ERCP in patients with PSC and cirrhosis is not associated with an increased rate of complications

Background: Primary sclerosing cholangitis (PSC) is a chronic inflammatory disease of intra- and extrahepatic bile ducts with progression to liver cirrhosis and ultimately the need for organ transplantation. Endoscopic treatment is recommended in patients with dominant stenosis and/or clinical symptoms such as pruritus or cholangitis. Whether ERCP is safe and effective in patients that have already progressed to cirrhosis is unknown. We aimed to assess efficacy and complications in a large PSC cohort from a single centre.

Methods: Out of 380 patients with PSC, 208 patients were treated endoscopically between the years 1999 and 2016. We identified 62 patients who had already developed liver cirrhosis at the time ERCP and another 146 patients with PSC without cirrhosis. Mean age was similar in both groups (47,4 vs. 44.8 years). A total of 592 ERCP procedures were analysed, with 186 ERCP procedures in the cirrhotic patients and 406 ERCP procedures in patients without cirrhosis. Data were analyzed retrospectively. As procedure related complications we considered acute pancreatitis, cholangitis, bleeding (requiring blood transfusion or re-intervention) and perforation (defined as bile duct injury requiring re-intervention, stenting, surgery or prolongation of hospital stay).

Results: Overall 43 (7.2%) procedure related complications were documented. Complications were slightly more frequent in the group without cirrhosis (5.4% vs. 8.1%). In patients with liver cirrhosis, we identified 10 complications including three patients with post-ERCP pancreatitis (2%), four patients developed post-ERCP cholangitis (2,1%), two perforations (1%) and one bleeding (0.5%). There were no operations needed. In the group of PSC patients without liver cirrhosis, 33 complications were noted (8.1%), including 15 patients with post-ERCP pancreatitis (3,7%), 10 patients with post-ERCP cholangitis (2%), 6 perforations (1.4%) and 2 bleedings (0.5%). One operation with drainage of abdominal bile collection was needed to manage this patient. Rate of sphincterotomy during ERCP was similar in both groups (24% vs. 23%).

Discussion: Endoscopic therapy in patients with PSC and progression to liver cirrhosis was not associated with a higher rate of complications. Therefore cirrhosis should not preclude ERCP intervention if needed.