Preventing Pancreatitis after Endoscopic Retrograde Cholangiopancreatography

https://doi.org/10.1016/j.giec.2013.06.003Get rights and content

Section snippets

Key points

  • 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

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

First page preview

First page preview
Click to open first page preview

References (108)

  • D. Verma et al.

    EUS vs MRCP for detection of choledocholithiasis

    Gastrointest Endosc

    (2006)
  • P. Boraschi et al.

    Choledocholithiasis: diagnostic accuracy of MR cholangiopancreatographyd3 year experience

    Magn Reson Imaging

    (1999)
  • T.B. Gardner et al.

    EUS diagnosis of chronic pancreatitis

    Gastrointest Endosc

    (2010)
  • H. Lambie et al.

    Tc99m-hepatobiliary iminodiacetic acid (HIDA) scintigraphy in clinical practice

    Clin Radiol

    (2011)
  • P. Darwin et al.

    Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks

    Gastrointest Endosc

    (2010)
  • M.L. Rosenblatt et al.

    Comparison of sphincter of Oddi manometry, fatty meal sonography, and hepatobiliary scintigraphy in the diagnosis of sphincter of Oddi dysfunction

    Gastrointest Endosc

    (2001)
  • P.B. Cotton et al.

    Challenges in planning and initiating a randomized clinical study of sphincter of Oddi dysfunction

    Gastrointest Endosc

    (2010)
  • A. Mariani et al.

    Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

    Gastrointest Endosc

    (2012)
  • M.S. Bassan et al.

    Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

    Gastrointest Endosc

    (2012)
  • A. Herreros de Tejada et al.

    Double-guidewire technique for difficult bile duct cannulation: a multicenter randomized, controlled trial

    Gastrointest Endosc

    (2009)
  • P.A. Testoni et al.

    Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis

    Dig Liver Dis

    (2011)
  • S. Sherman et al.

    Sphincter of Oddi manometry: decreased risk of clinical pancreatitis with use of a modified aspirating catheter

    Gastrointest Endosc

    (1990)
  • W.C. Liao et al.

    Balloon dilation with adequate duration is safer than sphincterotomy for extracting bile duct stones: a systematic review and meta-analyses

    Clin Gastroenterol Hepatol

    (2012)
  • J.H. Heo et al.

    Endoscopic sphincterotomy plus large balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones

    Gastrointest Endosc

    (2007)
  • M.L. Freeman et al.

    Cannulation techniques for ERCP: a review of reported techniques

    Gastrointest Endosc

    (2005)
  • H. Schwacha et al.

    A sphincterotome-based technique for selective transpapillary common bile duct cannulation

    Gastrointest Endosc

    (2000)
  • N.S. Abraham et al.

    5F sphincterotomes and 4F sphincterotomes are equivalent for the selective cannulation of the common bile duct

    Gastrointest Endosc

    (2006)
  • L. Somogyi et al.

    Guidewires for use in GI endoscopy

    Gastrointest Endosc

    (2007)
  • M.L. Freeman

    Complications of endoscopic retrograde cholangiopancreatography: avoidance and management

    Gastrointest Endosc Clin N Am

    (2012)
  • A. Choudhary et al.

    Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review

    Gastrointest Endosc

    (2011)
  • M.L. Freeman et al.

    Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success

    Gastrointest Endosc

    (2004)
  • P. Chahal et al.

    Short 5Fr vs long 3Fr pancreatic stents in patients at risk for post-endoscopic retrograde cholangiopancreatography pancreatitis

    Clin Gastroenterol Hepatol

    (2009)
  • S. Brackbill et al.

    A survey of physician practices on prophylactic pancreatic stents

    Gastrointest Endosc

    (2006)
  • A. Das et al.

    Pancreatic-stent placement for prevention of post-ERCP pancreatitis: a cost-effectiveness analysis

    Gastrointest Endosc

    (2007)
  • M.L. Freeman

    Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

    Clin Gastroenterol Hepatol

    (2007)
  • A. Rashdan et al.

    Improved stent characteristics for prophylaxis of post-ERCP pancreatitis

    Clin Gastroenterol Hepatol

    (2004)
  • A. Andriulli et al.

    Pharmacologic treatment can prevent pancreatic injury after ERCP: a meta-analysis

    Gastrointest Endosc

    (2000)
  • A. Andriulli et al.

    Prophylactic administration of somatostatin or gabexate does not prevent pancreatitis after ERCP: an updated metaanalysis

    Gastrointest Endosc

    (2007)
  • B. Murray et al.

    Diclofenac reduces the incidence of acute pancreatitis after endoscopic retrograde cholangiopancreatography

    Gastroenterology

    (2003)
  • M. Moreto et al.

    Transdermal glyceryl trinitrate for prevention of post-ERCP pancreatitis: a randomized doubleblind trial

    Gastrointest Endosc

    (2003)
  • C.W. Choi et al.

    Nafamostat mesylate in the prevention of post-ERCP pancreatitis and risk factors for post-ERCP pancreatitis

    Gastrointest Endosc

    (2009)
  • M.L. Freeman et al.

    Complications of endoscopic biliary sphincterotomy

    N Engl J Med

    (1996)
  • Healthcare Cost and Utilization Project. 2012. Available at: http://hcupnet.ahrq.gov. Accessed April 6,...
  • E. Masci et al.

    Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis

    Endoscopy

    (2003)
  • E.L. Fogel et al.

    Sphincter of Oddi dysfunction: pancreaticobiliary sphincterotomy with pancreatic stent placement has a lower rate of pancreatitis than biliary sphincterotomy alone

    Endoscopy

    (2002)
  • C.L. Cheng et al.

    Risk factors for post-ERCP pancreatitis: a prospective multicenter study

    Am J Gastroenterol

    (2006)
  • S. Friedland et al.

    Bedside scoring system to predict the risk of developing pancreatitis following ERCP

    Endoscopy

    (2002)
  • S.N. Mehta et al.

    Predictors of post-ERCP complications in patients with suspected choledocholithiasis

    Endoscopy

    (1998)
  • E.J. Williams et al.

    Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study

    Endoscopy

    (2007)
  • J.M. Dumonceau et al.

    European Society of Gastrointestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pancreatitis

    Endoscopy

    (2010)
  • Cited by (0)

    The authors have no conflicts of interest to disclose.

    View full text