Post-endoscopic retrograde cholangiopancreatography (ERCP) septic complications
- Andrea Tringali, MD, PhD
Andrea Tringali, MD, PhD
- Assistant Professor
- Catholic University of Rome
- Silvano Loperfido, MD
Silvano Loperfido, MD
- Consultant of Gastroenterology
- Center Salute&Cultura
- Treviso, Italy
- Francesco Ferrara, MD
Francesco Ferrara, MD
- Treviso Hospital, Italy
- Guido Costamagna, MD, FACG
Guido Costamagna, MD, FACG
- Professor of Surgery
- Universita Cattolica del Sacro Cuore, Rome
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 . 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 . 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 . 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 , 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".)
- Khashab MA, Tariq A, Tariq U, et al. Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis. Clin Gastroenterol Hepatol 2012; 10:1157.
- Subhani JM, Kibbler C, Dooley JS. Review article: antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP). Aliment Pharmacol Ther 1999; 13:103.
- Zong Z. Biliary tract infection or colonization with Elizabethkingia meningoseptica after endoscopic procedures involving the biliary tract. Intern Med 2015; 54:11.
- Anderson DJ, Shimpi RA, McDonald JR, et al. Infectious complications following endoscopic retrograde cholangiopancreatography: an automated surveillance system for detecting postprocedure bacteremia. Am J Infect Control 2008; 36:592.
- Llach J, Bordas JM, Almela M, et al. Prospective assessment of the role of antibiotic prophylaxis in ERCP. Hepatogastroenterology 2006; 53:540.
- Devière J, Motte S, Dumonceau JM, et al. Septicemia after endoscopic retrograde cholangiopancreatography. Endoscopy 1990; 22:72.
- Motte S, Deviere J, Dumonceau JM, et al. Risk factors for septicemia following endoscopic biliary stenting. Gastroenterology 1991; 101:1374.
- Davion T, Braillon A, Delamarre J, et al. Pseudomonas aeruginosa liver abscesses following endoscopic retrograde cholangiography. Report of a case without biliary tract disease. Dig Dis Sci 1987; 32:1044.
- Epstein L, Hunter JC, Arwady MA, et al. New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014; 312:1447.
- Aumeran C, Poincloux L, Souweine B, et al. Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography. Endoscopy 2010; 42:895.
- Muscarella LF. Risk of transmission of carbapenem-resistant Enterobacteriaceae and related "superbugs" during gastrointestinal endoscopy. World J Gastrointest Endosc 2014; 6:457.
- Gastmeier P, Vonberg RP. Klebsiella spp. in endoscopy-associated infections: we may only be seeing the tip of the iceberg. Infection 2014; 42:15.
- Kola A, Piening B, Pape UF, et al. An outbreak of carbapenem-resistant OXA-48 - producing Klebsiella pneumonia associated to duodenoscopy. Antimicrob Resist Infect Control 2015; 4:8.
- Wendorf KA, Kay M, Baliga C, et al. Endoscopic retrograde cholangiopancreatography-associated AmpC Escherichia coli outbreak. Infect Control Hosp Epidemiol 2015; 36:634.
- Verfaillie CJ, Bruno MJ, Voor in 't Holt AF, et al. Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa. Endoscopy 2015; 47:493.
- Ross AS, Baliga C, Verma P, et al. A quarantine process for the resolution of duodenoscope-associated transmission of multidrug-resistant Escherichia coli. Gastrointest Endosc 2015; 82:477.
- Rutala WA, Weber DJ. Gastrointestinal endoscopes: a need to shift from disinfection to sterilization? JAMA 2014; 312:1405.
- ASGE Technology Committee, Komanduri S, Abu Dayyeh BK, et al. Technologies for monitoring the quality of endoscope reprocessing. Gastrointest Endosc 2014; 80:369.
- Beilenhoff U. ERCP and reprocessing in focus: what can we do to prevent or manage infection outbreaks? Endoscopy 2015; 47:483.
