- •
Risk stratification and thoughtful patient selection are critical in preventing post-ERCP pancreatitis; in this era of highly accurate diagnostic alternatives, ERCP should be a near-exclusively therapeutic procedure.
- •
In the case of difficult cannulation, alternate techniques, such as double-wire cannulation and precut sphincterotomy, should be implemented early.
- •
Contrast-facilitated cannulation, aggressive/repeated pancreatic injection, dilation of an intact biliary sphincter, and sphincter of
Preventing Pancreatitis after Endoscopic Retrograde Cholangiopancreatography
Section snippets
Key points
Overview
Post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is defined as new or increased abdominal pain that is clinically consistent with a syndrome of acute pancreatitis, pancreatic enzyme elevation at least 3 times the upper limit of normal 24 hours after the procedure, and resultant hospitalization (or prolongation of existing hospitalization) by more than 1 night.1 Pancreatitis is still the most common complication of ERCP, occurring in 2% to 10% of cases and accounting
Recognizing patients at increased risk for PEP
PEP prevention begins with recognition of patients at increased risk, because a high index of suspicion for and early identification of post-ERCP pancreatitis are critically important in ensuring favorable clinical outcomes. The ability to risk stratify patients based on well-established clinical characteristics can concretely influence the decision-making process that surrounds PEP prevention and the management of its potentially devastating sequelae. Armed with the risk assessment information
Patient selection
Thoughtful patient selection before ERCP remains a fundamental strategy for preventing pancreatitis. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) allow highly accurate pancreaticobiliary imaging while avoiding the significant risks of ERCP.30, 31, 32 Two large meta-analyses have demonstrated that EUS is highly sensitive and specific in the detection of bile duct stones (sensitivity 89%–94%; specificity 94%–95%).33, 34 Similarly, MRCP has a sensitivity of
Procedure technique
Efficient and atraumatic technical practices during ERCP are central to minimizing the risk of pancreatitis. Many of the procedure-related risk factors listed earlier, while predisposing to PEP, are mandatory elements of a successful case. Even though these high-risk interventions are unavoidable for execution of the clinical objective, certain strategies can be utilized to minimize procedure-related risk.
As mentioned, difficult cannulation and PD injection are both independent risk factors for
Procedure equipment
Recent advances in ERCP equipment have increased technical success rates but have unfortunately not reduced the risk of post-ERCP pancreatitis.62 In particular, the use of a sphincterotome or a steerable catheter has been shown to improve cannulation success compared with a standard cannula but does not result in lower PEP rates.63 Similarly, comparative effectiveness studies evaluating sphincterotomes of various diameters have shown no difference in the risk of PEP.64, 65 There are no
Prophylactic Pancreatic Stent Placement
One of many proposed mechanisms of PEP implicates impaired PD drainage caused by trauma-induced edema of the papilla. PSP is therefore thought to reduce the risk of PEP by relieving PD hypertension that develops as a result of transient procedure–induced stenosis of the pancreatic orifice. Eight RCTs (>650 subjects) and at least 10 nonrandomized trials have consistently demonstrated that PSP reduces the risk of PEP by approximately 60% to 80%.69, 70 In the most recently published meta-analysis
Pharmacoprevention
Historically, pharmacoprevention for PEP has been a disappointing enterprise. In excess of 35 pharmacologic agents have been studied for the prophylaxis of pancreatitis, and more than 60 prospective clinical trials addressing chemoprevention have been published since the year 2000. Until recently, however, no medication had proved consistently effective in preventing PEP on the basis of high-quality clinical trial data, and no pharmacologic prophylaxis for PEP had been adopted into widespread
Future directions
Despite the approaches outlined earlier, up to 10% of high-risk patients will still develop PEP. Appropriate patient selection, sound procedural technique, NSAIDs, and pancreatic stents have been effective in improving the problem; however, additional research in multiple areas is necessary to achieve the goal of solving PEP.
In addition to the research questions presented throughout this article, several ongoing or soon to be initiated studies are worth noting. There are 4 enrolling
Summary
- a.
Pancreatitis is an important and potentially preventable complication of ERCP.
- b.
Patients can be risk-stratified for PEP according to patient and procedure-related characteristics, guiding prophylactic interventions and allowing early detection of the complication.
- c.
Thoughtful patient selection is critical in preventing PEP; in this era of highly accurate diagnostic alternatives, ERCP should be a near-exclusively therapeutic procedure.
- d.
In the case of difficult cannulation, alternate techniques, such
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The authors have no conflicts of interest to disclose.