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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is currently a primarily therapeutic procedure that is extensively employed to treat several biliopancreatic disorders. Although widely considered a safe procedure, ERCP is associated with a non-negligible morbidity and occasional mortality. Due to the number and complexity of operative ERCPs performed, radiologists are increasingly faced with urgent requests for investigation of suspected post-procedural complications, which often have similar clinical and laboratory manifestations. This pictorial essay reviews the usual post-procedural CT findings, the clinical features and imaging appearances of common and unusual post-ERCP occurrences including interstitial oedematous and necrotising acute pancreatitis, haemorrhages, retroperitoneal and intraperitoneal duodenal perforations, infections and stent-related complications. Emphasis is placed on the pivotal role of multidetector CT, which is warranted after complex or prolonged ERCP procedures as it represents the most effective modality to detect and grade ERCP-related complications and to monitor nonsurgically treated patients. Timely diagnosis and optimal management require a combination of clinical and laboratory data with imaging appearances; therefore, this article aims to provide an increased familiarity with interpretation of early post-ERCP studies, particularly to triage those occurrences that require interventional or surgical treatment. In selected patients MRI allows imaging pancreatitis and abnormal collections without the use of ionising radiation. Teaching Points • Endoscopic retrograde cholangiopancreatography (ERCP) allows treating many biliopancreatic disorders.• Due to the number and complexity of procedures, post-ERCP complications are increasingly encountered.• Main complications include acute pancreatitis, haemorrhages, duodenal perforation and infections.• Diagnosis and management of complications rely on combined clinical, laboratory and imaging data.• Multidetector CT is most effective to diagnose, categorise and monitor post-ERCP complications.
Highlights
BackgroundDue to the widespread availability of non-invasive imaging techniques such as magnetic resonance cholangiopancreatography (MRCP) and multidetector computed tomography (CT), during the last decade endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool towards a primarily therapeutic procedure
Considered a safe procedure that often obviates the need for surgery, Endoscopic retrograde cholangiopancreatography (ERCP) has limited contraindications such as upper aerodigestive obstruction, severe coagulopathy, oesophageal and/or gastric varices, anaphylactic reaction to iodinated contrast medium (CM), acute nonbiliary pancreatitis, severe cardiopulmonary impairment and recent myocardial infarction
According to the guidelines issued by the American Society for Gastrointestinal Endoscopy (ASGE) and the World Society of Emergency Surgery (WSES), diagnosis and management of ERCP-related complications should rely upon a combination of clinical, laboratory and imaging data
Summary
Due to the widespread availability of non-invasive imaging techniques such as magnetic resonance cholangiopancreatography (MRCP) and multidetector computed tomography (CT), during the last decade endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool towards a primarily therapeutic procedure. Following identification and cannulation of the ampullary orifice and CM injection under fluoroscopy, current endoscopic equipment allows performing sphincterotomy, extraction of common bile duct (CBD) stones, lithotripsy, biliary drainage, stricture dilatation, brush cytology and biopsy [1,2,3]. Plastic stents are commonly used to treat benign strictures, postoperative bile leaks and pancreatic diseases. The reported incidence of ERCP-specific complications ranges from 5 to 40 %, depending on the underlying diagnosis, patient age and comorbidities, complexity of the procedure, and operator experience. The risk of complications is increased by operative techniques such as use of balloons and dilating catheters, tissue sampling, mechanical lithotripsy and wire baskets for stone extraction, and plastic and metallic biliary stents. Related to operative procedures, ERCP-related mortality (0.5–1.4 %) may result from any of the above-mentioned complications and is high in elderly patients with comorbidities and in centres with limited caseloads [2, 6,7,8, 10]
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