Risk Factors For post-ERCP Pancreatitis Research Articles

Risk Factors of Post-ERCP Pancreatitis at a Tertiary Referral Center in Japan

Endoscopic retrograde cholangiopancreatography (ERCP) has played a major role in the diagnosis of biliary and pancreatic diseases. The prevalence and mortality rate of post-ERCP pancreatitis (PEP) remains a serious issue that needs to be resolved. Here, we report the first ERCP study that was conducted at a high-volume center of an educational institution in Japan. This study investigated patients with suspected biliary and pancreatic diseases who had undergone ERCP between April 2006 and June 2009. We created a database and analyzed preoperative and postoperative data. Patients who had undergone surgery and those with a history of undergoing duodenal papilla treatment were excluded. Mild (n=62) or moderate (n=3) pancreatitis was present in 65 cases (6.21%; 36 men and 29 women). A univariate analysis identified age under 50 years (P=0.01), pancreatography (P<0.001), and biliary stent placement (P<0.001). A Multivariate analysis was performed for evaluating the risk factors associated with PEP. This analysis identified age of the patients under 50 years [P=0.003; odds ratio (OR), 0.37; 95% confidence interval (CI), 0.19-0.71], endoscopic papillary balloon dilation (P=0.012; OR, 4.69; 95% CI, 1.41-15.54), pancreatography (P<0.001; OR, 5.55; 95% CI, 2.98-10.33), and plastic stent placement (P<0.001; OR, 3.77; 95% CI, 2.17-6.54). Descriptive statistics showed that only pancreatography was associated with PEP. An additional sphincterotomy did not increase the risk of PEP (P=0.306; OR, 2.03; 95% CI, 0.52-7.84), and even adjusted for pancreatography. We changed the size of the stent to 7-Fr. In the future, we plan to repeat the same study with a higher number of cases.

PTH-015 Post-ercp Pancreatitis In Secondary Care: Can We Predict Who Would Benefit From A Prophylactic Pancreatic Stent?

IntroductionPancreatitis is a recognised complication of ERCP. Measures taken to reduce the incidence in high-risk patients include placement of prophylactic pancreatic stents and use of NSAIDs, but current practice varies...

Risk factors for post-ERCP pancreatitis: a systematic review of clinical trials with a large sample size in the past 10 years.

BackgroundPost- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common and most severe complication associated with diagnostic and therapeutic ERCP. A multivariate analysis of risk factors for PEP is essential for identifying patients at high risk and subsequently choosing other suitable diagnoses.MethodsPertinent publications were identified through systematic searches of MEDLINE, Elsevier, and Springer; we performed a systematic review of 12 clinical studies published in the past ten years, selected out of 451 reviewed articles, in which risk factors for pancreatitis were identified. Seven probable risk factors were evaluated, and outcomes expressed in the case of dichotomous variables, as an odds ratio (OR) (with a 95% confidence interval, 95% CI).ResultsWhen the risk factors were analyzed, the OR for female gender was 1.40 (95% CI 1.24 to 1.58); the OR for previous PEP was 3.23 (95% CI 2.48 to 4.22); the OR for previous pancreatitis was 2.00 (95% CI 1.72 to 2.33); the OR for endoscopic sphincterotomy was 1.42 (95% CI 1.14 to 1.78); the OR for precut sphincterotomy was 2.11 (95% CI 1.72 to 2.59); the OR for Sphincter of Oddi dysfunction was 4.37 (95% CI 3.75 to 5.09); and the OR for non-prophylactic pancreatic duct stent was 2.10 (95% CI 1.63 to 2.69).ConclusionsIt appears that female gender, previous PEP, previous pancreatitis, endoscopic sphincterotomy, precut sphincterotomy, Sphincter of Oddi dysfunction, and non-prophylactic pancreatic duct stent are the risk factors for post-ERCP pancreatitis.

CT severity of post-ERCP pancreatitis: results from a single tertiary medical center.

