ampullary area. Research has found that ercp is generally safe during pregnancy. Duodenal perforations after endoscopic retrograde cholangiopancreatography ercp are an uncommon complication. Within 12 hours after the event, the patients underwent endoscopic or surgical approach.
Ercp endoscopic retrograde cholangiopancreatography. Endoscopic retrograde cholangiopancreatography ercp niddk. Alkawas, md keywords ercp, postercp pancreatitis, postercp hemorrhage, postercp perforation, postercp infection dr. For this test, you will have a narrow tube put through your mouth and throat into your small intestine. Endoscopy shows a high sensitivity and specificity for diagnosis of iatrogenic perforation 11. Iatrogenic duodenal injuries suny downstate medical center. Ercp bowel perforation lawsuit against hopkins baltimore. Post ercp pancreatitis pep is the most common complication of ercp and occurs in 3% to 15% of ercp cases, with roughly 5% of these patients developing a severe course of the condition. Endoscopic retrograde cholangiopancreatography in the. Materials and methods between march 2003 and march 20, 2,071 ercps were performed in our hospital. Complications of ercp include pancreatitis, bleeding, cholangitis, cholecystitis, and perforation. Management of duodenopancreatobiliary perforations after. Due to the number and complexity of operative ercps currently performed, radiologists are increasingly faced with imaging investigation of suspected postprocedural. An algorithm for the management of ercprelated perforations.
Endoscopic retrograde cholangiopancreatographyrelated perforation 18144 int j clin exp med 2016. Ercp pancreatitis pep is the most common complication of ercp and that its frequency is 2. You will need to make plans for getting a ride home after ercp. Ercp endoscopic retrograde cholangiopancreatography ercp is a test of the ducts of your gallbladder and pancreas. This study evaluated the early management experience of these perforations. The expected rate of ercpinduced pancreatitis is generally between 1% and 7%. Perforation of the duodenum is a recognized complication of endoscopic retrograde cholangiopancreatography ercp. Ercp features and outcome in patients with periampullary. Eightythree percent of these cases underwent surgical correction. We validate an algorithm for the management of ercprelated perforations and propose that it should function as a guide. Albeit generally safe procedures, endoscopic retrograde cholangiopancreatography ercp and biliary stenting are associated with a nonnegligible morbidity and occasional mortality.
However, bowel perforations are among the deadliest potential complications of an ercp. Ercp in one case and, in the second case, perforation was evident during ercp and a biliary stent was inserted. Post ercp cholangitis, which is a type of infection. Surgical or endoscopic management for postercp large. Imaging findings of complications after endoscopic. Algorithm for the management of ercprelated perforations. Endoscopic retrograde cholangiopancreatographyrelated. Duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare complication, but it is associated with significant mortality. Although periampullary diverticulum is usually asymptomatic and discovered incidentally in patients during endoscopic retrograde cholangiopancreatography ercp, it may lead to postercp morbidity. Duodenal perforation post ercp is rare, occurring in 1% range 0. Postercp, cbd perforations are relatively rare with the incidence ranging from 0.
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