ERCP Bootcamp: Cutting Edge Comprehensive Training for the Team

Widmer_ASGE ERCP Bootcamp PEP

Pdf Summary

This presentation reviews strategies to prevent post-ERCP pancreatitis (PEP), focusing on patient risk, procedural technique, and prophylactic therapies.

PEP risk is influenced by both patient factors and operator/procedural factors. The talk highlights how prevention evolved through key milestones and current guideline-based practice.

Two main prophylactic interventions are emphasized:

- <strong>Rectal NSAIDs</strong>: Indomethacin or diclofenac 100 mg rectally is recommended for most patients undergoing ERCP unless contraindicated. Large meta-analyses show about a 50% reduction in PEP risk, with no clear increase in bleeding or renal injury. NSAIDs should generally be given <strong>before</strong> the procedure when possible, since pre-procedural dosing appears more effective than post-procedural dosing. They should be avoided in patients with peptic ulcer disease, renal insufficiency, or NSAID allergy.

- <strong>Aggressive IV hydration with lactated Ringer’s</strong>: This may reduce PEP in some settings, especially in high-risk patients, but newer data suggest it does <strong>not</strong> add clear benefit when rectal NSAIDs are already used routinely. The FLUYT trial found no meaningful synergy between aggressive hydration and NSAIDs, though there may be a trend toward less severe disease.

Other key procedural prevention methods include:

- <strong>Wire-guided cannulation</strong> rather than contrast-guided cannulation, which lowers PEP risk in unselected patients.
- <strong>Prophylactic pancreatic duct (PD) stenting</strong> in high-risk situations such as repeated/deep PD access, difficult cannulation, or ampullectomy. PD stents can reduce overall PEP substantially, though questions remain about ideal patient selection and use in children.

Overall, the presentation supports a prevention approach centered on rectal NSAIDs, selective use of aggressive hydration, careful cannulation technique, and PD stenting in high-risk cases.

Keywords

post-ERCP pancreatitis

PEP prevention

rectal NSAIDs

indomethacin

diclofenac

aggressive IV hydration

lactated Ringer's

wire-guided cannulation

pancreatic duct stenting

ERCP guidelines