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Prevention of Post-ERCP Pancreatitis

Current Gastroenterology Reports volume 15, Article number: 352 (2013) Cite this article

Abstract

Pancreatitis is one of the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). A variety of patient-related and procedure-related factors have been identified to risk-stratify patients. Several measures can be undertaken in order to decrease the risk of post-ERCP pancreatitis in high-risk groups. These measures include pancreatic duct stenting and rectal indomethacin, amongst others.

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References

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  1. Cotton PB, Garrow DA, Gallagher J, et al. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc. 2009;70:80–8.

    PubMed  Article  Google Scholar 

  2. Cheng CL, Sherman S, Watkins JL, et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol. 2006;101:139–47.

    PubMed  Article  Google Scholar 

  3. Wang P, Li ZS, Liu F, et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol. 2009;104:31–40.

    PubMed  Article  Google Scholar 

  4. Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc. 1998;48:1–10.

    PubMed  Article  CAS  Google Scholar 

  5. Freeman ML. Complications of endoscopic retrograde cholangiopancreatography: avoidance and management. Gastrointest Endosc Clin N Am. 2012;22:567–86.

    PubMed  Article  Google Scholar 

  6. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991;37:383–93.

    PubMed  Article  CAS  Google Scholar 

  7. Lerch MM, Gorelick FS. Models of acute and chronic pancreatitis. Gastroenterology. 2013;144:1180–93.

    PubMed  Article  Google Scholar 

  8. Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc. 2001;54:425–34.

    PubMed  Article  CAS  Google Scholar 

  9. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–18.

    PubMed  Article  CAS  Google Scholar 

  10. Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol. 2001;96:417–23.

    PubMed  Article  CAS  Google Scholar 

  11. Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy. 2007;39:793–801.

    PubMed  Article  CAS  Google Scholar 

  12. Masci E, Mariani A, Curioni S, et al. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy. 2003;35:830–4.

    PubMed  Article  CAS  Google Scholar 

  13. Vandervoort J, Soetikno RM, Tham TC, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc. 2002;56:652–6.

    PubMed  Article  Google Scholar 

  14. Testoni PA, Mariani A, Giussani A, et al. Risk factors for post-ERCP pancreatitis in high- and low-volume centers and among expert and non-expert operators: a prospective multicenter study. Am J Gastroenterol. 2010;105:1753–61.

    PubMed  Article  Google Scholar 

  15. Balmadrid B, Kozarek R. Prevention and management of adverse events of endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am. 2013;23:385–403.

    PubMed  Article  Google Scholar 

  16. Banerjee N, Hilden K, Baron TH, et al. Endoscopic biliary sphincterotomy is not required for transpapillary SEMS placement for biliary obstruction. Dig Dis Sci. 2011;56:591–5.

    PubMed  Article  Google Scholar 

  17. Cennamo V, Fuccio L, Zagari RM, et al. Can early precut implementation reduce endoscopic retrograde cholangiopancreatography-related complication risk? Meta-analysis of randomized controlled trials. Endoscopy. 2010;42:381–8.

    PubMed  Article  CAS  Google Scholar 

  18. Gong B, Hao L, Bie L, et al. Does precut technique improve selective bile duct cannulation or increase post-ERCP pancreatitis rate? A meta-analysis of randomized controlled trials. Surg Endosc. 2010;24:2670–80.

    PubMed  Article  Google Scholar 

  19. Testoni PA, Giussani A, Vailati C, et al. Precut sphincterotomy, repeated cannulation and post-ERCP pancreatitis in patients with bile duct stone disease. Dig Liver Dis. 2011;43:792–6.

    PubMed  Article  Google Scholar 

  20. Disario JA, Freeman ML, Bjorkman DJ, et al. Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones. Gastroenterology. 2004;127:1291–9.

    PubMed  Article  Google Scholar 

  21. Watanabe H, Yoneda M, Tominaga K, et al. Comparison between endoscopic papillary balloon dilatation and endoscopic sphincterotomy for the treatment of common bile duct stones. J Gastroenterol. 2007;42:56–62.

    PubMed  Article  Google Scholar 

  22. Park SJ, Kim JH, Hwang JC, et al. Factors predictive of adverse events following endoscopic papillary large balloon dilation: results from a multicenter series. Dig Dis Sci. 2013;58:1100–9.

    PubMed  Article  Google Scholar 

  23. Paspatis GA, Konstantinidis K, Tribonias G, et al. Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: a randomized controlled trial. Dig Liver Dis. 2013;45:301–4.

    PubMed  Article  Google Scholar 

  24. Cheung J, Tsoi KK, Quan WL, et al. Guidewire versus conventional contrast cannulation of the common bile duct for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc. 2009;70:1211–9.

