From the Guidelines
The most common complication post ERCP is acute pancreatitis, which occurs in approximately 3-10% of cases, making it significantly more frequent than duodenal perforation. This is based on the evidence from the European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) clinical guideline, which states that post-ERCP pancreatitis (PEP) is the most common and feared complication associated with ERCP 1. The risk factors for PEP include female sex, guidewire in the pancreatic duct, prolonged papilla contact time, and therapeutic procedures such as biliary brush cytology, sphincterotomy, stenting, and dilation.
Some key points to consider in the management and prevention of post-ERCP pancreatitis include:
- The use of rectal non-steroidal anti-inflammatory drugs (NSAIDs) such as 100mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication, as recommended by the ESGE 1.
- The placement of a 5-Fr prophylactic pancreatic stent in patients at high risk for post-ERCP pancreatitis, such as those with precut biliary sphincterotomy, pancreatic guidewire-assisted biliary cannulation, or presence of more than three risk factors 1.
- The guidewire technique as the most appropriate first-line cannulation technique, as it increases the primary cannulation rate and reduces the risk of PEP 1.
Overall, the evidence suggests that acute pancreatitis is the most common complication post ERCP, and that prophylactic measures such as rectal NSAIDs and pancreatic duct stent placement can significantly reduce the risk of this complication. Therefore, it is essential to take preventive measures to minimize the risk of post-ERCP pancreatitis, especially in high-risk patients.
From the Research
Complications of ERCP
The most common complication of Endoscopic Retrograde Cholangiopancreatography (ERCP) is:
- Acute pancreatitis, which is reported to occur in 2-10% of unselected patient samples and up to 40% of high-risk patients 2
- Other complications include duodenal perforation, papillary bleeding, and biliary septic complications like acute cholecystitis and cholangitis 3
Risk Factors for Post-ERCP Pancreatitis
Risk factors for post-ERCP pancreatitis include:
- Difficult sphincterotomy with precut use
- Failure of CBD desobstruction
- Pancreatic sphincterotomy
- Repeated injection of contrast in the pancreatic ductal system
- Dysfunction of the sphincter of Oddi
- Absence of changes of chronic pancreatitis 3
- Young age, female sex, suspected sphincter of Oddi dysfunction, a history of post-ERCP pancreatitis, and normal serum bilirubin 2
Prevention of Post-ERCP Pancreatitis
Prevention strategies include:
- Careful patient selection and performing ERCP for specific indications
- Considering alternative diagnostic modalities when appropriate
- Using a guide wire for cannulation
- Minimizing the number of cannulation attempts
- Avoiding contrast injections or trauma to the pancreatic duct
- Placement of a temporary pancreatic duct stent in high-risk patients
- Administration of rectal non-steroidal anti-inflammatory agents (NSAIDs) in high-risk patients 2
- Use of rectally administered diclofenac or indomethacin before or closely after ERCP 4