Article | Published:

Adverse Events and Acute Chronic Liver Failure in Patients With Cirrhosis Undergoing Endoscopic Retrograde Cholangiopancreatography: A Multicenter Matched-Cohort Study

The American Journal of Gastroenterology (2018) | Download Citation

Subjects

Abstract

Background

Data on the outcome of adverse events (AEs) and the risk of developing acute-on-chronic liver failure (ACLF) after ERCP in patients with cirrhosis are unknown. We examined the incidence and risk factors of post-ERCP AEs in patients with cirrhosis and the appearance of ACLF after ERCP.

Methods

In this multicenter, retrospective, matched-cohort study, we evaluated ERCPs performed from January 2002 to 2015. A group of patients with cirrhosis with non-ERCP interventions and one without interventions was also analyzed for the development of ACLF.

Results

A total of 441 ERCPs were analyzed; 158 in patients with cirrhosis (cases) and 283 in patients without cirrhosis (controls). The overall rate of AEs after all ERCPs was significantly higher in cases compared to controls (17% vs 9.5, p = 0.02). Cholangitis developed more in cases compared to controls (6.3% vs 1.8%; p = 0.01). In a subanalysis of those with sphincterotomy, the rate of bleeding was higher in those with cirrhosis (9.4% vs 3.4%; p = 0.03). Logistic regression identified cirrhosis (OR, 2.48; 95% CI, 1.36–4.53; p = 0.003) and sphincterotomy (OR, 2.66; 95% CI, 1.23–5.72; p = 0.01) as risk factors of AEs. A total of 18/158 (11.4%) cases developed ACLF after ERCP. ACLF occurred in 7/27 cases with post-ERCP AEs and in 11/131 without post-ERCP AEs (25.9% vs 8.3%; p = 0.01). A total of 3.2% (13/406) patients without interventions developed ACLF compared to 17.5% (102/580) who developed ACLF after non-ERCP interventions. Patients with decompensated cirrhosis at ERCP had a higher risk of developing ACLF (17% vs 6.8%; p = 0.04). Patients with a MELD score ≥ 15 were 3.1 times more likely (95% CI: 1.14–8.6; p = 0.027) to develop ACLF after ERCP.

Conclusions

The rate of AEs after ERCP is higher in patients with cirrhosis compared to the non-cirrhotic population. The incidence of ACLF is higher in those with AEs after ERCP compared to those without AEs, especially cholangitis. The development of ACLF is common after ERCP and other invasive procedures. ACLF can be precipitated by numerous factors which include preceding events before the procedure, including manipulation of the bile duct, and AEs after an ERCP.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

References

  1. 1.

    ASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, et al. Adverse events associated with ERCP. Gastrointest Endosc. 2017;85:32–47.

  2. 2.

    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;60:180–5.

  3. 3.

    Adler DG, Haseeb A, Francis G, Kistler CA, Kaplan J, Ghumman SS, et al. Efficacy and safety of therapeutic ERCP in patients with cirrhosis: a large multicenter study. Gastrointest Endosc. 2016;83:353–9.

  4. 4.

    Inamdar S, Berzin TM, Berkowitz J, Sejpal DV, Sawhney MS, Chutanni R, et al. Decompensated cirrhosis may be a risk factor for adverse events in endoscopic retrograde cholangiopancreatography. Liver Int. 2016;36:1457–63.

  5. 5.

    Macías-Rodríguez RU, Ruiz-Margáin A, Rodriguez-Garcia JL, Zepeda-Gómez S, Torre A. Risk factors associated with complications in cirrhotic patients undergoing endoscopic retrograde cholangio-pancreatography. Eur J Gastroenterol Hepatol. 2017;29:238–43.

  6. 6.

    Acalovschi M. Gallstones in patients with liver cirrhosis: incidence, etiology, clinical and therapeutical aspects. World J Gastroenterol. 2014;20:7277–85.

  7. 7.

    Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102:1781–8.

  8. 8.

    Prat F, Tennenbaum R, Ponsot P, Altman C, Pelletier G, Fritsch J, et al. Endoscopic sphincterotomy in patients with liver cirrhosis. Gastrointest Endosc. 1996;43:127–31.

  9. 9.

    Fernández J, Navasa M, Gómez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002;35:140–8.

  10. 10.

    Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology. 2012;55:1551–61.

  11. 11.

    Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, CANONIC Study Investigators of the EASL–CLIF Consortium. et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144:1426–37.

  12. 12.

    Hernaez R, Solà E, Moreau R, Ginès P. Acute-on-chronic liver failure: an update. Gut . 2017;66:541–53.

  13. 13.

    Fernandez J, Acevedo J, Weist R, Gustot T, Amoros A, Deulofeu C, et al. Bacterial and fungal infections in acute-on chronic liver failure: prevalence, characteristics and impact on prognosis. Gut. 2017. Epub ahead of print.

  14. 14.

    Arroyo V, Moreau R, Kamath PS, Jalan R, Ginès P, Nevens F, et al. Acute-on-chronic liver failure in cirrhosis. Nat Rev Dis Prim. 2016;2:16041.

  15. 15.

    Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71:446–54.

  16. 16.

    Cotton PB, Eisen G, Romagnuolo J, Vargo J, Baron T, Tarnasky P, et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. Gastrointest Endosc. 2011;73:868–74.

  17. 17.

    Artifon EL, da Silveira EB, Aparicio D, Takada J, Baracat R, Sakai CM, et al. Management of common bile duct stones in cirrhotic patients with coagulopathy: a comparison of supra-papillary puncture and standard cannulation technique. Dig Dis Sci. 2011;56:1904–11.

