From the Guidelines
Pancreatic duct (PD) stent placement and rectal indomethacin alone are not sufficient to replace lactated Ringer's (LR) solution for preventing post-ERCP pancreatitis. The current recommendation is to use a combination approach that includes aggressive hydration with LR solution, along with PD stent placement and rectal indomethacin in high-risk patients, 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:
- Aggressive hydration with LR solution, which typically involves administering 3 mL/kg/hour during the procedure, a 20 mL/kg bolus immediately after, and then 3 mL/kg/hour for 8 hours post-procedure, has been shown to independently reduce post-ERCP pancreatitis risk by improving pancreatic microcirculation and reducing inflammatory cascades.
- PD stents help maintain pancreatic drainage, and
- Rectal indomethacin (100 mg) reduces inflammatory responses, as recommended by ESGE/EASL for routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication 1. For optimal prevention, especially in high-risk patients, all three preventive measures should be employed when possible, rather than relying on just stenting and indomethacin. High-risk conditions for post-ERCP pancreatitis include 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, as outlined in the ESGE/EASL guideline 1.
From the Research
Prevention of Post-ERCP Pancreatitis
- The use of rectal indomethacin and prophylactic pancreatic duct stent placement (PSP) is recommended for preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases 2, 3.
- A study published in The New England Journal of Medicine found that rectal indomethacin significantly reduced the incidence of PEP in patients at high risk for post-ERCP pancreatitis 2.
- Another study published in Trials aimed to determine whether rectal indomethacin alone is non-inferior to the combination of rectal indomethacin and PSP for preventing PEP in high-risk cases 3.
Role of Pancreatic Duct Stent Placement
- A study published in Clinical Gastroenterology and Hepatology found that placement of a temporary-type pancreatic duct stent reduces the incidence of PEP in high-risk patients 4.
- However, a study published in Digestive Diseases and Sciences found that prophylactic rectally administered indomethacin with PD stenting was not observed to affect the incidence or severity of post-ERCP pancreatitis when compared to PD stenting alone in patients with suspected type 3 sphincter of Oddi dysfunction 5.
Utilization of Prophylactic Measures
- A retrospective analysis published in Endoscopy International Open found that only one-third of all patients undergoing ERCP received prophylaxis in the form of rectal indomethacin and/or PSP, highlighting the need for increased implementation of prophylactic use in patients undergoing ERCP 6.