Opinion statement
Post-ERCP remains a major challenge, although significant progress has been made in predicting risk and methods of prevention. Facets of post-ERCP pancreatitis can be divided into the four “P’s”: they are patient-related factors, procedure-related factors, pancreatic stents, and pharmacoprophylaxis. New information about risk factors includes a description of IPMN as a patient-related risk, with smoking and chronic liver disease as protective factors. Procedure-related factors include one or more deep passages of a guidewire into the pancreatic duct as a salient risk, perhaps outweighing difficult cannulation or contrast injection, but one that can be mitigated by placement of a pancreatic stent. In addition, placement of transpapillary metallic stents has emerged as an independent risk for post-ERCP pancreatitis (PEP). Although there has been a rising wave of enthusiasm for rectal NSAIDs as a kind of panacea for prevention of post-ERCP pancreatitis, the newest data question their efficacy in unselected cohorts. Pancreatic stent placement remains the most proven and reliable method of preventing post-ERCP pancreatitis in both mixed- and high-risk ERCP. Success at placement of protective pancreatic stents is a paramount for safety and efficacy, and technical expertise at placing pancreatic stents widely among centers. The use of specialized techniques including very small caliber guidewires and stents is necessary to approach 100 % success.
Similar content being viewed by others
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc. 2001;54:425–34.
Dumonceau JM, Andriulli A, Deviere J, et al. European Society of Gastrointestinal Endoscopy (ESGE) guideline: prophylaxis of post-ERCP pancreatitis. Endoscopy. 2010;42:503–15.
DiMagno MJ, Spaete JP, Ballard DD, Wamsteker EJ, Saini SD. Risk models for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP): smoking and chronic liver disease are predictors of protection against PEP. Pancreas. 2013;42:996–1003.
Freeman ML. Complications of endoscopic retrograde cholangiopancreatography: avoidance and management. Gastrointest Endosc Clin N Am. 2012;22:567–86.
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. This was the first large prospective multicenter study of risk factors to assess pancreatic guidewire passage, and found it to be a powerful independent predictor of post-ERCP pancreatitis.
Ito K, Fujita N, Noda Y, et al. Can pancreatic duct stenting prevent post-ERCP pancreatitis in patients who undergo pancreatic duct guidewire placement for achieving selective biliary cannulation? A prospective trial. J Gastroenterol. 2010;45:1183–91.
Ito K, Fujita N, Kanno A, Matsubayashi H, Okaniwa S, Nakahara K, et al. Risk factors for post-ERCP pancreatitis in high risk patients who have undergone prophylactic pancreatic duct stenting: a multicenter retrospective study. Japan Intern Med. 2011;50(24):2927–32.
Coté 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.
Tse F, Yuan Y, Moayyedi P, et al. Guide wire-assisted cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis. Endoscopy. 2013;45:605–18.
Lee TH, Park DH, Park JY, et al. Can wire-guided cannulation prevent post-ERCP pancreatitis? A prospective randomized trial. Gastrointest Endosc. 2009;69:444–9.
Kobayashi G, Fujita N, Imaizumi K, Irisawa A, Suzuki M, Murakami A, et al. Wire-guided biliary cannulation technique does not reduce the risk of post-ERCP pancreatitis: multicenter randomized controlled trial. Dig Endosc. 2013;25(3):295–302.
Halttunen J, Meisner S, Aabakken L, Arnelo U, Grönroos J, Hauge T, et al. Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs. Scand J Gastroenterol. 2014;49(6):752–8.
Kogure H, Sasaki T, et al. Risk factors for post-ERCP pancreatitis in wire-guided cannulation for therapeutic biliary ERCP. Gastrointest Endosc. 2015;81(1):119–26.
Sasahira N, Kawakami H, Isayama H, Uchino R, Nakai Y, et al. Early use of double-guidewire technique to facilitate selective bile duct cannulation: the multicenter randomized controlled EDUCATION trial. Endoscopy. 2015;47:421–9.
Sundaralingam P, Masson P, Bourke MJ. Early precut sphincterotomy does not increase risk during endoscopic retrograde cholangiopancreatography in patients with difficult biliary access: a meta-analysis of randomized controlled trials. Clin Gastroenterol Hepatol. 2015;13:1722–9.
Mariani A, Di Leo M, Giardullo N, Giussani A, Marini M. A randomized trial. Endoscopy. 2016 Mar 18. [Epub ahead of print].
Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–18.
Cha SW, Leung WD, Lehman GA, Watkins JL, McHenry L, et al. Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy-associated pancreatitis? A randomized, prospective study. Gastrointest Endosc. 2013;77:209–16.
Arain MA, Freeman ML. Pharmacologic prophylaxis alone is not adequate to prevent post-ERCP pancreatitis. Am J Gastroenterol. 2014;109:910–12.
