Current approaches and questions yet to be resolved for the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

Table 3 Recommendations for post-endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis in American Society for Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy guidelines

ASGE guideline	ESGE guideline
PEP prophylaxis during ERCP	PEP prophylaxis during ERCP
Pancreatic duct stenting in high-risk patients (high quality of evidence)	Pancreatic duct stenting in high-risk patients (strong recommendation, moderate quality of evidence)
Early precut sphincterotomy for difficult cannulation (moderate quality of evidence)
Pharmacologic methods for PEP prophylaxis	Pharmacologic methods for PEP prophylaxis
Rectal NSAIDs in high-risk patients without contraindication (moderate quality of evidence)	Routine rectal NSAIDs of 100 mg of diclofenac or indomethacin immediately before in all patients without contraindication (strong recommendation, moderate quality of evidence)
Rectal indomethacin in average-risk patients without contraindication (moderate quality of evidence)	Hydration with lactated ringers in patients with contraindication to NSAIDs without at risk of fluid overload and without prophylactic pancreatic stenting (strong recommendation, moderate quality of evidence)
Hydration with lactated ringers (very-low quality of evidence)	Not suggested for the routine combination of rectal NSAIDs with other prophylactic measures (weak recommendation, low quality of evidence)
	Not recommended for protease inhibitors and epinephrine onto the papilla (strong recommendation, moderate quality of evidence)
	Somatostatin and octoreotide (no recommendation)

ERCP: Endoscopic retrograde cholangiopancreatography; ASGE: American Society for Gastrointestinal Endoscopy; ESGE: European Society of Gastrointestinal Endoscopy; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; NSAIDs: Nonsteroidal anti-inflammatory drugs.