E n d o s c o p i c R e t ro g r a d e C h o l a n g i o p a n c rea t o g r a p h y (ERCP)-Related Adverse Events Post-ERCP Pancreatitis Tarun Rustagi,
MD,
Priya A. Jamidar,
MD*
KEYWORDS Pancreatitis Indomethacin Pancreatic stents Sphincterotomy Manometry Precut Cannulation Sphincter of Oddi dysfunction KEY POINTS Post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP), the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), can be extremely serious, and may lead to long-term morbidity and even death. Diagnostic ERCP should be generally avoided, with few exceptions such as when accompanied by sphincter of Oddi manometry. Careful and judicious patient selection is paramount. The endoscopist must exercise meticulous technique, and patients deemed to be at high risk for PEP should receive rectal indomethacin and pancreatic stenting. Early recognition of PEP should initiate prompt supportive treatment.
INTRODUCTION
Post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is one of the most common and feared adverse events related to endoscopic retrograde cholangiopancreatography (ERCP), resulting in considerable morbidity and, rarely, death. The reported rate of PEP varies widely from 1% to 40%, with an average rate of 5% to 7% seen in most observational and retrospective studies.1–11 In a recent systematic review of 108 randomized controlled trials, which included 13,296 patients undergoing
Conflicts of Interest/Financial Disclosures/Funding/Grant Support/Writing Assistance: None. The authors disclose that there are no potential conflicts (financial, professional, or personal) that are relevant to the article. Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA * Corresponding author. Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT 06520-8019. E-mail address: [email protected] Gastrointest Endoscopy Clin N Am 25 (2015) 107–121 http://dx.doi.org/10.1016/j.giec.2014.09.006 giendo.theclinics.com 1052-5157/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
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both diagnostic and therapeutic ERCP, the overall rate of PEP was found to be 9.7%, with a mortality rate of 0.7% in the control group (placebo or no-pancreatic duct stent arms).12 PEP remains a serious health problem, accounting for health care expenditures in excess of $150 million annually in the United States.13 Physicians and patients alike should be aware that not all pain following ERCP is PEP. Similarly, transient hyperamylasemia without acute pancreatitis is common after ERCP. PEP is defined as new or increased abdominal pain that is clinically consistent with acute pancreatitis (typically epigastric pain radiating to the to the back), associated with a serum amylase at least 3 times normal at more than 24 hours after the ERCP, and requiring hospital admission or prolongation of a planned admission.2,8 The majority (80%–85%) of PEP cases are “mild” (requiring only up to 3 days of hospitalization). The remainder of PEP cases are described as either “moderately severe” (requiring 4–10 days’ hospitalization) or “severe” (requiring >10 days’ hospitalization), and these are associated with local and systemic complications.8 MECHANISMS OF POST–ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS
Several mechanisms of injury to the pancreas during ERCP have been postulated in the pathogenesis of PEP. A “trigger event” sets off a cascade of inflammatory activation similarly to acute pancreatitis from other causes. The initial triggering event could result from a variety of mechanisms listed in Box 1. RISK FACTORS FOR POST–ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS
Large observational studies and randomized controlled trials have contributed to our understanding of the pathogenesis of PEP, with identification of several risk factors that are independently associated with the development of PEP. PEP depends on patient-related and procedure-related factors and the type of interventions done, and is perhaps also operator-dependent. Box 2 summarizes the risk factors for PEP. Identification of preprocedure and intraprocedure risk factors allows risk stratification of patients and implementation of appropriate measures to reduce the incidence and severity of PEP, particularly in high-risk groups. Patient-Related Factors
The patient-specific risk factors that have been associated with higher rates of PEP on multivariate analyses include younger age (
MD,
Priya A. Jamidar,
MD*
KEYWORDS Pancreatitis Indomethacin Pancreatic stents Sphincterotomy Manometry Precut Cannulation Sphincter of Oddi dysfunction KEY POINTS Post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP), the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), can be extremely serious, and may lead to long-term morbidity and even death. Diagnostic ERCP should be generally avoided, with few exceptions such as when accompanied by sphincter of Oddi manometry. Careful and judicious patient selection is paramount. The endoscopist must exercise meticulous technique, and patients deemed to be at high risk for PEP should receive rectal indomethacin and pancreatic stenting. Early recognition of PEP should initiate prompt supportive treatment.
INTRODUCTION
Post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is one of the most common and feared adverse events related to endoscopic retrograde cholangiopancreatography (ERCP), resulting in considerable morbidity and, rarely, death. The reported rate of PEP varies widely from 1% to 40%, with an average rate of 5% to 7% seen in most observational and retrospective studies.1–11 In a recent systematic review of 108 randomized controlled trials, which included 13,296 patients undergoing
Conflicts of Interest/Financial Disclosures/Funding/Grant Support/Writing Assistance: None. The authors disclose that there are no potential conflicts (financial, professional, or personal) that are relevant to the article. Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA * Corresponding author. Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT 06520-8019. E-mail address: [email protected] Gastrointest Endoscopy Clin N Am 25 (2015) 107–121 http://dx.doi.org/10.1016/j.giec.2014.09.006 giendo.theclinics.com 1052-5157/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
108
Rustagi & Jamidar
both diagnostic and therapeutic ERCP, the overall rate of PEP was found to be 9.7%, with a mortality rate of 0.7% in the control group (placebo or no-pancreatic duct stent arms).12 PEP remains a serious health problem, accounting for health care expenditures in excess of $150 million annually in the United States.13 Physicians and patients alike should be aware that not all pain following ERCP is PEP. Similarly, transient hyperamylasemia without acute pancreatitis is common after ERCP. PEP is defined as new or increased abdominal pain that is clinically consistent with acute pancreatitis (typically epigastric pain radiating to the to the back), associated with a serum amylase at least 3 times normal at more than 24 hours after the ERCP, and requiring hospital admission or prolongation of a planned admission.2,8 The majority (80%–85%) of PEP cases are “mild” (requiring only up to 3 days of hospitalization). The remainder of PEP cases are described as either “moderately severe” (requiring 4–10 days’ hospitalization) or “severe” (requiring >10 days’ hospitalization), and these are associated with local and systemic complications.8 MECHANISMS OF POST–ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS
Several mechanisms of injury to the pancreas during ERCP have been postulated in the pathogenesis of PEP. A “trigger event” sets off a cascade of inflammatory activation similarly to acute pancreatitis from other causes. The initial triggering event could result from a variety of mechanisms listed in Box 1. RISK FACTORS FOR POST–ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS
Large observational studies and randomized controlled trials have contributed to our understanding of the pathogenesis of PEP, with identification of several risk factors that are independently associated with the development of PEP. PEP depends on patient-related and procedure-related factors and the type of interventions done, and is perhaps also operator-dependent. Box 2 summarizes the risk factors for PEP. Identification of preprocedure and intraprocedure risk factors allows risk stratification of patients and implementation of appropriate measures to reduce the incidence and severity of PEP, particularly in high-risk groups. Patient-Related Factors
The patient-specific risk factors that have been associated with higher rates of PEP on multivariate analyses include younger age (
