Endoscopic retrograde cholangiopancreatography (ERCP) is a technique used to diagnose and treat some bile duct, liver, gallbladder, and pancreatic duct problems. The procedure combines the use of endoscopy and fluoroscopy. The endoscope allows the doctor to see the inside of the stomach and duodenum so dyes may be injected into the biliary ducts and pancreas, allowing imaging through X-rays.
It is a wonderful invention. The technology is fantastic. ERCP combines the utilities of both x-rays and an endoscope. The doctor uses the endoscope to inject dyes into the biliary tree and ducts and the pancreas so they can be viewed on x-ray. Modern science is just incredible.
The strongest medical malpractice claims occur when the ERCP is not warranted. Many doctors recommend ERCP procedures to check for conditions such as gallstones or cancer. On some occasions, the patient may have clear scans showing no cancer or stones. Also, they may be no subjective complaints. In a situation like this, it would be unreasonable to perform an ERCP, which carries with it the risk of significant complications, including life-threatening pancreatitis.
Medical malpractice may also occur when a doctor fails to properly perform the test. However, small perforations can occur even with the best technique. Whether there is malpractice depends on the degree of injury in the context of the situation.
Our lawyers handle these cases. If you think you have a potential wrongful death or medical malpractice claim because of a mistake a doctor made giving an ERCP or doing an ERCP in the first place, call 800-553-8082 to discuss your potential malpractice case or get a free online case evaluation.How and When ERCPs Are Used
ERCP was an important medical advancement, in the 1970's when scans were not available, and surgery of the biliary ducts carried a 5 to 10% mortality rate. In the past two decades, multislice CT, MRCP (Magnetic resonance cholangiopancreatography), and EUS (Endoscopic ultrasound) are preferred for diagnosing problems associated with biliary or pancreatic ducts over ERCP as a diagnostic tool. ERCP is indicated in cases where patients present with abnormal liver function tests with dilated common bile duct, gallstones, and pancreatitis, or biliary stones determined through positive MRCP, finding a mass in the head of the pancreas and jaundice caused by obstruction. Many patients are being treated by ERCP for all types of pancreatitis, though ERCP has not been validated for all such procedures.Is the Doctor Trained to Use an ERCP?
Few looking at this issue disagree that training and experience with ERCPs is a game changer when it comes to keeping the patient safe. You have to be well versed with the technology, and you have to have done it frequently to get a handle how to do it.
In an online survey of gastroenterologists, 40% performed less than 50 ECRPs per year, considered to be "low volume." Further, 77% reported low training (less than 180 ECRPs in fellowship). How much training is required is not well defined. Some suggest doctors approach 80% competency after 180-200 ERCPs. (Only 18% of those asked to participate in this survey, actually participated, thus these numbers present great concern.) But the take home message is that experience counts. Studies have reported doctors performing more than 200 ERCPs annually have lower rates of negative outcomes than those performing less than 50 per year. In a 2006 publication, it was reported that 2659 hospitals in the United States were performing ERCPs, half of these hospitals performed less than 49 annually. Those hospitals would be better served to get those patients when possible to a facility that has more experience.A Look at ERCP Lawsuits
In 2006, Dr. Peter B. Cotton released a study in Gastrointestinal Endoscopy reviewing 59 lawsuits involving ERCP. In 2010, he followed up with another publication in the same journal, citing 20 more cases. In 12 of the 20 more recent cases reviewed, there were no indications for performing ERCP. Instead, non-invasive techniques should have been employed based on industry guidelines released in 2000 and 2005. Many practitioners involved in these types of lawsuits are unaware of these guidelines. Similarly, over half of the cases cited in the 2006 publication had no indication for ERCP. The second most common citation for the lawsuits was general negligence in performing the procedure.
