Skip to main content
SpringerLink
Log in

Complications of endoscopic retrograde cholangiopancreatography: an imaging review

  • Review
  • Published:
Abdominal Radiology Aims and scope Submit manuscript

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) has currently become an inseparable tool in the gastroenterologist’s armamentarium for treatment of pancreaticobiliary disorders. Given the increase in number of therapeutic ERCP procedures today, the need for prompt and correct diagnosis of its complications is pivotal. This review discusses the mechanisms, risk factors, imaging findings and general management aspects of common and rare complications of ERCP. Furthermore, the review elaborates on imaging indications, recommended protocol and normal imaging findings post ERCP.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14

Similar content being viewed by others

References

  1. Cohen S, Bacon BR, Berlin JA, et al. National Institutes of Health State-of-the-Science Conference Statement: ERCP for diagnosis and therapy, January 14-16, 2002. Gastrointest Endosc 2002;56:803–809

    Article  PubMed  Google Scholar 

  2. Adler DG, Baron TH, Davila RE, et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest Endosc 2005;62:1–8

    Article  PubMed  Google Scholar 

  3. Chathadi KV, Chandrasekhara V, Acosta RD, et al. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc 2015;81:795–803

    Article  PubMed  Google Scholar 

  4. ASGE Standards of Practice Committee, Anderson MA, Fisher L, et al. Complications of ERCP. Gastrointest Endosc 2012;75:467–473

  5. Wang P, Li Z-S, Liu F, et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 2009;104:31–40

    Article  PubMed  Google Scholar 

  6. Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007;39:793–801

    Article  CAS  PubMed  Google Scholar 

  7. Kochar B, Akshintala VS, Afghani E, et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 2015;81:143-149.e9

    Google Scholar 

  8. Andriulli A, Loperfido S, Napolitano G, et al. Incidence Rates of Post-ERCP Complications: A Systematic Survey of Prospective Studies. Am J Gastroenterol 2007;102:1781

    Article  PubMed  Google Scholar 

  9. Aliperti G. Complications related to diagnostic and therapeutic endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am 1996;6:379–407

    Article  CAS  PubMed  Google Scholar 

  10. Silviera ML, Seamon MJ, Porshinsky B, et al. Complications related to endoscopic retrograde cholangiopancreatography: a comprehensive clinical review. J Gastrointest Liver Dis JGLD 2009;18:73–82

    Google Scholar 

  11. Kapral C, Duller C, Wewalka F, Kerstan E, Vogel W, Schreiber F. Case volume and outcome of endoscopic retrograde cholangiopancreatography: results of a nationwide Austrian benchmarking project. Endoscopy 2008;40:625–630

    Article  CAS  PubMed  Google Scholar 

  12. Stapfer M, Selby RR, Stain SC, et al. Management of Duodenal Perforation After Endoscopic Retrograde Cholangiopancreatography and Sphincterotomy. Ann Surg 2000;232:191–198

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Kwon C-I, Song SH, Hahm KB, Ko KH. Unusual complications related to endoscopic retrograde cholangiopancreatography and its endoscopic treatment. Clin Endosc 2013;46:251–259

    Article  PubMed  PubMed Central  Google Scholar 

  14. Mady RF, Niaz OS, Assal MM. Migrated biliary stent causing perforation of sigmoid colon and pelvic abscess. BMJ Case Rep 2015;2015

  15. Kahaleh M, Freeman M. Prevention and management of post-endoscopic retrograde cholangiopancreatography complications. Clin Endosc 2012;45:305–312

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kozarek RA. The future of ERCP. Endosc Int Open 2017;5:E272–E274

    Article  PubMed  PubMed Central  Google Scholar 

  17. Sartelli M, Viale P, Catena F, et al. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg WJES 2013;8:3

    Article  PubMed  Google Scholar 

  18. Kamal A, Singh VK, Akshintala VS, et al. CT and MRI assessment of symptomatic organized pancreatic fluid collections and pancreatic duct disruption: an interreader variability study using the revised Atlanta classification 2012. Abdom Imaging 2015;40:1608–1616

