Mistakes in endoscopic retrograde cholangiopancreatography and how to avoid them

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Mistakes in endoscopic retrograde cholangiopancreatography and how to avoid them

Thierry Ponchon, Jerome Rivory, Mathieu Pioche

Summary

AI Generated

This material discusses 10 common or high-impact mistakes made during endoscopic retrograde cholangiopancreatography and strategies to avoid them.

Endoscopic retrograde cholangiopancreatography is a widespread technique used for treating diseases of the bile and pancreatic ducts.
ERCP is associated with rare but potentially severe morbidity.
Some adverse events associated with ERCP are directly linked to commonly made mistakes and can therefore be prevented.
The material covers 10 common or high-impact procedural mistakes and their prevention strategies, relevant to clinicians performing or overseeing ERCP.

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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Polkowski M, et al. Endoscopic ultrasound versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a randomized trial comparing two management strategies. Endoscopy 2007; 39: 296–303. [Link]

Manes G, et al.. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019 May;51(5):472-491. doi: 10.1055/a-0862-0346. Epub 2019 Apr 3. PMID: 30943551. [Link]

Dumonceau JM, et al.. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020 Feb;52(2):127-149. [Link]

Dickinson RJ and Davies S. Post-ERCP pancreatitis and hyperamylasaemia: the role of operative and patient factors. Eur J Gastroenterol Hepatol 1998; 10: 423–428. [Link]

Vandervoort J, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56: 652–656. [Link]

Christensen M, et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60: 721–731. [Link]

Testoni PA, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jul;48(7):657-83. [Link]

Veitch AM, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65: 374–389. [Link]

Buxbaum JL, et al. ASGE guideline on the management of cholangitis. Gastrointest Endosc. 2021 Aug;94(2):207-221.e14. doi: 10.1016/j.gie.2020.12.032. Epub 2021 May 20. PMID: 34023065. [Link]

10.

Kylänpää L, et al. Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial. Endoscopy. 2021 Oct;53(10):1011-1019. ) [Link]

11.

Levenick JM, et al. Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients. Gastroenterology 2016; 150: 911–917. [Link]

12.

Sethi S, et al. A meta-analysis on the role of rectal diclofenac and indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas 2014; 43: 190–197. [Link]

13.

Elmunzer BJ, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012; 366: 1414–1422. [Link]

14.

Hintze RE, et al. Clinical significance of magnetic resonance cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1997; 29: 182–187. [Link]

15.

Soares KC, et al. Hilar cholangiocarcinoma: diagnosis, treatment options, and management. Hepatobiliary Surg Nutr 2014; 3: 18–34. [Link]

16.

Dumonceau JM, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated October 2017. Endoscopy. 2018 Sep;50(9):910-930. doi: 10.1055/a-0659-9864. Epub 2018 Aug 7. PMID: 30086596. [Link]

17.

Draganov PV, et al. Diagnostic accuracy of conventional and cholangioscopy-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term follow-up study. Gastrointest Endosc 2012; 75: 347–353. [Link]

18.

Clinicopathologic session; biliary cirrhosis secondary to extrahepatic obstruction. Prensa Médica Mex 1950; 15: 119–122. Spanish.

19.

Warter J and Sacrez A. The problem of complicated jaundice (hepatitis-extrahepatic biliary obstruction syndrome). Strasbg Méd 1962; 13: 666–676. French.

20.

Pioche M and Ponchon T. Management of bile duct leaks. J Visc Surg 2013; 150: S33–S38. [Link]

21.

Dechêne A, et al. Endoscopic management is the treatment of choice for bile leaks after liver resection. Gastrointest Endosc 2014; 80: 626–633.e1. [Link]

22.

Kumar A, et al. Mirizzi’s syndrome: lessons learnt from 169 patients at a single center. Korean J Hepato-Biliary-Pancreat Surg 2016; 20: 17–22. [Link]

23.

