Risk Factors For post-ERCP Pancreatitis Research Articles

Risk Factors for Post Endoscopic Retrograde Cholangio Pancreatography(ERCP) Pancreatitis (PEP) and Efficacy of Octreotide in its Prevention

Background: Pancreatitis is a potentially fatal complication of ERCP, seen in 5-15% procedures. Factors precipitating its risk and effective pharmacological intervention for its prevention need exploration to improve patient safety. Objective: To identify risk factors for post-ERCP pancreatitis (PEP) and to determine efficacy of intravenous octreotide in preventing PEP. Methodology: A quasi-experimental triple blind placebo-based study included patients undergoing ERCP and randomize them in two groups through simple random sampling. Group A to receive intravenous Octreotide 4μg/kg before attempting cannulation during ERCP and 1cc N/S as placebo for group B. Patients were followed for PEP and data were analyzed using chi square (x2) and logistic regression analysis. Results: Of 203 included patients, 101 (49.3%) received octreotide while 102 (50.7%) were in control group. Post ERCP pancreatitis developed in 32 (15.8%) patients, in 8 (7.9%) patients of octreotide group while in 24 (23.8%) patients of control group (p value 0.002 with odds ratio (OR) for octreotide of 0.33 (95% CI 0.15- 0.71). We identified biliary surgery (p value 0.005), serum bilirubin ≥ 3 mg/dl (p value 0.03), cannulation
 time > 5 minutes (p value 5 minutes, use of needle knife, PD cannulation and procedure time > 30 minutes are associated with increased risk of PEP. Intravenous octreotide before cannulation reduces risk of post ERCP pancreatitis.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in children

Objective: To investigate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of biliary and pancreatic diseases in children. Methods: The clinical data of 127 children who were treated with ERCP in the First Affiliated Hospital of Nanchang University from January 2007 to July 2021 were analyzed. According to the diseases they suffered from, the children were divided into biliary group and pancreatic group. The operation times, technical success rate, diagnosis, interventions and post-ERCP complications between the groups were compared by t-test or χ2 test. The risk factors of post-ERCP pancreatitis (PEP) were analyzed by multivariate Logistic regression. Results: A total of 127 children, including 54 males and 73 females, with a median age of 14 years at first ERCP, were included in this study. ERCP was performed in 181 cases, with a success rate of 98.3% (178/181). In pre-ERCP imaging examination, the positive diagnostic rates of ultrasound, CT and magnetic resonance cholangiopancreatography (MRCP) for biliary and pancreatic diseases were 54.1% (53/98), 56.1% (37/66) and 79.3% (88/111), respectively. MRCP had the highest positive diagnostic rate, and the difference among the three measures was statistically significant (χ2=17.33, P<0.001). The most common indications for ERCP in biliary and pancreatic diseases were choledocholithiasis (77.0%, 107/139) and congenital structural abnormalities of the pancreas (31.0%, 13/42), respectively. After ERCP, the abdominal pain was dramatically relieved and the liver function was significantly improved (all P<0.001). The blood amylase level of the children with pancreatic diseases was significantly lower than that before ERCP (t=7.73, P<0.001). The overall incidence of post-ERCP complications was 12.2% (22/181), of which post-ERCP pancreatitis (PEP) was the most common (7.2%, 13/181). The incidence of PEP was significantly higher in the pancreatic group than in the biliary group (16.7% (7/42) vs. 4.3% (6/139),χ2=7.38, P=0.007). Multivariate Logistic regression analysis showed that young age was the independent risk factor of PEP (OR=0.80, 95%CI 0.67-0.96). Conclusions: MRCP is the first choice for pre-ERCP imaging examination of biliary and pancreatic diseases in children. ERCP can be safely and effectively used in the diagnosis and treatment of biliary and pancreatic diseases in children, with a high success rate and obvious alleviation of symptoms.

S1111 Post-ERCP Pancreatitis: Does Diet Matter?

