ERCP, even for diagnostic purposes, may be associated with very serious and even fatal complications. The use of the precut procedure for access should still be considered dangerous. Other means of investigating the bile ducts should be developed. If endoscopic ultrasonography and magnetic resonance cholangiography prove to have the same diagnostic value as ERCP, which must be considered the gold standard for visualizing the ducts today, they might replace ERCP as the primary investigation in patients with an intermediate or low risk of bile duct stones; this would reduce the numbers of patients exposed to the risks of ERCP.

Splenic injury is a rare and serious complication of colonoscopy. The most likely mechanism is tension on the splenocolic ligament and adhesions. Eight cases were identified among claims for compensation submitted to the Danish Patient Insurance Association during the period 1992-2006, seven of which were reported after 2000. The total number of colonoscopies in Denmark in 2004 was 39 067. Seven of the eight patients were aged 65 years or over. Loops causing difficulties during the colonoscopy had been reported in four patients. All the patients had a symptom-free interval after the colonoscopy, ranging from 4 hours to 7 days, before presenting with signs of splenic injury. In all cases the spleen was torn, and the amount of blood in the peritoneal cavity ranged from 1500 mL to 5000 mL. Two patients died postoperatively. The number of cases reported after 2000 indicates that this potentially lethal complication might be more common than was previously assumed, and it is possibly under-reported. Preventive measures include good colonoscopic technique to avoid loop formation and the use of excessive force; and it is possible that emerging endoscopic technologies will lead to a reduced risk of splenic injury. The information given to patients both before and after the procedure should include information on the signs of this complication, and patients should be also informed that these signs can develop after a symptom-free interval.

The predicive values of MRCP were fairly good, but MRCP misses some small stones <5 mm in size. Asymptomatic stones in the common duct are not common in this population and should not be screened for. The probability of stones increases with the number of predictive factors. Patients should be questioned carefully about signs of biliary obstruction, and only be offered preoperative MRCP should they have a suspicious history, raised LFTs, or a dilated common duct.

Detection of colorectal polyps > or = 6 mm or > or = 5 mm with CTC, followed by polypectomy by CC, can be performed cost-effectively at some institutions with the appropriate hardware and organization.