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Uncommon complications of endoscopic retrograde cholangiopancreatography (ERCP)

Uncommon complications of endoscopic retrograde cholangiopancreatography (ERCP)
Authors:
Andrea Tringali, MD, PhD
Silvano Loperfido, MD
Guido Costamagna, MD, FACG
Section Editor:
Douglas A Howell, MD, FASGE, FACG
Deputy Editor:
Kristen M Robson, MD, MBA, FACG
Literature review current through: Dec 2022. | This topic last updated: Jun 07, 2022.

INTRODUCTION — The most frequent complications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic biliary sphincterotomy are pancreatitis, cholangitis, hemorrhage, and duodenal perforation. A number of less common adverse events have also been described including cardiopulmonary complications, contrast allergy, impaction of a retrieval basket, and numerous other events reported in only small numbers of patients or individual case reports. These uncommon adverse events, which may be difficult to manage, can be associated with significant morbidity and mortality [1,2].

This topic will focus on uncommon complications of ERCP. Other complications, including post-ERCP pancreatitis, are discussed separately.

●(See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

●(See "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis".)

●(See "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding".)

INCIDENCE — Uncommon complications of ERCP have been described in several large studies.

●Miscellaneous complications occurred in 25 of 2347 cases (1 percent) in a prospective series of patients who underwent biliary sphincterotomy [3]. Six of these were cardiopulmonary events, which were fatal in three patients.

●Similar findings were noted in two Italian prospective series that included a total of 4872 patients undergoing diagnostic and therapeutic ERCP [4,5]. Miscellaneous complications were observed in 0.4 to 0.5 percent of patients, more than one-half of which were cardiopulmonary.

●In a systematic review of 14 prospective studies including a total of 12,973 patients, there were a total of 173 miscellaneous complications (1.3 percent) and nine deaths (0.07 percent) [6].

●A Danish study of 39 consecutive claims for compensation due to adverse events included five uncommon complications (back pain after ERCP under general anesthesia, Hashimoto thyroiditis, a fatal case of cholecystitis, tooth injury, and need for repeat uneventful ERCP due to a stone being missed at the first ERCP) [7].

CARDIOPULMONARY AND SEDATION-RELATED COMPLICATIONS — Severe respiratory and cardiac side effects of endoscopy are infrequent [8]. However, the risk is probably increased with ERCP due to relatively deep sedation, long duration of the examination, prone position of the patient, advanced age of the patient, and frequent comorbid diseases [9-11]. In a database study that included 6092 ERCPs, there were 129 cardiopulmonary events (2.1 percent) [12].

As a result, close surveillance of the patient, monitoring of cardiac function and oxygen saturation, aspiration of secretions, administration of flow oxygen when needed, and prompt availability of resuscitation equipment and reversal agents should be part of the routine support during ERCP. Gas embolisms should be considered, among other possibilities, in patients who develop sudden, severe cardiopulmonary events during ERCP. (See 'Portal vein gas and air embolism' below.)

CONTRAST ALLERGY — Anaphylactic reactions to contrast agents used during ERCP are rare [13]. Nevertheless, a history of sensitivity to iodine contrast or drug should always be considered in the preprocedure assessment and in the informed consent process.

In patients with prior allergy to contrast media, prophylactic measures adopted by most endoscopists include [14]:

●Use of nonionic/low-osmolarity contrast media.

●Premedication with oral steroids starting the day before ERCP, or intravenous steroids when allergy is discovered just before the procedure. Some endoscopists also give an intravenous antihistamine in combination with the steroids.

However, a study of 601 patients who did not receive prophylaxis (including 80 patients with a documented history of reactions to intravascular contrast media) failed to show any adverse reactions associated with the administration of contrast media [13].

ELECTROSURGICAL HAZARDS — Malfunction, incorrect use of electrosurgical equipment and accessories during therapeutic procedures, or defective devices can lead to potentially severe complications of ERCP such as perforation, bleeding, and pancreatitis. Other complications reported in case series include fracture of a Teflon-coated guidewire and retroperitoneal perforation following guidewire-assisted sphincterotomy [15,16] and rupture of a metal biliary endoprosthesis following electrocoagulation for tumor ingrowth, a risky maneuver which should be avoided [17].

Electrocautery can influence implantable devices such as pacemakers and defibrillators. Although most modern pacemakers are unaffected by electrocautery, cardiac arrhythmias can develop if a monopolar current passes through the pacemaker or the heart. The risk is greater for implantable cardioverter-defibrillators since electrocautery may trigger their activation. As a result, the American Society for Gastrointestinal Endoscopy Technology Assessment Committee recommends that implantable cardioverter-defibrillators be deactivated during endoscopic electrosurgery [18,19].

EXTRAVASATION OF CONTRAST MEDIUM INTO THE DUODENAL WALL — Extravasation of contrast medium into the duodenal wall surrounding the papilla during ERCP can interfere with cannulation and therapeutic procedures, and thereby is a risk factor for complications [4]. In addition, forceful attempts in cannulation with fine taper catheters or stiff guidewires, especially in patients with bile or pancreatic duct stenosis or those undergoing precut sphincterotomy, can cause transmural false passages and injection of contrast into the retroperitoneal space or vascular structures. A case of septic cholangitis was reported after an inadvertent submucosal contrast injection during a diagnostic ERCP [20].

OPACIFICATION OF PORTAL, ARTERIAL, OR LYMPHATIC VESSELS — Opacification of the portal vein has been described following sphincterotomy [21], ERCP for pancreatic cancer [22,23], needle-knife sphincterotomy [24,25], and cannulation of the accessory papilla [26]. In addition, documented cases of portal vein visualization during ERCP were reported in patients with pancreatitis (one from a traumatic inadvertent cannulation of the superior mesenteric vein, and another from a preexisting fistula between a pseudocyst and the portal vein) [27]. Two reports described accidental wire-guided cannulation of the portal vein despite the absence of sphincterotomy [28,29]. Guidewire cannulation of the portal vein via an accessory pancreatic duct has also been reported [30]. Accidental cannulation of the hepatic artery following needle-knife sphincterotomy has also been reported [31]. Accidental insertion of a plastic pancreatic into the portal vein was reported in a patient who had sustained a blunt abdominal trauma with pancreatic transection [32]. Opacification of the periampullary lymphatic system has also been described following injection of contrast into the pancreatic duct in a patient with pancreatic head carcinoma [33].

Filling of portal, arterial, or lymphatic vessels has potential risks, including sepsis, air embolism, bleeding, and thrombosis. Furthermore, failed prompt recognition of contrast in vascular structures may be a source of confusion leading to prolongation of the procedure, thereby further increasing the risk of complications. As an example, an opacified portal vein (picture 1) may be misinterpreted as an incompletely filled bile duct. Insertion of a stent into the portal vein may further worsen the consequences; a case has been reported of placement of an endoscopic nasobiliary drainage tube in the portal vein, fortunately without subsequent complications [34]. In a separate case report, a portobiliary fistula complicating endoscopic stenting was reported in a patient with pancreatic cyst [35].