Introduction: Post-ERCP pancreatitis (PEP) is one of the most feared and most common complications of an ERCP, with an incidence of approximately 9.7%. While several risk factors for PEP have been established, the relationship between post-procedure diet and PEP is not well understood. We sought to evaluate whether a regular diet immediately post-ERCP was associated with an increase in PEP. Methods: This was a retrospective study during which consecutive patients at two academic medical centers who underwent ERCP in 2021 were evaluated. Inclusion criteria were a) patients ≥ 18 years old; b) inpatient status prior to ERCP; c) no prior history of ERCP; d) no prior history of pancreatitis; e) no prior history of Sphincter of Oddi dysfunction. Data collected from these patients included patient demographics, ERCP procedure details, pre- and post- ERCP diet orders, and post- procedure complications. Association with PEP was evaluated using X2 and Fisher’s exact tests. Results: 100 consecutive patients met inclusion criteria and were included in this study. Overall, 74 patients (74%) received a modified post-ERCP diet, and 26 (26%) of patients received a regular post-ERCP diet. There was no significant difference in the incidence of PEP between these two groups (7/74 (9.4%) vs 0/26 (0%), p = 0.185). Cannulation type was found to be significantly associated with the development of PEP (standard cannulation, 2/72 (2.7%) vs other cannulation (double wire, needle knife, sphincteroplasty- assisted), 5/25 (20%), p=0.011). No other factors were found to have a significant association with the development of PEP (Table). Conclusion: In this cohort of 100 patients, post-ERCP diet choice was not found to be associated with the development of PEP. In fact, the only factor that was associated with PEP was a non-standard cannulation during ERCP, which is a well-established risk factor. The lack of association of post ERCP diet with PEP is an important finding because it is a common practice for endoscopists to recommend a modified consistency diet post ERCP to reduce the risk of PEP despite the lack of supporting evidence for this recommendation. Immediate advancement to a regular diet has significant benefits including aiding in patient recovery, reducing hospital length of stay, and improving patient satisfaction. Larger scale studies to corroborate this data in a prospective fashion are indicated. Table 1. - Factors Associated with the Development of Post-ERCP Pancreatitis Post-ERCP Pancreatitis Yes No p-value Main Exposure: Post-ERCP Diet, n (%) 0.1852 Modified 7 (9.46) 67 (90.54) Regular 0 26 (100.00) Demographic Characteristics Sex, n (%): 1.0000 Male 4 (7.27) 51 (92.73) Female 3 (6.67) 42 (3.33) Age in Years: 0.5122 Mean (SD) 58.29 (21.69) 63.46 (18.46) Comorbidities History of Pancreatitis, n (%) 1.0000 Yes 0 (0.00) 10 (100.00) No 7 (7.78) 83 (92.22) History of Cholelithiasis, n (%) 0.3411 Yes 0 (0.00) 19 (100.00) No 7 (8.64) 74 (91.36) ERCP Characteristics Indication, n (%) 0.8308 Benign Bile Duct Pathology 6 (8.45) 65 (91.55) Malignancy 1 (6.25) 15 (93.75) Benign Pancreas Duct Pathology 0 (0.00) 13 (100.00) Cannulation Type (N = 97*), n (%) 0.0116 Standard 2 (2.78) 70 (97.22) Other 5 (20.00) 20 (80.00) Sphincterotomy, n (%) 0.1856 Yes 4 (5.06) 75 (94.94) No 3 (14.29) 18 (85.71) Biliary Stent, n (%) 0.1139 Yes 6 (11.54) 46 (88.46) No 1 (2.08) 47 (97.92) Pancreatic Stent, n (%) 0.3108 Yes 2 (12.50) 14 (87.50) No 5 (5.95) 79 (94.05) Complexity Grade, n (%) 1.0000 Grade 3 1 (7.69) 12 (92.31) Grade 1-2 6 (6.90) 81 (93.10) Post-Procedure Fluid (mL, N = 81*), n (%) 0.9525 Mean (SD) 870.00 (710.28) 904.45 (778.64) Rectal Indomethacin Given, n (%) 0.1037 Yes 7 (9.86) 64 (90.14) No 0 (0.00) 29 (100.00) *N listed due to missing data for some patients at these data points

S61 Opiate Use Is Associated With Increased Risk of Post ERCP Pancreatitis: A National Cohort Study

