Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding

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


Bleeding was the most feared complication when therapeutic biliary endoscopy was first introduced [1]. Because of advances in equipment and experience, it has become a relatively uncommon complication of endoscopic retrograde cholangiopancreatography (ERCP), and it is mostly observed after sphincterotomy. Clinically significant bleeding is uncommon with diagnostic ERCP, apart from sporadic Mallory-Weiss tears and from minor submucosal hemorrhages observed following manipulation of the papilla, particularly in patients with ampullary tumors, a bleeding diathesis, or anatomical variants such as Billroth II gastrectomy [2-4]. Exceptions are case reports in which serious bleeding occurs from injury to the spleen, liver, or abdominal vessels. (See "Rare complications of endoscopic retrograde cholangiopancreatography (ERCP)".)

This topic review will focus on the risk factors and treatment of bleeding following ERCP with endoscopic sphincterotomy. An overview of the complications of ERCP and detailed discussions of individual complications are presented separately. (See "Endoscopic retrograde cholangiopancreatography: Indications, patient preparation, and complications".)


Post-ERCP bleeding can be defined as clinically significant or not clinically significant [5] and can be graded as mild, moderate, or severe based upon a consensus definition [6]:

Mild – clinical evidence of bleeding (ie, not just endoscopic), hemoglobin drop <3 g/dL, and no need for transfusion

Moderate – need for transfusion (4 units or less), and no angiographic intervention or surgery

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jul 11, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Rabenstein T, Schneider HT, Hahn EG, Ell C. 25 years of endoscopic sphincterotomy in Erlangen: assessment of the experience in 3498 patients. Endoscopy 1998; 30:A194.
  2. 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.
  3. Lin LF, Siauw CP, Ho KS, Tung JC. ERCP in post-Billroth II gastrectomy patients: emphasis on technique. Am J Gastroenterol 1999; 94:144.
  4. ASGE Standards of Practice Committee, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83:3.
  5. Ferreira LE, Baron TH. Post-sphincterotomy bleeding: who, what, when, and how. Am J Gastroenterol 2007; 102:2850.
  6. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37:383.
  7. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335:909.
  8. Finnie IA, Tobin MV, Morris AI, Gilmore IT. Late bleeding after endoscopic sphincterotomy for bile duct calculi. BMJ 1991; 302:1144.
  9. Boujaoudé J, Pelletier G, Fritsch J, et al. Management of clinically relevant bleeding following endoscopic sphincterotomy. Endoscopy 1994; 26:217.
  10. Gholson CF, Favrot D, Vickers B, et al. Delayed hemorrhage following endoscopic retrograde sphincterotomy for choledocholithiasis. Dig Dis Sci 1996; 41:831.
  11. Vásconez C, Llach J, Bordas JM, et al. Injection treatment of hemorrhage induced by endoscopic sphincterotomy. Endoscopy 1998; 30:37.
  12. Ferreira LE, Fatima J, Baron TH. Clinically significant delayed postsphincterotomy bleeding: a twelve year single center experience. Minerva Gastroenterol Dietol 2007; 53:215.
  13. Freeman ML, Nelson DB, Sherman S, et al. Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group. Gastrointest Endosc 1999; 49:580.
  14. Ho KY, Montes H, Sossenheimer MJ, et al. Features that may predict hospital admission following outpatient therapeutic ERCP. Gastrointest Endosc 1999; 49:587.
  15. Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001; 96:417.
  16. Vandervoort J, Soetikno RM, Tham TC, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56:652.
  17. Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60:721.
  18. 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.
  19. Wang P, Li ZS, Liu F, et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 2009; 104:31.
  20. 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.
  21. Nelson DB, Freeman ML. Major hemorrhage from endoscopic sphincterotomy: risk factor analysis. J Clin Gastroenterol 1994; 19:283.
  22. Kim HJ, Kim MH, Kim DI, et al. Endoscopic hemostasis in sphincterotomy-induced hemorrhage: its efficacy and safety. Endoscopy 1999; 31:431.
  23. Wilcox CM, Canakis J, Mönkemüller KE, et al. Patterns of bleeding after endoscopic sphincterotomy, the subsequent risk of bleeding, and the role of epinephrine injection. Am J Gastroenterol 2004; 99:244.
  24. 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.
  25. Hori Y, Naitoh I, Nakazawa T, et al. Feasibility of endoscopic retrograde cholangiopancreatography-related procedures in hemodialysis patients. J Gastroenterol Hepatol 2014; 29:648.
  26. Margulies C, Siqueira ES, Silverman WB, et al. The effect of endoscopic sphincterotomy on acute and chronic complications of biliary endoprostheses. Gastrointest Endosc 1999; 49:716.
  27. Leung JW, Chan FK, Sung JJ, Chung S. Endoscopic sphincterotomy-induced hemorrhage: a study of risk factors and the role of epinephrine injection. Gastrointest Endosc 1995; 42:550.
  28. Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut 2008; 57:1004.
  29. Prat F, Tennenbaum R, Ponsot P, et al. Endoscopic sphincterotomy in patients with liver cirrhosis. Gastrointest Endosc 1996; 43:127.
  30. Henning H, Lightdale CJ, Look D. Contraindications – Coagulation disorders. In: Color Atlas of diagnostic Laparoscopy, Stuttgart, Thieme, New York 1994. p.17.
  31. Sherlock S, Dooley J. Needle biopsy of the liver. In: Diseases of the Liver and Biliary System, 9th edition, Blackwell, Oxford 1993. p.33.
  32. Sherman S, Hawes RH, Nisi R, Lehman GA. Endoscopic sphincterotomy-induced hemorrhage: treatment with multipolar electrocoagulation. Gastrointest Endosc 1992; 38:123.
  33. ASGE Standards of Practice Committee, Pasha SF, Acosta R, et al. Routine laboratory testing before endoscopic procedures. Gastrointest Endosc 2014; 80:28.
  34. Egan RJ, Nicholls J, Walker S, et al. Routine coagulation screening is an unnecessary step prior to ERCP in patients without biochemical evidence of jaundice: a cross-centre study. Int J Surg 2014; 12:1216.
