Adverse Events and Acute Chronic Liver Failure in Patients With Cirrhosis Undergoing Endoscopic Retrograde Cholangiopancreatography: A Multicenter Matched-Cohort Study

Leal, Carles; Prado, Verónica; Colán, Juan; Chavez-Rivera, Karina; Sendino, Oriol; Blasi, A; Roura, P.; Juanola, Adrià; Miguel, Cristina Rodríguez de; Pavesi, Marco; Gómez, Cristina; Guarner, Carlos; Fernández, Javier; Cárdenas, Andrés

doi:10.1038/s41395-018-0218-1

Cited by 22 publications

(34 citation statements)

References 24 publications

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“…This finding adds to a growing body of research suggesting that only Child-Pugh class C is truly predictive of adverse events[5,8,9]. The implication that MELD-Na may be a more useful predictive tool is particularly notable as our review of the literature found that only a few studies evaluated MELD-Na score when examining outcomes of interventional GI procedures in patients with cirrhosis[6].…”

Section: Discussionmentioning

confidence: 76%

Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients

Yoo¹,

Epistola²,

Epistola³

et al. 2019

WJGE

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BACKGROUNDHepatic cirrhosis is associated with greater adverse event rates following surgical procedures and is thought to have a higher risk of complications with interventional procedures in general. However, these same patients often require interventional gastrointestinal procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). While studies examining this scenario exist, the overall body of evidence for adverse event rates associated with ERCP/EUS procedures is more limited. We sought add to the literature by examining the incidence of adverse events after ERCP/EUS procedures in our safety-net hospital population with the hypothesis that severity of cirrhosis correlates with higher adverse event rates.AIMTo examine whether increasing severity of cirrhosis is associated with greater incidence of adverse events after interventional ERCP/EUS procedures.METHODSWe performed a retrospective study of patients diagnosed with hepatic cirrhosis who underwent ERCP and/or EUS-guided fine needle aspirations/fine needle biopsies from January 1, 2016 to March 14, 2019 at our safety net hospital. We recorded Child-Pugh and Model for End-stage Liver Disease (MELD-Na) scores at time of procedure, interventions completed, and 30-day post-procedural adverse events. Statistical analyses were done to assess whether Child-Pugh class and MELD-Na score were associated with greater adverse event rates and whether advanced techniques (single-operator cholangioscopy, electrohydraulic lithotripsy/laser lithotripsy, or needle-knife techniques) were associated with higher complication rates.RESULTS77 procedures performed on 36 patients were included. The study population consisted primarily of middle-aged Hispanic males. 30-d procedure-related adverse events included gastrointestinal bleeding (7.8%), infection (6.5%), and bile leak (2%). The effect of Child-Pugh class C vs class A and B significantly predicted adverse events (β = 0.55, P < 0.01). MELD-Na scores also significantly predicted adverse events (β = 0.037, P < 0.01). Presence of advanced techniques was not associated with higher adverse events (P > 0.05). When MELD-Na scores were added as predictors with the effect of Child-Pugh class C, logistic regression showed MELD-Na scores were a significant predictor of adverse events (P < 0.01). The findings held after controlling for age, gender, ethnicity and repeat cases.CONCLUSIONIncreasing cirrhosis severity predicted adverse events while the presence of advanced techniques did not. MELD-Na score may be more useful in predicting adverse events than Child-Pugh class.