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) has evolved as a valuable tool in therapeutic management of pancreatobiliary disorders but is associated with a range of significant complications, the most common being post-ERCP pancreatitis (PEP). The aim of this study was to elucidate the impact of opiate use on the development and severity of post-endoscopic retrograde cholangiopancreatography. Pancreatitis (PEP). Methods: We retrospectively analyzed patients who were hospitalized in 2017 using the national inpatient sample (NIS) database who underwent endoscopic retrograde cholangiopancreatography (ERCP) (via ICD-10 procedure codes). Our study group consisted of patients who had a secondary diagnosis of opiate use, and our control group consisted of patients who did not have a secondary diagnosis of opiate use. Our primary end point was to elucidate if the presence of opiate use increased the risk of developing post-ercp pancreatitis. Additionally, we assessed if opiate use worsened outcomes in patients who underwent ERCP. We accomplished this by extracting variables such as length of hospital stay (LOS), total hospital charges and in hospital mortality rates. Categorical variables were compared using the chi-square test, and continuous variables were compared using t-test. Multivariate regressions models and all statistical analysis were performed using STATA 16 software. Results: A total of 172,255 patients who underwent ERCP were identified, of which 2,120 were opiate users. Opiate users were hospitalized at a younger age when compared to opiate non-users (53.7 years vs 60.5 years; p-value: < 0.01), had a longer length of hospital stay (8.3 days vs 6.0 days; p-value: < 0.01), total hospital charges ($102,469 vs $82,191; p-value: < 0.01) and higher incidence of PEP (4% vs 2.7%; p-value: < 0.01). Conclusion: Opiate use is associated with younger age of presentation, increased LOS, total hospital charges, and increased frequency of PEP amongst patients undergoing ERCP. Further investigation is needed to assess the extent to which chronic opiate use may be a risk factor for post-ERCP pancreatitis and worse outcomes. If so, discontinuation of opiates before ERCP may be reasonable when possible. (Table) Table 1. - Hospital outcomes in opiate users vs non-users undergoing ERCP Opiate Use (N=2,120) No Opiate Use (N=170,135) P-value Age of presentation 53.7 60.5 < 0.01 LOS (days) 8.3 6.0 < 0.01 Total charges (USD) $102,469 $82,191 0.087 Died 35 (1.6%) 2,520 (1.4%) 0.525 PEP 85 (4%) 4,740 (2.7%) < 0.01 LOS: Length of hospital stay; USD: United States Dollar; PEP: Post-ERCP Pancreatitis.

S1140 Gender and ERCP Complications: A Nationwide Inpatient Sample Database Analysis

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) can involve a variety of complications including pancreatitis, hemorrhage, and cholangitis. Some studies have identified female gender as a risk factor for post-ERCP pancreatitis, cholangitis, and overall complications, however other studies have shown contradictory results. Given these discrepancies, we evaluated gender as a risk factor for post-ERCP complications using the National Inpatient Sample database. Methods: The National Inpatient Sample (NIS) database was used to identify hospitalized patients over 18 years old who had an ERCP procedure between 2007 - 2017 using ICD-9 and ICD-10 codes. Patients were divided into two groups: males (726,352 [40.1%]) or females (1,084,048 [59.9%]), as defined by NIS as “indicator of sex”. Patients were matched by age, race, and by Elixhauser comorbidity index. Primary outcomes were rates of post-ERCP pancreatitis, cholangitis, cholecystitis, infection, hemorrhage, and perforation. Chi-squared tests were used to compare categorical data and multivariate analyses were performed to assess primary outcomes. Results: There were 1,810,400 patients hospitalized from 2007-2017 who underwent an ERCP procedure, of which 1,084,048 (59.9%) were female and 726,352 (40.1%) were male. Primary outcomes were significant for increased odds ratio of post-ERCP pancreatitis (OR 1.2, p< 0.001) and decreased odds ratio of post-ERCP cholangitis (OR 0.7, p< 0.001), cholecystitis (OR 0.4, p< 0.001), infection (OR 0.7, p< 0.001), and hemorrhage (OR 0.6, p< 0.001) in females compared to males. No significant difference was found between men and women for post-ERCP perforation. Conclusion: Although there are differences in the effects of gender on post-ERCP complications in the literature, the mechanisms causing these effects are not known. Women are known to have higher risks for biliary stones and sphincter of Oddi dysfunction which can further increase the odds of post-ERCP pancreatitis. We postulate that the decreased rates of cholangitis, cholecystitis, infection, and hemorrhage in women compared to men could be from an anatomical variation in the biliary tree that is gender specific. Therefore, endoscopists should further explore and consider this possibility when performing ERCPs. Table 1. - Clinical Outcomes in Females and Males who underwent ERCP p value Odds Ratio Confidence Interval Post-ERCP Pancreatitis < 0.001 1.2 1.1-1.3 Post-ERCP Cholangitis < 0.001 0.7 0.7-0.8 Post-ERCP Cholecystitis < 0.001 0.4 0.4-0.5 Post-ERCP Infection < 0.001 0.7 0.7-0.7 Post-ERCP Hemorrhage < 0.001 0.6 0.5-0.7 Post-ERCP Perforation 0.304 1.1 1.0-1.2

Post-ERCP Pancreatitis: Prevention, Diagnosis and Management.