  18. 18.

    Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy. 2007;39:793–801.

  19. 19.

    Zhang J, Ye L, Zhang J, Lin M, He S, Mao X, et al. MELD scores and Child-Pugh classifications predict the outcomes of ERCP in cirrhotic patients with choledocholithiasis: a retrospective cohort study. Medicine. 2015;94:e433.

  20. 20.

    Navaneethan U, Njei B, Zhu X, Kommaraju K, Parsi MA, Varadarajulu S. Safety of ERCP in patients with liver cirrhosis: a national database study. Endosc Int Open. 2017;5:303–14.

  21. 21.

    Li DM, Zhao J, Zhao Q, Qin H, Wang B, Li RX, et al. Safety and efficacy of endoscopic retrograde cholangiopancreatography for common bile duct stones in liver cirrhotic patients. J Huazhong Univ Sci Technol Med Sci. 2014;34:612–5.

  22. 22.

    Bangarulingam SY, Gossard AA, Petersen BT, Ott BJ, Lindor KD. Complications of endoscopic retrograde cholangiopancreatography in primary sclerosing cholangitis. Am J Gastroenterol. 2009;104:855–60.

  23. 23.

    Beilenhoff U. ERCP and reprocessing in focus: what can we do to prevent or manage infection outbreaks? Endoscopy. 2015;47:483–5.

  24. 24.

    Rubin ZA, Murthy RK. Outbreaks associated with duodenoscopes: new challenges and controversies. Curr Opin Infect Dis. 2016;29:407–14.

  25. 25.

    Shi Y, Yang Y, Hu Y, Wu W, Yang Q, Zheng M, et al. Acute-on-chronic liver failure precipitated by hepatic injury is distinct from that precipitated by extrahepatic insults. Hepatology. 2015;62:232–42.

Download references

Acknowledgements

Preliminary results of this study were presented at the American Gastroenterological Association Meeting and Digestive Disease Week as an Oral Presentation on May 7, 2017.

Author information

Affiliations

  1. GI/Endoscopy Unit. Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain

    • Carles Leal MD
    • , Karina Chavez-Rivera MD
    • , Oriol Sendino MD, PhD
    • , Cristina Rodriguez de Miguel RN
    •  & Andres Cardenas MD, PhD
  2. Gastroenterology Department, Hospital Universitari de Vic, Barcelona, Spain

    • Carles Leal MD
    •  & Pere Roura MD
  3. Liver Unit. Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain

    • Veronica Prado MD
    • , Adria Juanola MD
    • , Javier Fernández MD, PhD
    •  & Andres Cardenas MD, PhD
  4. Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca - IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain

    • Juan Colan MD
    • , Cristina Gomez MD, PhD
    • , Carlos Guarner MD, PhD
    •  & Carlos Guarner-Argente MD, PhD
  5. Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain

    • Oriol Sendino MD, PhD
    • , Adria Juanola MD
    • , Javier Fernández MD, PhD
    •  & Andres Cardenas MD, PhD
  6. Anesthesiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain

    • Anabel Blasi MD, PhD
  7. European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain

    • Marco Pavesi PhD
    •  & Javier Fernández MD, PhD

Authors

  1. Search for Carles Leal MD in:

  2. Search for Veronica Prado MD in:

  3. Search for Juan Colan MD in:

  4. Search for Karina Chavez-Rivera MD in:

  5. Search for Oriol Sendino MD, PhD in:

  6. Search for Anabel Blasi MD, PhD in:

  7. Search for Pere Roura MD in:

  8. Search for Adria Juanola MD in:

  9. Search for Cristina Rodriguez de Miguel RN in:

  10. Search for Marco Pavesi PhD in:

  11. Search for Cristina Gomez MD, PhD in:

  12. Search for Carlos Guarner MD, PhD in:

  13. Search for Carlos Guarner-Argente MD, PhD in:

  14. Search for Javier Fernández MD, PhD in:

  15. Search for Andres Cardenas MD, PhD in:

Guarantor of the article

Andres Cardenas, MD, MMSc, PhD, AGAF, FAASLD

Specific author contributions

C Leal—acquired, analyzed, and interpreted the results, performed the statistical analysis, and drafted and revised the manuscript. V Prado—acquired, analyzed, and interpreted the results and drafted and revised the manuscript. J Colan—acquired, analyzed, and interpreted the results, performed the statistical analysis, and drafted and revised the manuscript. K Chavez-Rivera—acquired, analyzed, and interpreted the results and revised the manuscript. A Blasi—interpreted the results, drafted, and revised the manuscript, P Roura—analyzed and interpreted the results; performed the statistical analysis. A Juanola ––acquired data and interpreted the results. C Rodriguez de Miguel—acquired, analyzed, and interpreted the results. C Gomez—interpreted the results and revised the manuscript. M Pavesi—analyzed and interpreted the results; performed the statistical analysis. C Guarner—interpreted the results and revised the manuscript. C Guarner-Argente—acquired, analyzed, and interpreted the results and revised the manuscript. J Fernandez—participated in its design, interpreted the results, and revised the manuscript. A Cardenas—acquired, analyzed, and interpreted the results; conceived the study and participated in its design; performed the statistical analysis; and drafted and revised the manuscript.

Financial support

Part of the research reported in this article was funded by Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBERHED), Barcelona, Spain.

Potential competing interests

The authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Andres Cardenas MD, PhD.

Electronic supplementary material

About this article

Publication history

Received

Accepted

Published

DOI

https://doi.org/10.1038/s41395-018-0218-1