Comparison of ERCP-Related Adverse Events in Cirrhotics versus Non-Cirrhotics: A Systematic Review and Meta-Analysis

Abstract

Introduction: Patients with cirrhosis requiring Endoscopic retrograde cholangiopancreatography (ERCP) are at an increased risk of adverse events due to underlying liver dysfunction. The poor synthetic function can lead to elevated PTT and/or thrombocytopenia; both of which can contribute to bleeding. We performed a systematic review and meta-analysis of studies reporting the comparison between the ERCP-related adverse events in cirrhotics and non-cirrhotic patients.Table: Table. Description of studiesTable: Table. Sub-group analysisFigure: Overall complication Meta-analysis.Methods: We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE and Web of Science databases (from inception through April 2017) to identify studies that compared ERCP-related adverse events between cirrhotics and non-cirrhotics. The primary outcome was to estimate the overall rates of adverse events. The secondary outcome was to do a sub-group analysis for individual adverse events including hemorrhage, post-ERCP pancreatitis (PEP) and infections. Results: 6 studies reporting on 5527 cirrhotic and 20620 non cirrhotic ERCPs were identified. The use of ERCP in cirrhotic patients showed increased overall complications (odds ratio {OR}=1.611; 95% confidence intervals {CI}= 1.261-2.058; p < 0.05; I2=63.516%) with Eggers' regression tests confirming free of publication bias. Sub-group analysis showed increased rates of hemorrhage in cirrhotic patients (OR= 2.017; 95%CI=1.611-2.526; p < 0.05; I2=21.133%), increased rates of PEP (OR=1.33; 95%CI=1.043-1.696; p < 0.05, I2=64.981%) and increased rates of infection but not statistically significant (OR=1.614; 95%CI= 0.546-4.772; p=0.386; I2=61.081%). Conclusion: Cirrhosis is a risk factor for increased rates of ERCP-related adverse events. A thorough risk/benefit assessment should be should be performed in cirrhotic patients prior to ERCP. Also, referral of cirrhotic patients for ERCP's to large hospitals may improve outcomes.