Post-ERCP Bleeding Risks Clarified in Large Meta-analysis : Gastrointest Endosc | May 2026

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a cornerstone therapeutic procedure in pancreatobiliary disease but carries a risk of clinically significant bleeding, particularly following therapeutic interventions such as sphincterotomy. Accurate identification of bleeding predictors is essential for procedural planning, risk stratification and optimization of preventive strategies.

Problem Statement

Existing studies evaluating post-ERCP bleeding risk factors have shown inconsistent findings, particularly regarding antithrombotic therapy, procedural techniques and patient-related comorbidities. A comprehensive evidence-based analysis was needed to better define independent predictors of bleeding after ERCP.

Summary

This systematic review and meta-analysis evaluated nearly 150,000 ERCP procedures and identified several major independent predictors of post-ERCP bleeding. Coagulopathy emerged as the strongest risk factor, followed by hemodialysis, anticoagulation therapy and cirrhosis, highlighting the critical role of impaired hemostatic reserve and advanced systemic disease in postprocedural hemorrhage. Procedural interventions also substantially influenced bleeding risk, with endoscopic sphincterotomy and precut sphincterotomy significantly increasing the likelihood of bleeding events. Intraoperative bleeding itself was an important predictor of subsequent clinically significant hemorrhage, emphasizing the importance of meticulous intraprocedural hemostasis. Male sex was associated with a modest increase in bleeding risk, although the biologic explanation remains uncertain. Importantly, several commonly presumed risk factors—including older age, obesity, cholangitis, choledocholithiasis, pancreatic duct stones, NSAID use and antiplatelet therapy—were not independently associated with increased bleeding risk after adjusted analysis. Notably, antiplatelet therapy did not significantly elevate bleeding risk, an observation that may influence future peri-ERCP medication management strategies. Similarly, endoscopic papillary balloon dilation and covered metal stent placement were not associated with excess bleeding risk. Overall, the findings provide a refined evidence-based framework for predicting post-ERCP bleeding and support the development of individualized risk assessment models to improve informed consent, procedural planning and prophylactic management in therapeutic ERCP.