    PubMed  Article  Google Scholar 

  25. Matsubayashi H, Fukutomi A, Kanemoto H, et al. Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage. HPB (Oxford). 2009;11:222–8.

    Article  Google Scholar 

  26. Meister T, Heinzow H, Heinecke A, et al. Post-ERCP pancreatitis in 2364 ERCP procedures: is intraductal ultrasonography another risk factor? Endoscopy. 2011;43:331–6.

    PubMed  Article  CAS  Google Scholar 

  27. Cote GA, Kumar N, Ansstas M, et al. Risk of post-ERCP pancreatitis with placement of self-expandable metallic stents. Gastrointest Endosc. 2010;72:748–54.

    PubMed  Article  Google Scholar 

  28. Soderlund C, Linder S. Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc. 2006;63:986–95.

    PubMed  Article  Google Scholar 

  29. Kahaleh M, Behm B, Clarke BW, et al. Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video). Gastrointest Endosc. 2008;67:446–54.

    PubMed  Article  Google Scholar 

  30. Isayama H, Komatsu Y, Tsujino T, et al. A prospective randomised study of “covered” versus “uncovered” diamond stents for the management of distal malignant biliary obstruction. Gut. 2004;53:729–34.

    PubMed  Article  CAS  Google Scholar 

  31. Moss AC, Morris E, Leyden J, et al. Malignant distal biliary obstruction: a systematic review and meta-analysis of endoscopic and surgical bypass results. Cancer Treat Rev. 2007;33:213–21.

    PubMed  Article  Google Scholar 

  32. Schmassmann A, von Gunten E, Knuchel J, et al. Wallstents versus plastic stents in malignant biliary obstruction: effects of stent patency of the first and second stent on patient compliance and survival. Am J Gastroenterol. 1996;91:654–9.

    PubMed  CAS  Google Scholar 

  33. Yoon WJ, Lee JK, Lee KH, et al. A comparison of covered and uncovered Wallstents for the management of distal malignant biliary obstruction. Gastrointest Endosc. 2006;63:996–1000.

    PubMed  Article  Google Scholar 

  34. Siddiqui AA, Mehendiratta V, Loren D, et al. Self-Expanding Metal Stents (SEMS) for Preoperative Biliary Decompression in Patients with Resectable and Borderline-Resectable Pancreatic Cancer: Outcomes in 241 Patients. Dig Dis Sci. 2013;58:1744–50.

    PubMed  Article  CAS  Google Scholar 

  35. Lella F, Bagnolo F, Colombo E, et al. A simple way of avoiding post-ERCP pancreatitis. Gastrointest Endosc. 2004;59:830–4.

    PubMed  Article  Google Scholar 

  36. Shao LM, Chen QY, Chen MY, et al. Can wire-guided cannulation reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis? A meta-analysis of randomized controlled trials. J Gastroenterol Hepatol. 2009;24:1710–5.

    PubMed  Article  Google Scholar 

  37. Adler DG, Verma D, Hilden K, et al. Dye-free wire-guided cannulation of the biliary tree during ERCP is associated with high success and low complication rates: outcomes in a single operator experience of 822 cases. J Clin Gastroenterol. 2010;44:e57–62.

    PubMed  Article  Google Scholar 

  38. Trifan A, Sfarti C, Cretu M, et al. Guide-wire versus conventional contrast cannulation of the common bile duct for the prevention of post-ERCP pancreatitis in patients with choledocholithiasis. J Gastrointest Liver Dis. 2011;20:149–52.

    Google Scholar 

  39. Nakai Y, Isayama H, Tsujino T, et al. Impact of introduction of wire-guided cannulation in therapeutic biliary endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol. 2011;26:1552–8.

    PubMed  Article  Google Scholar 

  40. • Tse F, Yuan Y, Moayyedi P, et al. Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev. 2012;12, CD009662. This meta-analysisdemonstrated that guidewire-assisted cannulation was associated with a significantly decreasedrisk of PEP when compared to contrast-assisted cannulation.

  41. Choudhary A, Bechtold ML, Arif M, et al. Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc. 2011;73:275–82.

    PubMed  Article  Google Scholar 

  42. Mazaki T, Masuda H, Takayama T. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: a systematic review and meta-analysis. Endoscopy. 2010;42:842–53.

    PubMed  Article  CAS  Google Scholar 

  43. Mazaki T, Mado K, Masuda H, et al. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol 2013. doi:10.1007/s00535-013-0806-1.

  44. 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.

    PubMed  Article  Google Scholar 

  45. Sofuni A, Maguchi H, Mukai T, et al. Endoscopic pancreatic duct stents reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients. Clin Gastroenterol Hepatol. 2011;9:851–8. quiz e110.

    PubMed  Article  Google Scholar 

  46. Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc. 1990;36:93–5.

