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Post-endoscopic retrograde cholangiopancreatography (ERCP) septic complications

Andrea Tringali, MD, PhD
Silvano Loperfido, MD
Francesco Ferrara, MD
Guido Costamagna, MD, FACG
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Biliary drainage, usually by urgent endoscopic retrograde cholangiopancreatography (ERCP), is essential in the management of patients with acute obstructive cholangitis, and delayed or failed ERCP is associated with worse outcomes [1]. On the other hand, infection is one of the most morbid complications of ERCP and among the most common causes of ERCP-related death. Septic complications of ERCP include ascending cholangitis, liver abscess, acute cholecystitis, infected pancreatic pseudocyst, infection following perforation of a viscus, and less commonly, endocarditis/endovasculitis.

The post-ERCP septic complications of acute cholangitis, acute cholecystitis, and pancreatic sepsis will be reviewed here. Post-ERCP perforation and general overviews of acute cholangitis and acute cholecystitis are discussed separately. (See "Post-ERCP perforation" and "Acute cholangitis" and "Acute cholecystitis: Pathogenesis, clinical features, and diagnosis" and "Treatment of acute calculous cholecystitis".)


Bacteria can enter the biliary tract by either a hematogenous or, more frequently, a retrograde route. In patients with a normal biliary tract, anatomical barriers impede both these routes. In contrast, patients who are immunocompromised or who have obstruction of the biliary system have impaired bacterial defenses, making them more susceptible to these complications [2,3].

The most frequent organisms responsible for post-ERCP infections are enteric bacteria [4,5]. Although polymicrobial enteric flora are often found in infected bile, single organisms are isolated from blood cultures in the majority of patients [2]. In the 1980s, cross infection via contaminated endoscopes and ancillary ERCP equipment, such as cannulation catheters, was implicated in severe cases or outbreaks of septicemia from pseudomonas [6-8]. Improvements in the methods of disinfection have now made such nosocomial infections rare.

However, in recent years, outbreaks of multidrug-resistant pathogens (Klebsiella, Escherichia coli, Pseudomonas aeruginosa) associated with ERCP procedures have been reported [9-16]. The source of infection may be related to difficulty cleaning the elevator mechanism of duodenoscopes [9,17]. Therefore, when reprocessing duodenoscopes, the scientific societies and manufacturers recommend strict adherence to guidelines and reprocessing protocols. The elevator mechanism and the recesses surrounding it should be cleaned meticulously. As always, special care should be dedicated to routine microbial surveillance and regular quality assessment in preventing infection transmission [18]. Close cooperation between customers, regulatory bodies, and manufacturers is essential in the development of new equipment and in the management of outbreaks [17,19]. On August 4, 2015, the US Food and Drug Administration sent out a communication with supplemental measures to enhance reprocessing of duodenoscopes. Taking one or more of these additional steps may further reduce the risk of infection: microbiological culturing, ethylene oxide sterilization, use a liquid chemical sterilant processing system, or repeat high-level disinfection. In a single study center, the addition of ethylene oxide sterilization and frequent monitoring with cultures reduced duodenoscope contamination and eliminated clinical infections, but further investigation is necessary [20], especially because the time needed to sterilize the duodenoscopes is long (16 hours) and many facilities do not have the required equipment. (See "Endoscope disinfection", section on 'Endoscope reprocessing'.)

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Literature review current through: Nov 2017. | This topic last updated: May 17, 2016.
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