Endoscopic retrograde cholangiopancreatography (ERCP) carries a post-ERCP pancreatitis (PEP) rate of 2–10%, which could be as high as 30–50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. The risk of PEP is potentially predictable and may be modified with pharmacological measures and endoscopist technique. This review covers the definition, epidemiology and risk factors for PEP, with a focus on the latest evidence-based medical and endoscopic strategies to prevent and manage PEP.

Increased severity of complications after therapeutic ERCP in geriatric patients with chronic pancreatitis: An observational study.

Studies of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in geriatric patients have mainly examined patients with biliary diseases, rather than chronic pancreatitis (CP). This study aimed to evaluate the safety and success rate of therapeutic ERCP in geriatric patients with CP.The medical records of patients with CP aged over 65 years (group A) were retrospectively collected in a tertiary hospital from January 2013 to December 2018. Sex-matched CP patients under 65 years (group B) were randomly selected into the control group (matching ratio = 1:2). The success rate and the complication rate of therapeutic ERCP in 2 groups were compared. The risk factors for post-ERCP pancreatitis were investigated by univariate and multivariate analyses.A total of 268 ERCPs were performed in 179 patients of group A and 612 ERCPs in 358 patients of group B. The success rate of ERCP in group A was similar to that of group B (92.16% vs 92.32%; P = .936). The overall incidence of post-ERCP complications was 7.09% (19/268) and 5.72% (35/612) in group A and B, respectively (P = .436). However, geriatric patients had a significantly increased occurrence of moderate to severe complications (2.61% vs 0.16%; P = .002). Female gender (odds ratio [OR] = 3.40; P = .046), pancreas divisum (OR = 7.15; P = .049), dorsal pancreatogram (OR = 7.40; P = .010), and lithotripsy (OR = 0.15; P = .016) were significantly associated with risk of post-ERCP pancreatitis in geriatric patients.Therapeutic ERCP is safe and feasible in elderly patients with CP. However, occurrence of moderate to severe complications after ERCP increased in geriatric patients.

The effect of nafamostat mesilate infusion after ERCP for post-ERCP pancreatitis

BackgroundNafamostat mesilate decreases the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, no studies have administered nafamostat mesilate after ERCP. So we investigated if the infusion of nafamostat mesilate after ERCP can affect the post-ERCP pancreatitis (PEP) in high-risk patients.MethodsIn a tertiary hospital, 350 high-risk patients of PEP were reviewed retrospectively. Among them, 201 patients received nafamostat mesilate after ERCP. Patient-related and procedure-related risk factors for PEP were collected. We performed a propensity score matching to adjust for the significant different baseline characteristics. The incidence and severity of PEP were evaluated according to the infusion of nafamostat mesilate. The risk factors of PEP were also analyzed by multivariate logistic regression.ResultsThe baseline characteristics were not different after the matching. The PEP rate (17.4% vs. 10.3%, P = 0.141) was insignificant. Among the PEP patients, mild PEP was significantly higher in the nafamostat mesilate group (85.7% vs. 45.5%, P = 0.021). Only one patient in the nafamostat mesilate group developed severe PEP. Although young age (odds ratio [OR] 3.60, 95% CI 1.09–11.85, P = 0.035) was a risk factor, nafamostat mesilate (odds ratio [OR] 0.30, 95% CI 0.09–0.98, P = 0.047) was a protective factor for moderate to severe PEP.ConclusionsThe administration of nafamostat mesilate after ERCP in high-risk patients was not effective in preventing PEP, but may attenuate the severity of PEP.

Multicenter prospective cohort study of adverse events associated with biliary endoscopic retrograde cholangiopancreatography: Incidence of adverse events and preventive measures for post-endoscopic retrograde cholangiopancreatography pancreatitis.

