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Pre-endoscopic retrograde cholangiopancreatography (ERCP) administration of rectal indomethacin in unselected patients to reduce post-ERCP pancreatitis: A systematic review and meta-analysis

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Abstract

Introduction

Previous studies have reported that peri-procedural administration of rectal indomethacin reduces the risk of pancreatitis in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Based on these studies, gastrointestinal (GI) societies recommend prophylactic rectal indomethacin for all patients undergoing ERCP. However, recent studies have reported contradictory results. The aim of this study was to perform a systematic review and meta-analysis to estimate the pooled relative risk (RR) of post-ERCP pancreatitis (PEP) in unselected patients who received rectal indomethacin before the ERCP (pre-ERCP) compared to patients who received pre-ERCP rectal placebo.

Methods

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through September 1, 2017) to identify randomized control trials (RCTs) investigating the role of pre-ERCP rectal indomethacin in reducing the risk of PEP in unselected patients undergoing ERCP. The databases included Ovid, Medline, In-Process, and Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We calculated a pooled estimate of the RR of PEP in patients who received pre-ERCP rectal indomethacin compared to patients who received pre-ERCP rectal placebo. The meta-analysis was performed using the random effects model.

Results

Six RCTs with a total of 2229 patients were included in the final meta-analysis. There were 1143 patients in the rectal indomethacin group and 1086 patients in the rectal placebo group. There were 71 events of PEP in the rectal indomethacin group and 114 events of PEP in the rectal placebo group. Pre-ERCP administration of rectal indomethacin significantly reduced the risk of PEP compared to pre-ERCP rectal placebo (RR 0.60, 95% CI, 0.45–0.80; p<0.0001). There was no heterogeneity between the studies (I2 = 0).

Conclusion

The results of this meta-analysis support the routine pre-ERCP administration of rectal indomethacin in unselected patients to prevent PEP.

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Authors and Affiliations

  1. Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, MI, USA

    Rajat Garg

  2. Department of Internal Medicine, University of Alabama, Tuscaloosa, AL, USA

    Babu P. Mohan

  3. Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, WA, USA

    Rajesh Krishnamoorthi

  4. Division of Gastroenterology and Hepatology, University of New Mexico, MSC10 5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA

    Tarun Rustagi

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  1. Rajat Garg
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  2. Babu P. Mohan
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  3. Rajesh Krishnamoorthi
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Contributions

Garg R acquisition of data, drafting the article, final approval; Mohan BP acquisition of data, analysis and interpretation of data, drafting the article, final approval; Krishnamoorthi R revising the article, final approval; Rustagi T conception and design of the study, drafting the article, critical revision, and final approval.

Corresponding author

Correspondence to Tarun Rustagi.

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Conflict of interest

RG, BPM, RK, and TR declare that they have no conflicts of interest.

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Garg, R., Mohan, B.P., Krishnamoorthi, R. et al. Pre-endoscopic retrograde cholangiopancreatography (ERCP) administration of rectal indomethacin in unselected patients to reduce post-ERCP pancreatitis: A systematic review and meta-analysis. Indian J Gastroenterol 37, 120–126 (2018). https://doi.org/10.1007/s12664-018-0841-1

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  • DOI: https://doi.org/10.1007/s12664-018-0841-1

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