Beyond the Transplant: Understanding the High Risk of Post-ERCP Pancreatitis in Liver Recipients

Aims Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing liver transplant complications. Dilations, stent placement, and stone removal are typically performed during these procedures. Post-ERCP pancreatitis (PEP) occurs in 5-8% of the general population, but its incidence in liver transplant (LT) patients remains undefined. This patient group exhibits characteristics that warrant dedicated analysis (e.g., immunosuppression, biliary damage, altered anatomy, and increased complexity of ERCP). Conflicting data exist in the literature, and the risk factors for PEP in LT patients are poorly understood. This study aims to clarify the incidence of PEP in the LT population and identify risk factors for its development.

Methods We enrolled consecutive patients who underwent ERCP (2022-2024). Patient history and characteristics of ERCP were classified based on the onset of PEP (ESGE guidelines). Patients were divided into LT and non-LT groups based on similar demographic data and were further categorized according to previous sphincterotomy and native papilla (NP). In LT patients, immunosuppressive therapy, time since transplant, ERCP duration, stent placement, biliary dilation, and stone extraction were evaluated in NP and non-NP subgroups. Fisher’s exact test was used as appropriate, with a significance threshold set at p<0.05.

Results A total of 280 ERCPs were included. PEP occurred in 14.9% of LT patients compared to 5.4% in non-LT patients (p=0.0095, OR 3.03). In NP-LT patients, the incidence of PEP was 21.4%, compared to 5.3% in NP non-LT patients (p=0.0024, OR 4.79). Fisher’s exact test revealed a significant difference between the two populations. We further analyzed various factors in the LT population. In NP patients, time since transplant (within vs. beyond 1 year) was identified as a risk factor for PEP (OR=4.57, p<0.05). Stent placement in LT non-NP patients appeared to have a protective role (p=0.098, OR 0.22).

Conclusions This study clearly demonstrates that the LT population faces a significantly higher risk of developing PEP, even after accounting for previous sphincterotomy. Despite investigating multiple patient- and ERCP-related factors, statistical regression could not confirm a significant association for most of them. Time since transplant in NP and stent placement in non-NP patients were the only factors showing a trend toward significance. The high level of immunosuppression typically seen in the months following transplant may explain the increased risk of PEP in LT patients. Stent placement in non-NP patients is usually performed as part of a multistenting plan for anastomotic dilation. These maneuvers tend to be less traumatic during the first ERCP session but may become more traumatic in subsequent sessions.These findings provide valuable insights into the understanding of PEP. However, the heterogeneity of population and the complexity of the procedures suggest that a larger sample size is needed to confirm these results and further explore other potential associations.

Publication History

Article published online:
27 March 2025