ObjectivesThe reported incidence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) varies between 2.5% and 14%. The aim of this study was to evaluate the incidence and severity of AEs in biliary ERCP and to specify the risk factors and preventive measures for post‐ERCP pancreatitis (PEP).MethodsPatients with biliary disease with intact papilla were prospectively enrolled at 36 hospitals between April 2017 and March 2018. The primary outcomes were the incidence and severity of AEs.ResultsA total of 16,032 ERCP procedures were performed at the 36 hospitals during the study period and 3739 patients were enrolled. The overall incidence of AEs was 10.1% and ERCP‐related mortality was 0.08%. PEP developed in 258 cases (6.9%), bleeding in 33 (0.9%), instrumental AEs in 17 (0.5%), infections in 37 (1.0%), cardiovascular AEs in eight (0.2%), pulmonary AEs in eight (0.2%), drug reaction AE in one (0.03%), pain in 15 (0.4%), and other AEs in 15 (0.4%). Multivariable analysis showed significant risk factors for PEP were: female of younger age, pancreatic guidewire‐assisted biliary cannulation, temporary guidewire insertion into the pancreatic duct, total procedure time >60 min, and post‐ERCP administration of non‐steroidal anti‐inflammatory drugs. Effective preventive measures were prophylactic pancreatic stenting (PPS) and epinephrine spraying onto the papilla.ConclusionsIn patients with intact papilla who underwent biliary ERCP, the incidence of AEs was 10.1% and the mortality was 0.08%. PPS and epinephrine spraying may prevent PEP.RegistrationThis study was registered in the University Hospital Medical Information Network (UMIN000024820).

Larger Volume and Higher Fat Content of the Pancreatic Head Are Predictive Factors for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis.

Acute pancreatitis is the most critical complication of endoscopic retrograde cholangiopancreatography (ERCP). In this study, we investigated the association between the volume/fat content of the pancreatic head and the incidence of post-ERCP pancreatitis (PEP). We retrospectively enrolled 157 patients who underwent ERCP. The volume and fat content of the pancreas were calculated by multislice computed tomographic imaging by using a volume analyzer. Multivariate analysis was performed to identify risk factors for PEP. The mean volumes of the whole pancreas and pancreatic head were significantly larger, and the fat content of the pancreatic head was significantly higher in the PEP group (P < 0.01). There were no significant differences in the mean volume and fat content of the pancreatic body and tail in the PEP group. Multivariate analysis revealed that the pancreatic guidewire placement (odds ratio [OR], 12.4; P < 0.01), pancreatic head volume (OR, 5.3; P < 0.01), and the pancreatic head fat content (OR, 4.8; P < 0.01) were independent risk factors for PEP. The pancreatic head volume and fat content were independent predicting factors of PEP. Quantitative assessment of the pancreas may contribute to the prediction of PEP onset.

Efficacy of Chymotrypsin in the Prevention of Postendoscopicretrograde Cholangiopancreatography Pancreatitis

Introduction: Pancreatitis is common after endoscopic retrograde cholangiopancreatography (ERCP).To assess the pharmacological effect of diclofenac, allopurinol and chymotrypsin in the prevention of post ERCP pancreatitis (PEP). Calcular obstructive jaundice patients without pancreatitis scheduled for ERCP were randomized into three groups. Methods: The diclofenac group received 200mg rectal suppositories immediately after ERCP, allopurinol received oral 300mg 3 h before ERCP, and chymotrypsin received intramuscular injection immediately after ERCP. Serum amylase and lipase were measured before, 1, 6, and 24 h after ERCP and procedure-related risk factors for post-ERCP pancreatitis were recorded. Pancreatitis was considered when serum amylase or lipase levels elevated more than three times the upper limit of normal with newly developed abdominal pain lasting at least 24 h after ERCP. Results: 150 patients were included; diclofenac group (58 patients, 29 men, mean age 46.9±13.2 years), allopurinol (38 patients, 20 men, mean age 43.1±14.7 years) and chymotrypsin (54 patients, 28 men, mean age 40.6±17.3 years). 12 (8%) patients developed PEP: the diclofenac group (n=4; 6.9%), allopurinol (n=6; 15.8%) while chymotrypsin (n=2; 3.7%), but this was not statistically significant (P=0.318). In patients who received chymotrypsin, regression of serum amylase and lipase to normal levels was much better compared with the other groups and was associated with better clinical improvement. Conclusion: Chymotrypsin and allopurinol are comparable to diclofenac in the prevention of pancreatitis post-ERCP. Beside its prophylactic role, chymotrypsin could be effective in rapid improvement if PEP occurs.

Predictors of postendoscopic retrograde cholangiopancreatography associated cholangitis: a retrospective cohort study.