- Naryzhny I, Silas D, Chi K. Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak. Gastrointest Endosc 2016; 84:259.
- Kullman E, Borch K, Lindström E, et al. Bacteremia following diagnostic and therapeutic ERCP. Gastrointest Endosc 1992; 38:444.
- Mollison LC, Desmond PV, Stockman KA, et al. A prospective study of septic complications of endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol 1994; 9:55.
- Sauter G, Grabein B, Huber G, et al. Antibiotic prophylaxis of infectious complications with endoscopic retrograde cholangiopancreatography. A randomized controlled study. Endoscopy 1990; 22:164.
- Niederau C, Pohlmann U, Lübke H, Thomas L. Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study. Gastrointest Endosc 1994; 40:533.
- Byl B, Devière J, Struelens MJ, et al. Antibiotic prophylaxis for infectious complications after therapeutic endoscopic retrograde cholangiopancreatography: a randomized, double-blind, placebo-controlled study. Clin Infect Dis 1995; 20:1236.
- Mani V, Cartwright K, Dooley J, et al. Antibiotic prophylaxis in gastrointestinal endoscopy: a report by a Working Party for the British Society of Gastroenterology Endoscopy Committee. Endoscopy 1997; 29:114.
- Durack DT. Prevention of infective endocarditis. N Engl J Med 1995; 332:38.
- Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007; 102:1781.
- Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007; 39:793.
- Wang P, Li ZS, Liu F, et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 2009; 104:31.
- Kager LM, Sjouke B, van den Brand M, et al. The role of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography; a retrospective single-center evaluation. Scand J Gastroenterol 2012; 47:245.
- Deviere J, Baize M, de Toeuf J, Cremer M. Long-term follow-up of patients with hilar malignant stricture treated by endoscopic internal biliary drainage. Gastrointest Endosc 1988; 34:95.
- Polydorou AA, Cairns SR, Dowsett JF, et al. Palliation of proximal malignant biliary obstruction by endoscopic endoprosthesis insertion. Gut 1991; 32:685.
- Chang WH, Kortan P, Haber GB. Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage. Gastrointest Endosc 1998; 47:354.
- Rerknimitr R, Attasaranya S, Kladchareon N, et al. Feasibility and complications of endoscopic biliary drainage in patients with malignant biliary obstruction at King Chulalongkorn Memorial Hospital. J Med Assoc Thai 2002; 85 Suppl 1:S48.
- Bangarulingam SY, Gossard AA, Petersen BT, et al. Complications of endoscopic retrograde cholangiopancreatography in primary sclerosing cholangitis. Am J Gastroenterol 2009; 104:855.
- Rerknimitr R, Kladcharoen N, Mahachai V, Kullavanijaya P. Result of endoscopic biliary drainage in hilar cholangiocarcinoma. J Clin Gastroenterol 2004; 38:518.
- Paik WH, Park YS, Hwang JH, et al. Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach. Gastrointest Endosc 2009; 69:55.
- Rerknimitr R, Fogel EL, Kalayci C, et al. Microbiology of bile in patients with cholangitis or cholestasis with and without plastic biliary endoprosthesis. Gastrointest Endosc 2002; 56:885.
- Boender J, Nix GA, de Ridder MA, et al. Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones. Am J Gastroenterol 1995; 90:233.
- Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998; 48:1.
- Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335:909.
- Navaneethan U, Gutierrez NG, Jegadeesan R, et al. Delay in performing ERCP and adverse events increase the 30-day readmission risk in patients with acute cholangitis. Gastrointest Endosc 2013; 78:81.
- Khardori N, Wong E, Carrasco CH, et al. Infections associated with biliary drainage procedures in patients with cancer. Rev Infect Dis 1991; 13:587.