DUODENAL PNEUMATOSIS — A limited collection of air within the duodenal wall (duodenal pneumatosis) has been observed following needle-knife sphincterotomy in a patient with biliary obstruction from ampullary tumor [36]. The procedure should be stopped upon recognition of this complication since further bowel manipulation may lead to frank perforation.

PORTAL VEIN GAS AND AIR EMBOLISM — In the past, the appearance of gas in the portal venous system was usually a sign of lethal conditions such as advanced intestinal infarction, but portal venous gas has also been observed following abdominal interventions and gastrointestinal endoscopy [37]. (See "Air embolism".)

Gas embolism is largely iatrogenic. In most cases, the embolized gas is air. Air embolism is an uncommon but potentially catastrophic event. Cases of air embolism have been reported following upper and lower gastrointestinal endoscopy, although most described cases have been related to an ERCP [32,38-85]. In a review including 40 cases of systemic air embolism following an endoscopic procedure, 24 patients (60 percent) underwent ERCP [86]. In an analysis of an inpatient database including over two million endoscopic procedures, air embolism occurred in 13 patients, resulting in an air embolism rate of 0.57 per 100,000 endoscopies. Air embolism was more common with ERCP compared with EGD or colonoscopy (3.32 per 100,000 procedures versus 0.44 and 0.38 per 100,000 procedures, respectively) [87].

Possible pathophysiologic mechanisms for air embolism during endoscopy include:

●Air insufflated under pressure by the endoscope entering an exposed vessel through a compromised mucosa barrier, either via portal or hepatic veins.

●Air insufflated entering a previous communication between the biliary system and the circulation.

●Air insufflated directly into the hepatic veins while using small diameter endoscopes during intraductal biliary endoscopy.

There are two categories of air embolism, venous and arterial embolism:

●A venous air embolism occurs when air passes from the portal vein to the systemic venous circulation through the hepatic veins and then to the right ventricle and pulmonary circulation.

●An arterial air embolism occurs when air in the venous system enters the arterial system through a patent foramen ovale or pulmonary arteriovenous shunts; it may also occur in the absence of a shunt if the rate and volume of air entry exceeds the filtering capacity of the lung.

The true incidence of air embolism is unknown, and many cases are subclinical and thus go unreported [88].

The table illustrates a series of reported cases of air embolism during ERCP (table 1). General observations from the series include [89]:

●Reporting trends – The number of case reports has increased over time.

●Sex – The frequency is similar between men and women.

●Indication and procedures – Both benign and malignant diseases, and both diagnostic and therapeutic procedures were associated with embolism.

●Clinical presentation – The clinical presentation depends on the rapidity and amount of air entering the circulation; the reported clinical symptoms are cardiovascular, pulmonary, and neurologic. Both venous and arterial air embolism occurred in one-half of the cases.

●Diagnostic tests – Tests that provided supportive evidence were chest and abdominal radiography, cardiac auscultation, transthoracic and transesophageal echocardiography, abdominal and cerebral computed tomography scan, cerebral and spinal magnetic resonance imaging (MRI), and autopsy.

●Risks for air embolism – Factors associated with air embolism include previous biliary interventions, previous liver biopsy, percutaneous or transhepatic cholangiography, transjugular intrahepatic portosystemic shunt placement, using a rendezvous technique for ERCP, blunt or penetrating trauma to the liver, hepatic abscesses, tumors, choledochoscopy, insufflation of air with high pressure, and long procedure duration.

A potential area of concern is the increasing use of direct intraductal endoscopy using small caliber endoscopes (eg, cholangioscopy), which may increase the risk of air embolism. Several cases of air embolism during peroral cholangioscopy with slim endoscopes have been reported [59,90]. Data on the use of carbon dioxide insufflation during cholangioscopy and risk of air embolism are mixed [59,91,92]. As an example, cases of fatal systemic gas embolism during direct peroral cholangioscopy using carbon dioxide insufflation have also been reported [91,92]. However, the consequences of air embolism may be mitigated with the use of carbon dioxide insufflation rather than air insufflation because carbon dioxide is more rapidly absorbed and eliminated if embolism occurs. Thus, we use carbon dioxide insufflation for ERCP [85,93]. (See "Anesthesia for gastrointestinal endoscopy in adults", section on 'Complications'.)

●Differential diagnosis – Air embolism should be considered in any patient who has sudden onset of cardiopulmonary or neurologic decompensation during an endoscopic procedure. A bedside echocardiogram is a valuable diagnostic aid.

●Treatment – Once portal venous air is recognized during ERCP and air embolism is suspected, the procedure should be terminated immediately and the patient should be observed for signs of shock, bleeding, perforation, or sepsis [44]. Together with cardiopulmonary resuscitation, it is recommended to place the patient in Trendelenburg and left lateral decubitus position and give adequate oxygen or hyperbaric oxygenation therapy as soon as possible. Air aspiration via central venous catheter could be considered but is very difficult to perform, and the success of appreciable aspiration of air is far from ideal [94].

●Prognosis and outcomes – Patient survival and overall prognosis depend on rapid diagnosis and treatment. Death occurred in approximately one-half of the reported cases.

●Prevention – Clinicians should be aware of the risk of air embolism and prepared to manage adverse events. ERCP should be performed extremely cautiously or not at all in patients who are suspected of having a biliary-vascular fistula. In addition, we use carbon dioxide insufflation for ERCP because it may reduce the risk of air embolism [85,93].

Some authors have recommended deep sedation or even general anesthesia systematically during ERCP, but fatal cases have occurred with anesthesia assistance. The general consensus is that the patient must be carefully monitored by the operator and assistants with the help of electronic monitoring devices.

HEMORRHAGE FROM SPLENIC, HEPATIC OR VASCULAR TRAUMA — Hemorrhage following endoscopic sphincterotomy usually occurs in the duodenal lumen arising from the actual sphincterotomy site. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding".)

However, in rare cases intraperitoneal hemorrhage has been described from injury to the spleen, liver, or abdominal vessels.

