AccScience Publishing / STI / Volume 46 / Issue 1 / DOI: 10.36922/sti.0372
Submit to STI
Cite this article
5
Download
65
Views
Journal Browser
Volume | Year
Issue
Search
Forthcoming Issue
Current Issue
View All
News and Announcements
View All
RESEARCH ARTICLE

Assessing the Risk of Early Hemorrhage in Patients with Acute Cholangitis Undergoing Endoscopic Retrograde Cholangiopancreatography with Biliary Stent Placement

Erli Pei1 ,  Haibo Ding1 ,  Song Wang1 ,  Lei Huang1 ,  Hui Wang1* ,  Li Cai2*
Show Less
1 Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai, China
2 Department of Science and Research, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
STI 2026, 46(1), 0372 https://doi.org/10.36922/sti.0372
Received: 10 November 2025 | Revised: 28 February 2026 | Accepted: 9 March 2026 | Published online: 21 May 2026
© 2026 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by/4.0/ )
Download PDF
XML
Cite
Abstract

Background: Early postoperative hemorrhage is a serious complication of endo­scopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for acute cholangitis, but its patient-related risk factors remain insufficiently defined.

Objective: We aimed to identify the potential risk factors for early postoperative hem­orrhage in patients undergoing ERCP with biliary stent placement for acute cholangitis.

Methods: A retrospective cohort study was conducted, including 150 patients under­going ERCP with biliary stent placement at Yangpu Hospital from January 2017 to De­cember 2020 as the training set, and all patients were followed up for six months to assess postoperative complications. The least absolute shrinkage and selection operator and multivariate logistic regression were performed to identify independent risk fac­tors associated with early postoperative hemorrhage, and a dynamic nomogram mod­el was constructed. Another 40 patients treated between January 2023 and December 2023 were used for external validation. Model prediction performance was evaluated using the receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis.

Results: Inflammatory and liver function indicators recovered rapidly after the oper­ation. The incidence of early postoperative hemorrhage, defined as a hemoglobin (Hb) drop exceeding 20.0 g/L, was 26.0% in the training set and 12.5% in the validation set. Multivariate analysis identified the neutrophil proportion, presence of pancreatitis, total bilirubin (TBIL), and baseline Hb levels as significant predictors of early hemor­rhage. The area under the ROC curve was 0.848 in the training set and 0.846 in the validation set, which indicated favorable predictive performance.

Conclusion: Preoperative presence of pancreatitis, higher TBIL levels, higher neutro­phil proportion, and higher baseline Hb were independent predictors of early postoper­ative hemorrhage risk in patients undergoing ERCP with biliary stent placement