To evaluate the CT severity of post-ERCP pancreatitis (PEP) and determine the association between radiographic and clinical severity. There were 1332 patients admitted to the hospital with suspicion for PEP after undergoing ERCP as outpatients over a 10-year period, of whom 84 (6.3%) patients underwent at least one contrast-enhanced CT scan while hospitalized were evaluated. All CT scans were evaluated by two radiologists, and the modified CT severity index (MCTSI) score was calculated. Demographic, clinical, and procedural data as well as clinical severity parameters including systemic inflammatory response syndrome, organ failure, need for ICU, need for intervention, length of hospital stay, and mortality were recorded. Statistical analysis was performed using the χ (2) and Student's t test or ANOVA and logistic regression analysis. Patients were predominantly females (70%) with a mean age of 46.5 years (range 20-86). The most common indication for ERCP was sphincter of Oddi dysfunction. MCTSI was graded as mild in 45 (53.6%), moderate in 36 (42.8%), and severe in 3 (3.6%) patients. The interobserver agreement was excellent (κ: 0.91, p<0.0001) for MCTSI. The duration of ERCP (p=0.005) was the only risk factor for PEP that significantly correlated with the MCTSI score. Increasing MCTSI was significantly associated with hospital length of stay. PEP is typically a mild disease by radiologic and clinical criteria. Longer duration of ERCP is a risk factor for severe radiologic PEP. Severe radiographic PEP is associated with significantly longer hospital length of stay.

Post-endoscopic retrograde cholangiopancreaticography complications in liver transplanted patients, a single-center experience.

Complications in the biliary tract occur in 5%-30% after liver transplantation and the main part of the complications is successfully managed with endoscopic retrograde cholangiopancreaticography (ERCP). The incidence and risk factors for post-ERCP complications in liver transplantation patients are not well described. Our objective was to define the frequency of post-ERCP complications in liver transplantation patients at the Abdominal Center, Rigshospitalet, the only Liver Transplantation Center in Denmark. Retrospective study of all ERCPs performed in liver transplantation patients during a 9-year period. A total of 292 ERCPs were included. Overall post-ERCP complications occurred in 24 procedures (8.2%): pancreatitis in 8 (2.7%), bleeding in 5 (1.7%), and cholangitis in 13 (4.5%) procedures. Simultaneous pancreatitis and cholangitis, and simultaneous bleeding and cholangitis occurred after two procedures, respectively. Multivariate analysis concerning overall complications identified biliary sphincterotomy (p = 0.006) and time since liver transplantation within 90 days postoperatively (p = 0.044) as risk factors for post-ERCP complications. Specifically concerning post-ERCP pancreatitis (PEP), it was found that pre-ERCP cholangitis was another independent risk factor for PEP (p = 0.026). Stent in the biliary tract prior to ERCP seemed to be protective (p = 0.041). Complications were of surprisingly mild degree. The rates of post-ERCP complications in our study were in line with previous studies with liver transplantation patients. Cholangitis prior to ERCP may be another risk factor for post-ERCP pancreatitis.

Su1682 Risk Factors for Post-ERCP Pancreatitis in Therapeutic Biliary ERCP Using Wire-guided Cannulation

Wire-guided cannulation (WGC) reportedly improves biliary cannulation and decreases post-ERCP pancreatitis (PEP) by preventing contrast injection to the pancreatic duct (PD). However, little is known whether unintentional guidewire (GW) insertion into PD increases PEP or not. The aim of the study is to evaluate risk factors for PEP in therapeutic ERCP using WGC.

Su1684 Is Endoscopic Biliary Stenting a Risk Factor for Post-ERCP Pancreatitis? - a Systematic Review and Meta-Analysis

Placement of bile stent across the papilla could potentially block pancreatic duct opening which may result in acute pancreatitis. However, biliary stenting as a risk for post-ERCP pancreatitis (PEP) has not been studied widely. Limited number of studies that evaluated the risk of PEP from biliary stenting have shown variable results. The purpose of this meta-analysis is to examine whether the placement of biliary stent is associated with a higher rate of PEP.

Double Guidewire Technique for the Prevention of Post-ERCP Pancreatitis (PEP): Cochrane Collaboration Meta-analysis of RCTs

