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Post-ERCP Pancreatitis

  • Ernesto M. Llano
  • Christopher G. ChapmanEmail author
Chapter
  • 156 Downloads

Abstract

Post-ERCP pancreatitis (PEP) is the most common complication of ERCP and can be associated with significant morbidity and mortality. In the post-procedure setting, new-onset epigastric abdominal pain, elevated serum amylase and/or lipase, and characteristic cross-sectional imaging findings are all used to make the diagnosis. PEP results from an inflammatory reaction to pancreatic duct injury thought to be due to increased intraductal pressure and outflow obstruction associated with ERCP. Risk of PEP varies significantly among patients and is defined by multiple patient-, procedural-, and operator-related factors. Once it occurs, PEP management is not different than that of other etiologies of acute pancreatitis. Therefore, prevention measures are critical in PEP and include rectal NSAID administration, guidewire cannulation, aggressive periprocedural IV hydration, and prophylactic pancreatic duct stent placement. Despite these preventive measures, PEP continues to be a significant cause of morbidity and occasionally mortality to patients with multiple risk factors.

Keywords

Pancreatitis Post-endoscopic retrograde cholangiopancreatography pancreatitis Rectal nonsteroidal anti-inflammatory drugs Lactated Ringer’s solution Prophylactic pancreatic duct stent placement 

Supplementary material

Video 14.1

Ampullectomy with PD stent placement. A 12 mm ampullary adenoma is seen at the major papilla. After achieving successful biliary cannulation and completion of biliary sphincterotomy, the 0.025 inch guidewire is passed into the ventral pancreatic duct. The pancreatic duct is deeply cannulated with the sphincterotome and contrast, and methylene blue is injected. Using a 15 mm snare, the major papilla is grasped and then resected using electrocautery. A small residual villous area is noted to be refluxing at the pancreatic duct orifice. After resection, a guidewire is again passed into the ventral pancreatic duct, and a 5Fr by 3 cm plastic pancreatic stent with a full external pigtail and a single internal flap is placed. Biopsies are then obtained of the residual villous area. A guidewire is passed into the bile duct, and a 7Fr by 7 cm plastic biliary stent with a single external flap and a single internal flap is placed with fluid flowing through both stents. Pathologic analysis confirms a diagnosis of ampullary adenoma but unfortunately with residual adenoma at the pancreatic duct orifice (MP4 455426 kb)

Video 14.2

Minor papilla sphincterotomy. Minor papillotomy is associated with an increased risk of PEP, and therefore prophylactic pancreatic duct stent placement is recommended (MP4 314308 kb)

Video 14.3

Precut sphincterotomy using a needle knife followed by extension sphincterotomy: In cases of difficult cannulation, early transition to precut sphincterotomy can prevent excessive manipulation of the ampulla and facilitate biliary cannulation. Precut sphincterotomy can be completed with or without a pancreatic duct stent in place. After biliary cannulation is achieved, extension sphincterotomy can be performed (MP4 312383 kb)

