Review ArticlePrevention of post-ERCP pancreatitis: a comprehensive review
Section snippets
Definitions
One of the reasons for the variation in the reported frequency of post-ERCP pancreatitis is the thoroughness of follow-up and detection; for prospective studies, the rates reported typically are two to 3 times higher than those noted in retrospective studies.18 Another reason is the variety of criteria used to define pancreatitis.1., 19. More severe forms are obvious and rarely escape notice. However, up to 75% of asymptomatic patients develop elevations in serum amylase and lipase after
Mechanisms of post-ERCP pancreatitis
Numerous mechanisms have been postulated for the induction of post-ERCP pancreatitis.23 Obstruction to outflow of pancreatic juice may arise from mechanical injury to the papilla and pancreatic sphincter during instrumentation. Hydrostatic injury may result from contrast injection into the pancreatic duct or from infusion of water or saline solution through perfusion manometry catheters. Chemical or allergic injury may result from instillation of contrast medium into the pancreas. Enzymatic
Patient-related risk factors for post-ERCP pancreatitis
One of the most important revelations of recent multivariate analyses is that the risk of post-ERCP pancreatitis is determined at least as much by patient characteristics as by endoscopic techniques or maneuvers (Table 3).2., 3., 4., 7., 8., 9., 10., 11., 12., 14., 15., 24. This finding has practical implications in that the risk of pancreatitis can largely be estimated before ERCP. Young age is associated with a higher risk of post-ERCP pancreatitis by multivariate analyses and meta-analysis.2.
Procedure-related risk factors for post-ERCP pancreatitis
It has long been recognized that technical factors are important in the pathogenesis of post-ERCP pancreatitis. The injection of a radiographic contrast medium into the pancreatic duct is itself independently associated with risk, which increases incrementally with the number of injections.2., 3., 4., 7., 9., 10., 15., 24., 33. In a meta-analysis, pancreatic contrast injection was associated with an increased risk with an OR 2.2: 95% CI[1.6, 3.01].26 Radiographic opacification of acini in the
Pancreatic stents
Trans-sphincter placement of a pancreatic stent is a relatively new and increasingly popular approach to reducing the risk of post-ERCP pancreatitis (Fig. 1). Theoretically, stents mitigate instrumental papillary trauma and maintain the flow of pancreatic juice, and/or empty the gland of reactive enzyme substrate. According to the “plumbing” concept, drainage of manipulated pancreatic ducts should prevent pancreatitis, just as drainage of obstructed bile ducts prevents cholangitis. Five
Pharmacologic prevention
A pharmacologic agent that prevents post-ERCP pancreatitis has been a goal of investigators for many years. The rationale for this effort centers on the interruption of one or more of the various postulated mechanisms of injury. Some of these are unique to pancreatitis resulting from ERCP, including trauma to the pancreatic sphincter with obstruction to the flow of pancreatic secretions, hydrostatic injury, introduction of infectious agents, and acinar toxicity induced by contrast media. Others
Pharmacologic vs. endoscopic strategies for prevention of post-ERCP pancreatitis
Summarizing the results of the previous discussion, it appears that pharmacologic prophylaxis is not feasible, at least in the United States. The two most promising agents, gabexate and somatostatin, must be administered before ERCP and continuously thereafter for at least 12 hours to be effective, and neither is available in the United States. The viability and cost-effectiveness of these expensive regimens is dubious, because prolonged intravenous infusion generally is impossible when ERCP is
Suggested strategies for avoiding post-ERCP pancreatitis
Overall, the most feasible strategy for prevention of post-ERCP pancreatitis appears to be the combination of careful patient selection (avoiding unnecessary or inappropriate ERCP), meticulous endoscopic technique, and insertion of a pancreatic stent in selected patients by an endoscopist familiar with the technique. Specifically, before considering ERCP, patients with equivocal evidence of biliary obstruction should undergo an alternative imaging procedure, such as laparoscopic cholecystectomy
Disclosure
Dr. Freeman has received research grants from Boston Scientific Corp., speaking honoraria from Boston Scientific Corp. and Wilson-Cook Medical Inc., and is an unpaid consultant to Hobbs Medical Inc.
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