Skip to main content
SpringerLink
Log in

Rectal administration of low-dose diclofenac does not reduce post-endoscopic retrograde cholangiopancreatography pancreatitis: a propensity score matching analysis

  • Original Article
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is a popular technique; however, post-ERCP pancreatitis (PEP) remains a major adverse event. The administration of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) is reportedly effective in preventing PEP. However, the recommended dose varies and the efficacy of low-dose rectal NSAIDs remains unclear. Therefore, we decided to investigate the effectiveness of low-dose rectal diclofenac on PEP prevention, using propensity score matching.

Methods

This single-center retrospective study included 401 patients who underwent ERCP between July 2015 and March 2020. After December 2016, we administered rectal diclofenac within 30 min before the ERCP procedure as widely as possible. Patients were divided into those who did (diclofenac group) and did not (control group) receive rectal diclofenac. Patients weighing ≥ 50 kg were administered a 50 mg dose, while those weighing < 50 kg were administered a 25 mg dose. The incidence and severity of PEP in the two groups were assessed by propensity score matching analysis.

Results

Among 401 patients undergoing ERCP, 367 fulfilled the inclusion criteria. Overall, 187 patients received rectal diclofenac (diclofenac group) and 180 did not (control group). After propensity score matching, 105 pairs were selected for evaluation. Overall, seven (6.7%) patients in the diclofenac group and 10 (9.5%) in the control group developed PEP (P = 0.45). Moderate or severe PEP occurred in four (3.8%) patients in the diclofenac group and six (5.7%) in the control group (P = 0.52).

Conclusions

The administration of low-dose rectal diclofenac could not reduce the incidence and severity of PEP.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM (2017) Adverse events associated with ERCP. Gastrointest Endosc 85:32–47

    Article  PubMed  Google Scholar 

  2. Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, Beyna T, Dinis-Ribeiro M, Hritz I, Mariani A, Paspatis G, Radaelli F, Lakhtakia S, Veitch AM, van Hooft JE (2020) ERCP-related adverse events: european society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy 52:127–149

    Article  PubMed  Google Scholar 

  3. Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, Liguory C, Nickl N (1991) Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 37:383–393

    Article  CAS  PubMed  Google Scholar 

  4. Kochar B, Akshintala VS, Afghani E, Elmunzer BJ, Kim KJ, Lennon AM, Khashab MA, Kalloo AN, Singh VK (2015) Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc 81:143-149.e149

    Article  PubMed  Google Scholar 

  5. Murray B, Carter R, Imrie C, Evans S, O’Suilleabhain C (2003) Diclofenac reduces the incidence of acute pancreatitis after endoscopic retrograde cholangiopancreatography. Gastroenterology 124:1786–1791

    Article  CAS  PubMed  Google Scholar 

  6. Khoshbaten M, Khorram H, Madad L, Ehsani Ardakani MJ, Farzin H, Zali MR (2008) Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis. J Gastroenterol Hepatol 23:e11-16

    Article  CAS  PubMed  Google Scholar 

  7. Sotoudehmanesh R, Khatibian M, Kolahdoozan S, Ainechi S, Malboosbaf R, Nouraie M (2007) Indomethacin may reduce the incidence and severity of acute pancreatitis after ERCP. Am J Gastroenterol 102:978–983

    Article  CAS  PubMed  Google Scholar 

  8. Elmunzer BJ, Waljee AK, Elta GH, Taylor JR, Fehmi SM, Higgins PD (2008) A meta-analysis of rectal NSAIDs in the prevention of post-ERCP pancreatitis. Gut 57:1262–1267

    Article  CAS  PubMed  Google Scholar 

  9. Elmunzer BJ, Scheiman JM, Lehman GA, Chak A, Mosler P, Higgins PD, Hayward RA, Romagnuolo J, Elta GH, Sherman S, Waljee AK, Repaka A, Atkinson MR, Cote GA, Kwon RS, McHenry L, Piraka CR, Wamsteker EJ, Watkins JL, Korsnes SJ, Schmidt SE, Turner SM, Nicholson S, Fogel EL (2012) A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 366:1414–1422

