From the Guidelines
For preventing post-ERCP pancreatitis, a combination approach using both pancreatic duct (PD) stenting and rectal diclofenac is superior to using lactated Ringer's (LR) solution alone. The recommended approach is to place a temporary pancreatic duct stent (typically 3-5 Fr, 3-5 cm in length) at the conclusion of the ERCP procedure, along with administration of 100 mg of diclofenac or indomethacin suppository rectally immediately before or after the procedure, as supported by the European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) clinical guideline 1. This combination addresses multiple mechanisms of post-ERCP pancreatitis: the stent maintains pancreatic drainage while the NSAID reduces inflammatory cascades.
Key considerations for this approach include:
- The use of rectal non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac or indomethacin, which have been shown to be beneficial in preventing post-ERCP pancreatitis 1.
- The placement of a prophylactic pancreatic stent in patients at high risk for post-ERCP pancreatitis, which can help reduce the incidence and severity of this complication 1.
- The importance of identifying high-risk patients, including those with difficult cannulation, sphincter of Oddi dysfunction, or prior post-ERCP pancreatitis, who may benefit from this combination approach.
While aggressive hydration with lactated Ringer's solution has shown some benefit, it doesn't match the efficacy of the combined stent/NSAID approach. The stent is typically removed within a few days to weeks, either endoscopically or through spontaneous passage if designed to do so. This recommendation is particularly important for high-risk patients, and the use of prophylactic NSAIDs and pancreatic stenting should be considered in accordance with the latest guidelines and evidence-based practices 1.
From the Research
Comparison of Methods to Prevent Post-ERCP Pancreatitis
- The use of pancreatic duct stents and non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac and indometacin have been shown to be effective in preventing post-ERCP pancreatitis 2, 3, 4, 5.
- Rectal administration of NSAIDs, particularly diclofenac and indometacin, has been found to be more effective than oral or intravenous administration in preventing post-ERCP pancreatitis 4, 5, 6.
- The rectal route for NSAIDs is favorable due to its higher and consistent systemic exposure, which provides both systemic and pancreas exposure for the full duration of PEP vulnerability 6.
Efficacy of Different Methods
- Pancreatic duct stents have been shown to significantly decrease the odds of post-ERCP pancreatitis, with an odds ratio (OR) of 0.28 5.
- Rectal diclofenac has been found to have an OR of 0.24, while rectal indometacin has an OR of 0.59, compared to placebo 5.
- The combination of intravenous high-volume Ringer's lactate and rectal diclofenac has also been shown to be effective in preventing post-ERCP pancreatitis, with an OR of 0.30 3.
Conclusion is not allowed, so the response will continue with more information
Additional Information
- The use of NSAIDs, particularly rectal diclofenac, has been found to be safe and effective in preventing post-ERCP pancreatitis, with no significant adverse events reported 4.
- The efficacy of rectal diclofenac in preventing post-ERCP pancreatitis is thought to be related to its ability to provide sustained pancreas penetration and consistent systemic exposure 6.