Keywords
Biliary stent
Choledocholithiasis
Endoscopic retrograde cholangiopancreatography
Hemorrhage
Pancreatitis
Risk factors
Funding
This study was supported by Shanghai Municipal Health Commission Clinical Research Program (No. 20194Y0457 to Erli Pei) and Shanghai Municipal Health Commission Policy Program (No. 2022HP70 to Li Cai).
Conflict of interest
The authors declare that they have no competing interests.
References
  1. Coucke EM, Akbar H, Kahloon A, Lopez PP. Bil­iary obstruction. In: StatPearls [Internet]. Treasure Island, FL, USA: StatPearls Publishing; 2026.
  2. von Seth E, Hult M. Acute cholangitis. Br J Surg. 2026;113(3). doi: 10.1093/bjs/znag010
  3. Martins OC, Antunes V, Florencio de Mesquita C, et al. The addition of endoscopic sphincterotomy to biliary stent placement and its impact on the risk of adverse events: an updated meta-analy­sis of randomized controlled trials. Gastrointest Endosc. 2024;100(3):406-414.e2. doi: 10.1016/j.gie.2024.05.014
  4. Miura F, Okamoto K, Takada T, et al. Tokyo Guide­lines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):31-40. doi: 10.1002/jhbp.509
  5. Dufera RR, Berake TB, Maliakkal B. Post-en­doscopic Retrograde Cholangiopancreatog­raphy Complications: A Case of Duodenal Perforation and Literature Review. Cureus. 2023;15(6):e40303. doi: 10.7759/cureus.40303
  6. Goubert K, Degroote H, De Vos M, Khalen­kow M, Hindryckx P. Factors Associated with the Severity of ERCP-Related Complications: A Retrospective Single-Centre Study. J Clin Med. 2024;13(23):7481. doi: 10.3390/jcm13237481
  7. Li S, Guizzetti L, Ma C, et al. Epidemiology and outcomes of choledocholithiasis and cholangitis in the United States: trends and urban-rural vari­ations. BMC Gastroenterol. 2023;23(1):254. doi: 10.1186/s12876-023-02868-3
  8. Ye X, Zhang Y, Wan X, Deng T. Analysis of Risk Factors in Endoscopic Retrograde Cholangiopan­creatography-Related Immediate and Delayed Hemorrhage. Dig Dis Sci. 2021;66(12):4467- 4474. doi: 10.1007/s10620-020-06815-0
  9. Wu CCH, Lim SJM, Khor CJL. Endoscopic retro­grade cholangiopancreatography-related compli­cations: risk stratification, prevention, and man­agement. Clin Endosc. 2023;56(4):433-445. doi: 10.5946/ce.2023.013
  10. Bishay K, Ruan Y, Barkun AN, et al. Incidence, Predictors, and Outcomes of Clinically Significant Post-Endoscopic Retrograde Cholangiopancrea­tography Bleeding: A Contemporary Multicenter Study. Am J Gastroenterol. 2024;119(11):2317- 2325. doi: 10.14309/ajg.0000000000002946
  11. Zhou L, Liu X, Yan M, et al. Postoperative Nadir Hemoglobin and Adverse Outcomes in Patients Undergoing On-Pump Cardiac Opera­tion. Ann Thorac Surg. 2021;112(3):708-716. doi: 10.1016/j.athoracsur.2021.01.016
  12. Hokka M, Egi M, Kubota K, Mizobuchi S. Periop­erative Serum Free Hemoglobin and Haptoglobin Levels in Valvular and Aortic Surgery With Car­diopulmonary Bypass: Their Associations With Postoperative Kidney Injury. J Cardiothorac Vasc Anesth. 2021;35(11):3207-3214. doi: 10.1053/j.jvca.2021.04.029
  13. Lu Y, Jin H, Zhao Y, et al. Impact of Increased Hemoglobin on Spontaneous Intracerebral Hem­orrhage. Neurocrit Care. 2021;36(2):395-403. doi: 10.1007/s12028-021-01305-1
  14. Young MF, Oaks BM, Rogers HP, et al. Maternal low and high hemoglobin concentrations and asso­ciations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis. BMC Pregnancy Childbirth. 2023;23(1):264. doi: 10.1186/s12884-023-05489-6
  15. Pribadi RR, Yoga V, Tandan M, Rani AA, Makmun D. Periendoscopic care continuum in acute chol­angitis caused by common bile duct stone. Acta Med Indones. 2024;56(2):240-248.
  16. Jeong HT, Yim GH, Han J. Long-Term Patency of Plastic Stents in Elderly Patients with Common Bile Duct Stones: A Prospective Pilot Study. J Clin Med. 2025;14(16):5715. doi: 10.3390/jcm14165715
  17. Xu JQ, Qu YF, Zhang ZC, et al. Unsedated emer­gent ERCP is feasible and efficient for acute chol­angitis in old patients over 80 years. Surg Endosc. 2025;39(5):2847-2854. doi: 10.1007/s00464-025-11609-4
  18. Zhang W, Sun H, Wu Q, Liu Z, Shao B, Linghu E. Temporary sphincter-preserving covered biliary stent: a novel adjunctive device for cholangiosco­py-guided calculi clearance. Endoscopy. 2025;57(S01):E995-E996. doi: 10.1055/a-2674-4861
  19. Turan A, Cohen B, Rivas E, et al. Association between postoperative haemoglobin and myocar­dial injury after noncardiac surgery: a retrospec­tive cohort analysis. Br J Anaesth. 2021;126(1):94-101. doi: 10.1016/j.bja.2020.08.056
  20. Chaudhry YP, MacMahon A, Rao SS, et al. Predic­tors and Outcomes of Postoperative Hemoglobin of <8 g/dL in Total Joint Arthroplasty. J Bone Joint Surg. 2021;104(2):166-171. doi: 10.2106/jbjs.20.01766
