# 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?

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> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

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?

## 보기

1. Perforation of the duodenum
2. Bleeding at the sphincterotomy site
3. Recurrent infection behind a retained stone
4. Inflammation of the pancreas **✔ 정답**

**정답: 4**

## 해설

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.

## 심화 해설

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].References (research sources)

- [1]Post-ERCP Pancreatitis: Prevention, Diagnosis and Management.Research articleCahyadi O, Tehami N, de-Madaria E, Siau K (2022) · DOI: 10.3390/medicina58091261

- [2]Clinical Practice Guidelines for post-ERCP pancreatitis 2023.GuidelineMukai S, Takeyama Y, Itoi T, Ikeura T, Irisawa A, Iwasaki E (2025) · DOI: 10.1111/den.15004

- [3]Post-ERCP pancreatitis.Research articleArata S, Takada T, Hirata K, Yoshida M, Mayumi T, Hirota M (2010) · DOI: 10.1007/s00534-009-0220-5

- [4]Complications of ERCP.Research articleTalukdar R (2016) · DOI: 10.1016/j.bpg.2016.10.007

## 임상 시나리오

Post-ERCP Pancreatitis RecognitionEarly identification of the most common ERCP complication
Post-ERCP pancreatitis typically presents within hours after the procedure as severe, constant epigastric pain that radiates to the back, often with tachycardia.

Report new epigastric pain immediately and anticipate a serum lipase level. A tender but non-rigid abdomen supports pancreatic inflammation over perforation.

CautionA rigid abdomen suggests perforation, falling hemoglobin suggests bleeding, and returning fever with jaundice suggests retained stone with recurrent cholangitis.

## 핵심 개념

- **Post-ERCP pancreatitis** — Most common complication of ERCP, presenting within hours as severe epigastric pain radiating to the back.
- **Sphincterotomy** — Endoscopic incision of the sphincter of Oddi during ERCP, which can cause bleeding or pancreatitis.
- **Serum lipase** — Preferred laboratory test to confirm pancreatitis; more specific than amylase.
- **Rigid abdomen** — Sign of peritoneal irritation suggesting perforation rather than pancreatitis.

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