Endoscopic retrograde cholangiopancreatography (ERCP) remains the mainstay for biliary and pancreatic interventions but carries an increased risk of adverse events in patients with portal hypertension (PH). This study aimed to compare the incidence and profile of post-ERCP complications in patients with cirrhotic versus non-cirrhotic PH.

A retrospective observational study was conducted on 109 patients with PH who underwent ERCP between January 2019 and May 2024 at a tertiary referral center. Patients were divided into two groups: cirrhotic PH (n = 48) and non-cirrhotic PH (n = 61, mainly portal vein thrombosis or cavernoma). Clinical, laboratory, and endoscopic data were analyzed, including post-ERCP pancreatitis (PEP), bleeding, and cholangitis. Statistical analysis used Chi-square, Fisher’s exact, t-test, and logistic regression, with p < 0.05 considered significant.

Overall complication rates were significantly higher in cirrhotics (39.6%) compared with non-cirrhotics (6.5%, p < 0.001). Post-ERCP bleeding occurred in 14.6% vs. 3.3% (OR 5.04, 95% CI 1.00–25.48, p = 0.033), cholangitis in 12.5% vs. 1.6% (OR 6.98, 95% CI 0.79–61.87, p = 0.022), and PEP in 12.5% vs. 1.6% (OR 8.57, 95% CI 1.00–73.84, p = 0.022). No perforations were observed. Within the cirrhotic cohort, Child-Pugh B/C stages were significantly associated with higher complication rates (p = 0.008).

Cirrhotic patients—particularly those with decompensated disease—have a markedly increased risk of post-ERCP adverse events compared with non-cirrhotic PH. Rigorous pre-procedural optimization, careful risk stratification, and enhanced post-ERCP monitoring are essential to minimize morbidity in this high-risk population.