Pancreatits after endoscopic retrograde cholangio-pancreatography

Table 3 Suggested strategies for avoiding post-ERCP pancreatitis

Risk factors	Recommendations
Suspected SOD (sphincter of Oddi manometry is to be performed)	- Usage of an aspirating catheter technique is strongly recommended, particularly for pancreatic manometry. - Stent the pancreas after. - Do in high volume referral centers.
Difficult cannulation	- Once cannulation is begun, traumatic manipulation of the papilla should be kept to a minimum. - Placement of a pancreatic stents to assist biliary cannulation, should be considered.
Pre-cut sphincterotomy	- Should be used for biliary access only if the indication for therapy is relatively clear and the endoscopist is experienced in pre-cut techniques. - Strongly consider placement of temporary pancreatic stent before or after cutting.
During traction biliary and pancreatic sphincterotomy	- Biliary sphincterotomy should be oriented toward the region from 11:00 to 1:00 o’clock on the papilla (i.e., away from the pancreatic orifice). - Consider use of pure-cut current for pancreatic ES.
Balloon dilation of the intact biliary sphincter for stone extraction	- Should be avoided in routine practice, unless the risk of sphincterotomy is unusually high (e.g., patients with severe coagulopathy). - Stent the pancreas after.
Biliary stents	- Generally should not be placed through an intact biliary sphincter in patients with suspected SOD - When placing a plastic biliary stent > 7F for any reason, consider biliary ES first, to help prevent pancreatic orifice occlusion.
Pancreatic brush cytology	- Consider temporary pancreatic stent placement.
Patients with hilar tumors	- Biliary sphincterotomy is recommended before placement of transpapillary biliary stents.
Pancreatic duct injection	- Pancreatic injection should be avoided if the indication for ERCP pertains to the biliary tract alone.
and/or Pancreatic acinarization	- Avoid filling of the body and tail of the pancreas unless clinically needed. - Over injection (acinarization) of the pancreas should be avoided. - Use guidewire to aid view of duct entered (instead of repeat dye injection. - Limit pancreatic filling in obese patients or other settings with suboptimal fluoroscopic viewing.
High risk patients (normal serum bilirubin, female gender, recurrent abdominal pain, absence of biliary dilatation, conditions suggesting possible sphincter of Oddi dysfunction, prior post-ERCP pancreatitis, recurrent pancreatitis or absent chronic pancreatitis)	- Consider non-invasive imaging techniques such as MRCP, EUS, or laparoscopic cholecystectomy with intra-operative cholangiography. - Once a decision for ERCP need is made, the endoscopist should assess the risk profile of the patient and plan maneuvers and modify technique accordingly. - Consider referral to a high volume centers with the capability to reliably place protective small caliber pancreatic stents