- Katsinelos P, Dimiropoulos S, Katsiba D, et al. Pseudomonas aeruginosa liver abscesses after diagnostic endoscopic retrograde cholangiography in two patients with sphincter of Oddi dysfunction type 2. Surg Endosc 2002; 16:1638.
- Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37:383.
- Nelson DB. Infectious disease complications of GI endoscopy: part II, exogenous infections. Gastrointest Endosc 2003; 57:695.
- Lillemoe KD, Pitt HA, Kaufman SL, Cameron JL. Acute cholecystitis occurring as a complication of percutaneous transhepatic drainage. Surg Gynecol Obstet 1989; 168:348.
- Leung JW, Chung SC, Sung JY, Li MK. Acute cholecystitis after stenting of the common bile duct for obstruction secondary to pancreatic cancer. Gastrointest Endosc 1989; 35:109.
- Ainley CC, Williams SJ, Smith AC, et al. Gallbladder sepsis after stent insertion for bile duct obstruction: management by percutaneous cholecystostomy. Br J Surg 1991; 78:961.
- Dolan R, Pinkas H, Brady PG. Acute cholecystitis after palliative stenting for malignant obstruction of the biliary tree. Gastrointest Endosc 1993; 39:447.
- Alvarez C, Hunt K, Ashley SW, Reber HA. Emphysematous cholecystitis after ERCP. Dig Dis Sci 1994; 39:1719.
- Takano H, Yoshikawa T, Nishida K, et al. Candida cholecystitis as an unusual complication of endoscopic retrograde cholangiography. Endoscopy 1996; 28:790.
- Benchimol D, Bernard JL, Mouroux J, et al. Infectious complications of endoscopic retrograde cholangio-pancreatography managed in a surgical unit. Int Surg 1992; 77:270.
- Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001; 96:417.
- Ho H, Mahajan A, Gosain S, et al. Management of complications associated with partially covered biliary metal stents. Dig Dis Sci 2010; 55:516.
- Harris HW, Davis BR, Vitale GC. Cholecystectomy after endoscopic sphincterotomy for common bile duct stones: is surgery necessary? Surg Innov 2005; 12:187.
- Hawes RH. Endoscopic management of pseudocysts. Rev Gastroenterol Disord 2003; 3:135.
- Sherman S. ERCP and endoscopic sphincterotomy-induced pancreatitis. Am J Gastroenterol 1994; 89:303.
- Fujinaga T, Nishida T, Miyazaki M, et al. Acute suppurative pancreatic ductitis associated with pancreatic duct obstruction. Endoscopy 2013; 45 Suppl 2 UCTN:E135.
- Isono Y, Matsusaki S, Tanaka H, et al. [Acute obstructive suppurative pancreatic ductitis after endoscopic retrograde cholangiopancreatography in a patient with carcinoma of the pancreatic head:a case report]. Nihon Shokakibyo Gakkai Zasshi 2016; 113:289.
- Inamdar S, Berzin TM, Berkowitz J, et al. Decompensated cirrhosis may be a risk factor for adverse events in endoscopic retrograde cholangiopancreatography. Liver Int 2016; 36:1457.
- ASGE STANDARDS OF PRACTICE COMMITTEE, Banerjee S, Shen B, et al. Infection control during GI endoscopy. Gastrointest Endosc 2008; 67:781.
- Collen MJ, Hanan MR, Maher JA, Stubrin SE. Modification of endoscopic retrograde cholangiopancreatography (ERCP) septic complications by the addition of an antibiotic to the contrast media. Randomized controlled investigation. Am J Gastroenterol 1980; 74:493.
- Bernadino KP, Howell DA, Lawrence C, et al. Near absence of septic complications following successful therapeutic ERCP justifies selective intravenous and intracontrast use of antibiotics. Gastrointest Endosc 2005; 61:AB187.
- Ramirez FC, Osato MS, Graham DY, Woods KL. Addition of gentamicin to endoscopic retrograde cholangiopancreatography (ERCP) contrast medium towards reducing the frequency of septic complications of ERCP. J Dig Dis 2010; 11:237.
