Is a pancreatic stent and rectal indomethacin (Indocin) sufficient to prevent post-ERCP (Endoscopic Retrograde Cholangiopancreatography) pancreatitis, making a nasojejunal lavage (LR) unnecessary?

From the Guidelines

Pancreatic duct (PD) stent placement and rectal indomethacin administration during ERCP do not eliminate the need for lactated Ringer's (LR) solution to prevent post-ERCP pancreatitis. The current evidence suggests that a combination approach is the most effective way to prevent post-ERCP pancreatitis, especially in high-risk patients. According to the European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) clinical guideline 1, routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP is recommended in all patients without contraindication. Additionally, the placement of a 5-Fr prophylactic pancreatic stent should be considered in cases of high risk for post-ERCP pancreatitis. However, this does not replace the need for aggressive hydration with LR solution. Some key points to consider include:

• The risk factors for post-ERCP pancreatitis, such as female sex, guidewire in the pancreatic duct, and prolonged papilla contact time, are not different in patients with primary sclerosing cholangitis (PSC) compared to the general population 1.
• Rectal non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to reduce the risk of post-ERCP pancreatitis, with a strong recommendation and high-quality evidence supporting their use 1.
• Pancreatic stenting has also been shown to reduce the incidence and severity of post-ERCP pancreatitis, particularly in high-risk patients 1. The use of LR solution, typically administered at 3 mL/kg/hr during the procedure, 8 mL/kg bolus after the procedure, and 3 mL/kg/hr for 8 hours post-procedure, has been shown to independently reduce the risk of post-ERCP pancreatitis by maintaining pancreatic microcirculation and reducing inflammatory cascades. Therefore, a multi-modal approach that includes aggressive hydration with LR solution, PD stent placement, and rectal indomethacin administration is recommended for preventing post-ERCP pancreatitis, especially in high-risk patients.

From the Research

Post-ERCP Pancreatitis Prevention

The use of prophylactic pancreatic duct stent (PD stent) placement and rectal indomethacin to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has been studied in several trials.

• The combination of PD stent placement and rectal indomethacin is recommended for preventing PEP in high-risk cases 2.
• However, some studies suggest that rectal indomethacin alone may be sufficient to prevent PEP, potentially eliminating the need for PD stent placement 3.
• A randomized controlled trial found that rectal indomethacin alone was more effective in preventing PEP than no prophylaxis, PD stent placement alone, or the combination of indomethacin and PD stent placement 3.

Efficacy of Rectal Indomethacin

• Rectal indomethacin has been shown to reduce the incidence of PEP in high-risk patients 4, 3.
• A study found that rectal indomethacin alone was associated with a lower incidence of PEP compared to PD stent placement alone or the combination of indomethacin and PD stent placement 3.
• However, another study found that the addition of rectal indomethacin to PD stent placement did not significantly reduce the incidence of PEP in patients with suspected type 3 sphincter of Oddi dysfunction 5.

Cost-Benefit Analysis

• A post hoc analysis of a randomized controlled trial found that using rectal indomethacin alone as a prevention strategy could save approximately $150 million annually in the United States compared to a strategy of PD stent placement alone, and $85 million compared to a strategy of indomethacin and PD stent placement 3.
• The study suggested that prophylactic rectal indomethacin could replace PD stent placement in patients undergoing high-risk ERCP, potentially improving clinical outcomes and reducing healthcare costs 3.

PD Stent Placement

• PD stent placement has been shown to reduce the incidence of PEP in high-risk patients 6.
• A randomized controlled trial found that PD stent placement was associated with a lower incidence of PEP compared to no stent placement 6.
• However, the use of PD stent placement is not without risks, and the potential benefits and risks of PD stent placement should be carefully considered in each patient 2, 6.