Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) abdominal pain in patients without post-ERCP pancreatitis

BackgroundAbdominal pain is often observed after endoscopic retrograde cholangiopancreatography (ERCP). Few studies have focused on the risk factors of post-ERCP abdominal pain without post-ERCP pancreatitis (PEP). This study aimed to identify risk factors of post-ERCP abdominal pain without PEP and investigate characteristics of the abdominal pain in non-PEP patients.MethodsData from patients who underwent ERCP from August 2019 to January 2020 were retrospectively collected. Characteristics of the abdominal pain after ERCP were recorded and compared between PEP and non-PEP patients. Multivariate analysis was conducted to identify risk factors of non-PEP abdominal pain.ResultsA total of 1295 ERCP procedures were investigated in this study, among which 100 (7.72%) patients presented post-ERCP abdominal pain without PEP and 63 (4.86%) patients with PEP. Multivariate analysis found 9 risk factors of non-PEP abdominal pain: age ≤ 65 years [odds ratio (OR): 1.971], primary ERCP (OR: 2.442), dilated extrahepatic bile duct (OR: 1.803), no papilla opening (OR: 2.095), pancreatic guidewire passages (OR: 2.258), white blood cells (WBC) ≤ 6.0 × 10⁹/L (OR: 1.689), platelet (PLT) ≤ 250 × 10⁹/L (OR: 2.505), serum γ-glutamyl transferase (γ ? GT) ≤ 35 U/L (OR: 2.190), and albumin ≥ 40 g/L (OR: 1.762). The PEP group had later pain onset, higher pain frequency and longer hospital stay than those of the non-PEP pain group (P < 0.05). There were no significant differences in the pain duration, visual analogue scale score and mortality between the PEP group and non-PEP pain group (P > 0.05).ConclusionsThis study indicated that age ≤ 65 years, primary ERCP, dilated extrahepatic bile duct, no papilla opening, pancreatic guidewire passages, lower WBC, lower PLT, normal γ ? GT and elevated albumin were independent risk factors for post-ERCP abdominal pain without PEP. The pain occurred earlier in non-PEP patients than in PEP patients.     

Effects of Medications on Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Background and Aims: Drug-induced pancreatitis accounts for about 2% of acute pancreatitis. The aim of this study is to determine whether propofol and other medications are associated with increased risk for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Methods: A retrospective study was conducted at a single tertiary care hospital. All patients who underwent ERCP from 2001 to 2004 were included. Diagnosis of acute post-ERCP pancreatitis was based on a consensus definition. Results: A total of 506 patients underwent ERCP. The total incidence of post-ERCP pancreatitis was 7.1%. There was no significant difference in post-ERCP pancreatitis between patients who received propofol compared to patients who received midazolam and fentanyl (9.0 vs. 5.9%, p = 0.18). Patients receiving an angiotensin receptor blocker were approximately 4 times more likely to develop post-ERCP pancreatitis (OR = 4.1, 95% CI 1.6–10.9). Patients younger than 65 years and smokers also had higher risk of developing acute post-ERCP pancreatitis than those who were older than 65 years (OR = 3.9, 95% CI 1.7–9.1) and non-smokers (OR = 2.8, 95% CI 1.3–6.2). Conclusions: Propofol is a safe sedative drug for ERCP without additional risk of developing acute post-ERCP pancreatitis. Use of angiotensin receptor blockers, smoking and younger age are independent risk factors for post-ERCP pancreatitis.     

Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study

BACKGROUND: Pancreatitis is the most frequent complication of ERCP. Injury to the papilla during ERCP could obstruct pancreatic duct outflow and initiate pancreatitis. A randomized prospective study was performed to evaluate the effect of pancreatic duct stent placement on the frequency and severity of post-ERCP pancreatitis in a selected group of patients. METHODS: The study group consisted of patients over 18 years of age at high risk for post-ERCP pancreatitis because of a difficult cannulation, sphincter of Oddi manometry, and/or the performance of endoscopic sphincterotomy. Patients were prospectively randomized to have a pancreatic duct stent placed or no stent upon completion of the ERCP. The endoprosthesis used was either a 5F nasopancreatic catheter or 5F, 2-cm long pancreatic stent. Study endpoints were the frequency and severity of post-ERCP pancreatitis. RESULTS: Patients undergoing pancreatic duct stent placement had a lower frequency of post-ERCP pancreatitis as compared with those in the control group (28% vs. 5%; p < 0.05). Pancreatitis tended to be less severe in patients who had pancreatic duct drainage. CONCLUSIONS: Pancreatic duct stent insertion after ERCP reduces the frequency of post-ERCP pancreatitis in patients at high risk for this complication.     

Risk factors for post-ERCP pancreatitis: a prospective, multicenter study

BACKGROUND: Post-ERCP pancreatitis is poorly understood. The goal of this study was to comprehensively evaluate potential procedure- and patient-related risk factors for post-ERCP pancreatitis over a wide spectrum of centers. METHODS: Consecutive ERCP procedures were prospectively studied at 11 centers (6 private, 5 university). Complications were assessed at 30 days by using established consensus criteria. RESULTS: Pancreatitis occurred after 131 (6.7%) of 1963 consecutive ERCP procedures (mild 70, moderate 55, severe 6). By univariate analysis, 23 of 32 investigated variables were significant. Multivariate risk factors with adjusted odds ratios (OR) were prior ERCP-induced pancreatitis (OR 5.4), suspected sphincter of Oddi dysfunction (OR 2.6), female gender (OR 2.5), normal serum bilirubin (OR 1.9), absence of chronic pancreatitis (OR 1.9), biliary sphincter balloon dilation (OR 4.5), difficult cannulation (OR 3.4), pancreatic sphincterotomy (OR 3.1), and 1 or more injections of contrast into the pancreatic duct (OR 2.7). Small bile duct diameter, sphincter of Oddi manometry, biliary sphincterotomy, and lower ERCP case volume were not multivariate risk factors for pancreatitis, although endoscopists performing on average more than 2 ERCPs per week had significantly greater success at bile duct cannulation (96.5% versus 91.5%, p = 0.0001). Combinations of patient characteristics including female gender, normal serum bilirubin, recurrent abdominal pain, and previous post-ERCP pancreatitis placed patients at increasingly higher risk of pancreatitis, regardless of whether ERCP was diagnostic, manometric, or therapeutic. CONCLUSIONS: Patient-related factors are as important as procedure-related factors in determining risk for post-ERCP pancreatitis. These data emphasize the importance of careful patient selection as well as choice of technique in the avoidance of post-ERCP pancreatitis.     

Prophecy about post-endoscopic retrograde cholangiopancreatography pancreatitis:From divination to science

One unresolved issue of endoscopic retrograde cholangiopancreatography(ERCP)is post-ERCP pancreatitis (PEP),which occurs in up to 40%of patients.Identification of risk factors for PEP is especially important in the field of ERCP practice because it may assist physicians in taking protective measures in situations with high risk.A decade ago,Freeman et al meticulously evaluated a large number of potentially relevant risk factors for PEP,which can be divided into patient-relat-ed and procedure-related issues.In this commentary, we summarize this classic article and reevaluate the risk factors for PEP from the current point of view.This is followed by assessment of strategies for prevention of PEP that can be divided into mechanical and pharmacologic methods.     

Placement of prophylactic pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A meta-analysis

