Endoscopic Retrograde Cholangiopancreatography ( ERCP ) in Cirrhotic Patients

Patients with cirrhosis can tolerate ERCP to treat their biliary tract or pancreatic diseases. Patients with liver cirrhosis are 3 times more susceptible to cholelithiasis, than the non-cirrhotic population plus the biliary and pancreatic cancer and other disease. Child—Pugh classification is the determinative factor of ERCP treatment and the most important predictor of outcome in these patients. The main severe complication post— ERCP is bleeding [2].


Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing upper endoscope is guided into the duodenum, the bile and pancreatic ducts are opacified by injection of a contrast medium, and allowing for a variety of therapeutic interventions [1].
Patients with cirrhosis can tolerate ERCP to treat their biliary tract or pancreatic diseases.Patients with liver cirrhosis are 3 times more susceptible to cholelithiasis, than the non-cirrhotic population plus the biliary and pancreatic cancer and other disease.Child-Pugh classification is the determinative factor of ERCP treatment and the most important predictor of outcome in these patients.The main severe complication post-ERCP is bleeding [2].

Complications of ERCP
According to American Society of Gastrointestinal Endoscopy guidelines in 2005 [4]: ERCP is associated with some complications and adverse events can be divided into two main groups:

1-Specific complications [6]:
Pancreatitis: The most frequent complication of ERCP, although most cases are mild and pass without complications.
Bleeding: Bleeding during ERCP typically develops after sphincterotomy.This is the most common & most serious in cirrhotic patients.
Infection: Infections occurring after ERCP are most often due manipulation of an obstructed biliary or pancreatic system.
Perforation: ERCP may rarely be complicated by perforation of the esophagus, stomach, duodenum, or jejunum.
In this issue of the Afro-Egyptian Journal of Infectious and Endemic diseases, El-Naggar et al., performed free hand needle fistulotomy in the subgroup of cirrhotic patients with difficult cannulation.The maneuver was performed with high success rate and fewer complications.These findings emphasis that invasive techniques can be performed safely and successfully in well prepared cirrhotic patients.Cirrhosis is a major health problem in the Egyptian community and cirrhotic patients are not infrequently referred to the ERCP due to a variety of causes.The major problems that may face patients with cirrhosis are related to the bleeding tendencies and problems of anesthesia.According to El-Naggar et al., both can be controlled by proper preparation using the fresh plasma, vitamin K supplementation as well as step wise use of sedation.This study open the doors for application of further invasive techniques in cirrhotic patients without fear from further complications.However, this study have some limitations.Firstly, the limited number of patients in each arm.Secondly, exclusion of patients with Child C cirrhosis, in fact these patients represent challenge for all invasive procedures and are frequently seen with indications for ERCP, probably further studies focusing these patients may answer the question whether or not Child C cirrhotics can tolerate ERCP.