ERCP Adverse Events - Still with us in the "Modern Era"

Review by Prof. Humphrey O'Connor (Ireland)

Study Summary 

Although capable of providing excellent patient outcomes, the Achilles heel of ERCP is the continued risk of life-threatening adverse events (AEs). With that in mind, two recent complementary studies deserve attention. The first is a systematic review and meta-analysis of ERCP AEs in 380 randomized controlled trials and observational studies from the year 2000 onwards involving > 2 million patients and described by the authors as the most comprehensive review of ERCP-associated AEs performed to date. The overall incidence of post-ERCP pancreatitis (PEP) was 4.6% among all-comers, 6.5% among first-time patients and remained stable between 2000 and 2023. The incidences of other AEs for all-comers were - bleeding 1.5%, cholangitis 2.5%, cholecystitis 0.8%, and perforation 0.2%. The incidence of death attributable to ERCP was 0.2%. The second study using multicenter prospective data correlated patient-reported experience during and after ERCP with post-ERCP AEs and unplanned healthcare utilization in 3434 patients undergoing first ERCP. Patient-reported abdominal pain after ERCP was significantly associated with PEP, perforation, and unplanned healthcare utilization.

Commentary 

Despite modern era improvements in endoscopy technology and techniques, post-ERCP AEs have not reduced and PEP remains a key concern. Rectal NSAIDs, prophylactic pancreatic stenting, and aggressive IV fluids have all been shown to reduce the risk of PEP yet are all underused in clinical practice (<50% in Study 2). The European Society for Gastrointestinal Endoscopy recommends rectal indomethacin for all patients undergoing ERCP. Also, watch out for abdominal pain after ERCP. These studies are a wakeup call on the current state of ERCP AEs and the need for measures to improve patient safety.

Citation

Bishay K, Meng ZW, Khan R, et al. Adverse events associated with Endoscopic Retrograde Cholangiopancreatography: Systematic Review and Meta-Analysis. Gastroenterology 2025;168: 568-586.

Ceccacci A, Gupta M, Eisele M, et al. Intra- and post-procedural patient-reported experience measures and their correlation with post-ERCP adverse events and unplanned healthcare utilization. Endoscopy 2025;57: 220-227.

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