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Puig I, Calvet X, Baylina M, Isava Á, Sort P, Llaó J, Porta F, Vida F (2014) How and when should NSAIDs be used for preventing post-ERCP pancreatitis? a systematic review and meta-analysis. PLoS ONE 9:e92922

    Article  PubMed  PubMed Central  Google Scholar 

  11. Sethi S, Sethi N, Wadhwa V, Garud S, Brown A (2014) A meta-analysis on the role of rectal diclofenac and indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas 43:190–197

    Article  CAS  PubMed  Google Scholar 

  12. Thiruvengadam NR, Forde KA, Ma GK, Ahmad N, Chandrasekhara V, Ginsberg GG, Ho IK, Jaffe D, Panganamamula KV, Kochman ML (2016) Rectal indomethacin reduces pancreatitis in high- and low-risk patients undergoing endoscopic retrograde cholangiopancreatography. Gastroenterology 151:288-297.e284

    Article  CAS  PubMed  Google Scholar 

  13. Abdelfatah MM, Gochanour E, Koutlas NJ, Hamed A, Harvin G, Othman MO (2020) Rectal indomethacin reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis in low-risk patients. Ann Gastroenterol 33:405–411

    PubMed  PubMed Central  Google Scholar 

  14. Otsuka T, Kawazoe S, Nakashita S, Kamachi S, Oeda S, Sumida C, Akiyama T, Ario K, Fujimoto M, Tabuchi M, Noda T (2012) Low-dose rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a randomized controlled trial. J Gastroenterol 47:912–917

    Article  CAS  PubMed  Google Scholar 

  15. Okuno M, Shiroko J, Taguchi D, Yamaguchi K, Takada J, Imai S, Sato H, Thanabashi S (2018) The effectiveness of the rectal administration of low-dose diclofenac for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Intern Med 57:2289–2294

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Katoh T, Kawashima K, Fukuba N, Masuda S, Kobatake H, Masaki K, Araki Y, Kawano K, Nishi K, Takenaka M, Ishihara S, Kinoshita Y (2020) Low-dose rectal diclofenac does not prevent post-ERCP pancreatitis in low- or high-risk patients. J Gastroenterol Hepatol 35:1247–1253

    Article  CAS  PubMed  Google Scholar 

  17. Tomoda T, Kato H, Miyamoto K, Matsumi A, Ueta E, Fujii Y, Saragai Y, Yamazaki T, Uchida D, Matsumoto K, Horiguchi S, Tsutsumi K, Okada H (2021) Efficacy of low dose rectal diclofenac for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: propensity score-matched analysis. Dig Endosc 33:656–662

    Article  PubMed  Google Scholar 

  18. Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman M, Geenen J, Ryan M, Parker H, Frakes JT, Fogel EL, Silverman WB, Dua KS, Aliperti G, Yakshe P, Uzer M, Jones W, Goff J, Lazzell-Pannell L, Rashdan A, Temkit M, Lehman GA (2006) Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 101:139–147

    Article  PubMed  Google Scholar 

  19. Chiba M, Kato M, Kinoshita Y, Shimamoto N, Tomita Y, Abe T, Kanazawa K, Tsukinaga S, Nakano M, Torisu Y, Toyoizumi H, Sumiyama K (2021) The milestone for preventing post-ERCP pancreatitis using novel simplified predictive scoring system: a propensity score analysis. Surg Endosc 35:6696–6707

    Article  PubMed  Google Scholar 

  20. Lee HJ, Cho CM, Heo J, Jung MK, Kim TN, Kim KH, Kim H, Cho KB, Kim HG, Han J, Lee DW, Lee YS (2020) Impact of hospital volume and the experience of endoscopist on adverse events related to endoscopic retrograde cholangiopancreatography: a prospective observational study. Gut Liver 14:257–264

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Yokoe M, Takada T, Mayumi T, Yoshida M, Isaji S, Wada K, Itoi T, Sata N, Gabata T, Igarashi H, Kataoka K, Hirota M, Kadoya M, Kitamura N, Kimura Y, Kiriyama S, Shirai K, Hattori T, Takeda K, Takeyama Y, Hirota M, Sekimoto M, Shikata S, Arata S, Hirata K (2015) Japanese guidelines for the management of acute pancreatitis: Japanese guidelines 2015. J Hepatobiliary Pancreat Sci 22:405–432

