Risk of Adverse Events Following ERCP in Patients with Cirrhosis

Abstract

Introduction: Patients with cirrhosis may be at increased risk for adverse events due to endoscopic retrograde cholangiopancreatography (ERCP) because of underlying ascites, coagulopathy, biliary abnormalities, encephalopathy and concern for decompensation. There are limited data regarding the safety of ERCP in cirrhosis and complications that may ensue. Our aim was to assess the risk of post-ERCP adverse events in patients with cirrhosis. Methods: A retrospective review of all ERCP procedures performed between 2012 and 2015 at a large tertiary care institution. Adverse events of cirrhotic patients were compared with a control group of randomly selected non-cirrhotic patients who underwent ERCP. Univariate analysis was performed using chi-square and ANOVA tests. Multivariate logistic regression was used to examine associations leading to adverse events. Results: Out of 1610 ERCPs, 129 procedures were performed in 56 patients with cirrhosis that were compared to 123 procedures in 79 non-cirrhotic patients (Table 1). Primary sclerosing cholangitis was the most frequent indication for ERCP in cirrhosis. The cirrhosis group had major hepatic functional compromise (Child-Turcotte-Pugh (CTP) class B and C, 55.8% and 17.8%, respectively) Thirty-day procedure-related adverse events included post-ERCP pancreatitis, hemorrhage, cholangitis and death (Table 2). Overall incidence of adverse events was higher in the cirrhosis group (19.4% vs 9%; p=0.019), with a trend towards increased risk of bleeding (1.6% vs 6.2%; p=0.065). Generally, complications were numerically higher in CTP class B and C patients (11.8% vs 22.2% vs 21.7%; p=0.424) with cholangitis more common with CTP class C cirrhosis (2.9% vs 4.2% vs 17.4%; p= 0.048). Sphincterotomy was more frequently performed in non-cirrhotic patients (42.6% vs 27.1%; p=0.011) with a higher rate of overall complications (p=0.001) and post-ERCP pancreatitis (p=0.004) in this group. Multivariate analysis identified sphincterotomy (OR=5.15, 95% CI 2.32-11.42; p < 0.001) and cirrhosis (OR=3.40, 95% CI 1.51-7.65; p=0.002) as significant predictors of post-ERCP adverse events.Table 1: Univariate analysis comparing ERCPs in cirrhotic vs. non-cirrhotic patientsTable 2: Adverse events associated with ERCPConclusion: Post-ERCP complications occur at a higher rate in patients with cirrhosis. Primary sclerosing cholangitis is the major indication for ERCP in our cohort of cirrhotic patients. Our data suggest that increased risks for bleeding and cholangitis may be the cause for the higher complication rate, although larger multicenter studies are needed to explore these potential associations.