  21. Parikh S, Bentz T, Crowley S, Greenspan S, Costa A, Bergese S. Perioperative Blood Management. J Clin Med. 2025;14(11):3847. doi: 10.3390/jcm14113847
  22. Sun Y, Chen C, Hou L, Zhao E. Short-term out­comes and quality of life of esophagogastrostomy versus the double-tract reconstruction after lap­aroscopic proximal gastrectomy. BMC Cancer. 2024;24(1):1194. doi: 10.1186/s12885-024-13095-8
  23. Kuno T, Numasawa Y, Mikami T, et al. Association of decreasing hemoglobin levels with the inci­dence of acute kidney injury after percutaneous coronary intervention: a prospective multi-cen­ter study. Heart Vessels. 2020;36(3):330-336. doi: 10.1007/s00380-020-01706-w
  24. Ndrepepa G, Neumann FJ, Menichelli M, et al. Prognostic value of haemoglobin drop in patients with acute coronary syndromes. Eur J Clin Invest. 2021;51(12):e13670. doi: 10.1111/eci.13670
  25. Parvizian MK, Edwards MV, Bhoey P, Zhang MC, Hookey LC, Rodrigues DM. Indication for endoscopic retrograde cholangiopancreatography and development of hemorrhage: a systematic review and meta-analysis. J Can Assoc Gastroenterol. 2024;7(5):352-367. doi: 10.1093/jcag/gwae014
  26. Hamesch K, Hollenbach M, Guilabert L, Lahmer T, Koch A. Practical management of severe acute pancreatitis. Eur J Intern Med. 2025;133:1-13. doi: 10.1016/j.ejim.2024.10.030
  27. Alparslan AS, Ocal S, Buldukoglu OC, et al. Effect of biliopancreatic tree anatomy on development of acute gallstone pancreatitis. BMC Gastroenterol. 2025;25(1):226. doi: 10.1186/s12876-025-03866-3
  28. Wang CY, Gu Y, Yan RP, et al. Severe Acute Pan­creatitis Complicated by Multiple Intra-Ab­dominal Hemorrhages. Case Rep Gastroenterol. 2025;19(1):79-88. doi: 10.1159/000543626
  29. Gonçalves M, Rebelo A, Caetano A, Costa D. Gastrointestinal: An unexpected cause of gas­trointestinal bleeding in a patient with recur­rent acute pancreatitis. J Gastroenterol Hepatol. 2022;38(6):841. doi: 10.1111/jgh.16020
  30. Cai YL, Wang SQ, Zhong HJ, He XX. The effect of anemia on the severity and prognosis of patients with acute pancreatitis: A single-center retrospec­tive study. Medicine. 2022;101(52):e32501. doi: 10.1097/md.0000000000032501
  31. Elhence A, Mahapatra SJ, Madhusudhan KS, et al. Pancreatic hemorrhage contributes to late mortality in patients with acute necrotizing pan­creatitis. Pancreatology. 2022;22(2):219-225. doi: 10.1016/j.pan.2022.01.002
  32. Bodine DM. Anemia of inflammation is all the RAGE. Blood. 2022;139(21):3106-3107. doi: 10.1182/blood.2021015337
  33. Khairullah S, Jackson N. Markers of ineffective erythropoiesis in non-transfusion dependent beta-thalassaemia. Med J Malaysia. 2021;76(1):41- 45.
  34. Ali SN, Arif A, Ansari FA, Mahmood R. Cytopro­tective effect of taurine against sodium chlorate-in­duced oxidative damage in human red blood cells: an ex vivo study. Amino Acids. 2022;54(1):33-46. doi: 10.1007/s00726-021-03121-5
  35. Cao C, Yu P, Chu C, et al. Magnesium hydride attenuates intestinal barrier injury during hemor­rhage shock by regulating neutrophil extracellular trap formation via the ROS/MAPK/PAD4 path­way. Int Immunopharmacol. 2024;130:111688. doi: 10.1016/j.intimp.2024.111688
  36. Virzì GM, Mattiotti M, de Cal M, Ronco C, Zanella M, De Rosa S. Endotoxin in Sepsis: Meth­ods for LPS Detection and the Use of Omics Tech­niques. Diagnostics. 2022;13(1):79. doi: 10.3390/ diagnostics13010079
  37. Liu JJ, Sun YM, Xu Y, Mei HW, Guo W, Li ZL. Pathophysiological consequences and treatment strategy of obstructive jaundice. World J Gastroin­test Surg. 2023;15(7):1262-1276. doi: 10.4240/ wjgs.v15.i7.1262
  38. Dietrich CF, Bekkali NL, Burmeister S, et al. Controversies in ERCP. Endosc Ultrasound. 2022;11(3):186-200. doi: 10.4103/eus-d-21- 00106
  39. Angelis A, Kostakis ID, Lilimpakis K, et al. Time-Related Evidence of Intestinal Oxida­tive Stress in Obstructive Jaundice-Induced Rats. Eur Surg Res. 2023;64(3):323-333. doi: 10.1159/000530087
  40. Fujii J, Homma T, Kobayashi S, Warang P, Madkaikar M, Mukherjee MB. Erythrocytes as a preferential target of oxidative stress in blood. Free Radic Res. 2021;55(8):781-799. doi: 10.1080/10715762.2021.1873318
  41. Qureshi N, Bloom M, Pevnick J. How Much Does Intravenous Fluid Cause Hematocrit to Drop? Improving Interpretation of Hematocrit Toward Better Post-Hemorrhage Care. Mil Med. 2024;190(1-2):e47-e53. doi: 10.1093/milmed/usae325
Share
Back to top
Surgical Technology International, Electronic ISSN: 1090-3941 Published by AccScience Publishing
We use cookies on our website to ensure you get the best experience.
Read more about our cookies here
Accept