Post-ERCP cholangitis (endoscopic retrograde cholangiopancreatography) and associated sepsis can be lifethreatening. Despite the wealth of studies on post-ERCP pancreatitis risk factors, there is limited data on post-ERCP cholangitis. This study aimed to investigate the rates, predictors, and outcomes of post-ERCP cholangitis. A retrospective review of 452 ERCP cases performed by a single endoscopist at a tertiary center between March 2019 and February 2021 was performed. Patient-related, organizational and periprocedural factors that could affect post-ERCP cholangitis were evaluated. Predictors of post-ERCP cholangitis were determined by multivariable analysis. The post-ERCP cholangitis rate was 19.5%. Cholangiocarcinoma (OR 15.72, CI 2.43-101.55, p = 0.004), the American Society of Anesthesiologist Score (ASA) (OR 2.87, CI 1.14-7.21, p = 0.024), an increase in bilirubin after ERCP (OR 1.81 CI 1.01-3.22, p = 0.043), body mass index (OR 1.15, CI 1.00-1.33, p = 0.04) and procedure duration (OR 1.02, CI 1.00-1.05, p = 0.049) were predictors of post-ERCP cholangitis. Biliary stone extraction using a balloon was found to be protective against cholangitis (OR 0.18, CI 0.05-0.60, p = 0.005). Sepsis rate related to post-ERCP cholangitis was 2.4% and death 1%.

Analysis of the Efficacy and Safety of Endoscopic Retrograde Cholangiopancreatography in Children With Symptomatic Pancreas Divisum.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly performed in children with symptomatic pancreas divisum (PD).Aim: To investigate the safety and efficacy of ERCP in the treatment of children with symptomatic PD.Methods: We performed a retrospective analysis on children with PD who were treated with ERCP at Shanghai Children's Medical Center between June 2015 and May 2020. Pertinent patient, clinical and procedural data were collected to assess the therapeutic effects and identify the risk factors for post-ERCP pancreatitis (PEP).Results: Overall, 114 ERCPs were performed in 46 children with PD. With a median follow-up of 28.5 months (12–71 months), 40 (87.0%) children achieved clinical remission, the median number of acute pancreatitis episodes decreased from four times per year pre-operatively to once per year post-operatively (P < 0.001), and the nutritional score improved post-operatively (P = 0.004). The incidence of PEP was 7.9%, and female sex, stone extraction, and gene mutations were identified as possible risk factors for PEP on univariate analysis. However, there was no statistical significance on multivariate analysis (P > 0.05).Conclusion: Therapeutic ERCP is an effective and safe intervention for children with symptomatic PD.

Increased post-endoscopic retrograde cholangiopancreatography pancreatitis for choledocholithiasis without acute cholangitis.

Choledocholithiasis is the most common indication for endoscopic retrograde cholangiopancreatography (ERCP). Identifying risk factors for post-ERCP pancreatitis (PEP) is important for reducing the risk of developing PEP after common bile duct (CBD) stone removal. However, studies examining the risk factors for PEP for CBD stones are scarce. The aim of this study was to examine whether the presence or absence of acute cholangitis is a clinical risk factor for PEP in patients with CBD stones. In this multicenter retrospective study, 1539 patients with naïve papillae were divided into patients without and with acute cholangitis. We compared the incidence of PEP between the two groups using one-to-one propensity score matching to adjust for the potential confounding factors of PEP. In the entire cohort, the rates of PEP in patients without and with acute cholangitis were 9.6% (52/542) and 1.8% (18/997), respectively (P<0.001, odds ratio=5.8). In the propensity-matched cohort, the rates of PEP in patients without and with acute cholangitis were 8.3% (27/326) and 2.5% (8/326), respectively (P=0.002, odds ratio=3.6). The rate of PEP was significantly higher in patients without acute cholangitis than in those with acute cholangitis after adjusting for the confounding factors of PEP. The absence of acute cholangitis may be an important clinical risk factor for PEP due to CBD stone removal. In patients without acute cholangitis, endoscopists should explain the specific risk of PEP carefully and actively implement prophylaxis against PEP.

Continuous Infusion of Fluid Hydration Over 24 Hours Does Not Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Aggressive intravenous fluid hydration, by administering 3500mL of lactated Ringer's solution (LRS) in 9h with a peri-procedural bolus, reduces post-ERCP pancreatitis (PEP) incidence. A concern of this strategy is adverse events related to volume overload; however, the impact of fluid hydration over an extended period without a bolus on PEP is unknown. To assess the effect of continuous infusion of high-volume fluid at a constant rate over 24h on PEP incidence and severity. Two-hundred patients were randomly assigned (1:1) to receive either 3600mL of LRS in 24h starting 2h before the ERCP (high-volume group) or maintenance fluid hydration calculated by the Holliday-Segar method (control group). The mean age of the patients was 50.6 ± 11.6years. The predominant indications were choledocholithiasis (48%) and malignancies (32%). Patient demographics and PEP risk factors were similar in both groups. Patients in the high-volume group received significantly more fluid than the control group (3600 vs. 2413ml, P < 0.001). PEP incidence was not different between the high-volume and the control group (14% vs. 15%; relative risk 0.93: 95% CI 0.48-1.83, P = 0.84). There were no differences in moderate to severe PEP (3% vs. 4%; relative risk 0.75: 95% CI, 0.17-3.27, P = 1.00). Subgroup analysis did not show a benefit in high-risk patients. Only one patient in the control group developed peripheral edema. An infusion of high-volume hydration over 24h is not sufficient to provide optimal hydration for PEP prevention. No. NCT02821546.

S1024 The Effect of Unintended Pancreatic Duct Cannulation on Post-ERCP Pancreatitis

Introduction: Post-ERCP pancreatitis (PEP) is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Numerous studies have identified multiple synergistic patient-based risk factors for PEP including suspected sphincter of Oddi dysfunction, prior PEP, female gender, younger age, normal serum bilirubin, and history of acute recurrent pancreatitis. However, unintended pancreatic duct (PD) cannulation is less well studied as a risk factor for PEP. Our study investigates the risk of PEP in unintended PD cannulation. Methods: We conducted a retrospective cohort study of all ERCPs by a single advanced endoscopist between December 2013 and January 2020 at a tertiary medical center. Patients with prior sphincterotomy were considered to have a non-native papilla and were excluded. Details of the ERCP, laboratory results, hospitalizations, clinic visits, and follow-up phone calls were identified via chart review. PEP was defined by the revised Atlanta classification. Multiple logistic regression analysis was used to model demographic and clinical features of those who did and did not develop PEP. Group differences for various factors were compared using odds ratios calculated via Fisher’s exact test. Results: 823 ERCPs were included in this analysis of which 3.77% were complicated by PEP. The incidence of PEP was 8.4% among unintended PD cannulation, 3.2% among intentional PD cannulation, and 1.5% among no PD cannulation (Fisher's exact p-value < 0.00005). Using multiple logistic regression, PEP positively correlated with unintended PD cannulation (p-value < 0.005) but not intended PD cannulation. When controlled for age and gender, needle knife sphincterotomy was also identified as a risk factor for PEP (p-value = 0.017). Additionally, age was negatively correlated with PEP in unintended PD cannulation (p-value = 0.027). In both unintended and intended PD cannulation, PEP rates were not affected by contrast injection into the PD compared with just guidewire cannulation without contrast injection. Conclusion: While unintended PD cannulation appears to increase the likelihood of PEP, intentional cannulation does not seem to have the same effect, suggesting that underlying pancreatic disease such as chronic pancreatitis or pancreatic trauma confers a lower risk of PEP. Further studies are needed to determine whether patients with unintended PD cannulation could benefit from more aggressive PEP prophylaxis or monitoring after ERCP.

S3367 Obesity and In-Hospital Outcomes of Endoscopic Retrograde Cholangiopancreatography

Introduction: Multiple risk factors associated with post-Endoscopic Retrograde Cholangiopancreatography (ERCP) complications have been investigated in numerous studies. However, there are only a few studies focusing on the relationship between obesity and ERCP outcomes. In our study, we compared the in-hospital outcomes of ERCP in obese vs non-obese patients. Methods: The study cohort is derived from the Nationwide Inpatient Sample (NIS) for the years 2007-2018. Adult patients undergoing ERCP were identified using previously validated ICD-9-CM/ICD-10-CM codes. Procedural complications and other diagnoses of interest were also identified by ICD-9/10-CM codes. We utilized the Chi-Square test, Wilcoxon Rank Sum test, and multivariable survey logistic regression models to analyze the data. Results: We analyzed 1,973,398 ERCP procedures from 2007-2018, out of which 279,620 (14.2%) were performed in obese patients. Proportion of obese patients undergoing ERCP increased from 7.6% in 2007 to 20.0% in 2018 (P < 0.01). Obese patients under going ERCP were younger (53-years vs 60-years; P < 0.01), female (68% vs 57%: P < 0.01) and Hispanic (18% vs 15%; P < 0.01). In univariate analysis, obesity was associated with higher post-ERCP pancreatitis (2.0% vs 1.6%; P < 0.001). Even after adjusting for confounding factors, obesity was associated with a higher risk of post-ERCP pancreatitis (1.2; 95%CI 1.1-1.3; P < 0.01). Detailed comparison of in-hospital outcomes of ERCP in obese vs non-obese has been depicted in Table. Conclusion: We demonstrated the in-hospital outcomes of ERCP in obese vs non-obese patients and found out that obesity is an independent risk factor for post-ERCP pancreatitis and cholangitis. Our study highlights the need for focused interventions to reduce the incidence of these complications to improve the overall outcomes of ERCP in obese patients.Table 1.: In-Hospital Outcomes of ERCP in Obese vs Non- Obese patients.