AIM:To assess the effectiveness of pancreatic stents for preventing pancreatitis in high-risk patients after endoscopic retrograde cholangiopancreatography(ERCP).METHODS:PubMed,Embase,Science Citation Index,and Cochrane Controlled Trials Register were searched to identify relevant trials published in English.Inclu-sion and exclusion criteria were used to screen for suitable studies.Two reviewers independently judged the study eligibility while screening the citations.The methodological quality of the included trials was assessed using the Jadad scoring system.All results were expressed as OR and 95%CI.Data were analyzed using Stata12.0 software.RESULTS:Ten eligible randomized controlled trials were selected,including 1176 patients.A fixed-effects model in meta-analysis supported that pancreatic duct stents significantly decreased the incidence of postERCP pancreatitis(PEP)in high-risk patients(OR=0.25;95%CI:0.17-0.38;P<0.001).Pancreatic stents also alleviated the severity of PEP(mild pancreatitis after ERCP:OR=0.33;95%CI:0.21-0.54;P<0.001;moderate pancreatitis after ERCP:OR=0.30;95%CI:0.13-0.67;P=0.004).The result of severe pancreatitis after ERCP was handled more rigorously(OR=0.24;95%CI:0.05-1.16;P=0.077).Serum amylase levels were not different between patients with pancreatic stents and control patients(OR=1.08;95%CI:0.82-1.41;P=0.586).CONCLUSION:Placement of prophylactic pancreatic stents may lower the incidence of post-ERCP pancreatitis in high-risk patients and alleviate the severity of this condition.     

Indomethacin for post-endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis:Is it the magic bullet?

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Pancreatic duct stent insertion after ERCP has been widely accepted as the standard of care for the prevention of this complication in high-risk patients. Unfortunately, the placement of pancreatic stents requires higher level of endoscopic expertise and is not always feasible due to anatomic considerations. Therefore, effective non-invasive pharmacologic prophylaxis remains appealing, particularly if it is inexpensive, easily administered, has a low risk side effect profile and is widely available. There have been multiple studies evaluating potential pharmacologic candidates for post-ERCP pancreatitis (PEP) prophylaxis, most of them yielding disappointing results. A recently published large, multi-center, randomized controlled trial reported that in high risk patients a single dose of rectal indomethacin administered immediately after the ERCP significantly decreased the incidence of PEP compare to placebo.     

Risk for post-ERCP pancreatitis after needle knife precut sphincterotomy following repeated cannulation attempts

GOALS: The aim of this study was to determine the risk and identify the factors associated with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients who undergo needle knife precut sphincterotomy (NKS). In addition, we evaluated the effect of gabexate for the prevention of post-ERCP pancreatitis. BACKGROUND: NKS, after repeated cannulation attempts during ERCP, is known to increase the risk of post-ERCP pancreatitis. However, the specific risk factors for post-ERCP pancreatitis have not been identified, and the preventive role of protease inhibitors, such as gabexate, has not yet been established. STUDY: The medical records of 200 patients who underwent NKS, after repeated cannulation attempts during ERCP, were reviewed retrospectively. The potential risk factors for post-ERCP pancreatitis were investigated. The effect of gabexate infused after the ERCP procedure was also evaluated. RESULTS: Thirteen (6.5%) patients out of 200 developed post-ERCP pancreatitis. Sex, age, the presence of pancreatitis at procedure, underlying disease, direction of the sphincterotomy, success or failure of cannulation after NKS, diameter of common bile duct, pancreatic duct status, and the presence of acinar filling were not associated with the risk of pancreatitis. Gabexate infusion after ERCP increased the incidence of ERCP-associated pancreatitis. CONCLUSIONS: We could not identify any risk factors associated with the development of post-ERCP pancreatitis in patients who underwent NKS after repeated cannulation attempts during ERCP. However, gabexate administered after the ERCP procedure was found to increase the incidence of pancreatitis.     

NSAIDs for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography:Ready for prime time?

Acute pancreatitis is the most common and the most fearful complication of endoscopic retrograde cholangiopancreatography (ERCP). Prevention of post-ERCP pancreatitis has therefore been of great interest to endoscopists performing ERCP procedures. So far, only pancreatic duct stenting during ERCP and rectal administration of a non-steroidal anti-inflammatory drug (NSAID) prior to or immediately after ERCP have been consistently shown to be effective for prevention of post-ERCP pancreatitis. This commentary focuses on a short discussion about the rates, mechanisms, and risk factors for post-ERCP pancreatitis, and effective means for its prevention with emphasis on the use of NSAIDs including a recent clinical trial published in The New England Journal of Medicine by Elmunzer et al([11]).     

