Endoscopic retrograde cholangiopancreatography in cirrhosis - a systematic review and meta-analysis focused on adverse events

Abstract

AIMTo investigate indications and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhotics, especially adverse events. Patients with cirrhosis undergoing ERCP are believed to have increased risk. However, there is a paucity of literature describing the indications and outcomes of ERCP procedures in patients with cirrhosis, especially focusing on adverse events.METHODSWe performed a systematic appraisal of major literature databases, including PubMed and EMBASE, with a manual search of literature from their inception until April 2017.RESULTSA total of 6,505 patients from 15 studies were analyzed (male ratio 59%, mean age 59 years), 11% with alcoholic and 89% with non-alcoholic cirrhosis, with 56.2% Child-Pugh class A, and 43.8% class B or C. Indications for ERCP included choledocholithiasis 60.9%, biliary strictures 26.2%, gallstone pancreatitis 21.1% and cholangitis 15.5%. Types of interventions included endoscopic sphincterotomy 52.7%, biliary stenting 16.7% and biliary dilation 4.6%. Individual adverse events included hemorrhage in 4.58% (95%CI: 2.77-6.75%, I2 = 85.9%), post-ERCP pancreatitis (PEP) in 3.68% (95%CI: 1.83-6.00%, I2 = 89.5%), cholangitis in 1.93% (95%CI: 0.63-3.71%, I2 = 87.1%) and perforation in 0.00% (95%CI: 0.00-0.23%, I2 = 37.8%). Six studies were used for comparison of ERCP-related complications in cirrhosis vs non-cirrhosis, which showed higher overall rates of complications in cirrhosis patients with pooled OR of 1.63 (95%CI: 1.27-2.09, I2 = 65%): higher rates of hemorrhage with OR of 2.05 (95%CI: 1.62-2.58, I2 = 2.1%) and PEP with OR of 1.33 (95%CI: 1.04-1.70, I2=65%), but similar cholangitis rates with OR of 1.23 (95%CI: 0.67-2.26, I2 = 44.3%).CONCLUSIONThere is an overall higher rate of adverse events related to ERCP in patients with cirrhosis, especially hemorrhage and PEP. A thorough risk/benefit assessment should be performed prior to undertaking ERCP in patients with cirrhosis.

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

“…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].…”

Endoscopic papillary balloon dilation decreases the risk of bleeding in cirrhotic patients compared with endoscopic biliary sphincterotomy

“…There is an overall higher rate of hemorrhage related to ERCP in patients with cirrhosis. [19] One meta-analysis showed the incidence of post-ERCP bleeding is 4.58% (95%CI: 2.77–6.75%, I 2 = 85.9%). [19] The incidences vary from 1.1% to 25% in different reports.…”

“…[19] One meta-analysis showed the incidence of post-ERCP bleeding is 4.58% (95%CI: 2.77–6.75%, I 2 = 85.9%). [19] The incidences vary from 1.1% to 25% in different reports. [1,15–17,20,21] The variations among these studies could arise because of differences in the patient populations, types of procedures and the definition of bleeding.…”

Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery?

“… 22 In addition, early cholecystectomy should be considered after patients are stabilized because later onset episodes of complications may impose a higher risk on these patients. 23 , 24 Although LC is recognized as a safe procedure under emergency circumstances, even for cirrhotic patients, 25 planned and elective LC should be the first choice for symptomatic GB stones.…”