Efficacy and safety of therapeutic ERCP in patients with cirrhosis: a large multicenter study

Adler, Douglas G.; Haseeb, Abdul; Francis, Gloria; Kistler, C. Andrew; Kaplan, Jeremy; Prasad, Anand; Laique, Sobia N.; Munigala, Satish; Taylor, Linda J.; Cox, Kristen; Root, Benjamin; Hayat, Umar; Siddiqui, Ali A.

doi:10.1016/j.gie.2015.08.022

Cited by 46 publications

(106 citation statements)

References 21 publications

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“…There have been other studies that have found higher risks of hemorrhage in CTP class C than in other cirrhotics [15]. In addition, although Adler et al found no difference in the adverse events amongst CTP class A, B and C (P = 0.068), CTP class B and C had a higher incidence of adverse events when compared with CTP class A (P = 0.048) [10]. Adler et al also found that patients with encephalopathy had a higher risk of adverse events [10].…”

Section: Discussionmentioning

confidence: 95%

“…In addition, there was a statistical difference in the frequency of cholangitis post-ERCP in the cirrhosis group, which we feel is largely related to our patient population, with PSC being the primary indication for ERCP in 43% of patients with cirrhosis. In the study by Adler et al, of 328 patients with cirrhosis, all patients were preoperatively administered vitamin K or FFP if INR was greater than 1.5, and ERCP was avoided if INR > 1.7 [10]. The authors, nevertheless, report they found that there was no correlation between significant hemorrhage and presence of coagulopathy or CTP class amongst cirrhotic patients.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, although Adler et al found no difference in the adverse events amongst CTP class A, B and C (P = 0.068), CTP class B and C had a higher incidence of adverse events when compared with CTP class A (P = 0.048) [10]. Adler et al also found that patients with encephalopathy had a higher risk of adverse events [10]. Decompensated cirrhosis as a risk factor in predicting complications post-ERCP is further corroborated by the study by Inamdar et al who found no difference in patients with compensated cirrhosis vs. non-cirrhotic controls (except for post-ERCP pancreatitis) but found a statistically significant difference in the rate of GIB and post-ERCP pancreatitis between patients with decompensated cirrhosis and non-cirrhotic controls [16].…”

Section: Discussionmentioning

confidence: 99%

“…Hence, the primary goal of this study was to determine the relationship between INR and gastrointestinal bleeding (GIB) complications following ERCP in patients with cirrhosis. In addition, as there have only been a few studies [9, 10] that have evaluated complications after ERCP in this group of patients, our secondary goal was to determine the risk of post-ERCP adverse events in patients with cirrhosis.…”

Section: Introductionmentioning

confidence: 99%

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International Normalized Ratio Does Not Predict Gastrointestinal Bleeding After Endoscopic Retrograde Cholangiopancreatography in Patients With Cirrhosis

et al. 2017

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BackgroundCirrhosis is often accompanied by an elevated international normalized ratio (INR) due to a decrease in pro-coagulant factors. An elevated INR in cirrhosis is often interpreted as an increased risk of bleeding. There are a paucity of data in the literature on the use of INR to predict risk of gastrointestinal bleeding (GIB) following endoscopic retrograde cholangiopancreatography (ERCP) in patients with cirrhosis. The aims of the study were to determine if there is a correlation between INR and GIB following ERCP in patients with cirrhosis, and to determine if there is a difference in frequency of post-ERCP complications in patients with and without cirrhosis.MethodsA retrospective review of all ERCP procedures was performed at a tertiary care institution between 2012 and 2015. We identified ERCPs performed in patients with cirrhosis and compared them to a randomly selected group without liver cirrhosis. Univariate analysis was performed using Chi-square and ANOVA tests. A multivariable logistic regression model using generalized estimating equations was used to examine the association between INR and GIB.ResultsThere were a total of 1,610 ERCPs performed from 2012 to 2015 with 129 performed in 56 patients with cirrhosis compared with 392 ERCPs performed in 310 patients without cirrhosis. There was no difference in the frequency of GIB following ERCP in both groups (P = 0.117). However, there was a difference in overall complications between both groups (P = 0.007), but no difference observed amongst Child-Turcotte-Pugh classes (P = NS). In a multivariable analysis, sphincterotomy during ERCP (odds ratio (OR) = 3.22; 95% confidence interval (CI): 1.05 - 9.94; P = 0.042) and cirrhosis (OR = 3.58; 95% CI: 1.22 - 10.47; P = 0.02) were significant for predicting GIB. Anti-coagulation (OR = 2.90; 95% CI: 0.82 - 10.23; P = 0.097) and INR were not significant in the multivariable model (OR = 2.09; 95% CI: 0.85 - 5.12; P = 0.10).ConclusionThere was a statistical difference in overall complications between patients with and without cirrhosis but no difference was observed amongst Child-Turcotte-Pugh classes. Overall, INR was not a significant factor in predicting risk of bleeding in patients after ERCP.

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Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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International Normalized Ratio Does Not Predict Gastrointestinal Bleeding After Endoscopic Retrograde Cholangiopancreatography in Patients With Cirrhosis

et al. 2017

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“…Obstructive jaundice, especially in patients with high bilirubin level can be more challenging due to the risks of infection and bleeding [3,4]. Hyperbilirubinemia can lead to hemostasis impairment due to poor absorption of vitamin K. Bacterial translocation is also play a major role in hemostasis disturbance due to inflammation, septic complication, and disseminated intravascular coagulation (DIC) [5].…”

mentioning

confidence: 99%

Hyperbilirubinemia as a Post-Sphincterotomy Bleeding Risk during Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Procedure in Normal Hemostasis Profile Patients

Lesmana¹

2016

JGPLD

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Major bleeding events after endoscopic sphincterotomy and endoscopic papillary balloon dilatation in cirrhotic patients: A nationwide population‐based cohort study

Wang

Tsai

Tseng

et al. 2017

Adv in Digestive Medicine

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C.-C. Lin).in both groups (0.00% vs. 0.59%; p ＞ 0.999). Post-EST bleeding rate was higher than post-EPBD bleeding rate in both non-cirrhotic patients (2.12% vs. 0.59%; p = 0.269) and cirrhotic patients (4.55% vs. 0.00%; p ＞ 0.999), although results did not meet the significant statistical difference in our study. Conclusions: In contrast to EST, EPBD showed fewer post-EPBD major bleeding events especially in cirrhotic patients. Thus EPBD tend to be a relative safer method of therapeutic ERCP especially for cirrhotic patients.

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Efficacy and safety of therapeutic ERCP in patients with cirrhosis: a large multicenter study

Cited by 46 publications

References 21 publications

International Normalized Ratio Does Not Predict Gastrointestinal Bleeding After Endoscopic Retrograde Cholangiopancreatography in Patients With Cirrhosis

International Normalized Ratio Does Not Predict Gastrointestinal Bleeding After Endoscopic Retrograde Cholangiopancreatography in Patients With Cirrhosis

Hyperbilirubinemia as a Post-Sphincterotomy Bleeding Risk during Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Procedure in Normal Hemostasis Profile Patients

Major bleeding events after endoscopic sphincterotomy and endoscopic papillary balloon dilatation in cirrhotic patients: A nationwide population‐based cohort study

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