Elhanafy E, et al. Mirizzi Syndrome: how it could be a challenge. Hepatogastroenterology 2014; 61: 1182–1186. [Link]

24.

Hazzan D, et al. Combined endoscopic and surgical management of Mirizzi syndrome. Surg Endosc 1999; 13: 618–620. [Link]

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a widespread technique used for the treatment of different diseases of the bile and pancreatic ducts. The technique is, however, associated with rare but potentially severe morbidity. Some of the adverse events associated with ERCP are directly linked to commonly made mistakes and can, therefore, be prevented. Here, we discuss 10 common and/or high-impact mistakes that are made during ERCP and how they can be avoided.

Topics

Endoscopy Hepatobiliary Pancreas

Citation

Pioche M, Rivory J and Ponchon T. Mistakes in endoscopic retrograde cholangiopancreatography and how to avoid them. UEG Education 2016: 16: 24–26.

Published

2024

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UEG Mistakes In Articles

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Mistakes in cholangioscopy and how to avoid them

Marianna Arvanitakis, Malina Wiesand, Paraskevas Gkolfakis

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Dumonceau JM, et al.. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020 Feb;52(2):127-149. [Link]

Dickinson RJ and Davies S. Post-ERCP pancreatitis and hyperamylasaemia: the role of operative and patient factors. Eur J Gastroenterol Hepatol 1998; 10: 423–428. [Link]

Vandervoort J, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56: 652–656. [Link]

Christensen M, et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60: 721–731. [Link]

Testoni PA, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jul;48(7):657-83. [Link]

Buxbaum JL, et al. ASGE guideline on the management of cholangitis. Gastrointest Endosc. 2021 Aug;94(2):207-221.e14. doi: 10.1016/j.gie.2020.12.032. Epub 2021 May 20. PMID: 34023065. [Link]

10.

Kylänpää L, et al. Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial. Endoscopy. 2021 Oct;53(10):1011-1019. ) [Link]

11.

Levenick JM, et al. Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients. Gastroenterology 2016; 150: 911–917. [Link]

12.

13.

Elmunzer BJ, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012; 366: 1414–1422. [Link]

14.

Hintze RE, et al. Clinical significance of magnetic resonance cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1997; 29: 182–187. [Link]

15.

Soares KC, et al. Hilar cholangiocarcinoma: diagnosis, treatment options, and management. Hepatobiliary Surg Nutr 2014; 3: 18–34. [Link]

16.

17.

18.

Clinicopathologic session; biliary cirrhosis secondary to extrahepatic obstruction. Prensa Médica Mex 1950; 15: 119–122. Spanish.

19.

Warter J and Sacrez A. The problem of complicated jaundice (hepatitis-extrahepatic biliary obstruction syndrome). Strasbg Méd 1962; 13: 666–676. French.

20.

Pioche M and Ponchon T. Management of bile duct leaks. J Visc Surg 2013; 150: S33–S38. [Link]

21.

Dechêne A, et al. Endoscopic management is the treatment of choice for bile leaks after liver resection. Gastrointest Endosc 2014; 80: 626–633.e1. [Link]

22.

Kumar A, et al. Mirizzi’s syndrome: lessons learnt from 169 patients at a single center. Korean J Hepato-Biliary-Pancreat Surg 2016; 20: 17–22. [Link]

23.

Elhanafy E, et al. Mirizzi Syndrome: how it could be a challenge. Hepatogastroenterology 2014; 61: 1182–1186. [Link]

24.

Hazzan D, et al. Combined endoscopic and surgical management of Mirizzi syndrome. Surg Endosc 1999; 13: 618–620. [Link]

Abstract

Cholangioscopy is a minimally invasive, endoscopic technique that allows direct visualisation of the bile ducts, facilitating both diagnostic and therapeutic interventions. It is a useful tool in managing biliary diseases, allowing characterisation and tissue acquisition for strictures of undetermined aetiology, facilitating extension assessment for biliary cancer and providing intraductal lithotripsy for complex biliary stones.

