Digestive Diseases and Sciences

, Volume 60, Issue 8, pp 2509–2515 | Cite as

A Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis in Patients with Suspected Type 3 Sphincter of Oddi Dysfunction

  • Ali A. Siddiqui
  • Devi Patel
  • Jeremy Kaplan
  • Andrew H. Zabolotsky
  • David Loren
  • Thomas Kowalski
  • Saad S. Ghumman
  • Douglas G. Adler
  • Satish Munigal
  • Umar Hayat
  • Mohamad A. Eloubeidi
Original Article


Background and Aim

Recent data have suggested that rectal indomethacin can also reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The aim of this study was to determine whether prophylactic rectal indomethacin with PD stenting would reduce the incidence and severity of PEP compared to PD stenting alone in patients undergoing manometry for suspected SOD type 3.

Patients and Methods

A retrospective review of consecutive patients who underwent an ERCP with manometry for suspected SOD type 3 was performed. Patients were divided into two groups: (a) those who received a prophylactic PD stent (n = 285) and (b) those who received a prophylactic PD stent and a single dose of 100-mg indomethacin suppositories after ERCP (n = 57). The rate of PEP was compared between the two groups.


The two patient groups were similar with regard to patient and procedure risk factors for PEP. Post-ERCP pancreatitis developed in 22 % patients. There was no significant difference in the incidence of PEP in the PD stent group compared to the PD stent and indomethacin group (23 vs. 18 %, respectively; p = 0.39). Moderate-to-severe pancreatitis developed in 21 (7 %) patients in the PD stent group compared to 5 (9 %) patients in the PD stent and indomethacin group (p = 0.78). Among patients with PEP, the median length of hospital stay was not significantly longer in the PD stent group compared to the PD stent and indomethacin group (6 vs. 4 days, respectively; p = 0.11).


In patients with suspected SOD type 3, prophylactic rectally administered indomethacin with PD stenting was not observed to affect the incidence or severity of post-ERCP pancreatitis when compared to PD stenting alone.


Acute pancreatitis Endoscopic retrograde cholangiopancreatography Indomethacin Sphincter of Oddi dysfunction 



This study was funded entirely through existing intramural funds and salary support.

