Secondary Logo

Institutional members access full text with Ovid®

Adverse Events and Acute Chronic Liver Failure in Patients With Cirrhosis Undergoing Endoscopic Retrograde Cholangiopancreatography

A Multicenter Matched-Cohort Study

Leal, Carles, MD1,2; Prado, Veronica, MD3; Colan, Juan, MD4; Chavez-Rivera, Karina, MD1; Sendino, Oriol, MD, PhD1,5; Blasi, Anabel, MD, PhD6; Roura, Pere, MD2; Juanola, Adria, MD3,5; Rodriguez de Miguel, Cristina, RN1; Pavesi, Marco, PhD7; Gomez, Cristina, MD, PhD4; Guarner, Carlos, MD, PhD4; Guarner-Argente, Carlos, MD, PhD4; Fernández, Javier, MD, PhD3,5,7; Cardenas, Andres, MD, PhD1,3,5

American Journal of Gastroenterology: January 2019 - Volume 114 - Issue 1 - p 89–97
doi: 10.1038/s41395-018-0218-1

BACKGROUND: Data on the outcome of adverse events (AEs) and the risk of developing acute-on-chronic liver failure (ACLF) after ERCP in patients with cirrhosis are unknown. We examined the incidence and risk factors of post-ERCP AEs in patients with cirrhosis and the appearance of ACLF after ERCP.

METHODS: In this multicenter, retrospective, matched-cohort study, we evaluated ERCPs performed from January 2002 to 2015. A group of patients with cirrhosis with non-ERCP interventions and one without interventions was also analyzed for the development of ACLF.

RESULTS: A total of 441 ERCPs were analyzed; 158 in patients with cirrhosis (cases) and 283 in patients without cirrhosis (controls). The overall rate of AEs after all ERCPs was significantly higher in cases compared to controls (17% vs 9.5, p = 0.02). Cholangitis developed more in cases compared to controls (6.3% vs 1.8%; p = 0.01). In a subanalysis of those with sphincterotomy, the rate of bleeding was higher in those with cirrhosis (9.4% vs 3.4%; p = 0.03). Logistic regression identified cirrhosis (OR, 2.48; 95% CI, 1.36–4.53; p = 0.003) and sphincterotomy (OR, 2.66; 95% CI, 1.23–5.72; p = 0.01) as risk factors of AEs. A total of 18/158 (11.4%) cases developed ACLF after ERCP. ACLF occurred in 7/27 cases with post-ERCP AEs and in 11/131 without post-ERCP AEs (25.9% vs 8.3%; p = 0.01). A total of 3.2% (13/406) patients without interventions developed ACLF compared to 17.5% (102/580) who developed ACLF after non-ERCP interventions. Patients with decompensated cirrhosis at ERCP had a higher risk of developing ACLF (17% vs 6.8%; p = 0.04). Patients with a MELD score ≥ 15 were 3.1 times more likely (95% CI: 1.14–8.6; p = 0.027) to develop ACLF after ERCP.

CONCLUSIONS: The rate of AEs after ERCP is higher in patients with cirrhosis compared to the non-cirrhotic population. The incidence of ACLF is higher in those with AEs after ERCP compared to those without AEs, especially cholangitis. The development of ACLF is common after ERCP and other invasive procedures. ACLF can be precipitated by numerous factors which include preceding events before the procedure, including manipulation of the bile duct, and AEs after an ERCP.

1GI/Endoscopy Unit. Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain;

2Gastroenterology Department, Hospital Universitari de Vic, Barcelona, Spain;

3Liver Unit. Institut de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain;

4Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca - IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain;

5Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain;

6Anesthesiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain;

7European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain.

Correspondence: Andres Cardenas, MD, PhD. E-mail:

Supplementary material accompanies this paper at

Received February 12, 2018

Accepted July 19, 2018

© The American College of Gastroenterology 2019. All Rights Reserved.
You currently do not have access to this article

To access this article:

Note: If your society membership provides full-access, you may need to login on your society website