Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review

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May 16, 2010 (publication date) through Feb 7, 2025

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World Journal of Gastrointestinal Endoscopy

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1948-5190

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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World J Gastrointest Endosc. May 16, 2010; 2(5): 165-178
Published online May 16, 2010. doi: 10.4253/wjge.v2.i5.165

Table 1 Clinical trials evaluating the incidence of overall complications and post-ERCP pancreatitis

Author	Country	Year published	n	No. ERCP	Overall complications (%)	Post-ERCP pancreatitis (%)
Large prospective trials
Wang[20]	China	2009	2691	3178	7.92	4.31
Kapral[62]	Austrian	2008	NR^a	3132	12.60	5.10
Dundee[23]	Australia	2007	563	700	5.71	3.71
Williams[24]	United Kingdom	2007	4561	5234	5.00	1.60
Bhatia[25]	India	2006	1497	1497	NR^a	3.80
Cheng 2006 and Sherman 2003^b[111,154]	United States	2006	1115	NR^a	NR^a	15.10
Andriulli[59]	Italy	2004	1127	1050	NRNR^a	4.80
Christensen[13]	Denmark	2004	NR^a	1177	15.90	3.80
Barthet	France	2002	658	1159	NR^a	3.50
Vandervoort[10]	United States	2002	1223	1223	11.20	7.20
Freeman[58]	United States	2001	NR^a	1963	NR^a	6.70
Masci[35]	Italy	2001	2103	2044	4.95	1.80
DePalma[27]	Italy	1999	535	NR^a	NR^a	5.30
Deans[11]	United Kingdom	1997	958	1000	2.40	1.00
Johnson[28]	United States	1997	1979	NR^a	NR^a	10.40
Freeman[29]	United States and Canada	1996	2347	NR^a	9.80	5.40
Loperfido[12]	Italy	1995	2769	NR^a	4.00	1.30
Large retrospective trials
Cotton[29]	United States	2009	11497	NR^a	4.00	2.60
Lukens[30]	United States	2009	2606	3924	3.12	0.97
Andriulli[31]	Italy	2007	16855	NR^a	6.85	3.47
Cheon[60]	United States	2007	9872	14331	NR^a	4.00

^aNot reported;

^bSame patient cohort; ERCP: Endoscopic retrograde cholangiopancreatography.

Table 2 Patient and procedural risk factors associated with post-ERCP pancreatitis

Patient related factors

Female sex

Young age

History of or suspected sphincter of oddi dysfunction

History of pancreatitis, recurrent pancreatitis or post-ERCP pancreatitis

Procedure related factors

Difficult or multiple cannulation attempts

Multiple pancreatic contrast injections

Pancreatic acinarization

Precut sphincterotomy

Endoscopic papillary balloon dilation

Sphincter of oddi manometry

Distal common bile duct diameter ≤ 1 cm

Presence of a pancreatic stricture

Procedures not involving stone removal

Table 3 Frequency of post-ERCP pancreatitis - conventional contrast based cannulation versus guide-wire cannulation in randomized trials

				Rate of pancreatitis
Author	Year published	Country	n	CC (%)	GWC (%)	P value
Lee[72]	2009	Korea	300	11.30	2.00	0.001
Bailey[73]	2008	Australia	430	7.90	6.20	0.48
Artifon[70]	2007	Brazil and United States	300	16.60	8.60	0.037
Lella[69]	2004	Italy	392	4.10	0.00	< 0.01
Cortas[68]	1999	Canada	47	10.30	5.60	NR^a

n: Patients included in final analysis; GWC: Guide-wire cannulation (papillotome with guide-wire assistance); CC: Conventional cannulation (papillotome with contrast injection);

^aNot reported.

Table 4 Randomized controlled trials evaluating the effect of pancreatic duct stenting on prevention of post-ERCP pancreatitis

Author	Country	Year published	n	Rate of post-ERCP pancreatitis		P value
Author	Country	Year published	n	Without stent (%)	With stent (%)	P value
Tsuchiya[84]	Japan	2007	64	12.50	3.10	NR^a
Sofuni[78]	Japan	2007	201	13.60	3.20	0.02
Harewood[77]	United States	2005	19	33.00	0.00	0.02
Fazel[85]	United States	2003	74	28.00	5.00	< 0.05
Tarnasky[18]	United States	1998	80	26.00	7.00	0.03
Smithline[87]	United States	1993	93	18.00	14.00	0.299

n: Patients included in final analysis;

^aNot reported.