References

  1. 1.
    Cheng CL, Sherman S, Watkins JL, et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol. 2006;101:139–47.CrossRefGoogle Scholar
  2. 2.
    Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc. 2001;54:425–34.CrossRefGoogle Scholar
  3. 3.
    Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–18.CrossRefGoogle Scholar
  4. 4.
    Glomsaker T, Hoff G, Kvaloy JT, et al. Patterns and predictive factors of complications after endoscopic retrograde cholangiopancreatography. Br J Surg. 2013;100:373–80.CrossRefGoogle Scholar
  5. 5.
    Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc. 1998;48:1–10.CrossRefGoogle Scholar
  6. 6.
    Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol. 2001;96:417–23.CrossRefGoogle Scholar
  7. 7.
    Rabenstein T, Schneider HT, Bulling D, et al. Analysis of the risk factors associated with endoscopic sphincterotomy techniques: preliminary results of a prospective study, with emphasis on the reduced risk of acute pancreatitis with low-dose anticoagulation treatment. Endoscopy. 2000;32:10–9.CrossRefGoogle Scholar
  8. 8.
    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.CrossRefGoogle Scholar
  9. 9.
    Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy. 2007;39:793–801.CrossRefGoogle Scholar
  10. 10.
    Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102:1781–8.CrossRefGoogle Scholar
  11. 11.
    Kochar B, Akshintala VS, Afghani E, et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointest Endosc. 2015;81:143–9.. e9CrossRefGoogle Scholar
  12. 12.
    Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991;37:383–93.CrossRefGoogle Scholar
  13. 13.
    Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–11.CrossRefGoogle Scholar
  14. 14.
    Pezzilli R, Zerbi A, Di Carlo V, et al. Practical guidelines for acute pancreatitis. Pancreatology. 2010;10:523–35.CrossRefGoogle Scholar
  15. 15.
    Tenner S, Baillie J, DeWitt J, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108:1400–15, 1416CrossRefGoogle Scholar
  16. 16.
    Working Group IAPAPAAPG. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13:e1–15.CrossRefGoogle Scholar
  17. 17.
    Working Party of the British Society of Gastroenterology, Association of Surgeons of Great Britain and Ireland, et al. UK guidelines for the management of acute pancreatitis. Gut. 2005;54 Suppl 3:iii1–9.Google Scholar
  18. 18.
    Yokoe M, Takada T, Mayumi T, et al. Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015. J Hepatobiliary Pancreat Sci. 2015;22:405–32.CrossRefGoogle Scholar
  19. 19.
    Masci E, Mariani A, Curioni S, et al. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy. 2003;35:830–4.CrossRefGoogle Scholar
  20. 20.
    Sherman SLG, Earle D, et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Gastrointest Endosc. 1997;45:AB165.Google Scholar
  21. 21.
    Vandervoort J, Soetikno RM, Tham TC, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc. 2002;56:652–6.CrossRefGoogle Scholar
  22. 22.
    Mehta SN, Pavone E, Barkun JS, et al. Predictors of post-ERCP complications in patients with suspected choledocholithiasis. Endoscopy. 1998;30:457–63.CrossRefGoogle Scholar
  23. 23.
    Zhang H, Cho J, Buxbaum J. Update on the prevention of post-ERCP pancreatitis. Curr Treat Options Gastroenterol. 2018;16(4):428–40.CrossRefGoogle Scholar
  24. 24.
    Kawakubo K, Isayama H, Nakai Y, et al. Risk factors for pancreatitis following transpapillary self-expandable metal stent placement. Surg Endosc. 2012;26:771–6.CrossRefGoogle Scholar
  25. 25.
    Morales SJ, Sampath K, Gardner TB. A review of prevention of post-ERCP pancreatitis. Gastroenterol Hepatol (NY). 2018;14:286–92.Google Scholar
  26. 26.
    Cha SW, Leung WD, Lehman GA, 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.CrossRefGoogle Scholar
  27. 27.
    Testoni PA, Mariani A, Giussani A, et al. Risk factors for post-ERCP pancreatitis in high- and low-volume centers and among expert and non-expert operators: a prospective multicenter study. Am J Gastroenterol. 2010;105:1753–61.CrossRefGoogle Scholar
  28. 28.
    Schulman AR, Abougergi MS, Thompson CC. Assessment of the July effect in post-endoscopic retrograde cholangiopancreatography pancreatitis: Nationwide Inpatient Sample. World J Gastrointest Endosc. 2017;9:296–303.CrossRefGoogle Scholar
  29. 29.