Certainly, people who have ERCPs can die for other reason. It is estimated that approximately 1% of relatively healthy patients who have an ERCP will be hospitalized for months due to perforation or pancreatitis, and some will even die. Pancreatitis occurs in 3-15% of all ERCP cases. Failure to diagnose and treat pancreatitis can lead to death. Perforation is another risk associated with ERCP and occurs in approximately 1 in 1,000 ERCPs. Perforation can result in abscess formation, pancreatitis, peritonitis, and death. Complications can also arise from bleeding due to sphincterotomy which can occur in approximately 1 in 1000 patients. But, certainly, other complications that can arise due to negligent technique, including esophageal perforation and hepatic hematoma.
Many ERCP lawsuits stem from patients who never should have received an ERCP in the first place. Too many doctors order ERCPs when they are not likely to solve the patient's problems. This procedure comes with at 8-20% chance of severe complications. So they should not be ordered so the doctor can make money doing the procedure -- which we think happens frequently -- or to test for cancer when there is no real evidence of a concern.ERCP Verdicts and Settlements
Below are examples of successful settlements and verdicts in ERCP medical malpractice cases. We had to step over a lot of defense verdicts to find these victories.
Point blank: these cases are hard to win. You have to have the right case, the right client, and the right facts. These cases give you some idea of the kind of facts that can lead to successful outcomes.
- 2016, Maryland $1.5 Million Verdict: Plaintiff is referred to by her primary care physician because blood test revealed elevated lipase and CA19-9 levels and an abdominal ultrasound showed a “possible indistinct pancreatic head mass." The doctor is apparently unconcerned. He recommends no follow up. But she sees him months later and gets an endoscopic ultrasound (EUS). Still no sign of pancreatic cancer but the doctor recommends at ERCP without properly advising the patient of the risks. Making matters worse, he showed her the EUS results and wrote "tumor" and "mass" on the image. After a five-day trial, the jury awarded our client $1.5 million. Miller & Zois handled this case.
- 2014, New York: $750,000 Settlement: The plaintiff undergoes an ERCP after her gastroenterologist wanted to confirm the possible presence of gallstones. The plaintiff then sees a neurologist after she has a change in her mental status, who claims that she had a stroke during the ERCP. Plaintiff sues the gastroenterologist, claiming that she did not give informed consent to the ERCP. She also alleges that the doctors failed to treat the residual effects of the procedure (the stroke). While the jury deliberates, the parties negotiate a settlement for $750,000.
- 2010, Ohio: $200,000, Verdict: After complaining of pain from gallstones, the patient undergoes an ERCP. During the procedure, the surgeon unknowingly penetrates the patient’s small intestine. The next day, the patient is rushed back to the hospital after experiencing severe abdominal pain. The treating physician recommends a CT scan and possible surgery the next morning. However, the patient becomes so distressed that the doctors perform surgery that same day. The surgery is too late, though, and the patient dies of severe sepsis. The plaintiff’s estate sues alleging that any pain after ERCP should warrant a CT scan. The jury agrees and awards the plaintiff $200,000.
- 2005, Georgia: $3,500,000, Verdict: When the patient goes to the doctor with abdominal pain, the doctor scans the patient’s gallbladder. He misreads the scan, prompting him to suggest ERCP. During the procedure, the patient’s duodenum tears, requiring further surgery including kidney stents. The jury awards the patient $3,500,000.
- 2000, Maryland: $373,728 Verdict: The plaintiff goes to the hospital after suffering from abdominal pain. Her gastroenterologist performs an ERCP to see if she has any gallstones. After the procedure, the plaintiff’s pain is more severe. She finds out that her liver was torn during the ERCP. She sues the doctor, alleging that he used excessive force when performing the procedure. The doctor alleges that the liver was already damaged. In the end, the jury awards the plaintiff $373,728.
If you think you have a potential wrongful death and/or medical malpractice claim on your behalf or for someone you loved because a doctor caused injury during a ERCP, call 800-553-8082 to discuss your potential case or get a free no obligation case evaluation.
- Medical malpractice claims in Maryland: an overview
- Endoscopic Retrograde Cholangiopancreatography in Elderly Patients
- Example lawsuit filed in 2017 in Howard County claiming an unnecessary ERCP.