BJA Education, 22(10): 372e375 (2022)

doi: 10.1016/j.bjae.2022.04.002
Advance Access Publication Date: 19 July 2022

Matrix codes: 1A02,

2A08, 3A07

ESSENTIAL NOTES

Anaesthesia and sedation for endoscopic retrograde

cholangiopancreatography
A.M. Henriksson1,* and S.V. Thakrar2
1
Chelsea and Westminster Hospital, Chelsea and Westminster NHS Trust, London, UK and 2Hammersmith
Hospital, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare Trust, London, UK
*Corresponding author: anna.henriksson@nhs.net

Keywords: Cholangiopancreatography, endoscopic retrograde; conscious sedation; deep sedation; general anaesthesia;
patient selection; risk factors

Endoscopic retrograde cholangiopancreatography (ERCP) was
introduced in 1968 and is now the ‘gold standard’ for imaging
of the biliary tree. The subsequent development of non-
invasive diagnostic procedures such as magnetic resonance
cholangiopancreatography (MRCP) and endoscopic ultraso-
nography (EUS), means that ERCP is now largely reserved for
therapeutic rather than diagnostic indications.1 Endoscopic
retrograde cholangiopancreatography offers a range of
possible interventions for patients, including those deemed at
too high risk for surgery. The complexity of ERCP and
comorbidities of patients can present challenges to the
anaesthetist, which are discussed below.
What is ERCP?
Endoscopic retrograde cholangiopancreatography is com-
bined endoscopy and fluoroscopy serving as a diagnostic and
therapeutic tool for a range of pancreatobiliary conditions. An
endoscope is advanced into the second part of the duodenum,
Anna Maria Henriksson BSc (Hons) MRCP FRCA is a specialty
registrar with an interest in hepatobiliary surgery and experience in
undertaking deep sedation and general anaesthesia (GA) for various
endoscopy lists (adult and paediatric) as part of her training across
the North West Thames Deanery.
Sonali V Thakrar BSc (Hons) MRCP FRCA is a consultant hep-
atobiliary anaesthetist at a tertiary referral centre for hep-
atopancreaticobiliary disease specialising in balloon enteroscopy and
spyglass cholangioscopy. She was previously a clinical research
fellow in hepatobiliary surgery including liver transplantation.
where the opening of ampulla of Vater (AV) is found. Cannu-
lation of the biliary and pancreatic ducts allows for contrast to
be injected and visualised under X-ray guidance. Therapeutic
interventions such as stone retrieval, lithotripsy, stent inser-
tion, balloon dilation and sphincterotomy may be carried out.
Indications for ERCP
The main indications are1:

choledocholithiasis in patients unfit for surgery or who
have had cholecystectomy

patients with pancreatitis and cholangitis requiring
emergency drainage

inoperable malignancy causing obstructive jaundice

sphincter of Oddi dysfunction and biliary manometry

postoperative complications such as bile leaks or biliary
strictures
Endoscopic retrograde cholangiopancreatography can be
performed in conjunction with EUS and cholangioscopy to aid
ablation, tissue sampling and direct visualisation of the bil-
iopancreatic ducts. This expansion in available indications
has correlated with an increase in the number of ERCPs per-
formed, which has increased by 10% between 2017 and 2019 in
the UK.2
Considerations for the anaesthetist
Environment
Endoscopic retrograde cholangiopancreatography is usually
carried out in an endoscopy suite, remote from main theatres,
in a room that needs to accommodate staff, endoscopy stack,

Accepted: 13 April 2022

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372
 Table 1 Summary of sedation-related and procedure-related adverse events associated with ERCP. COPD, chronic obstructive pulmonary disease; ERCP, endoscopic retrograde chol-
angiopancreatography; OSA, obstructive sleep apnoea; PA, propofol anaesthesia.

Complications associated with ERCP

Complication Incidence Patient-related risk factors Anaesthesia or procedure-related risk

factors

Sedation-related Loss of airway in non-intubated patient 3.5e13.3% COPD Oversedation

adverse events3e5,8,9 requiring airway manoeuvres OSA Bolus rather than target-controlled infu-
BMI 30 sion of propofol
ASA grade 3 Procedure duration >1 h
Hypoxia (O2Sats <85%) 6.7e15% Known or suspected difficult airway Oversedation
COPD Bolus rather than target-controlled infu-
OSA sion PA
Severity of acute illness Procedure duration >1 h
BMI 30
ASA grade 3
Aspiration <1% Ileus Unprotected airway
Ascites Procedure duration >1 h
Alcohol excess
Conversion from sedation to GA 4.7e10% OSA Oversedation
COPD Procedure duration >1 h
BMI 30
ASA grade 3
Hypotension requiring vasopressor drugs 4.1e44.2% Cardiovascular disease General anaesthesia
Severity of acute illness Bolus rather than target-controlled infu-
Older age sion PA
ASA grade 3 Prolonged anaesthesia/procedure duration
Arrhythmia 2.5e14% Cardiovascular disease Hypoxia
Severity of acute illness Sympathetic stimulation
BJA Education - Volume 22, Number 10, 2022

