From the Guidelines
Post-ERCP pancreatitis prophylaxis should include routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication, as recommended by ESGE/EASL 1.
Key Recommendations
- In addition to NSAIDs, the placement of a 5-Fr prophylactic pancreatic stent should be considered in patients at high risk for post-ERCP pancreatitis, such as those with precut biliary sphincterotomy, pancreatic guidewire-assisted biliary cannulation, or presence of more than three risk factors including female gender, previous pancreatitis, and young age 1.
- The use of prophylactic NSAIDs, such as rectal indomethacin or diclofenac, has been shown to reduce the risk of post-ERCP pancreatitis in high-quality randomised control trials 1.
- Pancreatic duct stent placement can reduce the risk of post-ERCP pancreatitis in patients at increased risk, but the optimum duration of placement is unknown and may require reassessment and potential endoscopic removal if spontaneous migration does not occur 1.
Rationale
The rationale behind these recommendations is to reduce the risk of post-ERCP pancreatitis, which is a common and feared complication of ERCP. The use of NSAIDs and pancreatic stents can help reduce inflammation and facilitate pancreatic drainage, thereby decreasing the risk of pancreatitis.
Important Considerations
- The risk factors for post-ERCP pancreatitis include female gender, young age, normal bilirubin, prior post-ERCP pancreatitis, difficult cannulation, and pancreatic duct injection 1.
- The ESGE/EASL guideline recommends routine rectal administration of NSAIDs in all patients undergoing ERCP, unless there is a contraindication 1.
- The use of pancreatic stents should be considered in patients at high risk for post-ERCP pancreatitis, and the stent should typically be 5-Fr, 3-5 cm in length, and removed within 5-10 days if not spontaneously dislodged 1.
From the Research
Post-ERCP Pancreatitis Prophylaxis Techniques
- The European Society of Gastrointestinal Endoscopy (ESGE) recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication 2.
- In high-risk cases, the placement of a 5-Fr prophylactic pancreatic stent should be strongly considered, in addition to NSAIDs 2, 3.
- Sublingually administered glyceryl trinitrate or 250 µg somatostatin given in bolus injection might be considered as an option in high-risk cases if NSAIDs are contraindicated and if prophylactic pancreatic stenting is not possible or successful 2.
NSAIDs for Preventing Post-ERCP Pancreatitis
- Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be efficacious in preventing pancreatitis after ERCP, with a risk reduction of 49% 4.
- Rectal administration of either indomethacin or diclofenac was shown to be effective in preventing post-ERCP pancreatitis, with a number needed to treat of 14 4.
- The use of NSAIDs was effective in both high-risk and unselected patients, with a risk reduction of 47% and 43%, respectively 4.
Emerging Therapies for Preventing Post-ERCP Pancreatitis
- Aggressive hydration with lactated Ringer's solution may reduce the risk of pancreatitis in average-risk patients 5.
- Sublingual nitrate may provide additional benefit to rectal NSAIDs in preventing post-ERCP pancreatitis 5.
- Tacrolimus may be a promising potential agent to prevent post-ERCP pancreatitis, but needs further clinical study 5.
Current Practice Patterns in the United States
- A survey of advanced endoscopists in the United States found that most respondents reported using rectal NSAIDs for high-risk patients only, while less than half reported using rectal NSAIDs for average-risk patients 6.
- Most respondents reported using prophylactic pancreatic stent placement (PPS) in high-risk patients only, and using PPS in ≤25% of ERCPs 6.