Table 5 Frequency of post-ERCP pancreatitis - endoscopic sphincterotomy vs endoscopic papillary balloon dilation in randomized studies

Author	Year published	Country	n	Rate of pancreatitis		P value
Author	Year published	Country	n	ES (%)	EPBD (%)	P value
DiSario[98]^b	2004	United States	237	0.83	15.38	< 0.05
Fujita[87]	2003	Japan	282	2.80	10.90	< 0.05
Vlavianos[92]	2003	United Kingdom	202	1.01	4.86	NR^a
Arnold[89]	2001	Germany	60	10.00	20.00	NR^a
Bergman[99]	1997	The Netherlands	202	6.93	6.93	NR^a

n: Patients included in final analysis; ES : Endoscopic sphincterotomy; EPBD: Endoscopic papillary balloon dilation;

^bMulti-centered;

^aNot reported.

Table 6 Pharmacologic agents evaluated for potential reduction/prevention of post-ERCP pancreatitis

Pharmacologic agent	RCT showed benefit
Allopurinol	Yes
Cephtazidime	Yes
Diclofenac	Yes
Gabexate	Yes
Glyceryl trinitrate	Yes
Hydrocortisone	Yes
Indomethacin	Yes
Interleukin-10 (IL-10)	Yes
Nafamostat mesylate	Yes
Octreotide	Yes
Somatostatin	Yes
Ulinastatin	Yes
Anticholinergic drugs	No
Aprotinin	No
Botulinum toxin	No
Calcitonin	No
Epinephrine	No
Fresh frozen plazma	No
Glucagon	No
H-2 Blocker	No
Heparin	No
Lidocaine	No
Methylprednisolone	No
N-aceytyl cysteine (NAC)	No
Natural beta-carotene	No
Nifedipine	No
Nitroglycerin	No
Parenteral nutrition	No
Pentoxifylline	No
Prednisone	No
Recombinant PAF acetylhydrolase (rPAF-AH)	No
Selenium	No
Semapimod	No

Table 7 Randomized controlled trails of pharmacologic agents evaluated for reduction or prevention of post-ERCP pancreatitis