Splenic injury is more commonly caused by colonoscopy, but it has also been reported following ERCP [95,96]. Previous abdominal surgery with adhesion formation is recognized as a risk factor; concomitant liver laceration has also been reported [97,98]. The severity of the splenic injury varies from a subcapsular hematoma to the avulsion of splenic vessels. As a result, patients do not always present with shock and acute abdomen, and the injury may be overlooked. As an example, a subcapsular splenic laceration was diagnosed six days after ERCP in a patient with chronic pancreatitis [95]. The diagnosis of a subcapsular splenic laceration should be suspected in patients who develop the acute onset of left upper quadrant abdominal pain following ERCP. The pain is often delayed and is not always associated with obvious signs of peritoneal irritation, hemodynamic instability, or a drop in the hematocrit. A subcapsular splenic laceration was diagnosed six days after ERCP in a patient with chronic alcoholic pancreatitis [95]. A case of hemoperitoneum after endoscopic sphincterotomy was found from a capsular tear in the splenic hilum, possibly from "bowing" of the endoscope in the long position with torsion on the great curvature of the stomach resulting in splenic vascular avulsion or capsular tears [96]. Definitive diagnosis requires ultrasonography, computed tomography (CT) scan, angiography, laparoscopy, or laparotomy. Surgery is usually required for management.

Numerous other bleeding events have been described in case reports:

●One report documented intraperitoneal hemorrhage due to traumatic disruption of the right gastroepiploic artery following endoscopic sphincterotomy and technically difficult stone extraction [99].

●A retroperitoneal hematoma occurred as a complication of ERCP after liver transplantation [100].

●Transverse mesocolon disruption and ischemic colitis following ERCP with sphincterotomy, and requiring laparotomy and bowel resection [101].

●Another report documented an intra-abdominal hematoma following a difficult ERCP requiring prolonged manipulation and long looping of the endoscope in the stomach during the advancement into the duodenum [102].

●Hepatic hematoma after ERCP is a rare but potentially serious complication, and may be related to use of a guidewire [103-105].

●Duodenal hematoma following ERCP that was endoscopically treated with needle knife and transnasal drainage has also been reported [106].

●Bleeding from bile duct varices has been described as a complication of ERCP with sphincterotomy and dilatation of a distal common bile duct stricture in a patient with cirrhosis and cavernous transformation of the portal vein [43].

●Hemobilia following hydrostatic dilation of stenosis of common bile duct in a patient with hereditary hemorrhagic telangiectasia [107]. Hemobilia has also been attributed to a hepatic artery pseudoaneurysm secondary to plastic biliary stent insertion for a bile duct tumor [108,109].

●Bleeding from a pseudocyst that contained a pseudoaneurysm was reported following nontraumatic cannulation of the pancreatic duct [110].

●A pseudoaneurysm complicating precut-sphincterotomy [111].

●Life-threatening hemobilia from hepatic pseudoaneurysm following ERCP [112] and arteriobiliary fistulas caused by biliary stents [113,114].

●A potentially life-threatening bleed occurred following a needle-knife incision of a swollen papilla in a patient with acute pancreatitis [115]. What had been assumed to be a cystic lesion, on the basis of conventional abdominal ultrasound, was, in fact, a pseudoaneurysm of a branch of the pancreaticoduodenal artery (picture 2).

●Acute duodenal ischemia and periampullary intramural hematoma have been reported after ERCP with sphincterotomy and stone extraction in a patient with primary myelofibrosis on antiplatelet treatment [116].

●An intramural hematoma of the upper esophagus as a result of ERCP has been reported [117].

●Gastrointestinal bleeding resulting from a migrated plastic biliary plastic stent has been reported [118].

UNCOMMON SEPTIC COMPLICATIONS — Acute cholecystitis and liver abscess are uncommon but well-known septic complications of ERCP. (See "Infectious adverse events related to endoscopic retrograde cholangiopancreatography (ERCP)".)

Other uncommon infectious complications have included:

●Biliary obstruction and cholangitis due to a blood clot that obstructed the common bile duct after endoscopic sphincterotomy [119-122].

●Pyogenic cholangitis without evidence of biliary tract disease occurred after inadvertent injection of submucosal contrast in the papilla of Vater [20].

●A severe case of retropharyngeal abscess following instrumental injury during ERCP that was reported in the 1970s [123].

●A retroperitoneal abscess caused by Haemophilus influenzae and H. parainfluenzae following pancreatic sphincterotomy and stone extraction [124].

●A subcapsular hematoma that occurred during ERCP with sphincterotomy that was complicated by development of a splenic abscess [125].

●Abscess formation in a simple renal cyst has been described as a complication of pancreatitis following biliary sphincterotomy [126]. The septic involvement of the renal cyst originated from extrapancreatic collections in the perirenal space.

●A spinal epidural abscess after endoscopic treatment for chronic pancreatitis [127].

●A case of iatrogenic Escherichia coli endogenous pan-endophthalmitis after ERCP-associated biliary sepsis [128].

UNCOMMON PERFORATIONS — Three types of perforation complicating ERCP are most frequently recognized:

●Retroperitoneal duodenal perforation

●Free bowel-wall perforation

●Perforation of the bile ducts

Of these, retroperitoneal duodenal perforations are the most common. (See "Post-ERCP perforation".)

Some less common forms of perforation have also been described:

●Intestinal perforation related to biliary stents. (See 'Complications related to biliary and pancreatic stents' below.)

●Sigmoid colon perforation as a consequence of bowel air distension and diverticular disease [4,129].

●Cystic duct perforation as a complication of endoscopic stone extraction in a patient with chronic cholecystitis and dense adhesions [130].

●Subcutaneous emphysema of the penis and scrotum mimicking gas gangrene secondary to retroperitoneal duodenal perforation [131].

●Pneumoperitoneum following ERCP as a result of air traversing from the duodenum to the peritoneum through a ruptured T-tube in two patients who had undergone cholecystectomy with a retained common bile duct [132].

●Idiopathic perforation of acalculous gallbladder after insertion of a transpapillary pancreatic stent [133].

●A bilious pleural effusion occurred after ERCP with metal stent placement in a patient with gallbladder adenocarcinoma [134].

PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND PNEUMOPERITONEUM — Pneumothorax, pneumomediastinum, and pneumoperitoneum have been reported secondary to gastrointestinal perforation, including perforation following endoscopic sphincterotomy. However, pneumothorax has also been described during diagnostic upper endoscopy [135,136] and during ERCP without perforation [4]. Such cases are due to a rise in airway and intraalveolar pressure and the rupture of pulmonary blebs.

Data on pneumothorax related to ERCP are limited to case reports. In a systematic review of 44 studies reporting pneumothorax after ERCP, a total of 49 cases were identified [137]. Twenty-one patients (43 percent) had abnormal gastrointestinal anatomy (eg, periampullary diverticula, surgically altered anatomy, local tumor). Pneumothorax occurred bilaterally in 22 patients (45 percent). The cause of pneumothorax in most cases was duodenal perforation at a periampullary site in 20 procedures (41 percent) or distant from the papilla in 11 procedures (23 percent).

Data from individual case reports included:

●Reports described bilateral pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumoperitoneum, and pneumoretroperitoneum occurred in a patient who underwent endoscopic sphincterotomy and extraction of choledochal stones [138,139].

