ERCP and allergic reactions to iodized contrast media

Risk Evaluation of Endoscopic Retrograde Cholangiopancreatography-Related Contrast Media Allergic-Like Reaction: A Single Centre Experience

Background and Aims. Few cases of endoscopic retrograde cholangiopancreatography- (ERCP-) related contrast media (CM) adverse reactions have been reported in the current literature. There is a lack of standardisation in practice regarding premedication prophylaxis for at-risk patients undergoing ERCP and there are few data to guide the practitioners. Our goal is to evaluate the risk of CM adverse reaction in a group of patients with a past history of allergic-like reaction to iodine product undergoing ERCP. Methods. A retrospective chart review study was performed of patients who underwent ERCP at our single centre from January 2010 to December 2015. Results. 2295 ERCPs were performed among 1766 patients. No anaphylactoid or severe adverse reaction occurred. One (0.04%) ERCP-related CM benign reaction was reported in a patient known for penicillin allergy. Among 127 ERCPs performed on patients with a prior adverse reaction to iodine, 121 procedures were done without and 6 with a premedication prophylaxis. In both groups, no ERCP-related CM reaction occurred. Conclusions. To our knowledge, we report the largest cohort of iodine allergic patients undergoing ERCP ever published. These results suggest that ERCP-related CM adverse reactions are very rare even among patients at risk for CM reaction.

[Use of gadolinium as contrast agent in endoscopic retrograde cholangiopancreatography in patients with iodine allergy]

INTRODUCTION

Radiologic contrasts are required during endoscopic retrograde cholangiopancreatography (ERCP). The most frequently used are iodine-based contrast media. Controversy still surrounds the optimal strategy in patients with previous adverse reactions to iodine contrasts that need to undergo an ERCP.

OBJECTIVE

To evaluate the safety and efficacy of a gadolinium-derived contrast medium in patients with previous reactions to iodine-derived agents during ERCP.

MATERIAL AND METHODS

Thirteen ERCP were performed in 11 patients with well-established adverse reactions to iodine compounds. ERCP was carried out with gadobutrol, a non-ionic gadolinium compound and without prophylaxis.

RESULTS

In all patients, ERCP were satisfactorily completed. Thirteen cholangiograms and one pancreatogram were obtained. All procedures were technically successful, allowing diagnosis and endotherapy. The quality of the images was good, similar to those obtained with standard contrast media, and did not represent a limitation. No contrast-related adverse events were observed, and there were no post-ERCP complications.

CONCLUSIONS

Gadolinium-derived agents are a safe and effective alternative in iodine-allergic patients.

Prospective evaluation of adverse reactions to iodine-containing contrast media after ERCP

BACKGROUND

The incidence of contrast media reactions administered at the time of ERCP is unknown. Despite the lack of formal recommendations, numerous types of prophylactic regimens are routinely used in patients with a history of prior reactions to intravascular contrast media.

OBJECTIVE

Our purpose was to document the incidence of contrast media reactions at the time of ERCP and to determine whether various perceived risk factors are predictive of adverse reactions.

DESIGN

Prospective study.

SETTING

Tertiary academic center.

PATIENTS

A total of 601 patients undergoing ERCP as clinically indicated.

INTERVENTIONS

ERCP done with full-strength high osmolality contrast media. No prophylactic medications were given to any patient.

MAIN OUTCOME MEASUREMENTS

Adverse reactions to contrast media.

RESULTS

Six hundred one patients were enrolled. Eighty patients had prior documented reactions to intravascular contrast media (39 mild, 21 moderate, 20 severe). Of the 80 patients, 15 additionally reported shellfish allergy, and 46 reported allergic diathesis. Of the 521 patients with no prior reaction to intravascular contrast, 215 reported other history of allergic reaction. Forty-nine were allergic to shellfish, and 166 had underlying allergic diathesis. At ERCP, 277 patients had cholangiograms, 48 pancreatograms, and 276 both. The average volume of contrast per ERCP was 22 mL. No adverse reactions associated with the administration of contrast media at the time of ERCP were observed in any of the patients.

CONCLUSIONS

The incidence of adverse reaction to iodine-containing contrast media administered at the time of ERCP even in patients considered to be at high risk is exceedingly low. The use of prophylactic regimens before ERCP appears to be unnecessary.

Iodinated contrast sensitivity in ERCP

Iodine contrast media are detectable in the bloodstream after ERCP, and sensitivity reactions have been described. The risk is very small, and the phenomenon is therefore difficult to study. This review discusses the possible need for preventative strategies, and recommends that endoscopists consider the issue and define their own policies.

Endoscopic sphincterotomy complications and their management: an attempt at consensus

Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliary sphincterotomy is the most dangerous procedure routinely performed by endoscopists. Complications occur in about 10% of patients; 2 to 3% have a prolonged hospital stay, with a risk of dying. This document is an attempt to provide guidelines for prevention and management of complications, based on a workshop of selected experts, and a comprehensive review of the literature. We emphasize particularly the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues.