Pharmacological Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Where Do We Stand Now?

Wiqas Ahmad,Chenet Torrilus,Mst Khaleda Khatun,Nkechi A Okam,Dibyata Rana,Nusrat Jahan

doi:10.7759/cureus.10115

Abstract

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most frequently occurring complication of endoscopic retrograde cholangiopancreatography (ERCP). PEP is associated with significant morbidity and mortality; that is why the prevention of PEP is essential. Pharmacoprevention holds a central position in PEP prophylaxis. The current literature explores the efficacy of various pharmacological agents in preventing PEP, their routes of administration, and the correct administration timing. Data was collected on PubMed using regular keywords, the latter yielded 2077 papers. After applying inclusion and exclusion criteria, 218 papers were selected and screened and 28 studies were finally chosen after the removal of duplicate and irrelevant studies. The selected 28 articles comprised 25 randomized clinical trials and three systematic reviews.The study concludes that rectal non-steroidal anti-inflammatory drugs (NSAIDs) administered before ERCP are effective in preventing PEP in high-risk patients. The efficacy of rectal NSAIDs in low to medium risk group is not well established. A combination of rectal NSAIDs and intravenous hydration provides improved prophylaxis against PEP in high-risk patients than NSAIDs alone. Nafamostat, sublingual nitrates, and intravenous hydration are potential alternatives in patients with contraindications to NSAIDs.

Highlights

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is a procedure that is used in the diagnosis and management of hepatobiliary and pancreatic disorders [1]
Pharmacological prophylaxis is a crucial component of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prevention, and a significant number of pharmacological agents have been investigated in post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) prophylaxis
This study showed that diclofenac and indomethacin are more effective in reducing PEP

Summary

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that is used in the diagnosis and management of hepatobiliary and pancreatic disorders [1]. Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is severe in 0.1 to 0.5% cases only [3]. PEP has been described as the development of new pancreatic-type epigastric pain associated with at least three times rise in serum amylase/lipase levels occurring 24 hours post ERCP, with pain sufficiently severe to require hospital admission or prolong the stay of an admitted patient [4]. According to the European Society of Gastrointestinal Endoscopy (ESGE), risk factors associated with increased risk of PEP are female gender, suspected sphincter of Oddi dysfunction, prior episode of pancreatitis, prolonged cannulation time, passing guide wire into pancreatic duct more than once and injection of contrast into the pancreatic duct [5]

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