●A case of tension pneumoperitoneum without perforation was reported after insertion of an endoscopic biliary stent for postcholecystectomy biliary leak [140]. The authors' explanation was that air passed from the duodenum into the biliary system through the stent and then through the opening in the common bile duct into the peritoneum.

●Pneumoperitoneum from rupture or intrahepatic bile ducts occurred after ERCP and bile duct stent in a patient with pancreatic cancer and hepatic metastasis [141].

●Pneumoperitoneum occurred following therapeutic ERCP in a septic patient with hepatic abscess and rupture of Glisson's capsule [142].

IMPACTION OF RETRIEVAL BASKETS AND FRACTURE OF THE TRACTION WIRE — Impaction of a Dormia basket around a large calculus was a feared complication of bile duct extraction prior to the introduction of mechanical lithotripsy. Despite the availability of lithotripsy, cases are still reported. Usually the basket becomes trapped at the ampulla within the intraduodenal portion of the common bile duct. However, impaction above the intrapancreatic portion of the bile duct, in the intrahepatic ducts, in the main pancreatic duct, and even in the gallbladder has been described [143-146].

The risk for basket trapping is increased with big, irregular shaped and hard stones, or multiple stones, in association with small sphincterotomy size. Other risk factors are distal narrowing of the common bile duct and segmental dilatation of intrahepatic ducts as in Caroli disease.

Tailoring the sphincterotomy size appropriately and refraining from fully closing the basket around a large stone may prevent entrapment. In addition, prevention of basket impaction requires experience and good judgment in recognizing conditions in which standard techniques of stone extraction are likely to fail and alternative approaches should be considered.

Once the basket impaction has occurred, the first and common alternative is mechanical lithotripsy. Thus, retrieval baskets should always be suitable for mechanical lithotripsy; baskets that are not designed for lithotripsy can fracture. If mechanical lithotripsy is complicated by fracture of the central traction wire of the Dormia basket without breakage of the stone, a rescue second basket has been successfully used in rare cases [147]. Other nonsurgical methods, singularly or in combination, may be effective, including extended sphincterotomy, intracorporeal electrohydraulic lithotripsy (which requires the use of a "mother and baby" system or a percutaneous choledochoscopic approach), extracorporeal shock wave lithotripsy, and intracorporeal laser lithotripsy. Surgery is required when these techniques are not available or if they are unsuccessful [148]. Temporary drainage through nasobiliary drain or stent should be provided if the choice of a new option involves a delay. (See "Endoscopic management of bile duct stones".)

COMPLICATIONS RELATED TO BILIARY AND PANCREATIC STENTS

Plastic biliary and pancreatic stents — A common and generally late complication related to biliary and pancreatic stents is occlusion. Plastic stent insertion may also contribute to the development of post-ERCP pancreatitis (see "Pancreatic stenting at endoscopic retrograde cholangiopancreatography (ERCP): Indications, techniques, and complications"). Uncommon complications are misplacement, dislodgement, and fracture, the last being generally due to attempts at removal and replacement of the stent.

Inadvertent primary misplacement of plastic biliary stents into the retroperitoneum or into an intrahepatic extrabiliary position can occur in patients with malignant bile duct obstruction [149]. Duodenal wall ulceration and perforation resulting from pressure necrosis have been observed by several authors following the long-term use of straight prostheses with a long distal intraduodenal part [150-156]. A biliocutaneous fistula and a duodenoscrotal fistula have been described following distal migration of long biliary stents [157,158].

Impaction and perforation of the gut in sites distant from duodenum, especially at the level of sigmoid diverticula, have also been reported by several authors [159,160]. A complex colovesicular fistula has been reported as a late severe complication caused by distal migration of a biliary stent placed for choledocholithiasis [161-163]. A pericardio-biliary fistula developed in patient with IgG4-related sclerosing cholangitis when a plastic biliary stent migrated proximally [164]. Proximal or distal stent migration has been described in 5 to 7 percent of patients after placement of a plastic biliary stent and 5 to 8 percent of patient after placement of a pancreatic stent [165]. As a result, patients should be monitored for stent migration and stents should be removed orally [166,167].

The endoscopic retrieval of proximally migrated biliary and pancreatic stents can be technically challenging or unsuccessful [168-171]. One study described a late distal perforation of the common bile duct by the distal tip of a migrated straight endoprosthesis [172]. Cases of bile duct-duodenum and a pancreatic-gastric fistula have been reported secondary to proximal stent migration of a biliary and a pancreatic stent, respectively [173]. Cases of pleurobiliary fistula following intrahepatic biliary stent migration have also been reported [174]. Bronchobiliary fistula has been seen as a complication of long-term stenting of the hepatic ducts following hepatobiliary surgery for a hydatid cyst (the stents were placed during ERCP) [175]. A hepaticogastric fistula has been described as a late complication from a proximally migrated long biliary stent [176].

One report described a pancreatic fistula without pancreatitis after endoscopic biliary stent placement for a large bile leak in two patients who had undergone orthotopic liver transplantation [177]. The authors suggested that placement of a large diameter biliary stent without previous sphincterotomy caused relative obstruction of the pancreatic orifice at the papilla and retrograde flux of pancreatic juice into the bile duct. Acute portal vein thrombosis and massive necrosis of the liver occurred after stenting for chronic pancreatitis [178]. Another report described migration of a prophylactic pancreatic stent into the portal vein resulting in portal vein thrombosis [179].

Metal stents — Other than occlusion by tumor ingrowth, complications related to self-expandable metal biliary stents are less frequent than for plastic stents, in part because they have been relatively recently introduced, and are less commonly used. In addition, most patients who receive a metal stent have a limited life expectancy since they are typically placed for malignant obstruction. Nevertheless, a number of adverse events have been described, including:

●Migration of covered stents [180,181]

●Failed deployment, impaction of the delivery device, dislodgement, migration, rupture [17,166,180,182]

●Early stent occlusion by blood clot [183]

●Duodenal ulceration, stent-related bleeding and perforation [184-188]

●Upper gastrointestinal bleeding from a biliary-duodenal fistula [189]

●Hemobilia from hepatic artery pseudoaneurysm causing an arteriobiliary fistula [113,190]

●Lower intestinal hemorrhage due to a dislodged metallic stent [191]

●Impaction of a plastic biliary stent placed through an occluded metal stent [192]

●Biliorenal fistula [193]

●Cholecystitis related to both uncovered and covered biliary stents [180,194]

●Fatal air embolism occurred following placement of metallic stent for an ampulloma [55]

●Massive hemobilia (picture 3 and picture 4) during extraction of a covered self-expandable metal stent in a patient with portal hypertension [195]

●A malpositioned metallic self-expandable stent penetrated the liver and extended into the peritoneal cavity [196]

●Inferior vena cava syndrome secondary to compression by a biliary stent [197]

Guidewires — Guidewire fracture during ERCP is rare. It has been reported in a few cases involving hydrophilic wires with an angled tip [198-200], or following guidewire-assisted sphincterotomy [15]. Liver and pancreatic parenchymal perforation by the guidewire during ERCP are poorly recognized complications, and subcapsular liver hematoma and subcapsular biloma can occur in this context [201]. In one case, a guidewire used during ERCP was believed to cause an infected liver hematoma [202].

