Death after endoscopic retrograde cholangiopancreatography: findings at autopsy

More than half a million endoscopic retrograde cholangiopancreatography (ERCP) procedures are performed annually in the United States. The risk of severe complications after ERCP is less than 1%; however, autopsy pathologists see a select group of patients having fatality. Thirty-five autopsies were performed after ERCP over a 13-year period. Fourteen of these 35 patients died of ERCP complications. The remaining patients formed the control group. Fatal complications of ERCP included acute pancreatitis (7), sepsis (5), gastrointestinal/biliary perforation (3), bleeding (2), myocardial infarction (2), and cardiac arrhythmia (1). Cancer (14) and chronic pancreatitis (4) were the most reported causes of death in the control group. Median times to death after ERCP in ERCP-related deaths versus controls were 9.5 and 40 days, respectively. The most common indications for the procedure in ERCP-related deaths were suspected choledocholithiasis and jaundice/biliary obstruction; in controls, jaundice/biliary obstruction and chronic pancreatitis were more common. Patients having fatal ERCP complications had more cannulations reported as "difficult" (69% versus 20%; P = .003). The Klöppel chronic pancreatitis score was lower (mean, 2.6 versus 6.6; P = .03), and the percentage of nonfibrotic pancreatic parenchyma was higher (mean, 85% versus 56%; P = .02) in ERCP-related death group versus controls. Although patients rarely die after ERCP, our findings suggest that healthy acinar tissue is a risk factor for ERCP-related death, especially in the setting of difficult cannulation.