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Okano et al. Mini-invasive Surg 2021;5:29 https://dx.doi.org/10.20517/2574-1225.2021.15 Page 3 of 9

ERCP-ASSOCIATED BLEEDING
Bleeding is seldom encountered in normal ERCP cases. Papillary treatments such as endoscopic
sphincterotomy (EST), endoscopic papillary balloon dilation (EPBD), and endoscopic papillectomy are the
primary causes of bleeding. Although a majority of the cases of bleeding are minor and bleeding may
[1]
spontaneously stop during treatment , it sometimes may obscure the field of view. Patient-related risk
factors of post-EST bleeding include the presence of coagulopathy, undergoing anticoagulant therapy within
[12]
3 days of ERCP, and active cholangitis . Anticoagulants and antiplatelet agents (APA) are associated with
post-ERCP bleeding, and the American Society for Gastrointestinal Endoscopy suggests refraining from
APA when undergoing ERCP . Alternatively, aspirin use is considered safe and has not been reported to
[13]
increase the risk of post-ERCP bleeding [14-16] . The association between thienopyridine (i.e., ticlopidine,
clopidogrel, and prasugrel) and bleeding risk has not been sufficiently studied. However, it is recommended
that administration of these drugs should be halted for at least 5-7 days and instead, aspirin should be
administered when conducting EST, which is a high-risk procedure .
[13]
In regard to the angle of EST, the direction from 11 to 12 o’clock is thought to be associated with the lowest
perforation and bleeding risk. In the event of non-arterial bleeding, spraying epinephrine solution is useful.
Balloon tamponade of the sphincterotomy site is also used to stop the bleeding [Figure 1]. A randomized
[17]
trial of 120 patients found that prophylactic injection of hypertonic saline-epinephrine proximal to the
papilla significantly reduced the risk of post-EST bleeding . Hypertonic saline-epinephrine is also useful
[18]
for treating intraprocedural bleeding. Thermal therapies such as high-frequency coagulation hemostasis
[Figure 2] and argon plasma coagulation, cauterization hemostasis, or use of clips (hemoclips) [Figure 3] are
useful. If placement of hemoclips by using a duodenoscope is challenging, use of a forward-viewing
[19]
endoscope with a cap may be facilitated . In either case, it is important to avoid the pancreatic orifice
during thermal and mechanical applications. In case of bleeding from the papilla into the bile duct, it may
not be possible to implement any of the aforementioned hemostatic techniques, and in such cases, a covered
metallic stent may be effective for achieving hemostasis . In addition, interventional radiology should be
[20]
considered when endoscopic hemostasis is difficult. The rate of successful bleeding control with
interventional radiology has been reported to be 83%-91% and should thus be considered prior to
surgery [21-22] . In such cases, clipping at the bleeding site is a useful marker of the culprit vessel.

ERCP-ASSOCIATED PERFORATION
Treatment approaches differ according to the perforation site. According to one study, perforations can be
divided into three types: guide wire perforation, papillary perforation, and duodenal perforation . An
[23]
alternate classification has also been proposed: duodenal perforation, papillary perforation, bile duct
perforation, and retroperitoneal emphysema . A majority of bile duct perforations and papillary
[24]
perforations can be treated conservatively; however, most duodenal perforations require surgical treatment.
Because treatment approaches differ according to the perforation site, it is important to start immediate
treatment after having made a definite diagnosis in the event that a perforation has occurred.

Papillary perforation, bile duct perforation
Papillary perforation may also occur during EST, EPBD, and endoscopic papillary large balloon dilation
(EPLBD), as well as during insertion of biopsy forceps and basket forceps into the common bile duct after
EST and EPLBD. EST should be performed carefully so that incision is not made in an improper direction
or an unnecessarily large incision is avoided. When perforation is suspected in ERCP, it is preferable to
perform ERCP using CO gas, so that the retroperitoneal space would not be widened due to pressure from
2
the transport gas. It is important to perform sufficient bile duct drainage and minimize the collection of
intestinal juices and infection in the retroperitoneal space; this facilitates conservative treatment. For