Editing Endoscopic retrograde cholangiopancreatography (section)

==Risks==
One of the most frequent and feared complications after endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). In previous studies, the incidence of PEP has been estimated at 3.5 to 5%.<ref>{{cite journal |last1=Dumonceau |first1=Jean-Marc |last2=Andriulli |first2=Angelo |last3=Elmunzer |first3=B. |last4=Mariani |first4=Alberto |last5=Meister |first5=Tobias |last6=Deviere |first6=Jacques |last7=Marek |first7=Tomasz |last8=Baron |first8=Todd |last9=Hassan |first9=Cesare |last10=Testoni |first10=Pier |last11=Kapral |first11=Christine |title=Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Updated June 2014 |journal=Endoscopy |date=22 August 2014 |volume=46 |issue=9 |pages=799–815 |doi=10.1055/s-0034-1377875 |pmid=25148137 |citeseerx=10.1.1.886.8874 |s2cid=9899581 }}</ref><ref>GallRiks. ''Annual report 2016.'' http://www.ucr.uu.se/gallriks/fou/arsrapporter  [accessed 31 May 2018].</ref> According to Cotton et al., PEP is defined as a "clinical pancreatitis with amylase at least three times the upper limit of normal at more than 24 hours after the procedure requiring hospital admission or prolongation of planned admission". Grading of severity of PEP is mainly based on the length of hospital stay.<ref>{{cite journal |last1=Cotton |first1=P.B. |last2=Lehman |first2=G. |last3=Vennes |first3=J. |last4=Geenen |first4=J.E. |last5=Russell |first5=R.C.G. |last6=Meyers |first6=W.C. |last7=Liguory |first7=C. |last8=Nickl |first8=N. |title=Endoscopic sphincterotomy complications and their management: an attempt at consensus |journal=Gastrointestinal Endoscopy |date=May 1991 |volume=37 |issue=3 |pages=383–393 |doi=10.1016/S0016-5107(91)70740-2 |pmid=2070995 }}</ref>

Risk factors for developing PEP include technical matters related to the ERCP procedure and patient-specific ones. The technical factors include manipulation of and injection of contrast into the pancreatic duct, cannulation attempts lasting more than five minutes, and biliary balloon sphincter dilation; among patient-related factors are female gender, younger age, and Sphincter of Oddi dysfunction.{{citation needed|date=June 2022}} A systematic review of clinical trials concluded that a previous history of PEP or pancreatitis significantly increases the risk for PEP to 17.8% and to 5.5% respectively.<ref>{{cite journal |last1=Chen |first1=Jian-Jun |last2=Wang |first2=Xi-Mo |last3=Liu |first3=Xing-Qiang |last4=Li |first4=Wen |last5=Dong |first5=Mo |last6=Suo |first6=Zong-Wu |last7=Ding |first7=Po |last8=Li |first8=Yue |title=Risk factors for post-ERCP pancreatitis: a systematic review of clinical trials with a large sample size in the past 10 years |journal=European Journal of Medical Research |date=15 May 2014 |volume=19 |issue=1 |page=26 |id={{Gale|A541256167}} |doi=10.1186/2047-783X-19-26 |pmid=24886445 |pmc=4035895 |citeseerx=10.1.1.981.3789 |doi-access=free }}</ref><ref>{{cite journal | doi=10.1186/s12876-021-01755-z | title=Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction | year=2021 | last1=Park | first1=Namyoung | last2=Lee | first2=Sang Hyub | last3=You | first3=Min Su | last4=Kim | first4=Joo Seong | last5=Huh | first5=Gunn | last6=Chun | first6=Jung Won | last7=Cho | first7=In Rae | last8=Paik | first8=Woo Hyun | last9=Ryu | first9=Ji Kon | last10=Kim | first10=Yong-Tae | journal=BMC Gastroenterology | volume=21 | issue=1 | page=175 | pmid=33865307 | pmc=8052855 | doi-access=free }}</ref>

[[Gastrointestinal perforation|Intestinal perforation]] is a risk of any gastroenterologic endoscopic procedure, and is an additional risk if a [[sphincterotomy]] is performed. As the second part of the duodenum is anatomically in a [[Retroperitoneal space|retroperitoneal]] location (that is, behind the peritoneal structures of the abdomen), perforations due to sphincterotomies are retroperitoneal. Sphincterotomy is also associated with a risk of bleeding.<ref name="pmid17509029">{{cite journal|vauthors=Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R|year=2007|title=Incidence rates of post-ERCP complications: a systematic survey of prospective studies|journal=Am. J. Gastroenterol.|volume=102|issue=8|pages=1781–8|doi=10.1111/j.1572-0241.2007.01279.x |pmid=17509029|s2cid=38954883 }}</ref> ERCP may provoke hemobilia from trauma to friable hilar tumors or a guide-wire penetrating the bile duct wall, creating a [[biliary fistula]]. Delayed bleeding is a rare but potentially serious complication of sphincterotomy, particularly as many patients are discharged home within hours of ERCP.

