Chronic Liver Disease as a Risk Factor For Post-ERCP Complications: A Nationwide Retrospective Analysis

Endoscopic retrograde cholangiopancreatography (ERCP) is indicated for multiple pancreatic and biliary pathologies and carries a heightened risk profile compared with other endoscopic procedures. Considerable research has been directed towards discerning risk factors associated with complications such as post-ERCP pancreatitis and post-ERCP bleeding. Despite this, data on chronic liver disease (CLD) as a risk factor for complications is limited. We aimed to assess the outcomes of patients with CLD who underwent therapeutic or diagnostic ERCP to determine whether these patients had different outcomes relative to patients without CLD.

We used the National Inpatient Sample (NIS) database to inquire for all adult patients who underwent ERCP between 2016 and 2019 using the International Classification of Disease, Tenth Revision (ICD-10) coding. The group was stratified into 2 groups: patients with CLD and those without. The main outcome we looked at was the rate of post-ERCP pancreatitis, post-ERCP hemorrhage, and perforation between the 2 groups. The secondary outcomes were in-hospital mortality and length of stay. A multivariate regression model was used to estimate the association of CLD with ERCP outcomes.

We identified a total of 883,825 patients who underwent ERCP between 2016 and 2019. Among these, 21,212 (2.4%) had CLD and 862,613 (97.6%) did not have CLD. The mean age for patients in liver disease group was 61.66 years and in group without liver disease was 60.46 years. The predominant ethnicity in both groups was whites. Additional admission-related factors are outlined in Table 1. The rate of post-ERCP pancreatitis (8.8% vs. 6.7%, P < 0.001) with adjusted odds ratio (aOR) 1.3; and post-ERCP hemorrhage (8.8% vs. 6.69%, P < 0.001) with aOR 1.35, was higher in the patient group with CLD. The rate of post-procedure perforation was not significantly different in both groups. For secondary outcomes; the in-hospital mortality (3.03% vs. 1.58%, P < 0.001) and length of stay (7 days vs. 3 days, P < 0.001) were higher in the patients with chronic liver disease. The outcomes are mentioned in Table 2.

Although ERCP is considered a safe procedure, it is one of the endoscopic procedures associated with the highest risk of complications. As a result, risk stratification is crucial. Certain demographics, conditions like end-stage renal disease, liver cirrhosis, and procedural factors have been identified as risk factors for post-ERCP complications. Our study represents newer data, with use of revised ICD codes, to demonstrate increased risk in patients with liver disease. On the basis of these results, ERCP should be used judiciously in this population and further studies are required for identifying reversible risk factors to improve outcomes.