				Rate of post-ERCP pancreatitis (%)
Agent	Author	Factor studied	n	Overall	Control	Intervention	P value
Allopurinol
	Martinez–Torres[110]	Allopurinol 300 mg PO at 15 h; 300 mg PO at 3 h before ERCP	170	NR^a	9.40	2.30	0.049
	Romagnuolo[111]^b	Allopurinol 300 mg PO at 1 h before ERCP	586	NR^a	4.10	5.50	0.440
	Katsinelos[112]	Allopurinol 600 mg PO at 15 h; 600 mg PO at 3 h before ERCP	243	10.20	17.80	3.20	< 0.001
	Mosler[113]	Allopurinol 600 mg PO at 4 h; 300 mg PO at 1 h before ERCP	346	12.55	12.14	12.96	0.520
	Budzynska[114]	Allopurinol 200 mg PO at 15 h; 200 mg PO at 3 h before ERCP	300	10.70	7.90	12.10	0.320
Beta-carotene
	Lavy[115]	Natural beta-carotene 2 g at 12 h before ERCP	321	9.60	9.60	10.00	NR^a
Botulinum toxin
	Gorelick[116]	Botulinum toxin injection after biliary sphincterotomy	26	NR^a	43.00	25.00	0.340
Cephtazidime
	Raty[117]	Cephtazidime 2g IV 30 min before ERCP	321	NR^a	9.38	2.58	0.009
Hydrocortisone
	Kwanngern[118]	Hydrocortisone 100 mg IV at 1 h before ERCP	120	6.67	11.86	1.64	0.031
	Manolakopoulos[119]^b	Hydrocortisone 100 mg IV at 30 min before ERCP	340	10.00	13.00	7.10	0.380
	De Palma[31]	Hydrocortisone 100 mg IV immediately before ERCP	529	5.30	4.90	5.70	NS
Prednisone
	Sherman[120]^b	Prednisone 40 mg PO at 15 h and at 3 h before ERCP	1115	15.07	13.60	16.60	0.190
	Budzynska[114]	Prednisone 40 mg at 15 h; 40 mg at 3 h before ERCP		10.70	7.90	12.00	0.330
Methylprednisolone
	Dumot[43]	Methylprednisolone 125 mg IV immediately before ERCP	286	NR^a	8.70	12.40	0.340
Heparin
	Barkay[42]	Unfractionated heparin 5000 IU SC 20-30 min before ERCP	106	NR^a	7.40	7.80	NS
	Rabenstein[121]	Low molecular weight heparin Certoparin 3000 IU SC the day before ERCP	448	8.50	8.81	8.14	0.870
Interlukin-10
	Sherman[56]^b	IL-10 8 μg/kg IV 15-30 min before ERCP	305	17.38	14.30	15.40	0.830
		IL-10 20 μg/kg IV 15-30 min before ERCP				22.00	0.140
	Deviere[14]	IL-10 4 μg/kg IV 30 min before ERCP	144	29.90	24.40	10.41	0.046
		IL-10 20 μg/kg IV 30 min before ERCP				6.81	0.017
	Dumot[55]	IL-10 8 μg/kg IV 15 min before ERCP	200	10.00	9.10	10.90	0.650
N-acetyl cystine
	Milewski[122]	NAC 600 mg IV BID × 2 d after ERCP	106	9.43	11.76	7.27	NS
	Katsinelos[123]	NAC 70 mg/kg 2 h before and 35 mg/kg 4 h intervals for 24 h after procedure	249	10.80	9.60	12.10	> 0.500
Nifedipine
	Prat[124]	Nifedipine 20 mg PO 3-6 h before ERCP	155	15.50	17.70	13.20	NS
	Sand[125]	Nifedipine 20 mg PO q 8 h the day of ERCP	166	3.61	4.00	4.00	NR^a
Nitroglycerin
	Hao[126]	Glyceryl trinitrate 5 mg IV and 100 mg vitamin C 5 min before ERCP maneuvers	74	16.20	25.00	7.90	0.012
	Beauchant[127]^b	Nitroglycerin bolus of 0.1 mg, then 35 g/kg/min IV for 6 h after ERCP	208	12.00	15.00	10.00	0.260
	Kaffes[128]	Transdermal glyceryl trinitrate patch (15 mg) precordial area 30-40 min before ERCP	318	NR^a	7.40	7.70	NS
	Moreto[129]	Transdermal glyceryl trinitrate patch (15 mg) precordial area 30-40 min before ERCP	144	9.00	15.00	4.00	0.030
	Sudhindran[130]	Glyceryl trinitrate 2 mg SL 5 min before ERCP	186	13.00	18.00	8.00	< 0.050
Diclofenac
	Khoshbaten[131]	Diclofenac 100 mg PR immediately after ERCP	100	15.00	26.00	4.00	< 0.010
	Cheon[132]	Diclofenac 50 mg at 30-90 min before and at 4-6 h after ERCP	207	16.40	16.70	16.20	NS
	Murray[44]	Diclofenac 100 mg PR immediately after ERCP	220	11.00	15.45	6.36	0.049
Indomethacin
	Sotoudehmanesh[133]	Indomethacin 100 mg PR after ERCP	442	4.98	6.78	3.16	OR 0.4 (0.2 - 1.1)
Octreotide
	Kisli[134]	Octreotide 0.1 mg gtt 60 min before ERCP and continued during and after ERCP	120	NR^a	11.49	15.15	NS
	Li[135]^b	Octreotide 0.3 mg gtt 1 h before -6 h after ERCP; then 0.1 mg SC; 12 h later 0.1 mg SC	832	3.85	5.26	2.42	0.046
	Thomopoulos[136]	Octreotide 500 μg TID starting 24 h before ERCP	201	10.89	8.90	2.00	0.03
	Testoni[137]^b	Octreotide 200 μg TID × 24 h before ERCP	114	NR^a	14.30	12.00	NS
	Hardt[138]	Octreotide 200 μg SC the night before ERCP	94	NR^a	NR^a	NR^a	NS
	Duvnjak[139]	Octreotide 0.5 mg SC 60 min before ERCP	209	NR^a	9.52	3.85	NS