    PubMed  Article  CAS  Google Scholar 

  47. Bakman YG, Safdar K, Freeman ML. Significant clinical implications of prophylactic pancreatic stent placement in previously normal pancreatic ducts. Endoscopy. 2009;41:1095–8.

    PubMed  Article  CAS  Google Scholar 

  48. Pahk A, Rigaux J, Poreddy V, et al. Prophylactic pancreatic stents: does size matter? A comparison of 4-Fr and 5-Fr stents in reference to post-ERCP pancreatitis and migration rate. Dig Dis Sci. 2011;56:3058–64.

    PubMed  Article  Google Scholar 

  49. Lee TH, Moon JH, Choi HJ, et al. Prophylactic temporary 3F pancreatic duct stent to prevent post-ERCP pancreatitis in patients with a difficult biliary cannulation: a multicenter, prospective, randomized study. Gastrointest Endosc. 2012;76:578–85.

    PubMed  Article  Google Scholar 

  50. Zolotarevsky E, Fehmi SM, Anderson MA, et al. Prophylactic 5-Fr pancreatic duct stents are superior to 3-Fr stents: a randomized controlled trial. Endoscopy. 2011;43:325–30.

    PubMed  Article  CAS  Google Scholar 

  51. Sotoudehmanesh R, Khatibian M, Kolahdoozan S, et al. Indomethacin may reduce the incidence and severity of acute pancreatitis after ERCP. Am J Gastroenterol. 2007;102:978–83.

    PubMed  Article  CAS  Google Scholar 

  52. Khoshbaten M, Khorram H, Madad L, et al. Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis. J Gastroenterol Hepatol. 2008;23:e11–6.

    PubMed  Article  CAS  Google Scholar 

  53. Murray B, Carter R, Imrie C, et al. Diclofenac reduces the incidence of acute pancreatitis after endoscopic retrograde cholangiopancreatography. Gastroenterology. 2003;124:1786–91.

    PubMed  Article  CAS  Google Scholar 

  54. Elmunzer BJ, Waljee AK, Elta GH, et al. A meta-analysis of rectal NSAIDs in the prevention of post-ERCP pancreatitis. Gut. 2008;57:1262–7.

    PubMed  Article  CAS  Google Scholar 

  55. Ding X, Chen M, Huang S, et al. Nonsteroidal anti-inflammatory drugs for prevention of post-ERCP pancreatitis: a meta-analysis. Gastrointest Endosc. 2012;76:1152–9.

    PubMed  Article  Google Scholar 

  56. 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;47:912–7.

    PubMed  Article  CAS  Google Scholar 

  57. •• Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med. 2012;366:1414–22. This study showed that the use of rectal in domethacin significantly reduced the risk of post-ERCP pancreatitis in high-risk patients.

  58. Elmunzer BJ, Higgins PD, Saini SD, et al. Does rectal indomethacin eliminate the need for prophylactic pancreatic stent placement in patients undergoing high-risk ERCP? Post hoc efficacy and cost-benefit analyses using prospective clinical trial data. Am J Gastroenterol. 2013;108:410–5.

    PubMed  Article  CAS  Google Scholar 

  59. Prat F, Amaris J, Ducot B, et al. Nifedipine for prevention of post-ERCP pancreatitis: a prospective, double-blind randomized study. Gastrointest Endosc. 2002;56:202–8.

    PubMed  Article  Google Scholar 

  60. Schwartz JJ, Lew RJ, Ahmad NA, et al. The effect of lidocaine sprayed on the major duodenal papilla on the frequency of post-ERCP pancreatitis. Gastrointest Endosc. 2004;59:179–84.

    PubMed  Article  Google Scholar 

  61. Xu LH, Qian JB, Gu LG, et al. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis by epinephrine sprayed on the papilla. J Gastroenterol Hepatol. 2011;26:1139–44.

    PubMed  Article  Google Scholar 

  62. Matsushita M, Takakuwa H, Shimeno N, et al. Epinephrine sprayed on the papilla for prevention of post-ERCP pancreatitis. J Gastroenterol. 2009;44:71–5.

    PubMed  Article  Google Scholar 

  63. Bai Y, Xu C, Yang X, et al. Glyceryl trinitrate for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a meta-analysis of randomized, double-blind, placebo-controlled trials. Endoscopy. 2009;41:690–5.

    PubMed  Article  CAS  Google Scholar 

  64. Chen B, Fan T, Wang CH. A meta-analysis for the effect of prophylactic GTN on the incidence of post-ERCP pancreatitis and on the successful rate of cannulation of bile ducts. BMC Gastroenterol. 2010;10:85.

    PubMed  Article  Google Scholar 

  65. Shao LM, Chen QY, Chen MY, et al. Nitroglycerin in the prevention of post-ERCP pancreatitis: a meta-analysis. Dig Dis Sci. 2010;55:1–7.