A classification system for guidewire-related injuries has been proposed along with their possible consequences [201]:

●A – Pancreatic duct into parenchyma (peripancreatic fluid collection due to pancreatitis)

●B – Pancreatic duct through parenchyma (pancreatitis and leak from the pancreatic duct)

●C – Intrahepatic bile ducts into parenchyma (subcapsular hematoma or biloma)

●D – Intrahepatic bile ducts through parenchyma (free bile leak)

GALLSTONE ILEUS — Large stones, usually over 25 mm, can cause gallstone ileus when released into the duodenum following endoscopic biliary sphincterotomy. The clinical presentation may be delayed by months, and be atypical or severe [203-205]. Successful treatment by electrohydraulic lithotripsy and extracorporeal shock wave lithotripsy has been reported [206,207]. However, the management is usually surgical [208-210]. (See "Gallstone ileus".)

RADIOLOGICAL MISDIAGNOSES — Complications can arise from mistakes in the interpretation of diagnostic findings during ERCP. The most common mistake is missing common duct stones. Such patients may require subsequent investigations and have a delayed diagnosis resulting in potential insurance claims [7,211,212]. A more serious error is overlooking a hilar biliary stricture in a patient with biliary stones or erroneously considering a stricture to be benign.

MISCELLANEOUS — The following rare adverse events related to ERCP have been reported:

●Tooth injury.

●Conjunctival ecchymosis.

●Corneal abrasion [213].

●Uvular necrosis [214].

●Transient swelling of the parotid gland (authors' personal observation) and acute parotitis [215,216].

●Dislocation of temporomandibular joint [217,218].

●Hemolysis due to G6PD deficiency presumably induced by hypoxemia and temporary acidosis during ERCP [219].

●Methemoglobinemia caused by topical benzocaine spray [220].

●Thrombotic thrombocytopenic purpura following post-ERCP pancreatitis [221].

●Hashimoto's thyroiditis presumed to be caused by contrast exposure [7].

●An intramural duodenal hematoma [222,223].

●Mallory-Weiss tear [224].

●Hepatic subcapsular biloma (a collection of bile outside the biliary tree) secondary to bile leak induced by high pressure injection of contrast [225,226].

●Pancreatic duct perforation during brushing [227].

●Prolonged cholestasis responding to glucocorticoids, suspected drug-induced hepatitis [228-230].

●Development of a pseudotumor of the pancreatic head after therapeutic ERCP [231].

●Duodenal obstruction following papillary stenosis [232].

●Electrical burn in the liver secondary to sphincterotomy [233].

●Acute pulmonary embolism [234].

●Bronchobiliary fistula and lithoptysis after ERCP and liver biopsy [235].

●Reversible acute duodenitis as a complication of endoscopic biliary stenting [236].

●Vision loss due to isolated bilateral lateral geniculate body infarction in a 22-year-old healthy woman who underwent ERCP for suspected choledocholithiasis and developed acute post-ERCP pancreatitis despite rectal prophylaxis with indomethacin [237].

●Pituitary apoplexy [238].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endoscopic retrograde cholangiopancreatography (ERCP)".)

SUMMARY AND RECOMMENDATIONS

●The most frequent complications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic biliary sphincterotomy are pancreatitis, cholangitis, hemorrhage, and duodenal perforation. A number of uncommon adverse events have also been described. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

●Uncommon complications of ERCP include:

•Severe respiratory and cardiac side effects. (See 'Cardiopulmonary and sedation-related complications' above.)

•Anaphylactic reactions to contrast agents used during ERCP. (See 'Contrast allergy' above.)

•Malfunction or incorrect use of electrosurgical equipment and accessories during therapeutic procedures, or defective devices can lead to potentially severe complications such as perforation, bleeding, and pancreatitis. (See 'Electrosurgical hazards' above.)

•Opacification of the portal vein has been described with multiple therapeutic interventions. (See 'Opacification of portal, arterial, or lymphatic vessels' above.)

•Appearance of gas in the portal venous system. (See 'Portal vein gas and air embolism' above.)

•Cardiac and cerebral air embolism. (See 'Portal vein gas and air embolism' above.)

•Intraperitoneal hemorrhage from injury to the spleen, liver, or abdominal vessels. (See 'Hemorrhage from splenic, hepatic or vascular trauma' above.)

•Pneumothorax, pneumomediastinum, and pneumoperitoneum. (See 'Pneumothorax, pneumomediastinum, and pneumoperitoneum' above.)

•Impaction of retrieval baskets and fracture of the traction wire. (See 'Impaction of retrieval baskets and fracture of the traction wire' above.)

•Complications related to biliary and pancreatic stents. (See 'Complications related to biliary and pancreatic stents' above.)

•Gallstone ileus due to the release of large stones, usually over 25 mm, into the duodenum. (See 'Gallstone ileus' above.)

•Mistakes in the interpretation of diagnostic findings during ERCP. (See 'Radiological misdiagnoses' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff thank Francesco Ferrara, MD, for his contributions as author to prior versions of this topic review.

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  198. Pruitt A, Schutz SM, Baron T, et al. Fractured hydrophilic guidewire during ERCP: a case series. Gastrointest Endosc 1998; 48:77.
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Topic 638 Version 25.0

References

1 : Unusual complications related to endoscopic retrograde cholangiopancreatography and its endoscopic treatment.

2 : Uncommon and rarely reported adverse events of endoscopic retrograde cholangiopancreatography.

3 : Complications of endoscopic biliary sphincterotomy.

4 : Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.

5 : Complications of diagnostic and therapeutic ERCP: a prospective multicenter study.

6 : Incidence rates of post-ERCP complications: a systematic survey of prospective studies.

7 : Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.

8 : Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy.

9 : Death related to midazolam overdose during endoscopic retrograde cholangiopancreatography.

10 : Cardiopulmonary complications of ERCP in older patients.

11 : Cardiac Arrest from Asystole During Endoscopic Retrograde Cholangiopancreatography: A Rare But Fatal Complication.

12 : A national study of cardiopulmonary unplanned events after GI endoscopy.

13 : Prospective evaluation of adverse reactions to iodine-containing contrast media after ERCP.

14 : Iodinated contrast sensitivity in ERCP.

15 : Guidewire fracture during endoscopic sphincterotomy.

16 : The effect of guidewires during electrosurgical sphincterotomy.

17 : Broken biliary metal stent after repeated electrocoagulation for tumor ingrowth.