Predicting and preventing Post-ERCP pancreatitis

Pancreatitis is rightly the most feared complication of endoscopic retrograde cholangiopancreatography (ERCP). Ten percent to 15% of cases of post-ERCP pancreatitis (PEP) are severe by clinical and radiologic criteria. Such cases carry significant morbidity and mortality and are responsible for the vast majority of ERCP-related deaths. The prediction and prevention of PEP have been of great interest to endoscopists since the introduction of ERCP 30 years ago. Prediction and diagnosis of PEP have become more accurate with the widespread availability of serum amylase estimation. A variety of cytokines (eg, interleukin [IL]-1, IL-6, and IL-8) and acute phase reactants (eg, C-reactive protein) are also elevated in the serum in acute pancreatitis, and these form the basis of evolving tests for PEP. Urine testing (for amylase) in acute pancreatitis is obsolete, but it may soon undergo a revival in the form of a rapid (3-minute) dipstick test for trypsinogen-2, a sensitive and specific test for this disease. The prevention of PEP takes multiple forms. The following steps are recommended for clinicians: 1) avoid ERCP when other, less invasive or noninvasive imaging tests can do the job (eg, CT or magnetic resonance imaging); 2) avoid highrisk (of PEP) procedures, such as needle-knife papillotomy, balloon dilation of the biliary sphincter, and pancreatic sphincterotomy, and take steps to reduce risk when these procedures are unavoidable; 3) ensure that those who perform ERCP have adequate training and experience; and 4) consider pharmacologic intervention. Despite a depressing catalog of drug interventions that have failed over the years (eg, antihistamines, anticholinergics, and corticosteroids), three agents have recently shown promise: somatostatin; its octapeptide analogue, octreotide; and gabexate mesylate, a protease inhibitor.     

Risk factors for the development of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND Previous studies have revealed that patients with asymptomatic common bile duct(CBD) stones are at a high risk of developing post-endoscopic retrograde cholangiopancreatography(ERCP) pancreatitis(PEP). However, no studies to date have addressed the risk factors for PEP in patients with asymptomatic CBD stones.AIM To examine the risk factors for PEP in patients with asymptomatic CBD stones.METHODS Using medical records of three institutions in Japan for 6 years, we identified a total of 1135 patients with choledocholithiasis including 967 symptomatic patients and 168 asymptomatic patients with native papilla who underwent therapeutic ERCP. We performed univariate and multivariate analyses to examine the risk factors for PEP in the 168 patients with asymptomatic CBD stones.RESULTS The overall incidence rate of PEP in all the patients with during study period was4.7%(53/1135). Of the 168 patients with asymptomatic CBD stones, 24(14.3%)developed PEP. In univariate analysis, precut sphincterotomy(P = 0.009) and biliary balloon sphincter dilation(P = 0.043) were significant risk factors for PEP.In multivariate analysis, precut sphincterotomy(P = 0.002, 95%CI: 2.2-27.8, odds ratio = 7.7), biliary balloon sphincter dilation(P = 0.015, 95%CI: 1.4-17.3, odds ratio = 4.9), and trainee endoscopists(P = 0.048, 95%CI: 1.01-8.1, odds ratio = 2.9)were significant risk factors for PEP.CONCLUSION ERCP for asymptomatic CBD stones should be performed by experienced endoscopists. When performing precut sphincterotomy or biliary balloon sphincter dilation in patients with asymptomatic CBD stones, the placement of a prophylactic pancreatic stent is strongly recommended to prevent PEP.     