Conflict of interest



  1. 1.
    Maranki J, Yeaton P. Prevention of post-ERCP pancreatitis. Curr Gastroenterol Rep. 2013;15:352.CrossRefPubMedGoogle Scholar
  2. 2.
    Behar J, Corazziari E, Guelrud M, Hogan W, Sherman S, Toouli J. Functional gallbladder and sphincter of oddi disorders. Gastroenterology. 2006;130:1498–1509.CrossRefPubMedGoogle Scholar
  3. 3.
    Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991;37:383–393.CrossRefPubMedGoogle Scholar
  4. 4.
    Gottlieb K, Sherman S. ERCP and biliary endoscopic sphincterotomy-induced pancreatitis. Gastrointest Endosc Clin N Am. 1998;8:87–114.PubMedGoogle Scholar
  5. 5.
    Elton E, Howell DA, Parsons WG, Qaseem T, Hanson BL. Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique. Gastrointest Endosc. 1998;47:240–249.CrossRefPubMedGoogle Scholar
  6. 6.
    Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc. 2001;54:425–434.CrossRefPubMedGoogle Scholar
  7. 7.
    Masci E, Mariani A, Curioni S, Testoni PA. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy. 2003;35:830–834.CrossRefPubMedGoogle Scholar
  8. 8.
    Tarnasky PR, Palesch YY, Cunningham JT, Mauldin PD, Cotton PB, Hawes RH. Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction. Gastroenterology. 1998;115:1518–1524.CrossRefPubMedGoogle Scholar
  9. 9.
    Fazel A, Quadri A, Catalano MF, Meyerson SM, Geenen JE. Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study. Gastrointest Endosc. 2003;57:291–294.CrossRefPubMedGoogle Scholar
  10. 10.
    Beltz S, Sarkar A, Loren DE, Andrel J, Kowalski T, Siddiqui AA. Risk stratification for the development of post-ERCP pancreatitis by sphincter of Oddi dysfunction classification. South Med J. 2013;106:298–302.CrossRefPubMedGoogle Scholar
  11. 11.
    Elmunzer BJ, Waljee AK, Elta GH, Taylor JR, Fehmi SM, Higgins PD. A meta-analysis of rectal NSAIDs in the prevention of post-ERCP pancreatitis. Gut. 2008;57:1262–1267.CrossRefPubMedGoogle Scholar
  12. 12.
    Ding X, Chen M, Huang S, Zhang S, Zou X. Nonsteroidal anti-inflammatory drugs for prevention of post-ERCP pancreatitis: a meta-analysis. Gastrointest Endosc. 2012;76:1152–1159.CrossRefPubMedGoogle Scholar
  13. 13.
    Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–111.CrossRefPubMedGoogle Scholar
  14. 14.
    Freeman ML, Overby C, Qi D. Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success. Gastrointest Endosc. 2004;59:8–14.CrossRefPubMedGoogle Scholar
  15. 15.
    Saad AM, Fogel EL, McHenry L, et al. Pancreatic duct stent placement prevents post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction but normal manometry results. Gastrointest Endosc. 2008;67:255–261.CrossRefPubMedGoogle Scholar
  16. 16.
    Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med. 2012;366:1414–1422.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Cheng CL, Sherman S, Watkins JL, et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol. 2006;101:139–147.CrossRefPubMedGoogle Scholar
  18. 18.
    Rabenstein T, Hahn EG. Post-ERCP pancreatitis: new momentum. Endoscopy. 2002;34:325–329.CrossRefPubMedGoogle Scholar
  19. 19.
    Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointest Endosc. 2004;59:845–864.CrossRefPubMedGoogle Scholar
  20. 20.
    Sherman S. What is the role of ERCP in the setting of abdominal pain of pancreatic or biliary origin (suspected sphincter of Oddi dysfunction)? Gastrointest Endosc. 2002;56:S258–S266.CrossRefPubMedGoogle Scholar
  21. 21.
    Maldonado ME, Brady PG, Mamel JJ, Robinson B. Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry (SOM). Am J Gastroenterol. 1999;94:387–390.CrossRefPubMedGoogle Scholar
  22. 22.
    Fogel EL, Eversman D, Jamidar P, Sherman S, Lehman GA. Sphincter of Oddi dysfunction: pancreaticobiliary sphincterotomy with pancreatic stent placement has a lower rate of pancreatitis than biliary sphincterotomy alone. Endoscopy. 2002;34:280–285.CrossRefPubMedGoogle Scholar
  23. 23.
    Otsuka T, Kawazoe S, Nakashita S, et al. Low-dose rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a randomized controlled trial. J Gastroenterol. 2012;47:912–917.CrossRefPubMedGoogle Scholar
  24. 24.
    Geenen JE, Hogan WJ, Dodds WJ, Toouli J, Venu RP. The efficacy of endoscopic sphincterotomy after cholecystectomy in patients with sphincter-of-Oddi dysfunction. N Engl J Med. 1989;320:82–87.CrossRefPubMedGoogle Scholar
  25. 25.
    Neoptolemos JP, Bailey IS, Carr-Locke DL. Sphincter of Oddi dysfunction: results of treatment by endoscopic sphincterotomy. Br J Surg. 1988;75:454–459.CrossRefPubMedGoogle Scholar
  26. 26.
    Cotton PB, Durkalski V, Romagnuolo J, et al. Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial. JAMA. 2014;311:2101–2109.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Ali A. Siddiqui
    • 1
  • Devi Patel
    • 1
  • Jeremy Kaplan
    • 1
  • Andrew H. Zabolotsky
    • 1
  • David Loren
    • 1
  • Thomas Kowalski
    • 1
  • Saad S. Ghumman
    • 1
  • Douglas G. Adler
    • 2
  • Satish Munigal
    • 3
  • Umar Hayat
    • 1
  • Mohamad A. Eloubeidi
    • 4
  1. 1.Division of Gastroenterology and Hepatology, Department of Internal MedicineThomas Jefferson University HospitalPhiladelphiaUSA
  2. 2.Division of Gastroenterology and Hepatology, Department of Internal MedicineUniversity of UtahSalt Lake CityUSA
  3. 3.Department of Internal MedicineWashington University School of MedicineSt. LouisUSA
  4. 4.Division of GastroenterologyNortheast Alabama Regional Medical CenterAnnistonUSA

Personalised recommendations