From the Guidelines
When a pancreatic duct (PD) stent and rectal indomethacin are given during ERCP, lactated Ringer's (LR) solution is not needed to prevent post-ERCP pancreatitis. The use of a PD stent and rectal indomethacin during ERCP provides a comprehensive approach to preventing post-ERCP pancreatitis, as supported by the European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) clinical guideline 1. Key points to consider include:
- The ESGE/EASL recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication, as well as the placement of a 5-Fr prophylactic pancreatic stent in cases of high risk for post-ERCP pancreatitis 1.
- The combination of PD stent placement and rectal indomethacin administration addresses the risk of post-ERCP pancreatitis through different mechanisms, including maintaining pancreatic drainage and inhibiting inflammatory pathways 1.
- Aggressive hydration with LR solution has been shown to be beneficial in preventing post-ERCP pancreatitis when used alone, but its additional benefit is minimal when both PD stent and rectal indomethacin are employed 1.
- This approach simplifies post-procedure management and may be particularly beneficial for patients at risk for fluid overload. The guideline from the ESGE and EASL, published in the Journal of Hepatology in 2017, provides strong evidence for the effectiveness of this approach in preventing post-ERCP pancreatitis 1.
From the Research
Prevention of Post-ERCP Pancreatitis
- The use of a pancreatic stent and rectal indomethacin during ERCP is a common strategy to prevent post-ERCP pancreatitis (PEP) in high-risk patients 2, 3, 4, 5, 6.
- Studies have shown that the combination of rectal indomethacin and prophylactic pancreatic stent placement is effective in preventing PEP 2, 6.
- However, some studies suggest that rectal indomethacin alone may not be sufficient to prevent PEP in high-risk patients, and that prophylactic pancreatic stent placement may still be necessary 4, 5, 6.
- A study found that indomethacin did not reduce the incidence or severity of PEP in high-risk patients who routinely received prophylactic pancreatic stent placement 5.
- Another study found that prophylactic pancreatic stent placement was more effective than rectal indomethacin alone in preventing PEP in high-risk patients 6.
Role of Pancreatic Stent Placement
- Prophylactic pancreatic stent placement is a recommended strategy to prevent PEP in high-risk patients 2, 3, 6.
- The use of a pancreatic stent can help to reduce the risk of PEP by facilitating the flow of pancreatic juice and reducing the pressure in the pancreatic duct 2, 6.
- However, pancreatic stent placement is a technically complex and potentially harmful intervention, and its use should be carefully considered in each individual case 2, 3.
Role of Rectal Indomethacin
- Rectal indomethacin is a non-steroidal anti-inflammatory drug that has been shown to reduce the incidence of PEP in high-risk patients 2, 3, 4, 5, 6.
- The use of rectal indomethacin is a simple and inexpensive strategy to prevent PEP, and it may be effective in reducing the risk of PEP in some patients 3, 4.
- However, the effectiveness of rectal indomethacin in preventing PEP may be limited in high-risk patients, and it may not be sufficient to prevent PEP in all cases 4, 5, 6.