There is also a risk associated with the [[iodinated contrast|contrast dye]] in patients who are allergic to compounds containing [[organoiodine compound|iodine]], which can be very severe, even if the anaphylactoid reactions occur while patients are in a hospital.<ref>{{cite journal |last1=Dewachter |first1=Pascale |last2=Mouton-Faivre |first2=Claudie |title=Allergie aux médicaments et aliments iodés : la séquence allergénique n'est pas l'iode |trans-title=Allergy to iodinated drugs and to foods rich in iodine: Iodine is not the allergenic determinant |language=fr |journal=La Presse Médicale |date=1 November 2015 |volume=44 |issue=11 |pages=1136–1145 |doi=10.1016/j.lpm.2014.12.008 |pmid=26387623 }}</ref><ref>{{cite journal | pmc=3770975 | year=2013 | last1=Bottinor | first1=W. | last2=Polkampally | first2=P. | last3=Jovin | first3=I. | title=Adverse Reactions to Iodinated Contrast Media | journal=The International Journal of Angiology | volume=22 | issue=3 | pages=149–154 | doi=10.1055/s-0033-1348885 | pmid=24436602 }}</ref>

Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting.{{fact|date=August 2024}}

Other complications (less than 1%) may include heart and lung problems, infection in the bile duct called [[cholangitis]], that can be life-threatening, and is regarded as a medical emergency. Using antibiotics before the procedure shows some benefits to prevent cholangitis and septicaemia.<ref>{{cite journal |last1=Brand |first1=Martin |last2=Bizos |first2=Damon |last3=O'Farrell |first3=Peter JR |title=Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography |journal=Cochrane Database of Systematic Reviews |date=6 October 2010 |issue=10 |pages=CD007345 |doi=10.1002/14651858.CD007345.pub2 |pmid=20927758 }}</ref> In rare cases, ERCP can cause fatal complications.<ref>{{cite web |last=Cotton |first=Peter B. |url=http://www.ddc.musc.edu/public/testsProcedures/procedures/ERCP.cfm |title=ERCP (Endoscopic Retrograde Cholangio-Pancreatography) |publisher=Medical University of South Carolina (MUSC) Digestive Disease Center |date=2013-05-31 |access-date=2013-06-09 |archive-url=https://web.archive.org/web/20180321192751/http://ddc.musc.edu/public/testsprocedures/procedures/ercp.cfm |archive-date=2018-03-21 |url-status=dead }}</ref>

Cases of hospital-acquired (i.e., nosocomial) infections with [[carbapenem resistant enterobacteriaceae]] linked to incompletely disinfected duodenoscopes have occurred in the U.S. since at least 2009 per the [[Food and Drug Administration]].<ref>{{cite news|author1=Sharon Begley|author2=Toni Clarke|title=FDA knew devices spread fatal 'superbug' but does not order fix|url=https://www.reuters.com/article/us-usa-ucla-devices-idUSKBN0LO02Q20150220|access-date=20 February 2015|work=Reuters|date=20 February 2015}}</ref> Outbreaks were reported from [[Virginia Mason Hospital]] in Seattle in 2013, [[UCLA Health System]] Los Angeles in 2015, Chicago and Pittsburgh.<ref>{{cite news|title=Deadly superbug infected patients at Seattle hospital|url=http://www.cbsnews.com/news/deadly-superbug-infected-patients-at-seattle-hospital/|access-date=21 February 2015|work=CBS|publisher=CBS Interactive Inc.|date=January 22, 2015}}</ref> The FDA issued a safety communication "Design of ERCP Duodenoscopes May Impede Effective Cleaning" in February 2015,<ref>{{Cite news|url = https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm|archive-url = https://web.archive.org/web/20150220024405/http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm|url-status = dead|archive-date = February 20, 2015|title = Design of Endoscopic Retrograde Cholangiopancreatography (ERCP) Duodenoscopes May Impede Effective Cleaning: FDA Safety Communication|work=Medical Devices|publisher=US FDA|date = 19 February 2015|access-date = 19 February 2015}}</ref> which was updated in December 2015,<ref>Medwatch [https://web.archive.org/web/20151225092242/http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm478949.htm ED-530XT Duodenoscopes by FUJIFILM Medical Systems, U.S.A.: Safety Communication - FUJIFILM Medical Systems Validates Revised Reprocessing Instructions] Safety alerts for Human Medical Products. U.S. FDA, 23 December 2015, retrieved 5 January 2016</ref> and more recently in 2022 which recommended disposable components.<ref>{{cite journal | url=https://www.fda.gov/medical-devices/safety-communications/fda-recommending-transition-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication | archive-url=https://web.archive.org/web/20190904163815/https://www.fda.gov/medical-devices/safety-communications/fda-recommending-transition-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication | url-status=dead | archive-date=September 4, 2019 | title=The FDA is Recommending Transition to Duodenoscopes with Innovative Designs to Enhance Safety: FDA Safety Communication | journal=FDA | date=5 April 2022 }}</ref>

Prevalence of vitamin K and vitamin D deficiency,<ref>{{cite journal |last1=Fisher |first1=Leon |last2=Byrnes |first2=Elizabeth |last3=Fisher |first3=Alexander A. |title=Prevalence of vitamin K and vitamin D deficiency in patients with hepatobiliary and pancreatic disorders |journal=Nutrition Research |date=1 September 2009 |volume=29 |issue=9 |pages=676–683 |doi=10.1016/j.nutres.2009.09.001 |pmid=19854384 |hdl=1885/32031 |hdl-access=free }}</ref> as bile is to assist in the breakdown and absorption of fat in the intestinal tract; a relative deficiency of bile can lead to fat malabsorption and deficiencies of fat-soluble vitamins.