Cholangitis after endoscopic retrograde cholangiopancreatography: a rare complication?

Key words: Retrograde cholangiopancreatography. Cholangitis. Complication.

Dear Editor,

Cholangitis does not often occur after endoscopic retrograde cholangiopancreatography (ERCP), but it can be a serious complication of this procedure (1). Its clinical features, management and outcome are poorly characterized in the literature (2). In a recent study in a low-volume center (200 procedures in 22 months) the reported rate of this complication was less than 5%, with a tendency to reduce with increased experience of the practicioner (3). From a total of 487 ERCP performed in two years in our center, 24 patients developed cholangitis after the procedure (4.9% incidence). The majority of patients (54%) were female, with a median age of 60 year of age (interquartile range [IQR]: 42-72 years). The diagnosis was made after a median period of two days (IQR: 1-3 days), with a mortality of 29.2%. The median number of hospitalization days was seven (IQR: 4-16 days), and the majority of patients were attended in the outpatient clinic (71%). Ten patients had already undergone ERCP with sphincterotomy (43%) and seven patients were under antibiotic therapy or had received antibiotics in the previous three months (29%). The main reasons for the procedure were choledocholitiasis (38%) and obstructive jaundice (29%). A dominant stricture was present in 37.5% of cases and one or more biliary stents were placed in eleven patients (46%). Fever (75%), abdominal pain (50%) and jaundice (42%) were the main clinical manifestations. However, Charcot's triad was only present in three patients (13%). Almost all patients (92%) were treated with antibiotics, and this was within the first 24 hours in 86% of cases. Half of the patients had positive blood cultures. The duration of hospitalization (17 vs 6 days, p = 0.001) and higher levels of gamma-glutamyl transferase (651 vs 137 U/L, p = 0.04), alkaline phosphatase (459 vs 180 U/l, p = 0.03) and total bilirubin (12 vs 3 mg/dl, p = 0.02) were significantly associated with mortality.

In our experience, post-ERCP acute cholangitis developed in approximately 5% of cases with a not negligible mortality of nearly 30% in spite of antibiotic therapy. Analytical factors can help to identify the most serious cases that could benefit from a more aggressive approach.

Armando Peixoto, Marco Silva and Guilherme Macedo
Gastroenterology Department. Centro Hospitalar de São João. Porto, Portugal

References

1. Bai Y, Gao F, Gao J, et al. Prophylactic antibiotics cannot prevent endoscopic retrograde cholangiopancreatography-induced cholangitis: A meta-analysis. Pancreas 2009;38(2):126-30. DOI: 10.1097/MPA.0b013e318189fl6d.         [ Links ]

2. Kwon CI, Song SH, Hahm KB, et al. Unusual complications related to endoscopic retrograde cholangiopancreatography and its endoscopic treatment. Clin Endosc 2013;46(3):251-9. DOI: 10.5946/ce.2013.46.3.251.         [ Links ]

3. Riesco-López JM, Vázquez-Romero M, Rizo-Pascual JM, et al. Efficacy and safety of ERCP in a low-volume hospital. Rev Esp Enferm Dig 2013;105(2):68-73. DOI: 10.4321/S1130-01082013000200002.         [ Links ]