Published

2025

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UEG Poster

Standard Poster

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A RARE CASE OF AUTOIMMUNE HEPATITIS-PRIMARY BILIARY CHOLANGITIS AND IGG4- RELATED DISEASE OVERLAP SYNDROME IN A MALE PATIENT

Jonathan Koh 1, Cora Chau 1, Weida Chew 1

Affiliations

1 Tan Tock Seng Hospital, Singapore, Singapore

Summary

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Abstract

Clinical Case Summary

A 56-year-old Chinese male with chronic history of alcohol consumption presented with mixed derangement of liver function tests(LFTs) (alanine transaminase 227 U/L, asparate transaminase 329 U/L, alkaline phosphatase 472 U/L) and focal swellings in the pancreatic head and body on magnetic resonance imaging(MRI). Liver and biliary tree imaging were unremarkable. Autoimmune workup revealed raised antinuclear antibodies (>1:640), anti-M2 antibody (103 u/mL) but a normal immunoglobin(Ig)G4 (53.9 mg/dL) level. Liver and pancreatic biopsies demonstrated interface hepatitis, bile duct damage and pancreatic fibrosis, consistent with primary biliary cholangitis(PBC) but not diagnostic of autoimmune hepatitis(AIH) or pancreatitis. Ursodeoxycholic acid(UDCA) was started without steroids and rapid LFTs improvement was noted. Alcohol intake was stopped.
At subsequent review two years after (due to defaulting visits), the patient remained asymptomatic but LFTs remained abnormal and IgG4 levels rose to 7051 mg/dL. IgG2 levels were raised at 11558 mg/dL. MRI showed stable pancreatic swelling without any biliary or liver abnormalities. Clinical examination noted proptosis and cranial imaging showed thickened supraorbital nerves. Orbital nerve biopsy confirmed IgG4-related disease(IgG4-RD). He was commenced on prednisolone 40 mg daily with tapering and UDCA was restarted.
Despite steroid therapy, LFTs remained raised. Repeat liver biopsy showed progression of interface hepatitis and bile duct damage. Multidisciplinary review concluded the histology was more consistent with AIH-PBC than IgG4-RD. A final diagnosis of concurrent IgG4-RD with AIH-PBC overlap syndrome was made. Azathioprine and fenofibrate were added with LFTs improvement.
This rare and complex case illustrates the multisystem nature of autoimmune disease in a male phenotype and highlights the risk of overlapping immune-mediated conditions. Timely recognition and management are essential to improving patient outcomes.

References

Image 1: Abdominal magnetic resonance imaging of focal swellings in the pancreatic head and body
Image 2: Initial liver biopsy histological slide image
Image 3: Second liver biopsy histological slide image
Image 4: Computed Tomography scan image of thickened supraorbital nerves
Image 5: Orbital nerve biopsy histological slide image

Conference

UEG Week Berlin 2025

Topics

Hepatobiliary

Submission format

Clinical Case

Session

CLINICAL CASES (Posters)

Published

2025

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UEG Podcast Episode

UEG Podcast

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Oesophageal cancer with Massimiliano di Pietro (Part 2)

Massimiliano di Pietro, Pradeep Mundre

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AI Generated

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Abstract

Topics

Digestive Oncology Endoscopy Oesophagus

Published

2025

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Mistakes in cholangioscopy and how to avoid them

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UEG Podcast Episode

UEG Podcast

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Complications in endoscopy with Srisha Hebbar Part 2

Srisha Hebbar, Pradeep Mundre

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AI Generated

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Abstract

Topics

Endoscopy

Published

2025

More Like This:

Mistakes in cholangioscopy and how to avoid them

Marianna Arvanitakis

A RARE CASE OF AUTOIMMUNE HEPATITIS-PRIMARY BILIARY CHOLANGITIS AND IGG4- RELATED DISEASE OVERLAP SYNDROME IN A MALE PATIENT

