Post-ERCP Pancreatitis

  • Ernesto M. Llano
  • Christopher G. ChapmanEmail author


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.


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)


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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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