Endoscopic retrograde cholangiopancreatography-related adverse events in patients with type 1 autoimmune pancreatitis

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is frequently performed for the diagnosis and treatment of type 1 autoimmune pancreatitis (AIP). However, the prevalence of ERCP-related adverse events in patients with type 1 AIP has not been evaluated. We aimed to clarify the feasibility of ERCP in patients with type 1 AIP.MethodsWe retrospectively reviewed 82 consecutive ERCP procedures performed in patients with type 1 AIP from 2004 to 2014 in one university hospital and three tertiary-care referral centers. One hundred four ERCP procedures in chronic pancreatitis and 1123 in non-AIP cohort were enrolled as control groups. We compared the incidence of post-ERCP pancreatitis (PEP) between type 1 AIP and control groups. We evaluated the incidence of ERCP-related adverse events and various predictive factors for hyperamylasemia after ERCP.ResultsPancreatography and cholangiography by ERCP were obtained in 78 (95.1%) and 76 (92.7%) patients, respectively. The incidence of PEP, cholangitis, and bleeding was 1.2% (1/82), 0%, and 1.2%, respectively. PEP occurred in type 1 AIP patient with diffuse parenchymal imaging, and the severity was mild. The incidences of PEP were 2.9% (3/104) and 5.4% (61/1123) in chronic pancreatitis and normal cohort, respectively. The incidence of PEP was slightly lower in type 1 AIP than non-AIP cohort (1.2% vs 5.8%, p = 0.119). There were no significant predictive factors for hyperamylasemia after ERCP in type 1 AIP.ConclusionsThe incidence of ERCP-related adverse events is low in patients with type 1 AIP. ERCP-related procedures are feasible in the diagnosis and treatment of AIP.     

吲哚美辛在预防ERCP术后胰腺炎中作用的研究

目的观察直肠应用吲哚美辛对ERCP术后胰腺炎（PEP）及高淀粉酶血症的预防作用。方法将行ERCP检查的168例患者随机分为两组,吲哚美辛组在ERCP术前30 min直肠内给予吲哚美辛栓剂100 mg,对照组在ERCP术前30 min直肠内给予安慰剂栓。ERCP术后观察患者有无腹痛,并于术后12 h做血清及尿淀粉酶测定。结果吲哚美辛组PEP发生率（6.0%）与安慰剂组PEP发生率（10.6%）无显著差异（P=0.28）,但是吲哚美辛组ERCP术后高淀粉酶血症的发生率（18.1%）显著低于安慰剂组（37.6%,P=0.005）。结论直肠应用吲哚美辛可以预防ERCP术后高淀粉酶血症的发生。     

Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis

One of the most frequent and serious complications of endoscopic retrograde cholangiopancreatography (ERCP) is acute pancreatitis. The aim of this study was to evaluate the preventive effect of low-dose heparin (unfractionated or low-molecular-weight heparin) on post-ERCP pancreatitis (PEP) and its side-effects by a systematic review and meta-analysis of clinical trials. Searching PubMed and EMBASE, up to August 2011, two independent reviewers systematically identified prospective clinical trials detecting the effect of prophylactic low-dose heparin on the incidence of PEP, severe PEP, and post-ERCP hemorrhage complications. Four clinical trials fulfilled our selection criteria, with three prospective randomized and one nonrandomized. A meta-analysis of these clinical trials was then performed. A total of 1438 patients were included. Meta-analysis of these trials indicated that there was no significant association between the use of heparin and the reduction of PEP [relative risk (RR) 0.67, 95% confidence interval (CI): 0.44-1.03, P=0.07] and severe PEP (RR 0.62, 95% CI: 0.15-2.60, P=0.51). However, low-dose heparin did not increase the incidence of post-ERCP hemorrhage complications (RR 0.84, 95% CI: 0.34-2.03, P=0.69). This meta-analysis did not demonstrate a statistically significant benefit of prophylactic heparin use for the prevention of post-ERCP pancreatitis. More multicenter trials involving a larger number of patients are needed to show a possible prevention effect of PEP from heparin and its related compounds.     

The results of the Tokyo Trial of Prevention of Post-ERCP Pancreatitis with Risperidone (Tokyo P3R): a multicenter, randomized, phase II, non-placebo-controlled trial

Background

A previous study suggested that ulinastatin effectively prevented post-ERCP pancreatitis (PEP) and hyperenzymemia (PEH) in patients at average risk. In experimental models, risperidone, a selective serotonin 2A antagonist, ameliorated acute pancreatitis. We assessed the effect of risperidone combined with ulinastatin for the prevention of PEP in high-risk patients.

