Routine coagulation screening is an unnecessary step prior to ERCP in patients without biochemical evidence of jaundice: a cross-centre study.

INTRODUCTION

Guidelines suggest that all patients with choledocholithiasis should have a coagulation screen prior to endoscopic retrograde cholangiopancreatography (ERCP). This study aims to establish the incidence of deranged coagulation in such patients and its relationship with bleeding complications.

METHODS

Analysis of consecutive patients undergoing ERCP procedures at two NHS sites was undertaken. Exclusion criteria were anti-coagulation use, bleeding disorders or incomplete data. Demographic data, pre-procedure bilirubin and prothrombin time (PT), ERCP procedural information, and bleeding complications were recorded for each. The cohort was divided into jaundice and non-jaundiced groups. Statistical analysis was performed using the student's t-test, Chi-squared test and Fisher's exact test.

RESULTS

793 patients (419 jaundiced; 374 non-jaundiced) were included. PT was significantly higher in the jaundiced group (greater by 2 (1.35-2.64) seconds; p < 0.001). PT was prolonged in 26.7 per cent of the jaundiced group; 28 patients (6.7 per cent) had a PT of >16.8 s 5.9 per cent of the non-jaundiced group had prolonged PT, with 1 patient having a PT >16.8 s. There were 5 major, and 32 minor bleeding complications with no differences between groups. In those with abnormal coagulation, only 1 minor bleeding complication occurred in a jaundiced patient.

DISCUSSION: Normal pre-ERCP bilirubin was 99.7% (98.5-100) sensitive to predict a PT <16.8 s. Cost savings of £14,350 could have been achieved with judicial use of coagulation screening.

CONCLUSION

Pre-ERCP coagulation screening should only be indicated in patients with a raised bilirubin or individuals on anticoagulation therapy or with a history of bleeding diathesis.