  35. Bickerstaff KI, Berry AR, Chapman RW, Britton BJ. Endoscopic sphincterotomy for the palliation of ampullary carcinoma. Br J Surg 1990; 77:160.
  36. Kimchi NA, Broide E, Scapa E, Birkenfeld S. Antiplatelet therapy and the risk of bleeding induced by gastrointestinal endoscopic procedures. A systematic review of the literature and recommendations. Digestion 2007; 75:36.
  37. Hussain N, Alsulaiman R, Burtin P, et al. The safety of endoscopic sphincterotomy in patients receiving antiplatelet agents: a case-control study. Aliment Pharmacol Ther 2007; 25:579.
  38. Baron TH, Kamath PS, McBane RD. New anticoagulant and antiplatelet agents: a primer for the gastroenterologist. Clin Gastroenterol Hepatol 2014; 12:187.
  39. Ono S, Fujishiro M, Yoshida N, et al. Thienopyridine derivatives as risk factors for bleeding following high risk endoscopic treatments: Safe Treatment on Antiplatelets (STRAP) study. Endoscopy 2015; 47:632.
  40. Boustière C, Veitch A, Vanbiervliet G, et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2011; 43:445.
  41. Veitch AM, Vanbiervliet G, Gershlick AH, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374.
  42. Lee MG, Kim J, Lee SH, et al. Effect of sustained use of platelet aggregation inhibitors on post-endoscopic sphincterotomy bleeding. Dig Endosc 2014; 26:737.
  43. Hamada T, Yasunaga H, Nakai Y, et al. Bleeding after endoscopic sphincterotomy or papillary balloon dilation among users of antithrombotic agents. Endoscopy 2015; 47:997.
  44. Ratani RS, Mills TN, Ainley CC, Swain CP. Electrophysical factors influencing endoscopic sphincterotomy. Gastrointest Endosc 1999; 49:43.
  45. Verma D, Kapadia A, Adler DG. Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes. Gastrointest Endosc 2007; 66:283.
  46. Pasricha P. Current news about sphincterotomy-induced pancreatitis: does electrocautery setting make a difference? Gastroenterology 1998; 115:1024.
  47. Gorelick A, Cannon M, Barnett J, et al. First cut, then blend: an electrocautery technique affecting bleeding at sphincterotomy. Endoscopy 2001; 33:976.
  48. Stefanidis G, Karamanolis G, Viazis N, et al. A comparative study of postendoscopic sphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis. Gastrointest Endosc 2003; 57:192.
  49. Kohler A, Maier M, Benz C, et al. A new HF current generator with automatically controlled system (Endocut mode) for endoscopic sphincterotomy--preliminary experience. Endoscopy 1998; 30:351.
  50. Perini RF, Sadurski R, Cotton PB, et al. Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference? Gastrointest Endosc 2005; 61:53.
  51. Norton ID, Petersen BT, Bosco J, et al. A randomized trial of endoscopic biliary sphincterotomy using pure-cut versus combined cut and coagulation waveforms. Clin Gastroenterol Hepatol 2005; 3:1029.
  52. Parlak E, Köksal AŞ, Öztaş E, et al. Is there a safer electrosurgical current for endoscopic sphincterotomy in patients with liver cirrhosis? Wien Klin Wochenschr 2016; 128:573.
  53. Attasaranya S, Cheon YK, Vittal H, et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointest Endosc 2008; 67:1046.
  54. Katsinelos P, Paroutoglou G, Kountouras J, et al. Partially covered vs uncovered sphincterotome and post-endoscopic sphincterotomy bleeding. World J Gastroenterol 2010; 16:5077.
  55. Matsushita M, Takakuwa H, Shimeno N, et al. Prophylactic injection of hypertonic saline-epinephrine oral to the papilla for prevention of postsphincterotomy bleeding. J Clin Gastroenterol 2010; 44:e167.
  56. Grimm H, Soehendra N. [Infiltrating injection in the management of post-papillotomy hemorrhages]. Dtsch Med Wochenschr 1983; 108:1512.
  57. Costamagna G. What to do when the papilla bleeds after endoscopic sphincterotomy. Endoscopy 1998; 30:40.
  58. Park DH, Kim MH, Lee SK, et al. Endoscopic sphincterotomy vs. endoscopic papillary balloon dilation for choledocholithiasis in patients with liver cirrhosis and coagulopathy. Gastrointest Endosc 2004; 60:180.
  59. Loperfido S, Patelli G, La Torre L. Extensive necrosis of gastric mucosa following injection therapy of bleeding peptic ulcer. Endoscopy 1990; 22:285.
  60. Chester JF, Hurley PR. Gastric necrosis: a complication of endoscopic sclerosis for bleeding peptic ulcer. Endoscopy 1990; 22:287.
  61. Tsou YK, Lin CH, Liu NJ, et al. Treating delayed endoscopic sphincterotomy-induced bleeding: epinephrine injection with or without thermotherapy. World J Gastroenterol 2009; 15:4823.
  62. Born P, Ott R, Rösch T. Endoscopic hemostasis using fibrin sealant for postsphincterotomy bleeding: report of two cases. Gastrointest Endosc 2000; 51:731.