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Grazyna Rydzewska Wyszkowska

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João Pinto

UEG Poster

Audio / Video Poster

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EFFICACY AND SAFETY OF FECAL MICROBIOTA TRANSPLANTANTION (FMT) IN RECURRENT C.DIFFICILE INFECTION– RESULTS OF THE ONE-CENTER RETROSPECTIVE STUDY

Edyta Maria Tulewicz-Marti 1, Marcin Bzdyra 1, Anna Przepióra 1, Grazyna Rydzewska Wyszkowska 1

Affiliations

1 National Medical Institute of Ministry of Interior and Administration, Warsaw, Poland

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Abstract

Introduction

Many studies have indicated a high effectiveness of fecal microbiota transplantation (FMT) in treatment of recurrent or refractory Clostridioides difficile infection (rCDI). Nevertheless, there is still lack of data from subpopulations regarding application of FMT and factors related to its response.

Aims & Methods

The aim of the study was to analyse the data and evaluate retrospectively the efficacy and safety of FMT for recurrent CDI. While working on the task we analysed retrospectively data of characteristics and outcomes of hospitalised patients from tertiary center who received FMT from 2015 to 2022. In all cases FMT was performed through the nasoenteric tube placed during gastroscopy. Frozen donor faces were used for FMT from unrelated healthy donors. To avoid effect of the single donor, FMT from 2-3 unrelated donors was used. Three days prior FMT vancomycin was applied and preparation with macrogol was administered according to European guidelines. Good response to 1 FMT was considered as improvement, more than 1 FMT as suboptimal response.

Results

FMT was performed for total of 98 patients, out of which 75 patients with recurrent CDI (23 patients needed 2 FMT, 6 - 3FMT and 2 -5FMT). The average age of patients was 68 years. 56 % (42) were women. 41 (54.7%) of patients previously used antibiotics, 2 (2.6%) steroids and 4 (5.3%) proton pump inhibitors (PPI). None of them was under immunosuppressive therapy. After the first FMT procedure clinical improvement was observed in 52 patients (69.3%). What is more 23 out of 30 patients initially non-responding patients had a clinical resolution after a second FMT. Whereas, the remaining 6 patients needed 3 FMT and 1 needed 5 FMT. Though, patients who required more than 1 FMT comorbidity had any cardiovascular disease (CV) such as cardiac insufficiency, diabetes mellitus (DM) or inflammatory bowel disease (IBD). Odds of suboptimal effect of therapy (need of more than 1 FMT) was associated with prior use of metronidazole then vancomycin or fidaxomicin surprisingly. According to our data there was only one irrelevant adverse event documented (abdominal pain). There was no death attributed to CDI in the studied population.

Conclusion

In our study, FMT was effective and safe treatment of recurrent CDI in our population. Nevertheless, at the same time we have identified risk factors of suboptimal response to FMT in our cohort such as CV disease, DM and IBD, as well as use of metronidazole.

References

Cammarota G, Ianiro G, Tilg H, et al. European consensus conference on faecal microbiota transplantation in clinical practice. Gut. 2017;66(4):569-580
Rao K, Safdar N. Fecal microbiota transplantation for the treatment of Clostridium difficile infection. J Hosp Med. 2016 Jan;11(1):56-61
Ziakas PD, Zacharioudakis IM, Zervou FN, et al. Asymptomatic carriers of toxigenic C. difficile in long-term care facilities: A meta-analysis of prevalence and risk factors. PLoS One 2015;10:e0117195
Hvas CL, Dahl Jørgensen SM, Jørgensen SP, Storgaard M, Lemming L, Hansen MM, Erikstrup C, Dahlerup JF. Fecal Microbiota Transplantation Is Superior to Fidaxomicin for Treatment of Recurrent Clostridium difficile Infection. Gastroenterology. 2019 Apr;156(5):1324-1332.e3
Lee CH, Steiner T, Petrof EO, Smieja M, Roscoe D, Nematallah A, Weese JS, Collins S, Moayyedi P, Crowther M, Ropeleski MJ, Jayaratne P, Higgins D, Li Y, Rau NV, Kim PT. Frozen vs Fresh Fecal Microbiota Transplantation and Clinical Resolution of Diarrhea in Patients With Recurrent Clostridium difficile Infection: A Randomized Clinical Trial. JAMA. 2016 Jan 12;315(2):142-9
Crobach MJT, Vernon JJ, Loo VG, et al. Understanding Clostridium difficile colonization. Clin Microbiol Rev 2018;31:e00021-17