    Artifon EL, Chu A, Freeman M, et al. A comparison of the consensus and clinical definitions of pancreatitis with a proposal to redefine post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas. 2010;39:530–5.CrossRefGoogle Scholar
  30. 30.
    Gottlieb K, Sherman S, Pezzi J, et al. Early recognition of post-ERCP pancreatitis by clinical assessment and serum pancreatic enzymes. Am J Gastroenterol. 1996;91:1553–7.PubMedGoogle Scholar
  31. 31.
    Dumonceau JM, Andriulli A, Elmunzer BJ, et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014. Endoscopy. 2014;46:799–815.CrossRefGoogle Scholar
  32. 32.
    Banks PA, Freeman ML, Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101:2379–400.CrossRefGoogle Scholar
  33. 33.
    Tarnasky PR. ERCP cannulation may come down to the wire. Am J Gastroenterol. 2007;102:2154–6.CrossRefGoogle Scholar
  34. 34.
    Nakai Y, Isayama H, Sasahira N, et al. Risk factors for post-ERCP pancreatitis in wire-guided cannulation for therapeutic biliary ERCP. Gastrointest Endosc. 2015;81:119–26.CrossRefGoogle Scholar
  35. 35.
    Ito K, Fujita N, Noda Y, et al. Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography. World J Gastroenterol. 2008;14:5595–600; discussion 5599CrossRefGoogle Scholar
  36. 36.
    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.CrossRefGoogle Scholar
  37. 37.
    ASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, et al. Adverse events associated with ERCP. Gastrointest Endosc. 2017;85:32–47.CrossRefGoogle Scholar
  38. 38.
    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.CrossRefGoogle Scholar
  39. 39.
    Chahal P, Tarnasky PR, Petersen BT, et al. Short 5Fr vs long 3Fr pancreatic stents in patients at risk for post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol. 2009;7:834–9.CrossRefGoogle Scholar
  40. 40.
    Freeman ML. Use of prophylactic pancreatic stents for the prevention of post-ERCP pancreatitis. Gastroenterol Hepatol (NY). 2015;11:420–2.Google Scholar
  41. 41.
    Kerdsirichairat T, Attam R, Arain M, et al. Urgent ERCP with pancreatic stent placement or replacement for salvage of post-ERCP pancreatitis. Endoscopy. 2014;46:1085–94.CrossRefGoogle Scholar
  42. 42.
    Elmunzer BJ, Waljee AK, Elta GH, et al. A meta-analysis of rectal NSAIDs in the prevention of post-ERCP pancreatitis. Gut. 2008;57:1262–7.CrossRefGoogle Scholar
  43. 43.
    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.CrossRefGoogle Scholar
  44. 44.
    Levenick JM, Gordon SR, Fadden LL, et al. Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients. Gastroenterology. 2016;150:911–7; quiz e19CrossRefGoogle Scholar
  45. 45.
    Elmunzer BJ, Foster LD, Durkalski V. Should we still administer prophylactic rectal NSAIDs to average-risk patients undergoing ERCP? Gastroenterology. 2016;151:566–7.CrossRefGoogle Scholar
  46. 46.
    Yu LM, Zhao KJ, Lu B. Use of NSAIDs via the rectal route for the prevention of pancreatitis after ERCP in all-risk patients: an updated meta-analysis. Gastroenterol Res Pract. 2018;2018:1027530.CrossRefGoogle Scholar
  47. 47.
    Katsinelos P, Fasoulas K, Paroutoglou G, et al. Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial. Endoscopy. 2012;44:53–9.CrossRefGoogle Scholar
  48. 48.
    Yu G, Li S, Wan R, et al. Nafamostat mesilate for prevention of post-ERCP pancreatitis: a meta-analysis of prospective, randomized, controlled trials. Pancreas. 2015;44:561–9.CrossRefGoogle Scholar
  49. 49.
    Park KT, Kang DH, Choi CW, et al. Is high-dose nafamostat mesilate effective for the prevention of post-ERCP pancreatitis, especially in high-risk patients? Pancreas. 2011;40:1215–9.CrossRefGoogle Scholar
  50. 50.
    Andriulli A, Leandro G, Federici T, et al. Prophylactic administration of somatostatin or gabexate does not prevent pancreatitis after ERCP: an updated meta-analysis. Gastrointest Endosc. 2007;65:624–32.CrossRefGoogle Scholar
  51. 51.
    Taenaka N, Shimada Y, Hirata T, et al. New approach to regional anticoagulation in hemodialysis using gabexate mesilate (FOY). Crit Care Med. 1982;10:773–5.CrossRefGoogle Scholar
  52. 52.
    Yoo JW, Ryu JK, Lee SH, et al. Preventive effects of ulinastatin on post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: a prospective, randomized, placebo-controlled trial. Pancreas. 2008;37:366–70.CrossRefGoogle Scholar
  53. 53.
