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

Table 1 Comparison of patient-related risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis by multivariate analysis in the classic article and current knowledge by meta-analysis or multivariate studies

Risk factors in the classic article	Current knowledge1
Significant in multivariate analysis	High risk factors
Suspected sphincter of Oddi dysfunction	Suspected sphincter of Oddi dysfunction
Female gender	Female gender
History of post-ERCP pancreatitis	Previous pancreatitis
Normal serum bilirubin	Normal serum bilirubin
Absence of chronic pancreatitis	Young age
Significant only in univariate analysis	Possible risk factors
Pancreas divisum	Non-dilated extrahepatic ducts
Recurrent abdominal pain	Absence of chronic pancreatitis
History of acute pancreatitis of any etiology	Absence of definite common bile duct stone
Cholangiogram normal	Obesity2
Pancreatogram normal
Age < 55 yr
Prior cholecystectomy
Absence of definite common bile duct stone
Not significant	Not related
Previous sphincterotomy	Pancreas divisum
Distal common bile duct diameter ≤ 5 mm	Allergy to contrast media
Prior failed ERCP	Prior failed ERCP

¹Current knowledge is based on recent guidelines by American Society for Gastrointestinal Endoscopy[6] and European Society of Gastrointestinal Endoscopy[5], and relevant articles[3,22];

²Based on recent multivariate analysis in abstract form[13]. ERCP: Endoscopic retrograde cholangiopancreatography.

Table 2 Comparison of procedure-related risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis by multivariate analysis in the classic article and current knowledge by meta-analysis or multivariate studies

Risk factors in the classic article	Current knowledge1
Significant in multivariate analysis	High risk factors
Difficult cannulation	Difficult or failed cannulation
Balloon dilation of biliary sphincter	Balloon dilation of biliary sphincter
Pancreatic sphincterotomy	Pancreatic sphincterotomy
≥ 1 pancreatic contrast injections	Pancreatic duct injection
	Precut sphincterotomy
	Failed attempts at placing pancreatic duct stent
Significant only in univariate analysis	Possible risk factors
Sphincter of Oddi manometry	Ampullectomy
Pancreatic stent placement	Pancreatic acinarization
Minor papilla cannulation	Pancreatic brush cytology
Precut (access) papillotomy	Failure to clear bile duct stones
≥ 1 pancreatic deep wire pass/cannulation	Involvement of trainee during ERCP
Endoscopist performing > 2 ERCP/wk
Not significant	Not related
Acinarization of pancreas	Sphincter of Oddi manometry (using aspirated catheter)
Biliary sphincterotomy	Biliary sphincterotomy
Intramural contrast injection	Intramural contrast injection
Pancreatic stricture dilation by any method	Prior failed ERCP
Pancreatic duct tissue sampling by any method	Therapeutic vs diagnostic
Training fellow involved

¹Current knowledge is based on recent guidelines by American Society for Gastrointestinal Endoscopy[6] and European Society of Gastrointestinal Endoscopy[5], and relevant articles[3,22]. ERCP: Endoscopic retrograde cholangiopancreatography.

Table 3 Clinical pearls to help avoid post-endoscopic retrograde cholangiopancreatography pancreatitis

Remember that ERCP is the most dangerous endoscopic procedure that can be associated with bad outcomes

Instead of diagnostic ERCP, use alternative imaging techniques such as magnetic resonance cholangiopancreatography or EUS, especially in high-risk patients

Rectal NSAIDs before or after ERCP procedure can be a simple measure to prevent PEP

Tailor a variety of cannulation techniques to the individual risk profile and the papillary anatomy of the patient

In cases of difficult cannulation, early precut or fistulotomy technique with a pancreatic stent (performed by an expert endoscopist) can decrease the risk of PEP

Quit the ERCP procedure earlier in high-risk patients if success is not achieved quickly. After a failed ERCP, alternative therapeutic methods such as percutaneous or EUS-guided approaches can be considered

In high risk patients, make sure that a prophylactic pancreatic stent is placed. In cases with equivocal risk at the end of the procedure, a prophylactic pancreatic stent can eliminate the fear of PEP

ERCP: Endoscopic retrograde cholangiopancreatography; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; EUS: Endoscopic ultrasonography; NSAIDs: Non-steroidal anti-inflammatory drugs.

Table 4 Unresolved issues with prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

The ideal design of a prophylactic pancreatic stent

Cannulation technique to lower incidence of PEP, tailored to the shape of the major papilla

The ideal pharmacologic agent

Comparison of rectal NSAIDs vs pancreatic stent placement vs combination in high risk patients

The route (rectal or intravenous) and the timing (before or after ERCP) of NSAIDs administration

ERCP: Endoscopic retrograde cholangiopancreatography; PEP: Post-ERCP pancreatitis; NSAIDs: Non-steroidal anti-inflammatory drugs.