How to manage abdominal and back pain after ERCP
After endoscopic retrograde cholangiopancreatography (ERCP), a patient develops upper abdominal and back pain. What steps should be considered?
- CT scan or upper GI series can usually pinpoint an injury to the duodenum after ERCP or polypectomy.
- Repeat EGD can provide the option of endoscopic repair, but is less reliable for localization, especially with a small injury.
- The main focus should be on the location of the leak—is it the biliopancreatic system or the duodenum? Bile duct injury may be treated by endoscopic stent placement with percutaneous drainage of any biloma or exploration (open or laparoscopic) if the injury is complex.
- Pancreatitis is not uncommon and should be treated expectantly.
- A contained, small leak in the posterior duodenum (retroperitoneal) may be treated with bowel rest and gastric decompression; however, laparotomy is indicated in the presence of ongoing pain or signs of diffuse peritonitis.
As not all patients with pain and hyperamylasemia following ERCP have acute pancreatitis, clinicians may be having difficulty in establishing the diagnosis.
As a result, some patients with severe post-ERCP pancreatitis may not be identified in the early stages of their illness, when aggressive hydration is most important.
Some endoscopists may have difficulty acknowledging that post-ERCP pancreatitis has occurred, as this requires accepting that there has been a complication.
However, delay in both the diagnosis and treatment of post-ERCP pancreatitis may lead to adverse consequences.
Post-ERCP pancreatitis should be managed like other causes of acute pancreatitis.
This is sometimes complicated by difficulty distinguishing mild from severe disease during the early stages. The degree of elevation of serum amylase and lipase do not always correlate with severity.
Prospective systems using clinical criteria have been developed to predict severity in patients with acute pancreatitis, such as the Ranson, Imrie (Glasgow) and, APACHE scores.
The Ranson and Imrie scoring systems are effectively obsolete. They are cumbersome, requiring serial measurements of numerous physiologic, hematologic and biochemical indices. Additionally, it may take up to 48 hours to develop the predictive score.