Adverse Events Associated with ERCP

Publication Date: June 3, 2017
Last Updated: March 14, 2022


We recommend that physicians who perform ERCP be facile with procedural techniques that reduce the risk of pancreatitis (ie, wire-guided cannulation, prophylactic pancreatic duct stenting). (⊕⊕⊕⊕)

We recommend early precut sphincterotomy for difficult biliary cannulation when expertise is available. (⊕⊕⊕o)

We recommend pancreatic duct stenting to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk individuals. (⊕⊕⊕⊕)

We recommend administration of rectal nonsteroidal anti-inflammatory drugs (NSAIDS) to reduce the incidence and severity of PEP in high-risk individuals without contraindication. (⊕⊕⊕o)

We suggest that rectal indomethacin may reduce the risk and severity of post-ERCP pancreatitis in average-risk individuals. (⊕⊕oo)

We suggest that there is insufficient evidence that a combination of rectal NSAIDs and pancreatic duct stenting is superior to either technique alone for prevention of post-ERCP pancreatitis in high-risk individuals. (⊕⊕oo)

We suggest periprocedural intravenous hydration with lactated ringers when feasible to decrease the risk of post-ERCP pancreatitis. (⊕ooo)

We recommend against the routine use of endoscopic papillary large balloon dilation (EPLBD) of an intact sphincter rather than endoscopic sphincterotomy with or without adjunct balloon sphincteroplasty to facilitate biliary stone extraction in patients without coagulopathy because of the increased risk of pancreatitis. If EPLBD alone is used, dilation more than 1 minute is recommended. (⊕⊕⊕o)

We recommend that sphincterotomy should be selectively performed in patients considered high-risk for bleeding. Routine sphincterotomy should not be offered in high-risk individuals for bleeding when not absolutely indicated. (⊕⊕⊕o)

We recommend the use of a microprocessor-controlled generator with mixed current when sphincterotomy is being performed to reduce the risk of post-sphincterotomy bleeding. (⊕⊕⊕o)

We recommend that antibiotic prophylaxis be administered before ERCP in patients who have had liver transplantation or when there is a possibility of incomplete biliary drainage. Antibiotics that cover biliary flora such as enteric gram-negative organisms and enterococci should be used and continued after the procedure if biliary drainage is incomplete. (⊕⊕⊕o)

We recommend that facilities ensure strict compliance with current manufacturer protocols and U.S. Food and Drug Administration recommendations for duodenoscope reprocessing to limit duodenoscope-related transmission of infections. (⊕⊕⊕⊕)

We suggest that patients with suspected periampullary or instrument-related perforations from ERCP without evidence of peritonitis or systemic inflammatory response syndrome (SIRS) may be managed non-operatively. (⊕⊕oo)

We suggest that premedication is not necessary to prevent contrast media allergy during ERCP in patients with a prior history of food or intravenous contrast allergies. (⊕⊕oo)

Recommendation Grading



Adverse Events Associated with ERCP

Authoring Organization

Publication Month/Year

June 3, 2017

Last Updated Month/Year

June 6, 2023

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Prevention, Management

Diseases/Conditions (MeSH)

D010195 - Pancreatitis, D001660 - Biliary Tract Diseases


pancreatitis, pancreaticobiliary disorders, bleeding

Source Citation

Chandrasekhara, V., Khashab, M. A., Muthusamy, V. R., Acosta, R. D., Agrawal, D., Bruining, D. H., … DeWitt, J. M. (2017). Adverse events associated with ERCP. Gastrointestinal Endoscopy, 85(1), 32–47. doi:10.1016/j.gie.2016.06.051