Methods

In a multicenter, randomized, controlled, phase II trial, patients undergoing therapeutic ERCP were randomly assigned to receive ulinastatin (150000 U) with or without risperidone (1 mg). A risperidone tablet was taken orally 30–60 min before ERCP and ulinastatin was administered intravenously for 10 min immediately prior to ERCP. The primary end point was the incidence of PEP; secondary end points were PEH severity and enzyme levels (amylase, pancreatic amylase, lipase).

Results

A total of 226 patients (113 per group) were included in the study. Six patients in the risperidone + ulinastatin group and ten patients in the ulinastatin group developed pancreatitis (5.3 vs. 8.8 %, p = 0.438). The incidence of moderate/severe PEP was lower in the risperidone + ulinastatin group (1.8 %) than in the ulinastatin group (4.4 %), but this difference was not significant. Although the incidence of PEH did not differ significantly, post-ERCP levels of all pancreatic enzymes were significantly lower in the risperidone + ulinastatin group.

Conclusions

Prophylactic oral risperidone administration in combination with ulinastatin did not reduce the incidence and severity of PEP in high-risk patients as compared with ulinastatin alone. However, risperidone showed an additive effect with ulinastatin, reducing serum pancreatic enzyme levels.     

Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials

BACKGROUND: Impaired drainage of the pancreatic duct is one of the possible triggers for post-ERCP acute pancreatitis. The aim of this meta-analysis was to determine whether temporary stent placement across the main pancreatic-duct orifice lowers the frequency of post-ERCP acute pancreatitis in patients at high risk for this complication. METHODS: Two reviewers systematically identified prospective studies that (1) compared the risk of post-ERCP acute pancreatitis in patients with pancreatic stent placement vs. no stent placement and (2) included patients at high risk of developing this complication. Studies were assessed for methodologic quality and variations in execution and design. Frequency and severity of post-ERCP acute pancreatitis were the primary outcomes evaluated. RESULTS: Five trials involving 481 patients were selected. Of the 481, 55 (11.4%) patients developed pancreatitis after ERCP. Patients in the no stent group had 3-fold higher odds of developing pancreatitis compared with the stent group (15.5% vs. 5.8%; OR 3.2: 95% CI[1.6, 6.4]). Number needed to treat analysis showed that one in every 10 patients (95% CI[6,18]) could be expected to benefit from pancreatic-duct stent placement. CONCLUSIONS: Prophylactic temporary stent placement across the main pancreatic-duct orifice reduces the risk of post-ERCP acute pancreatitis in patients at risk for developing this complication.     

Risk factors for post-ERCP pancreatitis: a prospective multicenter study

OBJECTIVES: Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. METHODS: A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. RESULTS: Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. CONCLUSION: This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.     

Understanding risk factors and avoiding complications with endoscopic retrograde cholangiopancreatography

Complications and technical failures of endoscopic retrograde cholangiopancreatography (ERCP) cause significant morbidity and, occasionally, mortality. An understanding of patient- and procedure-related risks is important for decision making with regard to whether or how ERCP should be performed. Instances in which ERCP is the least clearly indicated are often the most likely to cause complications. Patient-related risk factors include suspected sphincter of Oddi (SO) dysfunction, female sex, normal serum bilirubin, or previous history of post-ERCP pancreatitis, with multiple risk factors conferring especially high risk. Techniquerelated risk factors include difficult cannulation, pancreatic contrast injection, balloon sphincter dilation, and precut sphincterotomy performed by endoscopists of varied experience. Pancreatic stents may reduce the risk of pancreatitis in a number of settings including SO dysfunction. Hemorrhage and perforation are rare and can be avoided with endoscopic technique and attention to the patient’s coagulation status. Cholangitis is avoidable with adequate biliary drainage. Because success rates are higher and complication rates lower for endoscopists performing large volumes of ERCP, ERCP should be concentrated as much as possible among endoscopists with adequate experience. Patients with a high risk for complications may be best served by referral to an advanced center.