Endoscopic retrograde cholangiopancreatography in cirrhosis - a systematic review and meta-analysis focused on adverse events

AIM To investigate indications and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhotics, especially adverse events. Patients with cirrhosis undergoing ERCP are believed to have increased risk. However, there is a paucity of literature describing the indications and outcomes of ERCP procedures in patients with cirrhosis, especially focusing on adverse events. METHODS We performed a systematic appraisal of major literature databases, including Pubmed and Embase, with a manual search of literature from their inception until April 2017. RESULTS A total of 6,505 patients from 15 studies were analyzed (male ratio 59%, mean age 59 years), 11% with alcoholic and 89% with non-alcoholic cirrhosis, with 56.2% Child-Pugh class A, and 43.8% class B or C. Indications for ERCP included choledocholithiasis 60.9%, biliary strictures 26.2%, gallstone pancreatitis 21.1% and cholangitis 15.5%. Types of interventions included endoscopic sphincterotomy 52.7%, biliary stenting 16.7% and biliary dilation 4.6%. Individual adverse events included hemorrhage in 4.58% (95% CI: 2.77-6.75%, I-2 = 85.9%), post-ERCP pancreatitis (PEP) in 3.68% (95% CI: 1.83-6.00%, I-2 = 89.5%), cholangitis in 1.93% (95% CI: 0.63-3.71%, I-2 = 87.1%) and perforation in 0.00% (95% CI: 0.00-0.23%, I-2 = 37.8%). Six studies were used for comparison of ERCP-related complications in cirrhosis vs non-cirrhosis, which showed higher overall rates of complications in cirrhosis patients with pooled OR of 1.63 (95% CI: 1.27-2.09, I-2 = 65%): higher rates of hemorrhage with OR of 2.05 (95% CI: 1.62-2.58, I-2 = 2.1%) and PEP with OR of 1.33 (95% CI: 1.04-1.70, I-2 = 65%), but similar cholangitis rates with OR of 1.23 (95% CI: 0.67-2.26, I-2 = 44.3%). CONCLUSION There is an overall higher rate of adverse events related to ERCP in patients with cirrhosis, especially hemorrhage and PEP. A thorough risk/benefit assessment should be performed prior to undertaking ERCP in patients with cirrhosis.