From the Guidelines
To prevent post-ERCP pancreatitis, rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP is superior and should be considered in all patients without contraindication, as it has been shown to reduce the risk of post-ERCP pancreatitis in multiple high-quality studies, including those published in the Journal of Hepatology 1 and Gut 1.
Key Recommendations
- Rectal non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac or indomethacin should be administered as a 100mg suppository immediately before or after the procedure to reduce the risk of post-ERCP pancreatitis.
- For high-risk patients, the placement of a 5-Fr prophylactic pancreatic stent should be considered in addition to rectal NSAIDs, as it has been shown to reduce the risk of post-ERCP pancreatitis in high-risk cases, particularly those with difficult cannulation or sphincter of Oddi dysfunction 1.
- Other helpful measures include limiting contrast injections into the pancreatic duct, using guidewire-assisted cannulation techniques, and avoiding unnecessary pancreatic sphincterotomy, as these interventions work by reducing mechanical trauma, chemical irritation, and the subsequent inflammatory cascade that leads to pancreatitis after ERCP 1.
High-Risk Patients
- Patients with precut biliary sphincterotomy, pancreatic guidewire-assisted biliary cannulation, endoscopic balloon sphincteroplasty, pancreatic sphincterotomy, and presence of more than three of the following risk factors: female gender, previous pancreatitis, younger age, non-dilated extrahepatic bile ducts, absence of chronic pancreatitis, normal serum bilirubin, duration of cannulation attempts [10 min, [1 pancreatic guidewire passage, pancreatic injection, failure to clear bile duct stones, IDUS, are considered high-risk for post-ERCP pancreatitis and may benefit from additional prophylactic measures such as pancreatic duct stenting 1.
Conclusion Not Applicable - Direct Answer Only
The use of rectal NSAIDs and pancreatic duct stenting in high-risk cases has been shown to be effective in reducing the risk of post-ERCP pancreatitis, and these interventions should be considered in all patients undergoing ERCP, unless there is a contraindication, as supported by high-quality evidence from recent studies, including those published in the Journal of Hepatology 1 and Gut 1.
From the Research
Prevention of Post-ERCP Pancreatitis
To prevent post-ERCP pancreatitis, several strategies have been studied, including the use of rectal indomethacin, prophylactic pancreatic stent placement, and other emerging therapies. The key findings from the available evidence are:
- Rectal Indomethacin: Studies have shown that rectal indomethacin is effective in preventing post-ERCP pancreatitis, particularly in high-risk patients 2, 3, 4.
- Prophylactic Pancreatic Stent Placement: The combination of rectal indomethacin and prophylactic pancreatic stent placement is recommended to prevent pancreatitis after ERCP in high-risk patients 5.
- Emerging Therapies: Other emerging therapies, such as aggressive hydration with lactated Ringer's, sublingual nitrate, and tacrolimus, may also be effective in preventing post-ERCP pancreatitis 6.
Comparison of Strategies
The available evidence suggests that:
- Indomethacin alone vs. Indomethacin plus Stent: A strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement in preventing post-ERCP pancreatitis 5.
- Rectal Indomethacin vs. Placebo: Rectal indomethacin significantly reduced the incidence of post-ERCP pancreatitis compared to placebo 2, 3, 4.
- Timing of Rectal Indomethacin Administration: The timing of rectal indomethacin administration (before or after ERCP) does not appear to affect its efficacy in preventing post-ERCP pancreatitis 3, 4.
Key Findings
The key findings from the available evidence are:
- Rectal indomethacin is effective in preventing post-ERCP pancreatitis, particularly in high-risk patients.
- Prophylactic pancreatic stent placement is recommended in addition to rectal indomethacin in high-risk patients.
- Emerging therapies, such as aggressive hydration with lactated Ringer's, sublingual nitrate, and tacrolimus, may also be effective in preventing post-ERCP pancreatitis.