Select the adverse event domain and clinical parameters to classify the severity of the ERCP complication.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Classifying and grading the severity of adverse events following ERCP
Standardized reporting in endoscopy research and quality improvement logs
Assessing Post-ERCP Pancreatitis (PEP), bleeding, and perforation
Timing of Assessment
Complications are graded based on the hospital stay length and intervention requirements. Thus, final grading often occurs weeks after the procedure.
Section 2
Formula & Logic
Post-ERCP Pancreatitis (PEP)
Mild
Amylase ≥ 3x ULN + unplanned stay 2-3 days
Moderate
Unplanned stay 4-10 days
Severe
Stay > 10 days, or ICU, or complication (necrosis/pseudocyst)
Haemorrhage (Post-Sphincterotomy)
Mild
Clinical bleeding with Hgb drop < 3g; no transfusion
Moderate
Transfusion ≤ 4 units; no surgery/angiography
Severe
Transfusion ≥ 5 units or surgery/angiography needed
Perforation
Mild
Self-limited; managed with medical therapy / suction
Moderate
Stay 4-10 days
Severe
Stay > 10 days or surgery needed
Section 3
Pearls/Pitfalls
Defining "True" PEP
Asymptomatic hyperamylasaemia (elevation without pain) occurs in up to 75% of ERCPs and does NOT constitute PEP. The Cotton criteria mandate "clinical pain requiring hospitalisation" before an event is logged.
PEP Prevention
The use of rectal Indomethacin or Diclofenac (100mg) pre-procedure and aggressive periprocedural hydration (Lactated Ringers) are the two highest-evidence interventions to reduce Cotton-graded PEP.
Clinical Pearls
Mild complications (2-3 day stay) are the most common adverse events (~5-10% of cases)
Post-sphincterotomy bleeding may be "immediate" or "delayed" (up to 10-14 days later)
Severe perforation is a surgical emergency; however, Type II (retroperitoneal) perforations can often be managed conservatively
Section 4
Next Steps
Management Decisions
01
Suspected PEP: Fasting, aggressive IV fluids, and pain management. Monitor for SIRS.
02
Suspected Perforation: Immediate CT scan with contrast; surgical and interventional radiology consultation.
Complementary Scoring
ERCP Pancreatitis Risk Score
ASGE Quality Indicators for ERCP
Tokyo Guidelines (Cholangitis)
Section 5
Evidence Appraisal
The Foundational Paper
Endoscopic sphincterotomy complications and their management: an attempt at consensus.
Cotton PB et al. • Gastrointestinal Endoscopy. 1991;37(3):383-93. The universal standard for ERCP complication grading.
Dr. Peter Cotton, a pioneer of ERCP, recognized that until complications were graded objectively (by length of stay and intervention), it was impossible to compare success rates between centers. His 1991 consensus remains the global currency of ERCP research.
