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

Table 1 Risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis in the European Society of Gastrointestinal Endoscopy and American Society for Gastrointestinal Endoscopy guidelines

ESGE guideline	ASGE guideline
Patient-related definitive risk factors	Patient-related risk factors
Suspected sphincter of Oddi dysfunction	Suspected sphincter of Oddi dysfunction
Female sex	Female sex
Previous pancreatitis	Previous recurrent pancreatitis
Previous post-ERCP pancreatitis	Previous post-ERCP pancreatitis
Procedure-related definitive risk factors	Younger age
Difficult cannulation	Absence of chronic pancreatitis
More than one pancreatic guidewire passage	Normal serum bilirubin
Pancreatic injection	Procedure-related risk factors
Patient-related likely risk factors	Difficult cannulation (> 10 min)
Younger age	Repeated pancreatic guidewire cannulation
Nondilated extrahepatic bile duct	Pancreatic injection
Absence of chronic pancreatitis	Endoscopic papillary large-balloon dilation of a native papilla
Normal serum bilirubin
End-stage renal failure
Procedure-related likely risk factors
Precut sphincterotomy
Pancreatic sphincterotomy
Papillary balloon dilation
Unsuccessful clearance of bile duct stones
Intraductal ultrasound

ASGE: American Society for Gastrointestinal Endoscopy; ERCP: Endoscopic retrograde cholangiopancreatography; ESGE: European Society of Gastrointestinal Endoscopy.

Table 2 Recommended strategies for suspected common bile duct stones in patients with symptomatic cholelithiasis based on the ESGE and ASGE guidelines

ESGE guideline			ASGE guideline
Likelihood	Predictors	Recommended strategy	Predictors	Recommended strategy
Low	Normal liver function tests and no CBD dilation at US	Proceed to cholecystectomy	No predictors	Cholecystectomy with/without laparoscopic cholangiography (IOC) or intraoperative US
Intermediate	Abnormal liver function tests and/or dilated CBD on US	Perform EUS/MRCP	Abnormal liver function tests or age > 55 years or dilated CBD on US/cross-sectional imaging	Perform EUS/MRCP, laparoscopic IOC, or intraoperative US
High	CBDSs identified at US or features of cholangitis	Proceed to ERCP	CBDSs identified at US/cross-sectional imaging	Proceed to ERCP
			or features of cholangitis or dilated CBD with total bilirubin > 4 mg/dL on US/cross-sectional imaging

ASGE: American Society for Gastrointestinal Endoscopy; CBD: Common bile duct; CBDSs: Common bile duct stones; ERCP: Endoscopic retrograde cholangiopancreatography; ESGE: European Society of Gastrointestinal Endoscopy; EUS: Endoscopic ultrasonography; MRCP: Magnetic resonance cholangiopancreatography; US: Ultrasonography.

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.