Anticholinergic drugs

Procedure-related Post-ERCP pancreatitis 3e10% History of post-ERCP pancreatitis Difficult cannulation

adverse events7 History of acute pancreatitis Pancreatic duct dilation
Normal bilirubin serum levels Pancreatic duct contrast injection
Sphincter of Oddi dysfunction Biliary sphincterotomy
Female
Young age
Haemorrhage 0.3e2% Coagulopathy Bleeding visible during procedure

Anaesthesia and sedation for ERCP

Active cholangitis Operator inexperience
Anticoagulation within 3 days of ERCP
Pancreatobiliary or duodenal perforation 0.1e0.6% Altered anatomy Difficult cannulation
Sphincter of Oddi dysfunction Biliary sphincterotomy
Cholangiocarcinoma Biliary stricture dilation
Primary sclerosing cholangitis Patient’s movement during procedure
Older age
Post-ERCP cholangitis 0.5e3% Bacteraemia Percutaneous endoscopic procedure
Malignant stricture stenting
Incomplete biliary drainage
Incomplete stone clearance in
choledochlithiasis
Omission of prophylactic antibiotics in
patients with biliary obstruction
Post-ERCP cholecystitis <0.5% Cholelithiasis Stent blocking cystic duct
373

Tumour of cystic duct orifice

Venous air embolus None <2.4% Direct cholangioscopy
Stent placement
Biliary sphincterotomy
Duct dilation
Anaesthesia and sedation for ERCP
anaesthetic and X-ray machines. Consequently, there is
limited access to the patient, who is on a non-tilting table and
sometimes positioned prone.
Safety standards
Essential monitoring includes pulse oximeter, blood pressure,
electrocardiography and capnography for any patient who is
sedated. A skilled anaesthetic assistant, WHO checklist and a
dedicated post-procedure recovery area are mandatory.3
Preoperative assessment
Thorough preoperative assessment is crucial before ERCP. A
retrospective study over 10 yrs (n¼17,538) reported that 63% of
patients have ASA score of 3, with common comorbidities
including ischaemic heart disease (20.3%), metastatic disease
(18.3%), diabetes (17.6%), chronic obstructive pulmonary dis-
ease (COPD; 12.8%), renal disease (9.0%), congestive heart
failure (7.7%) and atrial fibrillation (6.8%).4,5
ERCP: Sedation or general anaesthesia?
Endoscopists have traditionally delivered conscious sedation,
often with midazolam and fentanyl, during which patients
respond to verbal commands or tactile stimuli. However, with
the evolution of ERCP, procedure duration and discomfort has
increased and conscious sedation has been reported to be
inadequate in up to 14% of patients.6 Poor tolerance by the
patient increases failure rates and the risk of procedure-
related complications.
Endoscopic retrograde cholangiopancreatography is
increasingly performed under deep sedation with propofol
anaesthesia, in which patients lose response to verbal stimuli
but do not require tracheal intubation and continue sponta-
neous ventilation. Propofol has a rapid onset and offset, and
its hypnotic properties improve comfort and amnesia. This
leads to faster recovery, improved ERCP success and increased
satisfaction.3
The reported rates of sedation-related adverse events (AEs)
during ERCP varies between 2% and 26%5,7 (Table 1). The risk
of sedation-related AEs is linearly associated with the dura-
tion of the procedure, with the odds ratio increasing from 1.8
to 7.9 in procedures lasting less than 10 min compared with
those lasting more than 1 h.8
There is no significant difference in sedation-related AEs
between anaesthetist-delivered conscious sedation and pro-
pofol anaesthesia for ERCP.7 However, endoscopist-delivered
sedation has a higher incidence of oversedation requiring
reversal, hypotension and incomplete ERCPs, compared with
anaesthetist-delivered sedation.10 In the UK, propofol anaes-
thesia must be used with an anaesthetist present, as propofol
has a narrow therapeutic index and cannot be reversed.3
Overall, ERCP under general anaesthesia (GA) with tracheal
intubation and artificial ventilation accounts for 7e10% of
cases performed at tertiary centres in UK.4,5 General anaes-
thesia is indicated where ERCP under sedation has failed, in
patients at higher risk of sedation-related AEs (Table 1), in
complex and painful procedures, or both.
Sedation-related AEs and rates of conversion to GA in high-
risk patients are 51% and 10%, respectively, compared with 35%
and 3.7% in patients who are ASA grade 1e2 and non-obese.5,9
Hypotension is the most common sedation-related AE
during GA, occurring in half of patients compared with 12%
374 BJA Education - Volume 22, Number 10, 2022
receiving propofol anaesthesia.4 Hypotension may in turn
contribute to the occurrence of other AEs such as acute kidney
injury, longer hospital stays and higher mortality.4
Careful patient selection taking into account the risk fac-
tors for sedation-related AEs and the complexity of the pro-
cedure is key in selecting the approach to anaesthesia and
reducing complications.
Positioning
Prone positioning allows for easier cannulation of the AV.
Although the supine position is more comfortable for the
patient and easier for the anaesthetist, it means the endo-
scopist faces away from the patient, making it technically
more challenging. Supine or lateral decubitus positioning is
preferred in patients with obesity, ascites, or who are critically
ill.
Analgesia
Endoscopic retrograde cholangiopancreatography can be
painful. Multimodal analgesia including paracetamol, NSAIDs
and opioids are often given. Although there have been some
concerns over opioids causing contraction of sphincter of
Oddi, they are not contraindicated.
Antispasmodics
Duodenal peristalsis makes cannulation of the biliary ducts
difficult. Glucagon or hyoscine butylbromide can be given to
reduce peristalsis. Hyoscine butylbromide is used most
commonly; it is antimuscarinic and anticholinergic and
should be used with caution in patients with cardiac disease
and glaucoma.
Conclusions
As the number of ERCPs undertaken increases and the pos-
sibilities for intervention expand, the requirement for anaes-
thetists’ involvement grows. The procedure and its
environment, patients’ characteristics and possible compli-
cations can all present challenges. A good understanding of
the procedure and a comprehensive preoperative assessment
is imperative in managing the risks of anaesthesia and opti-
mising outcomes.
Declaration of interests
The authors declare that they have no conflicts of interest.
References
1. British Society of Gastroenterology Endoscopy. ERCP
Working Party. ERCP e the way forward, a standards frame-
work. 2014. Available from: https://www.bsg.org.uk/wp-
content/uploads/2019/12/ERCP-%E2%80%93-The-Way-
Forward-A-Standards-Framework-1.pdf. [Accessed 29
August 2021]
2. Ravindran S, Bassett P, Shaw T et al. National census of
UK endoscopy services in 2019. Frontline Gastroenterol
2021; 12: 451e60
3. Sidhu R, Turnbull D, Newton M et al. Deep sedation and
anaesthesia in complex gastrointestinal endoscopy: a
joint position statement endorsed by the British Society