    Article  PubMed  Google Scholar 

  22. Masci E, Mariani A, Curioni S, Testoni PA (2003) Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy 35:830–834

    Article  CAS  PubMed  Google Scholar 

  23. Levenick JM, Gordon SR, Fadden LL, Levy LC, Rockacy MJ, Hyder SM, Lacy BE, Bensen SP, Parr DD, Gardner TB (2016) Rectal indomethacin does not prevent post-ercp pancreatitis in consecutive patients. Gastroenterology 150:911–917

    Article  CAS  PubMed  Google Scholar 

  24. Mine T, Morizane T, Kawaguchi Y, Akashi R, Hanada K, Ito T, Kanno A, Kida M, Miyagawa H, Yamaguchi T, Mayumi T, Takeyama Y, Shimosegawa T (2017) Clinical practice guideline for post-ERCP pancreatitis. J Gastroenterol 52:1013–1022

    Article  PubMed  Google Scholar 

  25. Odom DM, Mladsi DM, Saag KG, Sherif BN, Miles L, Ronquest N, Wang J (2014) Relationship between diclofenac dose and risk of gastrointestinal and cardiovascular events: meta-regression based on two systematic literature reviews. Clin Ther 36:906–917

    Article  CAS  PubMed  Google Scholar 

  26. Phillip V, Pukitis A, Epstein A, Hapfelmeier A, Haf D, Schwab M, Demir IE, Rosendahl J, Hoffmeister A, Schmid RM, Weber A, Algül H (2019) Pancreatic stenting to prevent post-ERCP pancreatitis: a randomized multicenter trial. Endosc Int Open 7:E860-e868

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We thank all members of the Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, and all members of the Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine. We also thank Hajime Yamakage (Satista, Co., Ltd.) for assistance with the statistical analysis.

Funding

None.

Author information

Authors and Affiliations

  1. Department of Gastroenterology and Hepatology, Fukuchiyama City Hospital, 231 Atsunaka-Cho, Fukuchiyama-City, Kyoto, 620-8505, Japan

    Hiroaki Sakai, Naoto Iwai, Junichi Sakagami, Takashi Okuda, Chie Hattori, Masashi Taniguchi, Kohei Oka, Tasuku Hara, Toshifumi Tsuji, Toshiyuki Komaki & Keizo Kagawa

  2. Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan

    Naoto Iwai, Tomoya Ohara, Osamu Dohi, Hiroaki Yasuda, Hideyuki Konishi & Yoshito Itoh

Authors
  1. Hiroaki Sakai
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Naoto Iwai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Junichi Sakagami
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Takashi Okuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tomoya Ohara
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Chie Hattori
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Masashi Taniguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Kohei Oka
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Tasuku Hara
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Toshifumi Tsuji
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Toshiyuki Komaki
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Keizo Kagawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Osamu Dohi
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Hiroaki Yasuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Hideyuki Konishi
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Yoshito Itoh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Naoto Iwai.

Ethics declarations

Disclosures

Yoshito Itoh reports grants and personal fees from Takeda Pharmaceutical Company Limited., and ZERIA PHARMACEUTICAL CO., LTD., during the conduct of the study. Hiroaki Sakai, Naoto Iwai, Junichi Sakagami, Takashi Okuda, Tomoya Ohara, Chie Hattori, Masashi Taniguchi, Kohei Oka, Tasuku Hara, Toshifumi Tsuji, Toshiyuki Komaki, Keizo Kagawa, Osamu Dohi, Hiroaki Yasuda, and Hideyuki Konishi have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 25 kb)

Supplementary file2 (DOCX 20 kb)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sakai, H., Iwai, N., Sakagami, J. et al. Rectal administration of low-dose diclofenac does not reduce post-endoscopic retrograde cholangiopancreatography pancreatitis: a propensity score matching analysis. Surg Endosc 37, 2698–2705 (2023). https://doi.org/10.1007/s00464-022-09718-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-022-09718-5

Keywords

Search

Navigation