- Norouzi A, Khatibian M, Afroogh R, et al. The effect of adding gentamicin to contrast media for prevention of cholangitis after biliary stenting for non-calculous biliary obstruction, a randomized controlled trial. Indian J Gastroenterol 2013; 32:18.
- Zidi SH, Prat F, Le Guen O, et al. Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures. Gut 2000; 46:103.
- Lopera JE, Soto JA, Múnera F. Malignant hilar and perihilar biliary obstruction: use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions. Radiology 2001; 220:90.
- Freeman ML, Overby C. Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents. Gastrointest Endosc 2003; 58:41.
- De Palma GD, Pezzullo A, Rega M, et al. Unilateral placement of metallic stents for malignant hilar obstruction: a prospective study. Gastrointest Endosc 2003; 58:50.
- Rerknimitr R, Angsuwatcharakon P, Ratanachu-ek T, et al. Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma. J Gastroenterol Hepatol 2013; 28:593.
- Pisello F, Geraci G, Modica G, Sciumè C. Cholangitis prevention in endoscopic Klatskin tumor palliation: air cholangiography technique. Langenbecks Arch Surg 2009; 394:1109.
- Zhang R, Zhao L, Liu Z, et al. Effect of CO2 cholangiography on post-ERCP cholangitis in patients with unresectable malignant hilar obstruction - a prospective, randomized controlled study. Scand J Gastroenterol 2013; 48:758.
- Sud R, Puri R, Choudhary NS, et al. Air cholangiogram is not inferior to dye cholangiogram for malignant hilar biliary obstruction: a randomized study of efficacy and safety. Indian J Gastroenterol 2014; 33:537.
- Lee JM, Lee SH, Jang DK, et al. Air cholangiography in endoscopic bilateral stent-in-stent placement of metallic stents for malignant hilar biliary obstruction. Therap Adv Gastroenterol 2016; 9:189.
- McDougall NI, Edmunds SE. An audit of metal stent palliation for malignant biliary obstruction. J Gastroenterol Hepatol 2001; 16:1051.
- Harris A, Chan AC, Torres-Viera C, et al. Meta-analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1999; 31:718.
- Bai Y, Gao F, Gao J, et al. Prophylactic antibiotics cannot prevent endoscopic retrograde cholangiopancreatography-induced cholangitis: a meta-analysis. Pancreas 2009; 38:126.
- Brand M, Bizos D, O'Farrell P Jr. Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography. Cochrane Database Syst Rev 2010; :CD007345.
- Cotton PB, Connor P, Rawls E, Romagnuolo J. Infection after ERCP, and antibiotic prophylaxis: a sequential quality-improvement approach over 11 years. Gastrointest Endosc 2008; 67:471.
- Ishigaki T, Sasaki T, Serikawa M, et al. Evaluation of antibiotic use to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis and cholangitis. Hepatogastroenterology 2015; 62:417.
- ASGE Standards of Practice Committee, Anderson MA, Fisher L, et al. Complications of ERCP. Gastrointest Endosc 2012; 75:467.
- ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015; 81:81.
- Thosani N, Zubarik RS, Kochar R, et al. Prospective evaluation of bacteremia rates and infectious complications among patients undergoing single-operator choledochoscopy during ERCP. Endoscopy 2016; 48:424.
- PERIPROCEDURAL BACTEREMIA
- ASCENDING CHOLANGITIS
- Risk factors for cholangitis
- Clinical presentation and diagnosis
- Treatment of post-ERCP cholangitis
- ACUTE CHOLECYSTITIS
- Incidence and pathogenesis
- Treatment of cholecystitis
- PANCREATIC INFECTION
- BACTERIAL PERITONITIS
- PREVENTION OF POST-ERCP SEPTIC COMPLICATIONS
- Endoscopic technique
- Antibiotic prophylaxis
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS