Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a stone in the common bile duct. She has fever with chills, jaundice, and right upper quadrant (RUQ) pain. Her blood pressure is 112/70 mmHg, and she is alert and oriented. She has no drug allergies. Four hours after endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone removal, she reports severe, constant epigastric pain that bores through to her back. Heart rate is 108/min, blood pressure 110/68 mmHg, and temperature 37.4 °C. The abdomen is tender but not rigid, and her hemoglobin is unchanged from before the procedure. Which complication do these findings MOST suggest?

Pancreatitis is the most common complication of ERCP and presents as severe epigastric pain radiating to the back, often with tachycardia, within hours of the procedure. A rigid abdomen would point to perforation, a falling hemoglobin or black stools to bleeding, and returning fever with jaundice to recurrent cholangitis. The nurse reports the pain and anticipates a serum lipase.

Core interpretation
The findings point most strongly to post-ERCP pancreatitis (PEP). The key clue is the character and timing of the pain: severe, constant epigastric pain that bores through to the back, appearing within hours after ERCP with sphincterotomy and stone removal. This is the classic presentation of pancreatic inflammation triggered by the procedure.

Pancreatitis is the most common complication of ERCP and typically presents with epigastric pain radiating to the back, often accompanied by tachycardia, within hours of the procedure. The patient’s heart rate of 108/min reflects the systemic inflammatory response, while the mild temperature of 37.4 °C is consistent with early inflammation rather than established infection.

Why the other options are less likely
The abdomen is described as tender but not rigid. Watch out! A rigid abdomen would point more toward duodenal perforation, which typically causes peritoneal irritation and guarding. The absence of rigidity makes perforation less likely, although it cannot be completely excluded without imaging.

Bleeding at the sphincterotomy site would be suggested by a falling hemoglobin, melena, hematemesis, or hemodynamic instability. Here the hemoglobin is unchanged from before the procedure, and the blood pressure remains stable at 110/68 mmHg. Key point! A stable hemoglobin and stable blood pressure argue against significant bleeding.

Recurrent infection behind a retained stone would be expected to produce returning fever with chills and jaundice. This patient’s temperature is only mildly elevated, and the dominant symptom is pain rather than a septic or obstructive biliary picture. The pain pattern—boring through to the back—is more pancreatic than biliary.

Pathophysiology of post-ERCP pancreatitis
During ERCP, instrumentation of the papilla and common bile duct can cause mechanical trauma, edema, or transient obstruction of the pancreatic duct. Sphincterotomy and stone manipulation increase the risk because they involve direct contact with the ampullary region and can impair pancreatic outflow. The resulting ductal hypertension and premature intracellular activation of pancreatic enzymes lead to autodigestion and inflammation of the pancreas.

The pain of pancreatitis is typically epigastric and constant, with radiation to the back, reflecting the retroperitoneal location of the pancreas and the inflammatory involvement of surrounding nerve plexuses.

Epidemiology and risk context
The reported incidence of PEP varies. One review describes a rate of 2–10% in general ERCP populations, rising to 30–50% in high-risk cases ^[1]. Guidelines consistently identify PEP as the most common adverse event of ERCP ^[2][3][4]. This patient has several recognized risk factors: female sex, obesity, and a procedure involving sphincterotomy with stone removal. The presence of acute cholangitis prior to the procedure may also contribute to local inflammation and increased susceptibility.

Clinical differentiation at the bedside

Complication	Key findings	This patient
Post-ERCP pancreatitis	Severe epigastric pain radiating to back, tachycardia, onset within hours, elevated lipase	Matches: boring epigastric pain to back, HR 108/min, 4 hours post-procedure
Duodenal perforation	Rigid abdomen, peritoneal signs, free air on imaging	Not matching: abdomen tender but not rigid
Sphincterotomy bleeding	Falling hemoglobin, melena, hematemesis, hypotension	Not matching: hemoglobin unchanged, BP stable
Retained stone with cholangitis	Returning fever with chills, jaundice, biliary-type pain	Not matching: only mild temperature elevation, pain is pancreatic-type

Nursing priority and anticipated action
The nurse should report the pain immediately and anticipate a serum lipase level. Lipase is more specific than amylase for pancreatic inflammation and is the preferred laboratory test when PEP is suspected. Early recognition of PEP is critical because severe cases can progress to multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. ^[1] Supportive care includes intravenous fluids, analgesia, bowel rest, and close monitoring of hemodynamic status and urine output. Rectal NSAIDs such as indomethacin have been studied for prevention, but once PEP is established, management is primarily supportive ^[4].