S1018 Rectal NSAIDs Decrease Post-ERCP Pancreatitis (PEP) in Unselected Patients - Comprehensive Meta-Analysis of Randomized Controlled Trials

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is fundamental for treatment of pancreatico-biliary diseases, but results in PEP in up to 15% of patients. Phospholipase A2 (PLA2) is an important factor in the pancreatitis inflammatory cascade and NSAIDs, which inhibit PLA2 activity, prevent PEP in high-risk patients. We endeavored to identify and quantitatively synthesize the existing high-quality data to date on rectal NSAID use for the prevention of post ERCP pancreatitis in unselected patients without specific risk factors for PEP. Methods: In collaboration with a librarian, we searched the following databases: Ovid Medline (coverage 1946 – Present), Embase and Embase Classic (coverage 1947 – Present), Cochrane Library (coverage 1898-present), Web of Science (coverage 1900-present), Clinicaltrials.gov, and Google Scholar through April 2021. Using the Covidence system, two independent reviewers identified randomized controlled studies assessing rectal NSAIDs for PEP prevention in unselected patients. Our primary outcome was odds of developing PEP and our secondary outcome was odds of developing moderately severe or severe PEP. Pooled odds ratios were estimated using the random effects model. Results: After review of 504 abstracts and 234 full text documents, we identified 25 randomized controlled trials evaluating rectal NSAIDs for the prevention of PEP in unselected patients; 4071 patients received rectal NSAIDs and 4005 patients received a placebo. The most frequent NSAID used was diclofenac in 56% of studies, followed by indomethacin in 36%, ketoprofen in 4%, and naproxen in 4%. Unselected patients receiving rectal NSAIDs were less likely to develop PEP (OR 0.59, 95% CI 0.45-0.78) (Figure 1) as well as moderately severe and severe pancreatitis (OR 0.50, 95% CI 0.33-0.75). Conclusion: In unselected patients undergoing ERCP, rectal NSAID administration decreases the risk of post-ERCP pancreatitis and development of moderately severe or severe PEP. They should be considered for unselected patients undergoing ERCP, not simply those high risk for PEP.Figure 1.: Baseline characteristics and clinical outcomes in patients who has ERCP with glucagon (ERCP w glucagon, group 1) compared to individuals ERCP without glucagon (ERCP wo glucagon, group 2) Note: SD-Standard Deviation; € A 1:1 propensity score matching was done based on the following variables: age, gender, race, hypertension, diabetes mellitus, obesity, chronic kidney disease (CKD), Ischemic heart diseases (IHD), chronic obstructive pulmonary disease, indomethacin use, sphincter of Oddi dysfunction (SOD).

Endoscopy in Pregnancy: A Systematic Review

Abstract Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy. Methods A systematic literature search was performed using PubMed. All original research articles with sample size &gt; 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021. Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (&gt;95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (&gt; 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy. Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected.

Efficacy of endoscopic large balloon dilation extended for 2minutes in bile duct stone removal: A multicenter retrospective study.

There is no evidence regarding the optimal balloon dilation time during endoscopic papillary large balloon dilation (EPLBD). The study aim was to evaluate the efficacy of 2-minute extended balloon dilation for EPLBD. Two hundred and five patients who underwent EPLBD during endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones at three tertiary centers were included in the analysis. Clinical outcomes and the adverse events were compared between the 0-minute group (n=94, balloon deflated immediately after waist disappearance) and the 2-minute group (n=111, balloon dilation maintained for 2minutes after waist disappearance). The risk factors of post-ERCP pancreatitis (PEP) after EPLBD were assessed. There were no significant differences in the stone removal rates and hospitalization periods between the two groups. However, the total ERCP procedure time was significantly shorter in the 2-minute group (40.6 vs 48.9min, P=.03). The incidence of PEP was 7.4% in the 0-minute group and significantly lower at 0.9% in the 2-minute group (P=.04). Multivariate analysis identified without 2-minute extended EPLBD as a significant risk factor of PEP (OR: 9.9, P=.045). Extension of EPLBD for 2 minutes helped prevent PEP and shortened the procedure time.