	Arvanitidis[140]	Octreotide 0.1 mg SC 30 min before; 8 h and 16 h after ERCP	73	10.95	11.11	10.81	NS
	Tulassay[45]^b	Octreotide 0.1 mg SC 45 min after ERCP	1199	7.84	6.00	5.90	NS
	Arcidiacono[141]	Octreotide 0.1 mg SC 120 and 30 min before; 4 h after ERCP	151	6.62	NR^a	NR^a	NS
	Baldazzi[142]	Octreotide 0.1 mg SC 45 min before; 6 h after ERCP	100	NR^a	NR^a	NR^a	NR^a
	Testoni[143]	Octreotide 0.2 mg SC before ERCP	60	NR^a	NR^a	NR^a	NS
	Testoni[34]	Octreotide 200 μg TID × 3 d before ERCP	60	NR^a	NR^a	NR^a	NS
Gabexate
	Ueki[144]	Gabexate 600 mg IV 60-90 min before and 22 h after ERCP	68	2.90	NR^a	2.90	NS
	Manes[145]^b	Gabexate mesylate 500 mg within 1 h before ERCP	608	5.60	9.40	3.90	< 0.01
		Gabexate mesylate 500 mg within 1h after ERCP				3.40	< 0.01
	Xiong[146]	Gabexate 300 mg IV 30 min before gtt until 4 h after ERCP	200	6.70	10.50	3.10	0.04
	Fujishiro[151]^b	Gabexate 900 mg/1500 mL gtt for 13 h beginning 1 h before ERCP	139	NR^a	NR^a	4.30	NS
	Andriulli[59]^b	Gabexate 500 mg 30 min before gtt until 6 h after ERCP	1127	5.60	4.80	5.80	NS
	Masci[96]^b	Gabexate 500 mg IV 30 min before gtt until 6.5 h after ERCP and 1 g IV for 13 h after ERCP	434	1.80	2.20	1.40	NS
	Andriulli[147]^b	Gabexate 500 mg IV 30 min before and 2 h after ERCP	579	8.60	6.50	8.10	NS
	Cavallini[148]^b	Gabexate 1 g IV 30-90 min before gtt until 12 h after ERCP	418	5.00	8.00	2.00	0.03
Nafamostat mesylate
	Choi[149]	Nafamostat mesylate 20 mg gtt 1 h before and for 24 h after ERCP	704	5.40	7.40	3.30	0.018
Ulinastatin
	Yoo[150]	Ulinastatin 100 000 U gtt after ERCP for 5.5 h	227	6.20	5.60	6.70	0.715
	Ueki[144]	Ulinastatin 150 000 units 60-90 min before & for 22 h after ERCP	68	2.90	2.90	2.90	NS
	Fujishiro[151]^b	Ulinastatin 150 000 units 1 h before, during; 11 h after ERCP				6.50	NS
		Ulinastatin 50 000 units				8.50	NS
	Tsujino[152]^b	Ulinastatin 150 000 U gtt 10 min before ERCP	406	5.17	7.40	2.90	0.041
Pentoxifylline
	Kapetanos[153]	Pentoxifylline 400 mg PO TID before ERCP	320	4.38	3.00	5.60	0.28
Recombinant PAF acetylhydrolase
	Sherman[154]^b	Recombinant PAF acetylhydrolase (rPAF-AH) 1 mg/kg gtt < 1 h before ERCP	600	17.60	19.60	17.50	0.59
		Recombinant PAF acetylhydrolase (rPAF-AH) 5 mg/kg gtt < 1 h before ERCP				15.90	0.34
Semapimod
	van Westerloo[155]	Semapimod IV 50 mg/100 mL glucose gtt 1 h before ERCP	242	11.98	14.88	9.09	0.117
Somatostatin
	Lee[156]^b	Somatostatin 3 mg in 500 mL NS gtt 12 h starting 30min before ERCP	391	6.65	9.60	3.60	0.02
	Andriulli[59]^b	Somatostatin 750 μg IV 30 min before and continued for 6 h after ERCP				6.30	NS
	Arvanitidis[157]	Somatastatin 4 μg/kg gtt 12 h on identification of the papilla and before introduction of the catheter	372	NR^a	9.80	1.70	< 0.05
		Somatostatin 3 mg gtt 12 h on identification of the papilla and before introduction of the catheter				1.70	< 0.05
	Poon[158]	Somatostatin 250 mg IV bolus immediately after ERCP	270	NR^a	13.30	4.40	0.01
	Andriulli[147]^b	Somatastatin 750 μg IV 30 min before and 2 h after ERCP				11.50	NS
	Poon[159]	Somatostatin 3 mg in 500 mL NS gtt for 12 h starting 30 min before ERCP	220	5.91	10.00	3.00	0.03
	Bordas[160]	Natural somatostatin 4 mg/kg IV on identification of the papilla and before introduction of the catheter	160	NR^a	10.00	2.50	< 0.05
Topical spray on papilla
	Matsushita[15]	Epinephrine (10 mL of 0.02%) sprayed on papilla before cannulation	370	1.10	2.16	0.00	0.123
	Schwartz[161]	Lidocaine (10 mL of 1%) sprayed on the major papilla before cannulation	294	4.08	3.04	4.32	0.73

PEP: Post-ERCP pancreatitis; ERCP: Endoscopic retrograde cholangiopancreatography; IL-10: Ingerlukin-10; NAC: N-acetyl cystine; NS: Not significant;

^aNot reported/unable to acquire primary data from publication;

^bMulti-centered.

Citation: Woods KE, Willingham FF. Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review. World J Gastrointest Endosc 2010; 2(5): 165-178
URL: https://www.wjgnet.com/1948-5190/full/v2/i5/165.htm
DOI: https://dx.doi.org/10.4253/wjge.v2.i5.165