Purpose: Difficult cannulation is a risk factor for PEP. It has been postulated that the double guidewire (DGW) technique may improve biliary cannulation success and reduce the risk of PEP. We conducted a meta-analysis of randomized controlled trials (RCTs) of DGW technique vs. persistent attempts with conventional cannulation (CC), precut sphincterotomy or pancreatic duct (PD) stent in patients with difficult cannulation for the prevention of PEP. Methods: We searched Medline, Embase, Central, and CIinahl up to October, 2012. Conference proceedings were searched. RCTs that compared DGW technique vs. persistent attempts with CC, precut or PD stent in patients with difficult cannulation were included. Study selection, data extraction and quality assessment were conducted independently by two authors. Primary outcome was incidence of PEP. Secondary outcomes included CBD cannulation success with the randomized technique, overall CBD cannulation success, bleeding, cholangitis, perforation and mortality. Revman 5.1 was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI, Mandel-Haenszel method; random effects model). Heterogeneity was assessed by Chi2 test (P<0.15) and I2 test (>25%). Results: Six RCTs (503 participants) met the inclusion criteria (Figure 1). Definitions of difficult cannulation were variable. Among the two studies that compared DGW with precut, the incidence of PEP was 21.4% in the DGW group vs. 7.3% in the precut group (RR 2.83; 95% CI 0.96-8.34; I2=0%). Among the three studies that compared DGW with persistent CC, the incidence of PEP was 12.9% in the DGW group vs. 8.0% in the CC group (RR 1.63; 95% CI 0.84-3.19; I2=0%). In a post-hoc pooled analysis of the five studies that compared DGW vs. precut or persistent CC, DGW technique significantly increased the risk of PEP compared to precut or persistent CC (RR 1.90; 95% CI 1.08-3.36; I2=0%). In the one study that compared DGW vs. PD stent, there was no significant difference in the risk of PEP between the two techniques (RR 0.36; 95% CI 0.04-3.30). There was no significant difference in CBD cannulation success with the initial technique the patient was randomized to (RR 1.02; 95% CI 0.84 -1.24; I2 = 66%) or eventual overall CBD cannulation success (RR 1.05; 95% CI 0.90-1.22; I2 = 67%) between DGW technique vs. precut, persistent CC or PD stent. Conclusion: In patients with difficult CBD cannulation, the DGW technique appears to be associated with an increased risk of PEP. DGW is not superior to precut, persistent attempts with conventional cannulation or PD stent in achieving CBD cannulation. Sole DGW should be discouraged. PD stenting after use of a DGW cannulation technique may reduce the risk of PEP yet requires assessment.

Results of the Tokyo Trial of Prevention of Post-ERCP Pancreatitis with Risperidone-2: a multicenter, randomized, placebo-controlled, double-blind clinical trial

Our previous study suggested that a combination of ulinastatin and risperidone reduced post-ERCP pancreatitis (PEP) compared with ulinastatin alone. The aim of this study was to evaluate the efficacy of risperidone alone for prevention of PEP. A multicenter, randomized, placebo-controlled, double-blind clinical trial. Two academic hospitals and 5 referral hospitals in Tokyo and Saitama, Japan. Patients undergoing therapeutic or interventional-diagnostic ERCP. The patients were randomized to receive 2 mg of oral risperidone or oral placebo at 0.5 to 2 hours before ERCP. The primary endpoint was the incidence of PEP. Secondary endpoints were the incidence of hyperenzymemia and enzyme levels (amylase, pancreatic amylase, lipase). Risk factors for PEP were evaluated. We initially enrolled 500 patients in the study (250 in the risperidone group and 250 in the placebo group), but 17 (11 in the risperidone and 6 in the placebo group) were excluded after randomization. PEP developed in 24 patients (10.0%) in the risperidone group and 21 patients (8.6%) in the placebo group (P = .587). Serum amylase levels at 3 hours after ERCP were lower in the risperidone group (P = .007 in a single test of hypothesis, significance removed by Bonferroni correction for multiple testing). In multivariate analysis, a small papilla of Vater, total procedure time ≥40 minutes, and stenosis of the intrahepatic duct were significantly associated with PEP. Multiplicity of study centers and a relatively wide time range of drug administration time. Risperidone did not show a benefit in prevention of PEP in this trial. ( NCT000004592.).

Risk factors of iatrogenic pancreatitis following endoscopic retrograde cholangiopancreatography : a meta-analysis

Objective To study the iatrogenic risk factors of post-ERCP pancreatitis (PEP).Method A meta-analysis was carried out on 15 clinical studies which included more than 100 patients published in the medical literature in the last twenty years.Result When the risk factors were analysed,OR for endoscopic sphincterotomy (EST) was 3.75 (95％CI 3.01-4.68),OR for papillae precut was 2.17 (95％CI 1.76-2.67),OR for biliary sphincter balloon dilation was 1.66 (95％CI 1.16-2.39),OR for pancreatic contrast injection was 2.79 (2.31-3.37),OR for sphincter of Oddi manome try was 5.86 (95％CI 5.04-6.80),OR for pancreatic stenting was 2.57 (95％CI 2.09-3.17).Conclusion The analysis indicated EST,papillae precut,balloon dilation,pancreatic contrast injection,Oddi manometry,non-prophylactic pancreatic duct stenting were the risk factors of post-ERCP pancreatitis. Key words: Cholangiopancreatography, endoscopic retrograde; Pancreatitis; Risk factors; Meta-analysis

Analysis of risk factors for post-ERCP pancreatitis in patients who underwent prophylactic pancreatic duct stenting - Results of a prospective, multicenter, controlled study