18 : Endoscopy in patients with implanted electronic devices.

19 : An update on the management of implanted cardiac devices during electrosurgical procedures.

20 : Pyogenic cholangitis after inadvertent submucosal contrast injection in the papilla of Vater in a patient with cholestatic hepatitis.

21 : A frightening event during endoscopic papillotomy.

22 : Opacification of the portal system during ERCP: demonstration of an anomalous pancreatico-portal connection in a patient with pancreatic carcinoma.

23 : Portal vein filling during ERCP.

24 : Portal vein filling: a rare complication associated with ERCP for endoscopic biliary stent placement.

25 : Portal vein filling: an unusual complication of needle-knife sphincterotomy.

26 : Portal vein filling during ERCP.

27 : Portal vein opacification during ERCP in patients with pancreatitis.

28 : Portal vein cannulation: an uncommon complication of endoscopic retrograde cholangiopancreatography.

29 : Portobiliary fistula: unusual complication of wire-guided cannulation during endoscopic retrograde cholangiopancreatography.

30 : Accessory Pancreatic Duct-Portal Vein Fistula: A Rare Complication of Chronic Pancreatitis during Endoscopic Retrograde Cholangiopancreatography.

31 : [Accidental cannulation of the hepatic artery following needle-knife sphincterotomy].

32 : An unforeseeable adverse event during ERCP.

33 : Direct pancreatic lymphangiography during ERCP.

34 : A rare complication during ERCP and sphincterotomy: placement of an endoscopic nasobiliary drainage tube in the portal vein.

35 : Iatrogenic portobiliary fistula complicating endoscopic stenting of a pancreatic cyst, with possible carcinoma: a case report.

36 : Limited duodenal pneumatosis during needle-knife sphincterotomy.

37 : Air embolism complicating gastrointestinal endoscopy: A systematic review.

38 : Hepatic portal venous gas due to endoscopic sphincterotomy.

39 : Portal venous gas as a complication of ERCP and endoscopic sphincterotomy.

40 : Hepatic portal vein gas following endoscopic retrograde cholangiography with sphincterotomy. Case report.

41 : Hepatic portal venous gas after endoscopic biliary sphincterotomy.

42 : Uncomplicated portal venous gas associated with duodenal perforation following ERCP: CT features.

43 : Bleeding from bile duct varices: an unexpected hazard during therapeutic ERCP.

44 : Fatal hepatic air embolism following ERCP.

45 : Fatal air and bile embolism after percutaneous liver biopsy and ERCP.

46 : Biliary metal stents and air embolism: a note of caution.

47 : Fatal biliary-systemic air embolism during endoscopic retrograde cholangiopancreatography: a case with multifocal liver abscesses and choledochoduodenostomy.

48 : Cardiac and cerebral air embolism from endoscopic retrograde cholangio-pancreatography.

49 : Cardiac air embolism after endoscopic retrograde cholangiopancreatography in a patient with blunt hepatic trauma.

50 : [Air embolism: an unusual complication of endoscopic retrograde cholangiopancreatography].

51 : Systemic air embolism after ERCP: a case report and review of the literature (with video).

52 : Unexpected cardiovascular collapse from massive air embolism during endoscopic retrograde cholangiopancreatography.

53 : Fatal systemic air embolism during endoscopic retrograde cholangio-pancreatography.

54 : Fatal cerebral air embolism after endoscopic retrograde cholangiopancreatography.

55 : [Thoracoabdominal CT scan: a useful tool for the diagnosis of air embolism during an endoscopic retrograde cholangiopancreatography].

56 : Fatal cerebral arterial gas embolism after endoscopic retrograde cholangiopancreatography.

57 : [Cerebral artery air embolism secondary to endoscopic retrograde cholangiopancreatography].

58 : Myocardial and cerebral infarction due to massive air embolism following endoscopic retrograde cholangiopancreatography (ERCP).

59 : Peroral cholangioscopy for diagnosis and therapy of biliary tract disease using an ultra-slim gastroscope.

60 : Fatal systemic venous air embolism during endoscopic retrograde cholangiopancreatography.

61 : [Fatal venous air embolism during biliary endoscopy].

62 : Air embolism during endoscopic retrograde cholangiopancreatography in a pediatric patient.

63 : Complication of cardiac air embolism during ERCP and EUS-assisted cyst-gastrostomy for pancreatic pseudocyst.

64 : Complete neurological recovery after systemic air embolism during endoscopic retrograde cholangiopancreatography.

65 : Air embolism after percutaneous transhepatic biliary drainage and subsequent endoscopic retrograde cholangiopancreatography (ERCP).

66 : Fatal cerebral venous air embolism during endoscopic retrograde cholangiopancreatography-case report and review of the literature.

67 : Acute stroke due to air embolism complicating ERCP.

68 : Cerebral air embolism via port catheter and endoscopic retrograde cholangio-pancreatography.

69 : Cerebral air embolism during endoscopic retrograde cholangiopancreatography: treatment with therapeutic hypothermia.

70 : Life-threatening air embolism during ERCP.

71 : Cerebral air embolism as a complication of biliary endoscopy: A case report

72 : Portal venous air embolization.

73 : Fatal Cerebral Air Embolism Due to a Patent Foramen Ovale during Endoscopic Retrograde Cholangiopancreatography.

74 : Sudden death after endoscopic retrograde cholangiopancreatography (ERCP)--case report and literature review.

75 : Air embolism after endoscopic retrograde cholangiopancreatography in a patient with budd Chiari syndrome.

76 : Paradoxical air embolus during endoscopic retrograde cholangiopancreatography: an uncommon fatal complication.

77 : Fatal air embolism during endoscopic retrograde cholangiopancreatography (ERCP): An 'impossible' diagnosis for the forensic pathologist.

78 : Pulseless electrical activity arrest due to air embolism during endoscopic retrograde cholangiopancreatography: a case report and review of the literature.

79 : Two Cases of Cerebral Air Embolism That Occurred during Esophageal Ballooning and Endoscopic Retrograde Cholangiopancreatography.

80 : Endoscopic Bubble Trouble: Hyperbaric Oxygen Therapy for Cerebral Gas Embolism During Upper Endoscopy.

81 : [Massive cerebral air embolism following endoscopic retrograde cholangiopancreatography. A case report and review of the literature].

82 : Two Cardiac Arrests Because of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography: A Case Report.

83 : Cerebral air embolism after ERCP.

84 : Portal air embolism after endoscopic retrograde cholangiopancreatography.

85 : Incidence of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography.

86 : Systemic air embolism after endoscopy without vessel injury - A summary of reported cases.

87 : Air embolism secondary to endoscopy in hospitalized patients: results from the National Inpatient Sample (1998-2013).

88 : Diagnosis and treatment of vascular air embolism.

89 : Gas embolism during endoscopic retrograde cholangiopancreatography: diagnosis and management.

