Advanced Endoscopy Fellows Program | September 2024-ASGE ERCP PEP Prevention 2024

ASGE ERCP PEP Prevention 2024

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The American Society for Gastrointestinal Endoscopy (ASGE) has issued a guideline on preventing post-ERCP pancreatitis (PEP), highlighting evidence-based strategies to mitigate this common adverse event. The recommendations are based on comprehensive reviews using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, considering patient outcomes, cost-effectiveness, and feasibility.<br /><br />Key recommendations include:<br /><br />1. **Rectal NSAIDs**: Administer rectal nonsteroidal anti-inflammatory drugs, specifically indomethacin or diclofenac (100 mg), to all patients undergoing ERCP, including those at high risk. This approach has been shown to reduce the incidence of PEP by 50% with minimal adverse effects.<br /><br />2. **Wire-Guided Cannulation**: Use wire-guided cannulation over contrast-guided methods to minimize PEP risk. This is particularly important in reducing the likelihood of injuring the pancreatic duct (PD).<br /><br />3. **Prophylactic Pancreatic Stents**: Place pancreatic stents in high-risk patients, especially those with repeated or deep PD access during ERCP, to reduce both mild and severe PEP cases. Stents are highly effective, and their placement has a success rate of around 97%.<br /><br />4. **Aggressive Hydration**: Administer aggressive periprocedural and postprocedural intravenous hydration, particularly with lactated Ringer’s solution, to unselected patients. This reduces the incidence of PEP by nearly half, although it is more feasible in inpatient settings due to the required observation period.<br /><br />Despite these guidelines, real-world application varies due to factors such as the recent rise in the cost of rectal NSAIDs, technical challenges, and the need for clear clinical definitions of high-risk patients. The guidelines emphasize that clinical decisions should be tailored to individual patients' contexts and resources available.<br /><br />The guideline also calls for future research areas, including:<br />- The safety and efficacy of rectal NSAIDs in low-risk populations.<br />- Mechanisms of NSAID action in PEP prevention.<br />- Comparative effectiveness of different wire-assisted cannulation techniques.<br />- Validation of shorter hydration protocols.<br />- Developing standardized risk definitions for PEP to guide preventative measures better.<br /><br />These guidelines aim to improve patient outcomes by standardizing preventive strategies across different clinical settings and contexts.

Keywords

ASGE

post-ERCP pancreatitis

PEP prevention

rectal NSAIDs

wire-guided cannulation

pancreatic stents

aggressive hydration

GRADE framework

clinical guidelines

future research