Introduction: Guidelines suggest that all patients with choledocholithiasis should have a coagulation screen prior to endoscopic retrograde cholangiopancreatography (ERCP). This study aims to establish the incidence of deranged coagulation in such patients and its relationship with bleeding complications.
Methods: Analysis of consecutive patients undergoing ERCP procedures at two NHS sites was undertaken. Exclusion criteria were anti-coagulation use, bleeding disorders or incomplete data. Demographic data, pre-procedure bilirubin and prothrombin time (PT), ERCP procedural information, and bleeding complications were recorded for each. The cohort was divided into jaundice and non-jaundiced groups. Statistical analysis was performed using the student's t-test, Chi-squared test and Fisher's exact test.
Results: 793 patients (419 jaundiced; 374 non-jaundiced) were included. PT was significantly higher in the jaundiced group (greater by 2 (1.35-2.64) seconds; p < 0.001). PT was prolonged in 26.7 per cent of the jaundiced group; 28 patients (6.7 per cent) had a PT of >16.8 s 5.9 per cent of the non-jaundiced group had prolonged PT, with 1 patient having a PT >16.8 s. There were 5 major, and 32 minor bleeding complications with no differences between groups. In those with abnormal coagulation, only 1 minor bleeding complication occurred in a jaundiced patient.
Discussion: Normal pre-ERCP bilirubin was 99.7% (98.5-100) sensitive to predict a PT <16.8 s. Cost savings of £14,350 could have been achieved with judicial use of coagulation screening.
Conclusion: Pre-ERCP coagulation screening should only be indicated in patients with a raised bilirubin or individuals on anticoagulation therapy or with a history of bleeding diathesis.