of Gastroenterology (BSG), Joint Advisory Group (JAG) and
Royal College of Anaesthetists (RCoA). Frontline Gastro-
enterol 2019; 10: 141e7
4. Althoff FC, Agnihotri A, Grabitz SD et al. Outcomes after
endoscopic retrograde cholangiopancreatography with
general anaesthesia versus sedation. Br J Anaesth 2021;
126: 191e200
5. Barnett SR, Berzin T, Sankara S et al. Deep sedation
without intubation for ERCP is appropriate in healthy,
non-obese patients. Dig Dis Sci 2013; 58: 3287e92
6. Raymondos K, Panning B, Bachem I et al. Evaluation of
endoscopic retrograde cholangiopancreatography under
conscious sedation and general anesthesia. Endoscopy
2002; 34: 721e6
7. American Society for Gastrointestinal Endoscopy. Adverse
events associated with ERCP. 2017. Available from: https://
www.asge.org/docs/default-source/education/practice_
Anaesthesia and sedation for ERCP
guidelines/adverse_events_ercp.pdf?sfvrsn¼9ad4e851_4.
[Accessed 18 December 2021]
8. Behrens A, Kreuzmayr A, Manner H et al. Acute sedation-
associated complications in GI endoscopy (ProSed 2
Study): results from the prospective multicentre elec-
tronic registry of sedation-associated complications. Gut
2019; 68: 445e52
9. Smith ZL, Mullady DK, Lang GD et al. A randomised
controlled trial evaluating general endotracheal anes-
thesia versus monitored anesthesia care and the inci-
dence of sedation-related adverse events during ERCP in
high-risk patients. Gastrointest Endosc 2019; 89: 855e62
10. Smith ZL, Nickel KB, Olsen MA, Vargo JJ, Kushnir VM.
Type of sedation and the need for unplanned in-
terventions during ERCP: analysis of the clinical outcomes
research initiative national endoscopic database (CORI-
NED). Frontline Gastroenterol 2019; 11: 104e10
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