Mazaki T, Mado K, Masuda H, et al. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol. 2014;49:343–55. The most up-to-date meta-analysis of pancreatic stent placement for prevention of post-ERCP pancreatitis, demonstrating that stent placement reduces risk of mild, moderate, and severe PEP and in mixed-risk as well as high-risk cases.
Das A, Singh P, Sivak Jr MV, et al. Pancreatic-stent placement for prevention of post-ERCP pancreatitis: a cost-effectiveness analysis. Gastrointest Endosc. 2007;65:960–8.
Freeman ML, Overby CS, Qi DF. Pancreatic stent insertion: consequences of failure, and results of a modified technique to maximize success. Gastrointest Endosc. 2004;59:8–14.
Choksi NS, Fogel EL, Cote GA, et al. The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement. Gastrointest Endosc. 2015;81:150–5.
Arain MA, Freeman ML. Pancreatic stent placement remains a cornerstone for prevention of post ERCP pancreatitis, but requires specialized techniques. Gastrointest Endosc. 2015;81:156–8. This editorial summarizes the literature on various approaches to prevention of post-ERCP pancreatitis, and the importance of technical success in effectiveness of pancreatic stenting.
Kubiliun NM, Adams MA, Akshintala VS, Conte ML, Cote GA, Cotton PB, et al. Evaluation of pharmacologic prevention of pancreatitis following endoscopic retrograde cholangiopancreatography: a systematic review. Clin Gastroenterol Hepatol. 2015;S1542–3565(15):00008–7.
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.
Montano Loza A, Rodriguez Lomeli X, Garcia Correa JE, et al. Effect of the rectal administration of indomethacin on amylase serum levels after endoscopic retrograde cholangiopancreatography, and its impact on the development of secondary pancreatitis episodes. Revista Espanola de Enfermedades Digestivas. 2007;99:330–6.
Murray B, Carter R, Imrie C, et al. Diclofenac reduces the incidence of acute pancreatitis after endoscopic retrograde cholangiopancreatography. Gastroenterology. 2003;124:1786–91.
Khoshbaten M, Khorram H, Madad L, Ehsani Ardakani MJ, Farzin H, Zali MR. Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis. J Gastroenterol Hepatol. 2008;23:e11–6.
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.
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.
Ding X, Chen M, Huang S, et al. Nonsteroidal anti-inflammatory drugs for prevention of post-ERCP pancreatitis: a meta-analysis. Gastrointest Endosc. 2012;76:1152–59.
Yaghoobi M, Rolland S, Waschke KA, et al. Meta-analysis: rectal indomethacin for the prevention of post-ERCP pancreatitis. Aliment Pharmacol Ther. 2013;38:995–1001.
Sun HL, Han B, Zhai HP, et al. Rectal NSAIDs for the prevention of post-ERCP pancreatitis: a meta-analysis of randomized controlled trials. Surgeon. 2014;12:141–7.
Yuhara H, Ogawa M, Kawaguchi Y, et al. Pharmacologic prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: protease inhibitors and NSAIDs in a meta-analysis. J Gastroenterol. 2014;49:388–99.
Sethi S, Sethi N, Wadhwa V, et al. A meta-analysis on the role of rectal diclofenac and indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas. 2014;43:190–7.
Levenick JM, Gordon SR, Fadden LL, et al. Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients, a randomized trial. Gastroenterology. 2016;150:911–7. A recently published study demonstrating that rectal indomethacin had not even a trend towards efficacy in preventing post-ERCP pancreatitis in consecutive unselected ERCP, 30 % of whom were considered at high risk.
Cotton PB, Durkalski V, Romagnuolo J, Pauls Q, Fogel E, Tarnasky P, et al. Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial. JAMA. 2014;311:2101–9.
Akbar A, Abu Dayyeh BK, Baron TH, Wang Z, Altayar O, Murad MH. Rectal nonsteroidal anti-inflammatory drugs are superior to pancreatic duct stents in preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a network meta-analysis. Clin Gastroenterol Hepatol. 2013;11:778–83.
Li GD, Jia XY, Dong HY, Pang QP, Zhai HL, et al. Pancreatic stent or rectal indomethacin-which better prevents post-ERCP pancreatitis?: a propensity score matching analysis. Medicine (Baltimore). 2016;95:e2994.
Elmunzer BJ, Serrano J, Chak A, Edmundowicz SA, Papachristou GI. Rectal indomethacin alone versus indomethacin and prophylactic pancreatic stent placement for preventing pancreatitis after ERCP: study protocol for a randomized controlled trial. Trials. 2016;17:1251–2.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Martin L. Freeman has received personal fees from Boston Scientific Corporation and XLumena Corporation.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Pancreas
Rights and permissions
About this article
Cite this article
Freeman, M.L. Preventing Post-ERCP Pancreatitis: Update 2016. Curr Treat Options Gastro 14, 340–347 (2016). https://doi.org/10.1007/s11938-016-0097-8
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11938-016-0097-8