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Section: Discussionmentioning

confidence: 76%

Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients

Yoo¹,

Epistola²,

Epistola³

et al. 2019

WJGE

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“…With respect to post-sphincterotomy bleeding (PSB), risk factors mentioned in the above recommendation are independent and were evidenced in at least two of 10 studies summarized in Table 2s. Cirrhosis was confirmed as a risk factor in a meta-analysis (6 studies, 5526 patients) [39] and in a more recent matched cohort retrospective study (331 patients) [40]. Dialysis for end-stage renal disease was associated with PSB in all four casecontrol studies (7508 cases vs. 450 246 controls) on the topic (OR 1.4, 95 %CI 1.2 -1.6 in the largest study) [36,37,41,42], and particularly year-long hemodialysis [43].…”

Section: Risk Factors For Post-sphincterotomy Bleedingmentioning

confidence: 89%

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2019

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Main Recommendations Prophylaxis 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before endoscopic retrograde cholangiopancreatography (ERCP) in all patients without contraindications to nonsteroidal anti-inflammatory drug administration.Strong recommendation, moderate quality evidence. 2 ESGE recommends prophylactic pancreatic stenting in selected patients at high risk for post-ERCP pancreatitis (inadvertent guidewire insertion/opacification of the pancreatic duct, double-guidewire cannulation).Strong recommendation, moderate quality evidence. 3 ESGE suggests against routine endoscopic biliary sphincterotomy before the insertion of a single plastic stent or an uncovered/partially covered self-expandable metal stent for relief of biliary obstruction.Weak recommendation, moderate quality evidence. 4 ESGE recommends against the routine use of antibiotic prophylaxis before ERCP.Strong recommendation, moderate quality evidence. 5 ESGE suggests antibiotic prophylaxis before ERCP in the case of anticipated incomplete biliary drainage, for severely immunocompromised patients, and when performing cholangioscopy.Weak recommendation, moderate quality evidence. 6 ESGE suggests tests of coagulation are not routinely required prior to ERCP for patients who are not on anticoagulants and not jaundiced.Weak recommendation, low quality evidence. Treatment 7 ESGE suggests against salvage pancreatic stenting in patients with post-ERCP pancreatitis.Weak recommendation, low quality evidence. 8 ESGE suggests temporary placement of a biliary fully covered self-expandable metal stent for post-sphincterotomy bleeding refractory to standard hemostatic modalities.Weak recommendation, low quality evidence. 9 ESGE suggests to evaluate patients with post-ERCP cholangitis by abdominal ultrasonography or computed tomography (CT) scan and, in the absence of improvement with conservative therapy, to consider repeat ERCP. A bile sample should be collected for microbiological examination during repeat ERCP.Weak recommendation, low quality evidence.

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“…The risk of ACLF was significantly higher in those with greater hepatic decompensation (Model for End‐Stage Liver Disease score ≥15) at baseline. The occurrence of ACLF after ERCP was driven by adverse events, particularly cholangitis . Regardless of the invasive procedure, it appears that diligent assessment of hepatic reserve should be completed prior to any treatment, in an effort to prevent the development of ACLF.…”

Section: Invasive Proceduresmentioning

confidence: 99%

Precipitants of Acute‐on‐Chronic Liver Failure: An Opportunity for Preventative Measures to Improve Outcomes

et al. 2020

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Acute-on-chronic liver failure (ACLF) is a feared complication that can develop at any stage of chronic liver disease. The incidence of ACLF is increasing, leading to a significant burden to both the affected individual and health care systems. To date, our understanding of ACLF suggests that it may be initiated by precipitants such as systemic infection, alcohol use, or viral hepatitis. The prevalence of these vary significantly by geography and underlying liver disease, and these precipitants have a varying impact on patient prognosis. Herein, we present a review of our current understanding of the precipitants of ACLF, including gaps in current data and opportunities for meaningful intervention and areas of future research. Liver Transplantation 26 283-293 2020 AASLD.liveR tRAnsplAntAtion, vol. 26, no. 2, 2020 cullARo et Al.

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Adverse Events and Acute Chronic Liver Failure in Patients With Cirrhosis Undergoing Endoscopic Retrograde Cholangiopancreatography: A Multicenter Matched-Cohort Study

Cited by 22 publications

References 24 publications

Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients

Evaluating the risk of adverse events with interventional endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures in cirrhotic patients

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Precipitants of Acute‐on‐Chronic Liver Failure: An Opportunity for Preventative Measures to Improve Outcomes

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