Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic procedure in pancreatobiliary disease but remains associated with important adverse events, including postprocedural bleeding. Although bleeding occurs relatively infrequently, it can result in significant morbidity, need for intervention and prolonged hospitalization.
Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic procedure in pancreatobiliary disease but remains associated with important adverse events, including postprocedural bleeding. Although bleeding occurs relatively infrequently, it can result in significant morbidity, need for intervention and prolonged hospitalization.
Problem Statement
Previous studies evaluating predictors of post-ERCP bleeding have produced inconsistent results, particularly regarding patient comorbidities, antithrombotic therapy and procedural techniques. A comprehensive risk stratification framework is needed to better identify high-risk patients and optimize preventive strategies before ERCP.
Summary
This large systematic review and meta-analysis identified several clinically important predictors independently associated with post-ERCP bleeding. The strongest risk factors included coagulopathy, hemodialysis, anticoagulation therapy and cirrhosis, emphasizing the major contribution of impaired hemostatic reserve and advanced systemic disease to bleeding risk. Procedural factors also played a significant role, with endoscopic sphincterotomy, precut sphincterotomy and intraprocedural bleeding emerging as important predictors of subsequent hemorrhage. Male sex was additionally associated with modestly increased bleeding risk. In contrast, several traditionally presumed risk factors—including older age, elevated body mass index, cholangitis, choledocholithiasis, NSAID use and antiplatelet therapy—were not significantly associated with higher bleeding risk after adjusted analysis. Notably, antiplatelet therapy did not independently increase bleeding risk, an observation that may influence future periprocedural management decisions in selected patients. The study also demonstrated that not all technically advanced interventions confer equal bleeding liability, as endoscopic papillary balloon dilation and covered metal stent placement were not associated with significantly increased bleeding rates. Overall, the findings provide a more refined evidence-based understanding of post-ERCP bleeding risk and support development of predictive models integrating patient-related and procedure-related variables to guide individualized procedural planning, informed consent and preventive strategies in therapeutic ERCP.
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