From the Guidelines
Preparation for ERCP should prioritize the use of prophylactic NSAIDs, such as rectal indomethacin or diclofenac, to reduce the risk of post-ERCP pancreatitis (PEP), unless there are contraindications, as recommended by the most recent guidelines 1. To prepare for ERCP, several key steps should be taken to ensure safety and effectiveness.
Medication Management
Medication management is crucial, with blood thinners like warfarin, clopidogrel, and direct oral anticoagulants potentially needing to be temporarily discontinued 3-7 days before the procedure, depending on the specific medication and patient risk factors, as suggested by guidelines on managing patients on antithrombotic agents undergoing endoscopy 1.
Fasting and Sedation
Patients should fast for at least 6-8 hours before the procedure, with no solid foods and only clear liquids allowed until the designated cutoff time.
Antibiotic Prophylaxis
Prophylactic antibiotics are not routinely recommended for all patients undergoing ERCP but may be considered for those with specific risk factors for sepsis, such as sclerosing cholangitis or liver transplantation, as per the guidelines on the management of common bile duct stones 1.
Informed Consent and Laboratory Tests
Informed consent must be obtained after explaining potential complications, including pancreatitis, bleeding, infection, and perforation. Laboratory tests, including complete blood count, liver function tests, coagulation profile, and renal function, should be performed within 1-2 weeks before the procedure.
Anaesthetic Technique
The choice of anaesthetic technique, whether deep sedation or general anaesthesia, should be made based on patient-specific factors and the procedure's requirements, with monitored anaesthesia care (MAC) recommended over general anaesthesia for most patients undergoing ERCP, according to recent consensus guidelines 1.
Post-Procedure Care
Patients should arrange for someone to drive them home afterward, as sedation medications will impair their ability to drive safely. By following these steps and prioritizing the use of prophylactic NSAIDs to reduce the risk of PEP, the preparation for ERCP can be optimized to minimize complications and improve diagnostic and therapeutic outcomes.
From the Research
Preparation for ERCP
- Preparation for ERCP involves several key considerations to minimize the risk of complications, including the use of antibiotic prophylaxis and management of antiplatelet therapy 2, 3, 4.
- The use of prophylactic antibiotics before ERCP is recommended, especially in patients with an obstructed biliary system, to decrease the incidence of complications such as cholangitis, cholecystitis, septicaemia, and pancreatitis 2.
- Studies have shown that antibiotic prophylaxis can reduce the risk of bacteremia and may prevent cholangitis and septicaemia in patients undergoing elective ERCP 2, 3.
- In terms of antiplatelet therapy, research suggests that there is no significant difference in post-ERCP bleeding rates between dual antiplatelet agents and aspirin alone 5.
- Other measures to prevent post-ERCP pancreatitis (PEP) include the use of rectal administered non-steroidal anti-inflammatory agents, pancreatic duct stent placement, and aggressive hydration, particularly in high-risk patients 6.
Antibiotic Prophylaxis
- The choice of antibiotic prophylaxis may depend on the individual patient's risk factors and the specific procedure being performed 4.
- Oral ciprofloxacin and intravenous cefuroxime have been compared in patients at high risk of cholangitis after ERCP, with ciprofloxacin found to be safe and effective, as well as more economical 4.
- The use of antibiotic prophylaxis has been shown to reduce the risk of bacteremia, but its impact on other complications such as cholangitis, septicemia, pancreatitis, and mortality is less clear 3.
Management of Antiplatelet Therapy
- The management of antiplatelet therapy in patients undergoing ERCP is an important consideration to minimize the risk of bleeding complications 5.
- Research suggests that dual antiplatelet therapy does not significantly increase the risk of post-ERCP bleeding compared to aspirin alone 5.
- However, further studies are needed to fully understand the risks and benefits of antiplatelet therapy in the context of ERCP 5.