What are the risk factors for post-Endoscopic Retrograde Cholangiopancreatography (ERCP) pancreatitis?

From the Guidelines

Post-ERCP pancreatitis risk factors include female gender, younger age, normal bilirubin levels, history of previous post-ERCP pancreatitis, suspected sphincter of Oddi dysfunction, and absence of chronic pancreatitis, as well as procedure-related factors such as difficult cannulation, pancreatic duct injection, and pancreatic sphincterotomy 1.

Patient-Related Risk Factors

• Female gender
• Younger age
• Normal bilirubin levels
• History of previous post-ERCP pancreatitis
• Suspected sphincter of Oddi dysfunction
• Absence of chronic pancreatitis

Procedure-Related Risk Factors

• Difficult cannulation (more than 10 minutes or more than 5 attempts)
• Pancreatic duct injection (especially multiple injections)
• Pancreatic sphincterotomy
• Precut sphincterotomy
• Balloon dilation of an intact biliary sphincter
• Failure to clear bile duct stones

Technical Factors

• Operator inexperience
• Prolonged procedure time The mechanism behind post-ERCP pancreatitis involves mechanical trauma to the papilla causing edema and obstruction of pancreatic outflow, hydrostatic injury from contrast injection, enzymatic injury from activated digestive enzymes, thermal injury from electrocautery, and chemical injury from contrast agents 1. Pregnancy has also been reported to be an independent risk factor for post-ERCP pancreatitis, with a higher rate of post-ERCP pancreatitis in pregnant women compared to nonpregnant women 1. Recognizing these risk factors is important for identifying high-risk patients who may benefit from prophylactic measures such as rectal NSAIDs, aggressive hydration, or prophylactic pancreatic stent placement 1.

From the Research

Risk Factors for Post-ERCP Pancreatitis

The risk factors for post-ERCP pancreatitis can be categorized into patient-related and procedure-related factors.

• Patient-related factors:
  • Female gender 2, 3, 4
  • Previous pancreatitis 2, 3, 4
  • Previous post-ERCP pancreatitis 2, 3, 4
  • Suspected sphincter of Oddi dysfunction (SOD) 2, 3, 4
  • Intraductal papillary mucinous neoplasm (IPMN) 5, 3
  • Age <60 years 2
• Procedure-related factors:
  • Difficult cannulation 2, 3, 4
  • Endoscopic sphincterotomy (EST) 3
  • Precut sphincterotomy 3
  • Main pancreatic duct injection 3
  • Minor papilla sphincterotomy 2
  • Trainee involvement 2
  • Number of contrast injections into the pancreatic duct 2

Procedure-Related Technical Factors

Technical factors during the ERCP procedure also play a significant role in determining the risk of post-ERCP pancreatitis.

• The use of prophylactic pancreatic duct stenting has been shown to reduce the risk of post-ERCP pancreatitis in high-risk patients 5, 6
• The administration of rectal indomethacin has also been shown to be effective in preventing post-ERCP pancreatitis, although the combination of indomethacin and prophylactic pancreatic stent placement may be more effective in high-risk patients 6