  63. Mutignani M, Seerden T, Tringali A, et al. Endoscopic hemostasis with fibrin glue for refractory postsphincterotomy and postpapillectomy bleeding. Gastrointest Endosc 2010; 71:856.
  64. Baron TH, Norton ID, Herman L. Endoscopic hemoclip placement for post-sphincterotomy bleeding. Gastrointest Endosc 2000; 52:662.
  65. Katsinelos P, Paroutoglou G, Beltsis A, et al. Endoscopic hemoclip placement for postsphincterotomy bleeding refractory to injection therapy: report of two cases. Surg Laparosc Endosc Percutan Tech 2005; 15:238.
  66. Liu F, Wang GY, Li ZS. Cap-assisted hemoclip application with forward-viewing endoscope for hemorrhage induced by endoscopic sphincterotomy: a prospective case series study. BMC Gastroenterol 2015; 15:135.
  67. Mosca S, Galasso G. Immediate and late bleeding after endoscopic sphincterotomy. Endoscopy 1999; 31:278.
  68. Shah JN, Marson F, Binmoeller KF. Temporary self-expandable metal stent placement for treatment of post-sphincterotomy bleeding. Gastrointest Endosc 2010; 72:1274.
  69. Itoi T, Yasuda I, Doi S, et al. Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding. Endoscopy 2011; 43:369.
  70. Valats JC, Funakoshi N, Bauret P, et al. Covered self-expandable biliary stents for the treatment of bleeding after ERCP. Gastrointest Endosc 2013; 78:183.
  71. Ogura T, Masuda D, Takeuchi T, et al. Novel covered pancreatic metal stents for the treatment of bleeding after endoscopic pancreatic sphincterotomy. Gastrointest Endosc 2016; 83:1293.
  72. Odemis B, Shorbagi A, Yurdakul M, et al. Percutaneous placement of a biliary self-expandable metallic stent for severe post-ERCP bleeding. Gastrointest Endosc 2014; 80:187.
  73. Kang MH, Jeong JW, Han JH. Successful hemostasis by using endoscopic band ligation for uncontrolled postendoscopic sphincterotomy bleeding. Gastrointest Endosc 2014; 79:336.
  74. Katsinelos P, Kountouras J, Chatzimavroudis G, et al. Endoscopic hemostasis using monopolar coagulation for postendoscopic sphincterotomy bleeding refractory to injection treatment. Surg Laparosc Endosc Percutan Tech 2010; 20:84.
  75. Kuran S, Parlak E, Oguz D, et al. Endoscopic sphincterotomy-induced hemorrhage: treatment with heat probe. Gastrointest Endosc 2006; 63:506.
  76. Waye JD, Goh KL, Huibregtse K, et al. Endoscopic sphincterotomy: 2002. Gastrointest Endosc 2002; 55:139.
  77. Leese T, Neoptolemos JP, Carr-Locke DL. Successes, failures, early complications and their management following endoscopic sphincterotomy: results in 394 consecutive patients from a single centre. Br J Surg 1985; 72:215.
  78. Appleby VJ, Hutchinson JM, Beckett CJ, Moreea S. Use of the haemostatic agent TC-325 in the treatment of bleeding secondary to endoscopic retrograde cholangiopancreatography sphincterotomy. QJM 2015; 108:79.
  79. Romero-Castro R, Jiménez-Sáenz M, Pellicer-Bautista F, Herrerías-Gutiérrez JM. Refractory bleeding after endoscopic sphincterotomy: a new indication for recombinant factor VII therapy? Am J Gastroenterol 2004; 99:2063.
  80. Tyagi P, Sachdeva S, Agarwal AK, Puri AS. Terlipressin in control of acute hemobilia during therapeutic ERCP in patient with portal biliopathy. Surg Laparosc Endosc Percutan Tech 2009; 19:e198.
  81. Sharma M, Babu CS, Dhiman RK, Chawla Y. Induced hypotension in the management of acute hemobilia during therapeutic ERCP in a patient with portal biliopathy (with videos). Gastrointest Endosc 2010; 72:1317.
  82. Saeed M, Kadir S, Kaufman SL, et al. Bleeding following endoscopic sphincterotomy: angiographic management by transcatheter embolization. Gastrointest Endosc 1989; 35:300.
  83. Walker TG, Waltman AC. Angiographic diagnosis and therapy of upper gastrointestinal hemorrhage. In: Therapeutic Endoscopy and Radiology of the Gut, Bennet JR, Hunt RH (Eds), Williams and Wilkins, Baltimore 1990. p.167.
  84. So YH, Choi YH, Chung JW, et al. Selective embolization for post-endoscopic sphincterotomy bleeding: technical aspects and clinical efficacy. Korean J Radiol 2012; 13:73.
  85. Dunne R, McCarthy E, Joyce E, et al. Post-endoscopic biliary sphincterotomy bleeding: an interventional radiology approach. Acta Radiol 2013; 54:1159.
  86. Bardaxoglou E, Campion JP, Maddern G, et al. A simple method to control intractable bleeding after endoscopic sphincterotomy. Am J Surg 1994; 167:277.
  87. Goodall RJ. Bleeding after endoscopic sphincterotomy. Ann R Coll Surg Engl 1985; 67:87.
  88. Dimitroulis D, Antoniou E, Karidis NP, et al. Surgical control of life-threatening post-ERCP bleeding with a gelatin matrix-thrombin hemostatic agent. Int J Surg Case Rep 2012; 3:471.