90 : Air embolism complicated by left hemiparesis after direct cholangioscopy with an intraductal balloon anchoring system.

91 : Development of fatal systemic gas embolism during direct peroral cholangioscopy under carbon dioxide insufflation.

92 : Fatal outcome due to CO2 emboli during direct cholangioscopy.

93 : The use of carbon dioxide in gastrointestinal endoscopy.

94 : Gas embolism.

95 : Splenic Injury and ERCP: A Possible Risk for Patients with Advanced Chronic Pancreatitis.

96 : A dangerous loop.

97 : Injury to the liver and spleen after diagnostic ERCP.

98 : Splenic trauma following endoscopic retrograde cholangiopancreatography (ERCP).

99 : Intraperitoneal hemorrhage from injury to the gastroepiploic artery: a complication of endoscopic retrograde sphincterotomy.

100 : Abdominal compartment syndrome secondary to retroperitoneal hematoma as a complication of ERCP after liver transplantation.

101 : Rare complications of endoscopic retrograde cholangiopancreatography: two case reports.

102 : A rare complication of intra-abdominal hematoma after ERCP.

103 : Hepatic hematoma after ERCP: two new case reports.

104 : Infected hepatic hematoma 10 days after ERCP.

105 : Large Hepatic Subcapsular Hematoma Following Endoscopic Retrograde Cholangiopancreatography: A Case Report.

106 : Endoscopic drainage for duodenal hematoma following endoscopic retrograde cholangiopancreatography: a case report.

107 : Hemobilia in hereditary hemorrhagic telangiectasia: an unusual complication of endoscopic retrograde cholangiopancreatography.

108 : Right hepatic artery pseudoaneurysm: rare complication of plastic biliary stent insertion.

109 : Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer.

110 : Bloody drainage following endoscopic retrograde pancreatography as a presentation of a pseudoaneurysm-containing pseudocyst.

111 : False aneurysm of the pancreaticoduodenal artery complicating therapeutic endoscopic retrograde cholangiopancreatography.

112 : Intra-hepatic false aneurysm: a rare complication of ERCP.

113 : Pseudoaneurysm caused by a self-expandable metal stent: a report of three cases.

114 : Hemobilia due to arteriobiliary fistula complicating ERCP for residual bile duct stone in a case of Mirizzi syndrome.

115 : Needle knife precut-induced bleeding from a "pancreatic cyst".

116 : Acute duodenal ischemia and periampullary intramural hematoma after an uneventful endoscopic retrograde cholangiopancreatography in a patient with primary myelofibrosis.

117 : Intramural hematoma of the esophagus: An unusual complication of endoscopic retrograde cholangiopancreatography.

118 : Post ERCP gastrointestinal hemorrhage: An unusual complication of migrated biliary stent.

119 : Bleeding causing biliary obstruction after endoscopic sphincterotomy.

120 : Common bile duct thrombus: a cause of persisting obstructive jaundice after endoscopic sphincterotomy.

121 : [Cholangitis induced by an obstructive blood clot after endoscopic sphincterotomy].

122 : Obstructive jaundice due to a blood clot after ERCP: a case report and review of the literature.

123 : Retropharyngeal abscess after endoscopic retrograde cholangiopancreatography: an uncommon but potentially fatal complication.

124 : ERCP complicated by a retroperitoneal abscess caused by Haemophilus influenzae and Haemophilus parainfluenzae.

125 : Splenic injury and abscess complicating endoscopic retrograde cholangiopancreatography.

126 : Endoscopic biliary sphincterotomy complicated by abscess formation in a simple renal cyst.

127 : Spinal epidural abscess after endoscopic treatment for chronic pancreatitis.

128 : An unexpected case of iatrogenic Escherichia coli endogenous pan-endopthalmitis after ERCP-associated biliary sepsis: A case report.

129 : Perforation of the sigmoid colon after therapeutic UGI endoscopy.

130 : Cystic duct perforation as a complication of endoscopic stone extraction.

131 : Subcutaneous emphysema of the penis and scrotum mimicking gas gangrene: a rare complication of ERCP.

132 : Pseudobowel perforation following endoscopic retrograde cholangiopancreatography.

133 : Gaining competence in needle-knife fistulotomy - can I begin on my own?

134 : An Interesting Case of a Bilious Pleural Effusion.

135 : Tension pneumothorax complicating diagnostic upper endoscopy: a case report.

136 : Pneumothorax complicating diagnostic upper endoscopy.

137 : Systematic review of pneumothoraces after endoscopic retrograde cholangiopancreatography.

138 : Bilateral pneumothorax following endoscopic retrograde cholangiopancreatography: a case report.

139 : Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after ERCP.

140 : Pneumoperitoneum after insertion of endoscopic biliary stent for post-cholecystectomy biliary leak.

141 : A rare etiology of post-endoscopic retrograde cholangiopancreatography pneumoperitoneum.

142 : An unusual post-ERCP pneumoperitoneum.

143 : Percutaneous transhepatic management of an impacted endoscopic basket.

144 : Basket impaction at the pancreatic head.

145 : Novel methods of management of trapped dormia baskets in the pancreatic and biliary ducts.

146 : Impaction of a stone basket in the gallbladder with laparoscopic rescue.

147 : Impacted and Fractured Biliary Basket: A Second Basket Rescue Technique.

148 : Laparoscopic Common Bile Duct Exploration for Retrieval of Impacted Dormia Basket following Endoscopic Retrograde Cholangiopancreatography with Mechanical Failure: Case Report with Literature Review.

149 : Misplacement of endoscopic biliary endoprostheses.

150 : Duodenal-colic fistula resulting from migration of a biliary stent: a case report.

151 : Clip closure of a duodenal perforation secondary to a biliary stent.

152 : Complications of ERCP: a prospective study.

153 : [Duodenal perforation due to an endoscopic biliary prosthesis].

154 : A wire-loop technique for removal of migrated and embedded biliary stents.

155 : Migrated biliary stent predisposing to fatal ERCP-related perforation of the duodenum.

156 : An uncommon cause of abdominal pain after endoscopic retrograde cholangiopancreatography.

157 : Biliocutaneous fistula following biliary stent migration.

158 : Duodenoscrotal fistula secondary to retroperitoneal migration of an endoscopically placed plastic biliary stent.

159 : Gut perforation caused by biliary endoprosthesis.

160 : [Abdominal pain following placement of an endoprosthesis in the biliary duct].

161 : Complex colovesicular fistula: A severe complication caused by biliary stent migration.

162 : [Colovesicular fistula after migration of a biliary stent].

163 : Biliary Stent Migration: A Rare Cause of a Bladder Stone.

164 : Pericardiobiliary Fistulation: A Rare Complication of Therapeutic ERCP in a Patient With IgG4-Related Sclerosing Cholangitis.

