Indication for endoscopic retrograde cholangiopancreatography and development of hemorrhage: a systematic review and meta-analysis.

Background: Hemorrhage is a common complication associated with endoscopic retrograde cholangiopancreatography (ERCP), usually following sphincterotomy. Studies investigating risk factors for hemorrhage including ERCP indication have been conflicting. Therefore, we conducted a systematic review and meta-analysis to characterize the association between the ERCP indication and hemorrhage.

Methods: Database searches of MEDLINE, EMBASE, and CENTRAL were conducted to identify articles up to December 12, 2022. Randomized trials or observational studies of adult patients undergoing ERCP were included. Quality assessment using the Cochrane Risk of Bias 2.0 and Newcastle-Ottawa Scales for randomized trials and observational studies respectively was conducted. A random effects meta-analysis generating pooled odds ratios with 95% confidence intervals was conducted.

Results: A total of 1323 articles were identified of which 26 were included with up to 25 121 subjects in each meta-analysis. Rates of sphincterotomy (median 96.1%; IQR 60.5-100), biliary stent placement (median 17.2%; IQR 10.6-34.4), antiplatelet use (median 6.0%; IQR 0-10.1), and anticoagulant use (median 1.9%; IQR 0%-3.2%) varied among included studies. No specific indication was associated with hemorrhage in the meta-analyses including cholangitis (OR 1.50; 95% CI 0.97-2.32), choledocholithiasis/biliary stone (OR 1.28; 95% CI 0.95-1.73), malignancy (OR 0.97; 95% CI 0.66-1.42), sphincter of Oddi dysfunction (OR 1.32; 95% CI 0.72-2.40), and acute pancreatitis (OR 0.81; 95% CI 0.44-1.49).

Conclusions: Overall, no indication was significantly associated with increased hemorrhage following ERCP. However, given limitations in the included studies (ie, significant heterogeneity between studies), additional research to better characterize these associations is needed.

Protocol registration number: PROSPERO (CRD42021283978).