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Tarar ZI, Farooq U, Gandhi M, Saleem S, Daglilar E. Safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis compared to non-cirrhosis and effect of Child-Pugh score on post-ERCP complications: a systematic review and meta-analysis. Clin Endosc 2023; 56:578-589. [PMID: 37157959 PMCID: PMC10565436 DOI: 10.5946/ce.2023.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND/AIMS The safety of endoscopic retrograde cholangiopancreatography (ERCP) in hepatic cirrhosis and the impact of Child-Pugh class on post-ERCP complications need to be better studied. We investigated the post-ERCP complication rates in patients with cirrhosis compared with those without cirrhosis. METHODS We conducted a literature search of relevant databases to identify studies that reported post-ERCP complications in patients with hepatic cirrhosis. RESULTS Twenty-four studies comprising 28,201 patients were included. The pooled incidence of post-ERCP complications in cirrhosis was 15.5% (95% confidence interval [CI], 11.8%-19.2%; I2=96.2%), with an individual pooled incidence of pancreatitis 5.1% (95% CI, 3.1%-7.2%; I2=91.5%), bleeding 3.6% (95% CI, 2.8%-4.5%; I2=67.5%), cholangitis 2.9% (95% CI, 1.9%-3.8%; I2=83.4%), and perforation 0.3% (95% CI, 0.1%-0.5%; I2=3.7%). Patients with cirrhosis had a greater risk of post-ERCP complications (risk ratio [RR], 1.41; 95% CI, 1.16-1.71; I2=56.3%). The risk of individual odds of adverse events between cirrhosis and non-cirrhosis was as follows: pancreatitis (RR, 1.25; 95% CI, 1.06-1.48; I2=24.8%), bleeding (RR, 1.94; 95% CI, 1.59-2.37; I2=0%), cholangitis (RR, 1.15; 95% CI, 0.77-1.70; I2=12%), and perforation (RR, 1.20; 95% CI, 0.59-2.43; I2=0%). CONCLUSION Cirrhosis is associated with an increased risk of post-ERCP pancreatitis, bleeding, and cholangitis.
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Affiliation(s)
- Zahid Ijaz Tarar
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Umer Farooq
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Mustafa Gandhi
- Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | - Saad Saleem
- Department of Medicine, Sunrise Hospital and Medical Center, Las Vegas, NV, USA
| | - Ebubekir Daglilar
- Department of Gastroenterology and Hepatology, Charleston area Medical Center, West Virginia University School of Medicine, Charleston, WV, USA
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Mashiana HS, Dhaliwal AS, Sayles H, Dhindsa B, Yoo JW, Wu Q, Singh S, Siddiqui AA, Ohning G, Girotra M, Adler DG. Endoscopic retrograde cholangiopancreatography in cirrhosis - a systematic review and meta-analysis focused on adverse events. World J Gastrointest Endosc 2018; 10:354-366. [PMID: 30487946 PMCID: PMC6247096 DOI: 10.4253/wjge.v10.i11.354] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/17/2018] [Accepted: 08/21/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To 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. METHODS We performed a systematic appraisal of major literature databases, including PubMed and EMBASE, with a manual search of literature from their inception until April 2017. RESULTS A 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%, I 2 = 85.9%), post-ERCP pancreatitis (PEP) in 3.68% (95%CI: 1.83-6.00%, I 2 = 89.5%), cholangitis in 1.93% (95%CI: 0.63-3.71%, I 2 = 87.1%) and perforation in 0.00% (95%CI: 0.00-0.23%, I 2 = 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, I 2 = 65%): higher rates of hemorrhage with OR of 2.05 (95%CI: 1.62-2.58, I 2 = 2.1%) and PEP with OR of 1.33 (95%CI: 1.04-1.70, I 2=65%), but similar cholangitis rates with OR of 1.23 (95%CI: 0.67-2.26, I 2 = 44.3%). CONCLUSION There 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.
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Affiliation(s)
- Harmeet Singh Mashiana
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89102, United States
| | - Amaninder Singh Dhaliwal
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE 68198-2000, United States
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE 68198-2000, United States
| | - Banreet Dhindsa
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89102, United States
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89102, United States
| | - Qing Wu
- Nevada Institute of Personalized Medicine, Department of Environmental and Occupational Health, School of Community Health Sciences, University of Nevada, Las Vegas, NV 89154-4009, United States
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE 68198-2000, United States
| | - Ali A Siddiqui
- Division of Gastroenterology, Jefferson Medical College, Philadelphia, PA 19107, United States
| | - Gordon Ohning
- Division of Gastroenterology, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89102, United States
| | - Mohit Girotra
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, UT 84132, United States
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