    PubMed  Article  CAS  Google Scholar 

  66. Yoo KS, Huh KR, Kim YJ, et al. Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective, randomized, double-blind, controlled trial. Pancreas. 2011;40:181–6.

    PubMed  Article  CAS  Google Scholar 

  67. Manes G, Ardizzone S, Lombardi G, et al. Efficacy of postprocedure administration of gabexate mesylate in the prevention of post-ERCP pancreatitis: a randomized, controlled, multicenter study. Gastrointest Endosc. 2007;65:982–7.

    PubMed  Article  Google Scholar 

  68. Park KT, Kang DH, Choi CW, et al. Is high-dose nafamostat mesilate effective for the prevention of post-ERCP pancreatitis, especially in high-risk patients? Pancreas. 2011;40:1215–9.

    PubMed  Article  CAS  Google Scholar 

  69. Seta T, Noguchi Y. Protease inhibitors for preventing complications associated with ERCP: an updated meta-analysis. Gastrointest Endosc. 2011;73:700–6. e1-2.

    PubMed  Article  Google Scholar 

  70. Yoo YW, Cha SW, Kim A, et al. The use of gabexate mesylate and ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Gut Liver. 2012;6:256–61.

    PubMed  Article  CAS  Google Scholar 

  71. Jowell PS, Branch MS, Fein SH, et al. Intravenous synthetic secretin reduces the incidence of pancreatitis induced by endoscopic retrograde cholangiopancreatography. Pancreas. 2011;40:533–9.

    PubMed  Article  Google Scholar 

  72. Bai Y, Gao J, Zou DW, et al. Prophylactic octreotide administration does not prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of randomized controlled trials. Pancreas. 2008;37:241–6.

    PubMed  Article  CAS  Google Scholar 

  73. Andriulli A, Leandro G, Federici T, et al. Prophylactic administration of somatostatin or gabexate does not prevent pancreatitis after ERCP: an updated meta-analysis. Gastrointest Endosc. 2007;65:624–32.

    PubMed  Article  Google Scholar 

  74. Katsinelos P, Fasoulas K, Paroutoglou G, et al. Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial. Endoscopy. 2012;44:53–9.

    PubMed  Article  CAS  Google Scholar 

  75. Li S, Cao G, Chen X, et al. Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2012;24:477–81.

    PubMed  Article  CAS  Google Scholar 

  76. Oh HC, Cheon YK, Cho YD, et al. Use of udenafil is not associated with a reduction in post-ERCP pancreatitis: results of a randomized, placebo-controlled, multicenter trial. Gastrointest Endosc. 2011;74:556–62.

    PubMed  Article  Google Scholar 

  77. Gu WJ, Wei CY, Yin RX. Antioxidant supplementation for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of randomized controlled trials. Nutr J. 2013;12:23.

    PubMed  Article  Google Scholar 

  78. Tsujino T, Isayama H, Nakai Y, et al. The results of the Tokyo Trial of Prevention of Post-ERCP Pancreatitis with Risperidone (Tokyo P3R): a multicenter, randomized, phase II, non-placebo-controlled trial. J Gastroenterol. 2013;48(8):982–8.

    Google Scholar 

  79. Bai Y, Gao J, Shi X, et al. Prophylactic corticosteroids do not prevent post-ERCP pancreatitis: a meta-analysis of randomized controlled trials. Pancreatology. 2008;8:504–9.

    PubMed  Article  CAS  Google Scholar 

  80. Sherman S, Cheng CL, Costamagna G, et al. Efficacy of recombinant human interleukin-10 in prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in subjects with increased risk. Pancreas. 2009;38:267–74.

    PubMed  Article  CAS  Google Scholar 

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Jennifer Maranki and Paul Yeaton declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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  1. Temple University School of Medicine, 3401 N. Broad St., Suite 830 Parkinson Pavilion, Philadelphia, PA, 19140, USA

    Jennifer Maranki

  2. Carilion Virginia Tech School of Medicine, Roanoke, VA, USA

    Paul Yeaton

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  1. Jennifer Maranki
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  2. Paul Yeaton
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Correspondence to Jennifer Maranki.

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This article is part of the Topical Collection on Pancreas / Biliary Tract

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Maranki, J., Yeaton, P. Prevention of Post-ERCP Pancreatitis. Curr Gastroenterol Rep 15, 352 (2013). https://doi.org/10.1007/s11894-013-0352-2

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Keywords

  • Post-ERCP pancreatitis
  • ERCP
  • Pancreatitis
  • Complications
  • Prevention
  • Endoscopic retrograde cholangiopancreatography
  • Management
  • Stents
  • Indomethacin