From the Guidelines
Post-ERCP vomiting should be managed with antiemetics such as ondansetron 4-8 mg IV/PO every 8 hours or promethazine 12.5-25 mg IV/PO every 6 hours as needed, along with adequate hydration and monitoring for signs of complications like pancreatitis or perforation, as the risk of major complications from ERCP is between 4% to 5.2% 1.
Causes of Vomiting
The vomiting is likely due to sedation effects, delayed gastric emptying from the procedure, or a reaction to contrast material.
- Sedation effects can cause nausea and vomiting due to the impact on the chemoreceptor trigger zone in the brain.
- Delayed gastric emptying from procedural manipulation can also contribute to vomiting.
- Reaction to contrast material is another possible cause, although less common.
Management
Initial management should include:
- Antiemetics such as ondansetron or promethazine to control nausea and vomiting.
- Ensure adequate hydration with IV fluids if oral intake is limited.
- Monitor for signs of more serious complications like pancreatitis (persistent abdominal pain, fever) or perforation (severe pain, abdominal distension). Most post-ERCP vomiting resolves within 24 hours with supportive care.
Further Evaluation
If vomiting persists beyond 24 hours or is accompanied by severe abdominal pain, fever, or inability to tolerate fluids, further evaluation is necessary to rule out procedure-related complications.
- The vomiting mechanism is typically related to delayed gastric emptying from procedural manipulation and the effects of sedative medications on the chemoreceptor trigger zone in the brain.
- Gradual reintroduction of clear liquids followed by a bland diet once vomiting subsides will help with recovery. It is essential to weigh the potential benefits of ERCP against the risks, as the procedure has a significant risk of major complications, including pancreatitis, cholangitis, hemorrhage, and perforation, with a mortality risk of 0.4% 1.
From the Research
Post-ERCP Vomiting
- Vomiting after Endoscopic Retrograde Cholangiopancreatography (ERCP) can be a symptom of various complications, including pancreatitis, bleeding, infection, or perforation 2.
- The prevention of post-ERCP pancreatitis has been a major area of research, with studies showing that aggressive hydration with lactated Ringer's solution can reduce the incidence of pancreatitis after ERCP 3, 4, 5.
Management of Post-ERCP Complications
- The management of post-ERCP complications can be guided by the "5R model" of management: recognize, react, reach out, repent, and revisit 6.
- Aggressive intravenous hydration with lactated Ringer's solution has been shown to be effective in preventing post-ERCP pancreatitis, with a lower incidence of pancreatitis compared to standard hydration or aggressive hydration with normal saline 3, 4, 5.
Prevention of Post-ERCP Pancreatitis
- Studies have consistently shown that aggressive hydration with lactated Ringer's solution can reduce the incidence of post-ERCP pancreatitis, with a significant difference in the intention-to-treat PEP rate between the aggressive LRS group and the standard LRS group 3, 4, 5.
- The use of lactated Ringer's solution for aggressive hydration has been recommended as the best approach to intravenous hydration for the prevention of post-ERCP pancreatitis in average-to-high risk patients 5.