    Article  PubMed  Google Scholar 

  19. Wax BN, Katz DS, Badler RL, et al. Complications of abdominal and pelvic procedures: computed tomographic diagnosis. Curr Probl Diagn Radiol 2006;35:171–187

    Article  PubMed  Google Scholar 

  20. Masci E, Mariani A, Curioni S, Testoni PA. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy 2003;35:830–834

    Article  CAS  PubMed  Google Scholar 

  21. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc 2009;70:80–88

    Article  PubMed  Google Scholar 

  22. Moffatt DC, Coté GA, Avula H, et al. Risk factors for ERCP-related complications in patients with pancreas divisum: a retrospective study. Gastrointest Endosc 2011;73:963–970

    Article  PubMed  Google Scholar 

  23. Vandervoort J, Soetikno RM, Tham TCK, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002;56:652–656

    Article  PubMed  Google Scholar 

  24. Inamdar S, Berzin TM, Sejpal DV, et al. Pregnancy is a Risk Factor for Pancreatitis After Endoscopic Retrograde Cholangiopancreatography in a National Cohort Study. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc 2016;14:107–114

    Google Scholar 

  25. Njei B, Sharma P, McCarty TR, et al. Cannabis Use Is Associated With Increased Risk of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Analysis of the US Nationwide Inpatient Sample Database, 2004-2014. Pancreas 2018

  26. Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 2001;54:425–434

    Article  CAS  PubMed  Google Scholar 

  27. Liao W-C, Lee C-T, Chang C-Y, et al. Randomized trial of 1-minute versus 5-minute endoscopic balloon dilation for extraction of bile duct stones. Gastrointest Endosc 2010;72:1154–1162

    Article  PubMed  Google Scholar 

  28. Halttunen J, Meisner S, Aabakken L, et al. Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs. Scand J Gastroenterol 2014;49:752–758

    Article  PubMed  Google Scholar 

  29. Shah AP, Mourad MM, Bramhall SR. Acute pancreatitis: current perspectives on diagnosis and management. J Inflamm Res 2018;11:77–85

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Thoeni RF. The Revised Atlanta Classification of Acute Pancreatitis: Its Importance for the Radiologist and Its Effect on Treatment. Radiology 2012;262:751–764

    Article  PubMed  Google Scholar 

  31. Zaheer A, Singh VK, Qureshi RO, Fishman EK. The revised Atlanta classification for acute pancreatitis: updates in imaging terminology and guidelines. Abdom Imaging 2013;38:125–136

    Article  PubMed  Google Scholar 

  32. Shyu JY, Sainani NI, Sahni VA, et al. Necrotizing Pancreatitis: Diagnosis, Imaging, and Intervention. RadioGraphics 2014;34:1218–1239

    Article  PubMed  Google Scholar 

  33. Bollen TL, Singh VK, Maurer R, et al. Comparative evaluation of the modified CT severity index and CT severity index in assessing severity of acute pancreatitis. AJR Am J Roentgenol 2011;197:386–392

    Article  PubMed  Google Scholar 

  34. Woods RW, Akshintala VS, Singh VK, et al. CT severity of post-ERCP pancreatitis: results from a single tertiary medical center. Abdom Imaging 2014;39:1162–1168

    Article  PubMed  Google Scholar 

  35. Sundaralingam P, Masson P, Bourke MJ. Early Precut Sphincterotomy Does Not Increase Risk During Endoscopic Retrograde Cholangiopancreatography in Patients With Difficult Biliary Access: A Meta-analysis of Randomized Controlled Trials. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc 2015;13:1722-1729.e2

    Google Scholar 

  36. Chandrasekhara V, Khashab MA, Muthusamy VR, et al. Adverse events associated with ERCP. Gastrointest Endosc 2017;85:32–47

    Article  PubMed  Google Scholar 

  37. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335:909–918

    Article  CAS  PubMed  Google Scholar 

  38. Lee SH, Hong SG, Lee K yong, et al. Delayed Severe Hemobilia after Endoscopic Biliary Plastic Stent Insertion. Clin Endosc 2016;49:303–307