    Wang G, Xiao G, Xu L, et al. Effect of somatostatin on prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis and hyperamylasemia: a systematic review and meta-analysis. Pancreatology. 2018;18:370–8.CrossRefGoogle Scholar
  54. 54.
    Kubiliun NM, Adams MA, Akshintala VS, et al. Evaluation of pharmacologic prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a systematic review. Clin Gastroenterol Hepatol. 2015;13:1231–9; quiz e70–1CrossRefGoogle Scholar
  55. 55.
    Shao LM, Chen QY, Chen MY, et al. Nitroglycerin in the prevention of post-ERCP pancreatitis: a meta-analysis. Dig Dis Sci. 2010;55:1–7.CrossRefGoogle Scholar
  56. 56.
    Hao JY, Wu DF, Wang YZ, et al. Prophylactic effect of glyceryl trinitrate on post-endoscopic retrograde cholangiopancreatography pancreatitis: a randomized placebo-controlled trial. World J Gastroenterol. 2009;15:366–8.CrossRefGoogle Scholar
  57. 57.
    Moreto M, Zaballa M. Prospective randomized double-blind placebo-controlled trial of glyceryl trinitrate in endoscopic retrograde cholangiopancreatography-induced pancreatitis. Br J Surg. 2002;89:628; author reply 629PubMedGoogle Scholar
  58. 58.
    Moreto M, Zaballa M, Casado I, et al. Transdermal glyceryl trinitrate for prevention of post-ERCP pancreatitis: a randomized double-blind trial. Gastrointest Endosc. 2003;57:1–7.CrossRefGoogle Scholar
  59. 59.
    Sotoudehmanesh R, Eloubeidi MA, Asgari AA, et al. A randomized trial of rectal indomethacin and sublingual nitrates to prevent post-ERCP pancreatitis. Am J Gastroenterol. 2014;109:903–9.CrossRefGoogle Scholar
  60. 60.
    Buxbaum J, Yan A, Yeh K, et al. Aggressive hydration with lactated Ringer's solution reduces pancreatitis after endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 2014;12:303–7.. e1CrossRefGoogle Scholar
  61. 61.
    Choi JH, Kim HJ, Lee BU, et al. Vigorous periprocedural hydration with lactated ringer's solution reduces the risk of pancreatitis after retrograde cholangiopancreatography in hospitalized patients. Clin Gastroenterol Hepatol. 2017;15:86–92.. e1CrossRefGoogle Scholar
  62. 62.
    Ding J, Jin X, Pan Y, et al. Glyceryl trinitrate for prevention of post-ERCP pancreatitis and improve the rate of cannulation: a meta-analysis of prospective, randomized, controlled trials. PLoS One. 2013;8:e75645.CrossRefGoogle Scholar
  63. 63.
    Akshintala VS, Hutfless SM, Colantuoni E, et al. Systematic review with network meta-analysis: pharmacological prophylaxis against post-ERCP pancreatitis. Aliment Pharmacol Ther. 2013;38:1325–37.CrossRefGoogle Scholar
  64. 64.
    Matsushita M, Takakuwa H, Shimeno N, et al. Epinephrine sprayed on the papilla for prevention of post-ERCP pancreatitis. J Gastroenterol. 2009;44:71–5.CrossRefGoogle Scholar
  65. 65.
    Xu LH, Qian JB, Gu LG, et al. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis by epinephrine sprayed on the papilla. J Gastroenterol Hepatol. 2011;26:1139–44.CrossRefGoogle Scholar
  66. 66.
    Omata F, Deshpande G, Tokuda Y, et al. Meta-analysis: somatostatin or its long-acting analogue, octreotide, for prophylaxis against post-ERCP pancreatitis. J Gastroenterol. 2010;45:885–95.CrossRefGoogle Scholar
  67. 67.
    Mok SRS, Ho HC, Shah P, et al. Lactated Ringer's solution in combination with rectal indomethacin for prevention of post-ERCP pancreatitis and readmission: a prospective randomized, double-blinded, placebo-controlled trial. Gastrointest Endosc. 2017;85:1005–13.CrossRefGoogle Scholar
  68. 68.
    Elmunzer BJ, Higgins PD, Saini SD, et al. Does rectal indomethacin eliminate the need for prophylactic pancreatic stent placement in patients undergoing high-risk ERCP? Post hoc efficacy and cost-benefit analyses using prospective clinical trial data. Am J Gastroenterol. 2013;108:410–5.CrossRefGoogle Scholar
  69. 69.
    Elmunzer BJ, Serrano J, Chak A, et al. Rectal indomethacin alone versus indomethacin and prophylactic pancreatic stent placement for preventing pancreatitis after ERCP: study protocol for a randomized controlled trial. Trials. 2016;17:120.CrossRefGoogle Scholar
  70. 70.
    Rashdan A, Fogel EL, McHenry L Jr, et al. Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clin Gastroenterol Hepatol. 2004;2:322–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.University of Chicago Medicine, Center for Endoscopic Research and Therapeutics (CERT)ChicagoUSA

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