Cannabis Use Disorder Is Associated With Increased Risk of Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis: Analysis of the U.S. Nationwide Inpatient Sample (NIS) Database, 2004-2014

Abstract

Introduction: Post-ERCP pancreatitis (PEP) is the most common complication following ERCP. Studies in mice with cerulein-induced pancreatitis have shown that administration of anandamide, a cannabinoid receptor agonist, to mice increases the severity of pancreatitis. We hypothesized that cannabis use is associated with increased incidence of PEP. The purpose of this study was to investigate the impact of cannabis use on PEP and hospital resources in patients after ERCP. Methods: The NIS database was queried to identify patients who had an ERCP with or without PEP from 2004 to 2014. We adopted the previously validated definition for PEP from the NIS database. The primary outcome was PEP and secondary outcomes were in-hospital death, length of stay and hospital costs. Cannabis use was identified on the basis of ICD-9 codes 304.3* and 305.2* in adults aged 18 years or more. We excluded cases coded “in remission”. Poisson regression models were used to derive adjusted incidence risk ratios (IRR) for outcomes in patients with Cannabis use compared to those without Cannabis use. Results: Of 381,288 discharges (60.8% females) for patients who underwent ERCP, we found a total of 37,712 discharges for PEP (9.9%). Among the included patients, 1,479 had a cannabis use disorder. The median age was 60 (IQR 46-75) years. From 2004 to 2014, the rate of PEP increased by 23.6 % (8.9% to 11.0%, p-trend <0.01, Fig 1). Cannabis use significantly increased over the study period (0.20 % to 0.70 %, P<0.01, Fig 2). Univariate Poisson regression analysis showed that cannabis use was associated with a 67% increased risk of PEP (IRR 1.67; 95% CI 1.47-1.90). In a multivariate Poisson analysis, adjusting for age, sex, race, Elixhauser Comorbidities, hospital teaching status, diagnostic vs therapeutic indication for ERCP, biliary vs pancreatic indications for ERCP and ERCP related interventions such as sphincterotomy and pancreatic stent placement, cannabis use remained an independent predictor of PEP (IRR, 1.39; 95% CI 1.21-1.59). Cannabis use was not associated with in-hospital death (IRR, 0.44; 95% CI 0.10-3.15), but was associated with a shorter length of stay (IRR, 0.80; 95% CI 0.76-0.84) and lower hospital costs (IRR, 0.761; 95% CI 0.760-0.762).Figure: Proportion of Discharges with Post-ERCP Pancreatitis from 2004 to 2014.Figure: Proportion of ERCP Discharges with Cannabis Use disorder from 2004 to 2014.Conclusion: Cannabis use is on the rise among patients undergoing ERCP. Cannabis use was associated with significant increase in post-ERCP pancreatitis without significant increase in mortality in “realworld” U.S. clinical practice.