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©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
Endoscopic retrograde cholangiopancreatography in cirrhosis - a systematic review and meta-analysis focused on adverse events
Harmeet Singh Mashiana, Amaninder Singh Dhaliwal, Harlan Sayles, Banreet Dhindsa, Ji Won Yoo, Qing Wu, Shailender Singh, Ali A Siddiqui, Gordon Ohning, Mohit Girotra, Douglas G Adler
Harmeet Singh Mashiana, Banreet Dhindsa, Ji Won Yoo, Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89102, United States
Amaninder Singh Dhaliwal, Shailender Singh, 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
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
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
Author contributions: Mashiana HS contributes to literature search, quality assessment, data collection, manuscript preparation; Dhaliwal AS contributes to literature search, data collection; Sayles H is the statistician; Banreet Dhindsa B contributes to data collection, manuscript preparation, and final edit of the manuscript; Yoo JW contributes to manuscript preparation and biostatistics; Wu Q, Singh S, Siddiqui AA, Ohning G, and Girotra M contributes to manuscript preparation and final editing; and Adler DG contributes to preparation and final edit of the manuscript.
Conflict-of-interest statement: All authors have no conflicts of interest to report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Douglas G Adler, MD, FACG, AGAF, FASGE, Professor, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, 30 N 1900 E, Room 4R118, Salt Lake City, UT 84132, United States. douglas.adler@hsc.utah.edu
Telephone: +1-801-5817878 Fax: +1-801-5818007
Received: February 28, 2018
Peer-review started: February 28, 2018
First decision: July 9, 2018
Revised: July 17, 2018
Accepted: August 21, 2018
Article in press: August 21, 2018
Published online: November 16, 2018
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%, I2 = 85.9%), post-ERCP pancreatitis (PEP) in 3.68% (95%CI: 1.83-6.00%, I2 = 89.5%), cholangitis in 1.93% (95%CI: 0.63-3.71%, I2 = 87.1%) and perforation in 0.00% (95%CI: 0.00-0.23%, I2 = 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, I2 = 65%): higher rates of hemorrhage with OR of 2.05 (95%CI: 1.62-2.58, I2 = 2.1%) and PEP with OR of 1.33 (95%CI: 1.04-1.70, I2=65%), but similar cholangitis rates with OR of 1.23 (95%CI: 0.67-2.26, I2 = 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.
Core tip: Patients with cirrhosis undergoing endoscopic retrograde cholangiopancreatography (ERCP) are considered to have increased risk. However, there is a paucity of literature describing the indications and outcomes of ERCP procedures in these patients. Our meta-analysis included 6,505 patients from 15 studies, with indications including choledocholithiasis, biliary strictures, gallstone pancreatitis and cholangitis. Types of interventions included sphincterotomy, stenting and dilation. Individual adverse events included hemorrhage, post-ERCP pancreatitis (PEP), and cholangitis. Comparison of ERCP-related complications in cirrhosis vs non-cirrhosis suggested higher overall rates of complications in cirrhosis patients with pooled (especially hemorrhage and PEP) but similar cholangitis rates.
