The complexity of stenosis as a risk factor for post-ERCP cholangitis

Aims Infectious complications of ERCP are increasingly coming into focus. The mere presence of a hilar biliary stricture already increases the risk of post-ERCP cholangitis (PEC). However, which additional risk factors play a role, especially in the presence of a hilar stenosis, is not yet sufficiently characterized.

Aim of the work: Identification of risk factors for PEC in patients with hilar stenosis.

Methods We conducted a retrospective analysis of data from patients with hilar stenosis who underwent endoscopic biliary drainage. The endoscopic examinations were performed in the endoscopy department of a tertiary centre from June 2018 to June 2022. Patients who initially presented with cholangitis were excluded. The remaining patients were analysed according to the occurrence of PEC, and factors such as gender, underlying disease, and bilirubin levels (before and after the procedure) were examined. Additionally, the number of procedures per patient until PEC, the dose-area product (DAP) during the procedure as a marker of procedure complexity, and the number, type, position, length, and diameter of the stents were analysed.

Results A total of 406 ERCP procedures were performed on 143 patients. Fifty patients were excluded due to initial presentation with cholangitis. Among the remaining 93 patients, 35 (38%) developed at some point PEC. Neither age, gender, underlying diseases, number of ERCPs performed per patient, nor the different numbers, types, lengths, and diameters of the stents used, or bilirubin levels were correlated with an increase in PEC rate. Patients who developed PEC had a significantly higher DAP (1595 µGy·m² vs. 2304 µGy·m²; p=0.0029). Using a cutoff value of 1900 µGy·m², we found a relative risk of 4.26 for developing PEC (95% CI: 1.7447 to 10.3982, p=0.0015). Additionally, leaving undrained liver segments was associated with an increased PEC risk (relative risk 3.80, 95% CI: 1.32 to 10.90, p=0.0130). This increase was even higher for undrained liver segments that were contrasted (relative risk 4.90, 95% CI: 3.76 – 63.78, p=0.0030).

Conclusions In conclusion, the complexity of hilar stenosis, along with the opacification of undrained liver segments, plays a significant role in the risk of post-ERCP cholangitis (PEC). Tailoring the drainage strategy based on pre-procedural imaging could help assess the complexity of biliary stenosis, potentially reducing the risk of procedure-related biliary infections.

Publication History

Article published online:
27 March 2025