165 : Incidence and risk factors for biliary and pancreatic stent migration.

166 : Stent migration necessitating surgical intervention.

167 : Forgotten biliary stents: ignorance is not bliss.

168 : Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center.

169 : Endoscopic techniques for retrieval of proximally migrated biliary stents: the Amsterdam experience.

170 : A rare complication with extraction of proximally migrated biliary stent by using a basket catheter.

171 : Endoscopic extraction of proximally migrated biliary stent by intrastent balloon inflation.

172 : Unusual migration of a straight Amsterdam-type endoprosthesis for bile duct stones.

173 : Bile duct-duodenum and pancreatic-gastric fistulas: two exceptional complications of biliary and pancreatic stenting.

174 : Pleurobiliary fistula following Tannenbaum biliary stent insertion.

175 : Bronchobiliary fistula as a complication after long-term stenting of hepatic ducts, applied by ERCP after hepatobiliary surgery due to hydatid cyst.

176 : Hepaticogastric fistulation from a proximally migrated biliary stent.

177 : Pancreatic fistula without pancreatitis after endoscopic biliary stent placement for bile leak after orthotopic liver transplantation.

178 : Acute portal vein thrombosis and massive necrosis of the liver. An unusual complication after stenting for chronic pancreatitis.

179 : Pancreatic stent migration into the portal vein causing portal vein thrombosis: a rare complication of a prophylactic pancreatic stent.

180 : Efficacy and complications of covered Wallstents in malignant distal biliary obstruction.

181 : Endoscopic removal of a migrated duodenal stent into the ileum using double-balloon enteroscopy.

182 : Spontaneous rupture of a biliary metal stent.

183 : Hemobilia-induced occlusion of a biliary metal expandable stent.

184 : Haemorrhage due to erosion of a metal biliary stent through the duodenal wall.

185 : Metallic biliary endoprosthesis causing duodenal perforation and acute upper gastrointestinal bleeding.

186 : Hemobilia in advanced pancreatic cancer with portal vein obstruction and a metal endobiliary stent: a case report.

187 : Upper gastrointestinal hemorrhage secondary to erosion of a biliary Wallstent in a woman with pancreatic cancer.

188 : Fatal upper gastrointestinal bleeding caused by a metal biliary stent despite stent shortening with APC.

189 : Biliary-duodenal fistula caused by metal stent.

190 : Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent.

191 : Lower intestinal hemorrhage due to a dislodged metallic stent.

192 : Removal of plastic biliary stents placed through metal stent.

193 : Biliorenous fistula related to self-expandable biliary metallic stent placement: a rare complication of endoscopic retrograde cholangiopancreatography.

194 : Cholecystitis after metallic stent placement in patients with malignant distal biliary obstruction.

195 : Massive hemobilia during extraction of a covered self-expandable metal stent in a patient with portal hypertensive biliopathy.

196 : Liver injury from endoscopic insertion of self-expandable metallic stent to relieve biliary obstruction: a fatal complication.

197 : A rare case of inferior vena cava syndrome secondary to compression by a biliary stent.

198 : Fractured hydrophilic guidewire during ERCP: a case series.

199 : An unusual complication in attempted non-surgical treatment of pancreatic bile duct stones.

200 : Unusual migration of fractured ERCP guidewire: A case report.

201 : Parenchymal Guidewire Perforation during ERCP: An Unappreciated Injury.

202 : Liver hematoma following endoscopic retrograde cholangiopancreatography (ERCP).

203 : Gall stone ileus following multiple endoscopic retrograde cholangiopancreatographies.

204 : Intermittent gallstone ileus following endoscopic biliary sphincterotomy. A case report.

205 : Necrotizing fasciitis--a complication of "successful" endoscopic sphincterotomy.

206 : Gallstone ileus treated by extracorporeal shockwave lithotripsy.

207 : Electrohydraulic lithotripsy of a gallstone causing gallstone ileus.

208 : Delayed gallstone ileus presentation after ERCP and sphincterotomy.

209 : [Gallstone ileus after endoscopic retrograde cholangiopancreatography].

210 : Gallstone ileus following therapeutic endoscopic retrograde cholangiopancreatography.

211 : Misdiagnosis using endoscopic retrograde cholangiopancreatography in a patient with postcholecystectomy pain.

212 : [Missed gallstones in endoscopic retrograde cholangiopancreatography (ERCP). Case reports].

213 : Corneal abrasion occurring during ERCP.

214 : Post-endoscopic retrograde cholangiopancreatography uvular necrosis.

215 : Acute parotitis after ERCP.

216 : Parotitis After Endoscopic Retrograde Cholangiopancreatography.

217 : Pseudo stroke after an ERCP.

218 : Temporomandibular joint dislocation during endoscopic retrograde cholangiopancreatography examination.

219 : Hemolysis caused by G-6PD deficiency after a difficult and prolonged therapeutic endoscopic retrograde cholangiopancreatography.

220 : Methemoglobinemia caused by topical benzocaine.

221 : Thrombotic thrombocytopenic purpura following post-ERCP pancreatitis.

222 : Intramural duodenal hematoma--a complication of ERCP.

223 : Pancreatic duct disruption and duodenal hematoma associated with endoscopic retrograde cholangiopancreatography.

224 : [A rare complication of ERCP: Mallory-Weiss syndrome].

225 : Hepatic subcapsular biloma. An unusual complication of endoscopic retrograde cholangiopancreatography.

226 : Huge biloma after endoscopic retrograde cholangiopancreatography and endoscopic biliary sphincterotomy.

227 : Inadvertent pancreatic duct perforation during brushing.

228 : Dramatic increase in bilirubin after ERCP - pethidine as a possible cause of drug-induced hepatitis.

229 : Prolonged cholestatic jaundice after endoscopic retrograde cholangiography.

230 : Prolonged cholestasis following endoscopic retrograde cholangiopancreatography, a rare complication of contrast agent induced liver injury: A case report and literature review.

231 : CT before and after ERCP: detection of pancreatic pseudotumor, asymptomatic retroperitoneal perforation, and duodenal diverticulum.

232 : Duodenal obstruction following papillary stenosis: a rare complication after endoscopic sphincterotomy.

233 : Unusual complications during endoscopic retrograde cholangiopancreatography (ERCP): electrical burn in the liver.

234 : Acute pulmonary embolism during an endoscopic retrograde cholangiopancreatography.

235 : Bronchobiliary fistula and lithoptysis after endoscopic retrograde cholangiopancreatography and liver biopsy in a patient with paroxysmal nocturnal hemoglobinuria.

236 : Reversible acute duodenitis as a complication of endoscopic biliary stenting.

237 : Vision loss: another ERCP-related adverse event, also known as isolated bilateral lateral geniculate body infarction.

238 : Pituitary Apoplexy Following Endoscopic Retrograde Cholangiopancreatography.