S2308 Increased Risk of ERCP-Related Complications in Patients With Decompensated Cirrhosis: A Real-World Multicenter Analysis

Introduction: Endoscopic Retrograde Cholangiopancreatography (ERCP) is often needed in patients with liver disease. However, the safety of ERCP in those with decompensated cirrhosis remains uncertain. We aimed to evaluate the risk of post-ERCP adverse events (AEs) in patients with compensated versus decompensated cirrhosis. Methods: We queried the TriNetX Research Network, a national research database, to identify adult patients (≥18 years) with cirrhosis who underwent ERCP between 2010 and 2025. Patients were stratified into compensated and decompensated cirrhosis based on ICD-10 codes for hepatic decompensating events (ascites, hepatic encephalopathy, variceal hemorrhage, or spontaneous bacterial peritonitis). Propensity score matching (1:1) was used to adjust for baseline demographics, comorbidities, and laboratory values. We evaluated post-ERCP outcomes using odds ratios (OR) with 95% confidence intervals (CI). Results: A total of 54,039 patients with cirrhosis were identified, including 5,939 with decompensated cirrhosis. The mean age was 61 years in compensated cirrhosis vs 60 years in decompensated cirrhosis. After matching, each group had 5,939 patients (mean [SD] age, 61 [15] years; 42% women, and were evenly matched in baseline characteristics and liver disease severity. Compared to compensated cirrhosis, patients with decompensated cirrhosis had significantly higher odds of post-ERCP pancreatitis (4.4% vs 3.1%; OR: 1.40, 95% CI: 1.13–1.74, P = 0.002), bleeding (4.5% vs 2.6%; OR: 1.79, 95% CI: 1.52–2.11, P < 0.001), cholangitis (5.5% vs 3.3%; OR: 1.71, 95% CI: 1.46–2.01, P < 0.001), and perforation (0.4% vs 0.2%; OR: 2.64, 95% CI: 1.21–5.76, P = 0.01). Decompensated cirrhosis was also associated with increased 30-day mortality (5.6% vs 1.9%; OR: 2.82, 95% CI: 2.32–3.55, P < 0.001). There were no significant differences in the rates of cholecystitis between the 2 groups (1.5% vs 1.6%; OR: 0.95, 95% CI: 0.79–1.14, P = 0.57). Conclusion: In this large, real-world cohort, patients with decompensated cirrhosis undergoing ERCP had significantly increased risks of post-procedural AEs, including pancreatitis, bleeding, cholangitis, perforation, and 30-day mortality. These findings suggest that the severity of liver disease should be a critical consideration when assessing the risks and benefits of ERCP.