  39. Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001;96:417–423

    Article  CAS  PubMed  Google Scholar 

  40. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010;71:446–454

    Article  PubMed  Google Scholar 

  41. So YH, Choi YH, Chung JW, Jae HJ, Song S-Y, Park JH. Selective Embolization for Post-Endoscopic Sphincterotomy Bleeding: Technical Aspects and Clinical Efficacy. Korean J Radiol 2012;13:73–81

    Article  PubMed  Google Scholar 

  42. Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events: post-ERCP pancreatitis. Gastrointest Endosc Clin N Am 2015;25:107–121

    Article  PubMed  Google Scholar 

  43. Kubiliun NM, Adams MA, Akshintala VS, et al. Evaluation of Pharmacologic Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc 2015;13:1231–1239; quiz e70-71

  44. Canena J, Liberato M, Horta D, Romão C, Coutinho A. Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations. Surg Endosc 2013;27:313–324

    Article  PubMed  Google Scholar 

  45. Itoi T, Yasuda I, Doi S, Mukai T, Kurihara T, Sofuni A. Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding. Endoscopy 2011;43:369–372

    Article  CAS  PubMed  Google Scholar 

  46. Dunne R, McCarthy E, Joyce E, et al. Post-endoscopic biliary sphincterotomy bleeding: an interventional radiology approach. Acta Radiol Stockh Swed 1987 2013;54:1159–1164

    Google Scholar 

  47. Cho KB. The Management of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforation. Clin Endosc 2014;47:341–345

    Article  PubMed  PubMed Central  Google Scholar 

  48. Avgerinos DV, Llaguna OH, Lo AY, Voli J, Leitman IM. Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations. Surg Endosc 2009;23:833–838

    Article  PubMed  Google Scholar 

  49. Morgan KA, Fontenot BB, Ruddy JM, Mickey S, Adams DB. Endoscopic retrograde cholangiopancreatography gut perforations: when to wait! When to operate! Am Surg 2009;75:477–483; discussion 483-484

  50. Jin Y-J, Jeong S, Kim JH, et al. Clinical course and proposed treatment strategy for ERCP-related duodenal perforation: a multicenter analysis. Endoscopy 2013;45:806–812

    Article  PubMed  Google Scholar 

  51. Kumbhari V, Sinha A, Reddy A, et al. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc 2016;83:934–943

    Article  PubMed  Google Scholar 

  52. Park WY, Cho KB, Kim ES, Park KS. A Case of Ampullary Perforation Treated with a Temporally Covered Metal Stent. Clin Endosc 2012;45:177–180

    Article  PubMed  PubMed Central  Google Scholar 

  53. Vezakis A, Fragulidis G, Nastos C, Yiallourou A, Polydorou A, Voros D. Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent. World J Gastroenterol WJG 2011;17:4539–4541

    Article  PubMed  Google Scholar 

  54. Tonolini M, Pagani A, Bianco R. Cross-sectional imaging of common and unusual complications after endoscopic retrograde cholangiopancreatography. Insights Imaging 2015;6:323–338

    Article  PubMed  PubMed Central  Google Scholar 

  55. Salminen P, Laine S, Gullichsen R. Severe and fatal complications after ERCP: analysis of 2555 procedures in a single experienced center. Surg Endosc 2008;22:1965–1970

    Article  CAS  PubMed  Google Scholar 

  56. Colton JB, Curran CC. Quality indicators, including complications, of ERCP in a community setting: a prospective study. Gastrointest Endosc 2009;70:457–467

    Article  PubMed  Google Scholar 

  57. Ismail S, Kylänpää L, Mustonen H, et al. Risk factors for complications of ERCP in primary sclerosing cholangitis. Endoscopy 2012;44:1133–1138

    Article  CAS  PubMed  Google Scholar 

  58. Catalano OA, Sahani DV, Forcione DG, et al. Biliary Infections: Spectrum of Imaging Findings and Management. RadioGraphics 2009;29:2059–2080

