ASGE Postgraduate Course at ACG: Innovative Practices for the Endoscopist of Today, Tomorrow and Beyond | October 2023-1

1_Elmunzer Post ERCP Pancreatitis

Pdf Summary

The prevention of post-ERCP pancreatitis (PEP) is highly critical due to its occasionally severe nature. Current strategies emphasize appropriate patient selection, risk stratification, efficient procedural techniques, prophylactic pancreatic stent placement, and pharmacoprevention.<br /><br />### Procedural Technique<br />Techniques such as guidewire-assisted cannulation have been found effective, with a meta-analysis showing a relative risk (RR) of 0.51 for PEP. Early use of alternative techniques offers similar benefits, emphasizing the need to avoid aggressive pancreatic duct contrast injection and balloon dilation of an intact biliary sphincter.<br /><br />### Prophylactic Pancreatic Stent Placement<br />Prophylactic pancreatic stents preserve pancreatic duct drainage and are beneficial, as demonstrated by multiple RCTs and non-randomized studies, showing a reduction in severe pancreatitis with an absolute risk reduction (ARR) of 10-15% and a need-to-treat (NNT) number of 8. Despite some complications (4-5%) and logistical challenges, it is recommended for high-risk patients.<br /><br />### Pharmacoprevention<br />The use of rectal NSAIDs like indomethacin has shown effectiveness, reducing the need for stent placement in high-risk cases. Studies suggest that indomethacin alone could potentially replace stent placement in some scenarios, and routine administration is recommended before or after ERCP.<br /><br />### Fluid Management<br />Aggressive use of lactated Ringer's (LR) solution during ERCP is recommended to reduce the incidence and severity of PEP. Studies have shown its effectiveness, especially when administered at specific rates and volumes.<br /><br />### Recommendations<br />1. **ERCP should be mainly therapeutic.**<br />2. **Ensure thorough risk stratification of patients.**<br />3. **Follow sound procedural techniques.**<br />4. **Use prophylactic stents and rectal indomethacin for high-risk patients.**<br />5. **Consider rectal NSAIDs even for average-risk patients, balancing cost considerations.**<br /><br />These strategies highlight the importance of a well-rounded approach combining patient selection, procedural care, and pharmacological intervention to prevent PEP effectively.

Keywords

post-ERCP pancreatitis

PEP prevention

patient selection

risk stratification

procedural techniques

prophylactic pancreatic stents

pharmacoprevention

rectal NSAIDs

lactated Ringer's solution

ERCP recommendations