Analysis of risk factors for post-ERCP pancreatitis in patients who underwent prophylactic pancreatic duct stenting - Results of a prospective, multicenter, controlled study

Sa1528 Pancreatic Duct Guidewire Placement for Biliary Cannulation for the Prevention of Post-ERCP Pancreatitis (PEP): Cochrane Collaboration Meta-Analysis of Randomized Controlled Trials

Sa1528 Pancreatic Duct Guidewire Placement for Biliary Cannulation for the Prevention of Post-ERCP Pancreatitis (PEP): Cochrane Collaboration Meta-Analysis of Randomized Controlled Trials

Needle Knife Sphincterotomy Does Not Increase the Risk of Pancreatitis in Patients With Difficult Biliary Cannulation

Biliary cannulation is unsuccessful during 5%-10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. Needle knife sphincterotomy (NKS) can improve success of cannulation but is often used as a last resort and is associated with post-ERCP pancreatitis (PEP). We evaluated the safety and efficacy of performing NKS during early stages of difficult cannulation and the relationship between difficult cannulation and the risk of PEP. We performed a prospective trial of consecutive patients with an intact papilla who were undergoing ERCP at tertiary referral center; 73 patients were defined as having difficult biliary cannulation according to predefined cannulation parameters. These patients were randomly assigned to groups that received either NKS or continued standard cannulation. Main outcome measures were PEP and successful biliary cannulation. Of 464 patients with an intact papilla undergoing ERCP, 73 met the criteria for difficult cannulation. Cannulation success in difficult cannulation cases was 86%, with a PEP rate of 19%. There was no difference in eventual cannulation success between the groups. However, 65% of the patients assigned to the standard cannulation group required crossover to NKS. There was no significant difference in development of PEP among patients in the early NKS group (20.5%) vs standard cannulation (17.6%). Pancreatic duct stents were inserted in 23 of the patients in the early NKS arm and in 15 in the standard cannulation arm. The number of cannulation attempts (more than 7) increased the risk of PEP (P < .01). On the basis of multivariate analysis, independent risk factors for PEP were failure of early cannulation and failure of biliary cannulation. Early application of NKS during difficult cannulation does not increase the risk of PEP. The risk of PEP increases greatly after 7-8 attempts at or failure of cannulation. Further studies are required to assess whether early implementation of NKS during difficult cannulation reduces the development of PEP. Australia and New Zealand Clinical Trials registry: ANZTRN 12,612,000,060,842.

Prophecy about post-endoscopic retrograde cholangiopancreatography pancreatitis: From divination to science

One unresolved issue of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP), which occurs in up to 40% of patients. Identification of risk factors for PEP is especially important in the field of ERCP practice because it may assist physicians in taking protective measures in situations with high risk. A decade ago, Freeman et al meticulously evaluated a large number of potentially relevant risk factors for PEP, which can be divided into patient-related and procedure-related issues. In this commentary, we summarize this classic article and reevaluate the risk factors for PEP from the current point of view. This is followed by assessment of strategies for prevention of PEP that can be divided into mechanical and pharmacologic methods.

Can postendoscopic retrograde cholangiopancreatography pancreatitis be prevented by a pharmacological approach?

Acute pancreatitis remains the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP), with reported incidence rates that have changed little over several decades. Patient- and procedure-related risk factors for post-ERCP pancreatitis (PEP) are well-defined. Effective measures to prevent PEP have been identified, including improvements in cannulation techniques and pancreatic stenting, as well as pharmacological intervention. Pharmacotherapy has been widely studied in the prevention of PEP, but the effect in averting PEP has been inconclusive. Although pharmacological prophylaxis is appealing, attempts to find an ideal drug are incomplete. Most available data on the efficacy of pharmacological agents for PEP prophylaxis have been obtained from patients at average risk for PEP. However, recently, a randomized prospective controlled trial of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent PEP in high-risk patients was published. The results revealed that rectal indomethacin reduced the incidence of PEP significantly. Thus, rectal administration of diclofenac or indomethacin immediately before or after ERCP is used routinely to prevent PEP. However, additional studies with NSAIDs using large numbers of subjects are necessary to confirm the prophylactic effect of these drugs and to establish whether they act synergistically with other prophylactic interventions, including pancreatic stenting.

Post-ERCP Pancreatitis: Mechanisms, Risk Factors, and Prevention

Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), occurring in up to 30 to 40% of high risk patients. The most prominent theories of post-ERCP pancreatitis (PEP) pathogenesis include mechanical trauma to the papillary orifice, hydrostatic injury, and enzymatic injury from activated proteolytic enzymes introduced from the duodenum. Investigators have proposed a number of patient-related, procedure-related, and physician-related risk factors for PEP. However, when evaluated in large prospective trials, the role of these factors in increasing risk of PEP is inconsistent. Placement of a pancreatic duct stent and administration of rectal non-steroidal anti-inflammatory drugs (NSAIDs) are the two interventions with the greatest body of evidence supporting efficacy in PEP prevention.

Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy–associated pancreatitis? A randomized, prospective study

Pancreatitis is the most common major complication of ERCP and precut endoscopic sphincterotomy (ES). Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk settings. To determine whether leaving a main PD stent in place after precut ES would reduce the incidence and severity of PEP. Single-center, randomized, prospective study. Tertiary care ERCP referral center. Consecutive patients who underwent ERCP with a clear indication for biliary access and standard biliary ES whereby free cannulation of the bile duct was not possible and precut ES was undertaken. When free bile duct cannulation for ES was not possible and selective PD cannulation was achieved, a PD stent was placed. Using the PD stent as a guide, we used a needle-knife sphincterotome to perform precut ES. The patients were then randomized to either leaving the PD stent in place for 7 to 10 days (stent group) or immediate removal after the procedure (stent removed group). The remaining patients who did not undergo selective PD cannulation and stent placement were not randomized (no stent group) and had a free-hand needle-knife ES performed. Patients were prospectively followed for the development of complications. Standardized criteria were used to diagnose and grade the severity of PEP. A total of 151 patients were enrolled. The groups were similar with regard to patient demographics and patient and procedure risk factors for PEP. The overall incidence of PEP was 13.2% (20/151). It occurred in 4.3% (2/46), 21.3% (10/47), and 13.8% (8/58) of patients in the stent, stent removed, and no stent groups, respectively. The stent group had a significantly lower frequency and severity of PEP compared with the stent removed group (4.3% vs 21.3%; P = .027 for frequency and 0% vs 12.8%; P = .026 for moderate and severe pancreatitis). Single center. Randomization scheme not optimal. These data suggest that placing and maintaining a PD stent for needle-knife precut ES reduces the frequency and severity of postprocedure pancreatitis.

Prophylactic temporary 3F pancreatic duct stent to prevent post-ERCP pancreatitis in patients with a difficult biliary cannulation: a multicenter, prospective, randomized study

Post-ERCP pancreatitis (PEP) is the most common and serious complication of ERCP. Difficult biliary cannulation can be a procedure-related risk factor for PEP. Recent studies reported that a prophylactic pancreatic stent (PS) can reduce the frequency and severity of PEP. To evaluate the efficacy and usefulness of a temporary 3F PS to prevent PEP in patients with difficult biliary cannulations. A multicenter, prospective, randomized study. Two tertiary-care academic medical centers. In total, 101 patients with a difficult biliary cannulation were randomly divided into the 3F PS placement group (PS group, n = 50) or the nonstent (NS) group (NS group, n = 51). Endoscopic placement of a 3F unflanged PS. The incidence and severity of PEP in the 2 groups, spontaneous dislodgment of stents, and procedure-related complications. The technical success rate of 3F PS placement was 96% (48/50). The lengths of the stents were 4 cm (n = 21), 6 cm (n = 15), and 8 cm (n = 12). Spontaneous stent dislodgment within 7 days occurred in 94% of patients (45/48). The mean duration until spontaneous dislodgment was 3.5 days. The incidence rate of PEP was 12% (6/50: mild, 5; moderate, 1) in the PS group and 29.4% (15/51: mild, 12; moderate, 2; severe, 1) in the NS group. Severe pancreatitis occurred in only 1 patient in the NS group. In a multivariate analysis, prophylactic placement of PS was the only prophylactic factor for PEP (odds ratio, 0.126; 95% CI, 0.025-0.632, P = .012). No comparative results for stent size and diameter and a low-risk cohort group. Prophylactic temporary 3F PS placement in patients with a difficult biliary cannulation during ERCP seems to be a safe and effective method for reducing PEP and results in a high rate of spontaneous passage of stents without complications.

Sa1136 Increased Fat in Pancreas: A Risk Factor for Post-ERCP Pancreatitis?

Sa1136 Increased Fat in Pancreas: A Risk Factor for Post-ERCP Pancreatitis?

Su1368 Two Institution-Study of Risk Factors of Post-ERCP Pancreatitis Following Transpapillary Biliary Stent Placement for Malignant Biliary Obstruction

Pancreatitis is one of complications after biliary stent placement for malignant biliary obstruction(MBO).The purpose of this study was to evaluate risk factors of post-ERCP pancreatitis(PEP) after endoscopic biliary stent placement for MBO.Patient and