    Article  PubMed  Google Scholar 

  59. Eun HW, Kim JH, Hong SS, Kim YJ. Assessment of acute cholangitis by MR imaging. Eur J Radiol 2012;81:2476–2480

    Article  PubMed  Google Scholar 

  60. Cao J, Peng C, Ding X, et al. Risk factors for post-ERCP cholecystitis: a single-center retrospective study. BMC Gastroenterol 2018;18:128

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  61. Chawla A, Bosco JI, Lim TC, Srinivasan S, Teh HS, Shenoy JN. Imaging of acute cholecystitis and cholecystitis-associated complications in the emergency setting. Singapore Med J 2015;56:438–444

    Article  PubMed  PubMed Central  Google Scholar 

  62. Catalano O, De Bellis M, Sandomenico F, de Lutio di Castelguidone E, Delrio P, Petrillo A. Complications of biliary and gastrointestinal stents: MDCT of the cancer patient. AJR Am J Roentgenol 2012;199:W187-196

  63. El Zein MH, Kumbhari V, Tieu A, et al. Duodenal perforation as a consequence of biliary stent migration can occur regardless of stent type or duration. Endoscopy 2014;46 Suppl 1 UCTN:E281-282

  64. van Boeckel PGA, Vleggaar FP, Siersema PD. Plastic or metal stents for benign extrahepatic biliary strictures: a systematic review. BMC Gastroenterol 2009;9:96

    Article  PubMed  PubMed Central  Google Scholar 

  65. Thomas S, Patel RP, Oto A. Resolution of pneumobilia as a predictor of biliary stent occlusion. Clin Imaging 2015;39:650–653

    Article  PubMed  Google Scholar 

  66. Dumonceau J-M, Tringali A, Blero D, et al. Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2012;44:277–298

    Article  PubMed  Google Scholar 

  67. Donepudi S, Chavalitdhamrong D, Pu L, Draganov PV. Air embolism complicating gastrointestinal endoscopy: A systematic review. World J Gastrointest Endosc 2013;5:359–365

    Article  PubMed  PubMed Central  Google Scholar 

  68. Gordy S, Rowell S. Vascular air embolism. Int J Crit Illn Inj Sci 2013;3:73–76

    Article  PubMed  PubMed Central  Google Scholar 

  69. Kalaitzakis E, Stern N, Sturgess R. Portal vein cannulation: An uncommon complication of endoscopic retrograde cholangiopancreatography. World J Gastroenterol WJG 2011;17:5131–5132

    Article  PubMed  Google Scholar 

  70. Woo KH, Kim JB, Chang YJ, et al. Portal Vein Occlusion after Biliary Metal Stent Placement in Hilar Cholangiocarcinoma. Gut Liver 2008;2:47–50

    Article  PubMed  PubMed Central  Google Scholar 

  71. Chavalitdhamrong D, Donepudi S, Pu L, Draganov PV. Uncommon and rarely reported adverse events of endoscopic retrograde cholangiopancreatography. Dig Endosc Off J Jpn Gastroenterol Endosc Soc 2014;26:15–22

    Google Scholar 

  72. Heo JH, Kang DH, Jung HJ, et al. Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones. Gastrointest Endosc 2007;66:720–726; quiz 768, 771

Download references

Author information

Authors and Affiliations

  1. Department of Radio Diagnosis, All India Institute of Medical Science, Ansari Nagar, New Delhi, 110029, India

    Dinesh Manoharan, Deep Narayan Srivastava, Arun Kumar Gupta & Kumble Seetharama Madhusudhan

Authors
  1. Dinesh Manoharan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deep Narayan Srivastava
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Arun Kumar Gupta
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kumble Seetharama Madhusudhan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kumble Seetharama Madhusudhan.

Ethics declarations

Conflict of interest

We authors declare that there are no disclosures to make.

IRB statement

This review article does not need IRB clearance.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Manoharan, D., Srivastava, D.N., Gupta, A.K. et al. Complications of endoscopic retrograde cholangiopancreatography: an imaging review. Abdom Radiol 44, 2205–2216 (2019). https://doi.org/10.1007/s00261-019-01953-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00261-019-01953-0

Keywords

Search

Navigation