Choledocholithiasis is an acute or chronic calculous disease located in the common bile duct, often occurring at the lower end of the common bile duct. According to their source, they can be divided into primary and secondary choledocholithiasis. The formation of primary gallstones in bile ducts is closely related to biliary tract infection, cholestasis and biliary ascaris. Bile duct stones from the gallbladder, called secondary bile duct stones, cholesterol stones are more common. The prevalence of choledocholithiasis varies from country to country, ranging from 8 to 18% in symptomatic gallstones (1–5). Typical choledocholithiasis will have abdominal pain, chills, high fever and jaundice, even combined with a drop in blood pressure and neuropsychiatric symptoms. During physical examination, yellow skin, sclera, right upper abdominal tenderness, rebound pain, muscle tension can be found. European guidelines recommend that all suitable patients with choledocholithiasis should be treated with lithotomy (6). Choledocholithiasis can be treated with endoscopic retrograde cholangiopancreatography (ERCP). ERCP is the most common method for choledocholithiasis removal according to current guidelines (7, 8). However, ERCP also has associated complications, including post-ERCP pancreatitis (PEP), bleeding, perforation, infection, etc. Among them, PEP is the most common complication of ERCP, with a reported incidence of about 10.2%, and even 14.1% for high-risk groups (9). Bleeding is one of the most serious complications of ERCP, with an incidence of about 0.3 to 2% (10–13).

Cirrhosis is a chronic progressive liver disease that is caused by multiple causes of long-term or repeated liver damage. The common causes are viral hepatitis, fatty liver, alcoholic liver, drug hepatitis and so on, of which chronic hepatitis B is the most common patient. The main clinical manifestations are liver function damage and portal hypertension, and multiple organs are involved. Complications such as upper digestive tract bleeding, hepatic encephalopathy, hepatorenal syndrome, secondary infection and liver cancer may occur in the late stage. Patients with cirrhosis are prone to choledocholithiasis, and cirrhosis with acute cholangitis may have a high mortality rate due to bacterial infection and permanent liver dysfunction caused by acute liver injury and cholestasis. Studies showed that the cirrhotic group had a significantly higher mortality rate than the non-cirrhotic group after ERCP (14, 15). Therefore, the purpose of this study was to compare the postoperative complications of ERCP between choledocholithiasis patients with cirrhosis and choledocholithiasis patients without cirrhosis.

Choledocholithiasis is a common digestive tract disease. Complications of choledocholithiasis include acute pancreatitis, cholangitis (18) and others. Therefore, early diagnosis and treatment of choledocholithiasis are very necessary. ERCP is the gold standard for diagnosing choledocholithiasis and is the preferred treatment for choledocholithiasis (19, 20). However, ERCP also has many complications, such as postoperative acute pancreatitis, delayed hemorrhage, perforation, and biliary tract infection. PEP is the most common complication. A study published in 2024 showed that the incidence of PEP in patients with asymptomatic choledocholithiasis was 11.7% (21). A study by Çağatay et al. (22) showed that the incidence of PEP was 7.9%. In our study, PEP also was the most common complication, with an incidence of 10.81%, basically consistent with the above two studies. However, there was no significant difference in the incidence of PEP between the choledocholithiasis with cirrhosis group and the group without cirrhosis (8.82% vs. 11.11%). A retrospective study published in 2022 (23) showed that patients with cirrhosis were at higher risk for PEP, the postoperative acute incidence was as high as 44% in the cirrhosis group. Another study (24) also found the incidence of PEP was higher in the cirrhosis group than non-cirrhosis group. But a study showed that patients with cirrhosis had lower incidence of post-ERCP pancreatitis (8.6% vs. 7%; p < 0.0001) (25). This study is not consistent with the above findings. However, a study (26) published in 2014 proved that there was no significant difference in the incidence of PEP between the cirrhotic and non-cirrhotic groups, which is consistent with the results of this study. The reason may be that the patients with postoperative amylase elevation but no abdominal pain or imaging signs were not classified as PEP in this study. Retrospective studies may not be able to do this accurately.

In this study, the delayed hemorrhage rate in the cirrhosis group was significantly higher than that in the non-cirrhosis group (5.88% vs. 0.44%, p = 0.046). Previous studies have shown that the incidence of delayed hemorrhage is 0.3–10.9% (10–13, 27, 28). The rate of delayed hemorrhage in the group without cirrhosis was consistent with previous studies, and the rate of hemorrhage in the group with cirrhosis was significantly higher than that in previous studies. Sumant Inamdar et al. (24) found that ERCP-associated bleeding were more common in the cirrhosis group than non-cirrhosis group (2.3% vs. 1.0%). This is consistent with our findings. Analysis of the reason may be that decompensated cirrhosis patients with reduced liver function, so that the liver synthesis of clotting factors decreased, which function weakened, more prone to postoperative delayed bleeding. In this study, the INR of the liver cirrhosis patient group was significantly higher than that of the non-liver cirrhosis group, confirming this speculation. In addition, patients with cirrhosis are often complicated with hypersplenism, resulting in thrombocytopenia, and the function of platelets is to participate in hemostasis, and thrombocytopenia leads to weakened hemostatic function. In this study, the platelet count in the liver cirrhosis group was lower than that in the non-liver cirrhosis group. Although there was no significant statistical difference, the p value was 0.053, which was very close to 0.05. This does not rule out the possibility that the lack of significant difference was due to the small sample size. There is also increased capillary fragility in patients with cirrhosis, coupled with the lack of vitamin C in patients, and cannot make good use of vitamin potassium, anticoagulant substances in the blood increase, will increase bleeding. In this study, there were no significant differences between the group with liver cirrhosis and the group without liver cirrhosis in terms of diabetes, hypertension, coronary heart disease, and chronic kidney disease. This excluded the influence factors of underlying diseases on delayed bleeding. Therefore, ERCP treatment for choledocholithiasis with cirrhosis patients requires sufficient hemostasis during the operation, and close attention should be paid to the occurrence of delayed hemorrhage after surgery, and measures should be actively taken to deal with delayed hemorrhage.

The two choledocholithiasis patients who died in this study had cirrhosis and were both elderly. One of the patients died of delayed postoperative hemorrhage and the other died of septic shock due to severe postoperative biliary tract infection. These results showed that elderly choledocholithiasis patients with cirrhosis may have higher risk of death after ERCP. The results of this study are consistent with previous studies (14). As to whether there are significant differences in biliary tract infection, perforation and stone clearance between the two groups after ERCP, the results of different studies are inconsistent, while there is no significant difference in this study (23, 24, 26, 29–31).

This study has some limitations. First, this study only had 34 choledocholithiasis patients with cirrhosis, the sample size was small. Secondly, because some patients had biliary tract infection before surgery and were treated with antibiotics, these patients were not classified as postoperative biliary tract infection, thus affecting the results. Last, a one-month follow-up period may be insufficient to capture late-onset complications, particularly in cirrhotic patients who may experience a delayed progression of liver dysfunction or other complications related to their underlying condition. Our findings suggest liver cirrhosis may increase the incidence of delayed bleeding and mortality after ERCP for CBDS. However, given the observational nature of this study and the small number of cirrhosis patients, no causal relationships can be inferred. Further prospective studies with larger cohorts are required to confirm these observations and to better understand the underlying mechanisms.

In conclusion, while this study found that liver cirrhosis may increase the incidence of delayed bleeding and mortality after ERCP for CBDS. However, due to the small sample size of this study, a multivariate logistic analysis could not be conducted, thus could not rule out other factors that might be independent of liver cirrhosis. Future research with larger, well-designed studies is necessary to draw more definitive conclusions regarding these associations.