Conference

UEG Week Vienna 2024

Topics

Colorectal

Submission format

Abstract

Session

LOWER GI (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Mistakes in cholangioscopy and how to avoid them

Marianna Arvanitakis

A RARE CASE OF AUTOIMMUNE HEPATITIS-PRIMARY BILIARY CHOLANGITIS AND IGG4- RELATED DISEASE OVERLAP SYNDROME IN A MALE PATIENT

Weida Chew

Oesophageal cancer with Massimiliano di Pietro (Part 2)

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Grazyna Rydzewska Wyszkowska

SEVERE HERPETIC ESOPHAGITIS IN IMMUNOCOMPETENT YOUNG ADULT

João Pinto

UEG Poster

Standard Poster

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

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SEVERE HERPETIC ESOPHAGITIS IN IMMUNOCOMPETENT YOUNG ADULT

Marco Pereira 1, João Pinto 1, Inês Pestana 1, Joana Barreiro 1, Ana Caldeira 1, Antonio Jose Duarte Banhudo 1

Affiliations

1 Hospital Castelo Branco, Castelo Branco, Portugal

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Abstract

Clinical Case Summary

Infectious esophagitis occurs most commonly in immunocompromised patients. Candida is the most common cause, followed by Herpes simplex virus. While HSV is known to cause esophagitis in immunocompromised patients, its occurrence in immunocompetent patients is rare.
We present the case of a 23 year-old male patient who was admitted to the emergency room with retrosternal chest pain, odynophagia, dysphagia, fever and hematemesis. Blood results showed leukocytosis and C-reactive protein of 93.5 mg/L.
An esophagogastroduodenostomy revealed multiple round and coalescing white plaques in the entire esophagus. The distal esophagus was severely affected and highly friable. Biopsies were taken.
A diagnosis of severe infectious esophagitis was assumed with an endoscopic appearance suggestive of esophageal candidiasis. He started treatment with fluconazole 400mg daily. Considering the medical history and clinical findings, intravenous acyclovir 5mg/Kg every 8 hours was added.
The patient denied drug and alcohol abuse but confirmed unprotected sexual intercourse with two women. HIV-1/2, HBV and HCV were negative. Serological results revealed positive HSV 1/2 IgM and negative IgG.
Clinical improvement allowed discharge on day 3 with oral fluconazole and acyclovir treatment.
Biopsies later confirmed herpetic esophagitis.
On follow-up, the patient was asymptomatic and with complete endoscopic resolution. Serological tests revealed HSV-1 seroconversion, confirming a diagnosis of HSV-1 primo-infection esophagitis.
Herpetic esophagitis in immunocompetent hosts is usually related to a primo-infection and the patient is often a young healthy male. It is an endoscopic and histopathological diagnosis with multiple, discrete, volcano-shaped or coalescent small ulcers. In some cases, the endoscopic appearance may mimic Candida esophagitis. While most cases in immunocompetent patients require no specific treatment, evidence indicates that acyclovir may shorten the duration of the disease.

Conference

UEG Week Copenhagen 2023

Topics

Oesophagus

Submission format

Clinical Case

Session

PP 12 Clinical Cases (Posters)

Published

2023

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SEVERE HERPETIC ESOPHAGITIS IN IMMUNOCOMPETENT YOUNG ADULT

João Pinto