This case involves a male patient who presented to the ER with acute abdominal pain. He was diagnosed with gallstones, however it was noted that there was no evidence of obstruction. The decision was made to take the patient for an ERCP, a medical imaging procedure in which an endoscope is used to introduce contrast medium into the patient’s bile ducts to allow visualization on a subsequent x-ray. The patient was classified as a “high risk” for complications from the procedure, based on his history of obesity, hypertension, and smoking. Nevertheless, he had no cardiac or pulmonary examination or clearance prior to proceeding with the procedure. After undergoing the procedure he was extubated, however he required re-intubation almost immediately, after his breathing was found to be dangerously slow and labored. At this point, he was transferred to the post-anesthesia care unit, where doctors again attempted to extubate the patient. Almost immediately after the patient was extubated, he suffered cardiac arrest. Doctors were unable to successfully revive the patient, and he expired in the PACU.
Question(s) For Expert Witness
- 1. How many ERCPs do you perform per month?
- 2. Are you familiar with the indications for an emergent ERCP?
- 3. Have you ever had a patient have this complication?
Expert Witness Response E-035088
I perform 30-40 ERCPs per month. The only definitive indications for an emergent ERCP are cholangitis or hemobilia and, even in these situations, there are situations where one must consider additional diagnostic evaluation and/or medical management (iv fluid, antibiotics for cholangitis or blood transfusion for hemobilia) prior to ERCP. In this case, the patient should have been cleared for the procedure by a cardiology and/or pulmonology consult. I have been performing ERCP and EUS on a referral patient population independently for 7 years, and I perform nearly 360-480 ERCPs annually. I have published extensively on ERCP and ERCP related complications. In addition, I am currently involved in two international trials evaluating post-ERCP pancreatitis prophylaxis (one as principal investigator) and recently published a study on ERCP related duodenal perforations.