1
|
Kubiliun NM, Adams MA, Akshintala VS, Conte ML, Cote GA, Cotton PB, Dumonceau JM, Elta GH, Fogel EL, Freeman ML, Lehman GA, Naveed M, Romagnuolo J, Scheiman JM, Sherman S, Singh VK, Elmunzer BJ. Evaluation of Pharmacologic Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review. Clin Gastroenterol Hepatol 2015; 13:1231-9; quiz e70-1. [PMID: 25579870 DOI: 10.1016/j.cgh.2014.11.038] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy over the efficacy of pharmacologic agents for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). We performed a systematic review of PEP pharmacoprevention to evaluate safety and efficacy. METHODS We performed a systematic search of the literature for randomized controlled trials (RCTs) and meta-analyses of PEP pharmacoprevention through February 2014. After identifying relevant studies, 2 reviewers each extracted information on study characteristics, clinical outcomes, and risk of bias. A research classification scale was developed to identify pharmacologic agents ready for clinical use, agents for which a confirmatory RCT should be considered a high priority, agents for which exploratory studies are still necessary, and agents for which additional research should be of low priority. Clinical and research recommendations for each agent were made by consensus after considering research classification results and other important factors such as magnitude of benefit, safety, availability, and cost. RESULTS After screening 851 citations and 263 potentially relevant articles, 2 reviewers identified 85 RCTs and 28 meta-analyses that were eligible. On the basis of these studies, rectal nonsteroidal anti-inflammatory drugs were found to be appropriate for clinical use, especially for high-risk cases. Sublingual nitroglycerin, bolus-administered somatostatin, and nafamostat were found to be promising agents for which confirmatory research is warranted. Additional research was found to be required to justify confirmatory RCTs for topical epinephrine, aggressive intravenous fluids, gabexate, ulinastatin, secretin, and antibiotics. CONCLUSIONS On the basis of a systematic review, NSAIDs are appropriate for use in prevention of PEP, especially for high-risk cases. Additional research is necessary to clarify the role of other pharmacologic agents. These findings could inform future research and guide clinical decision-making and policy.
Collapse
Affiliation(s)
- Nisa M Kubiliun
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas
| | - Megan A Adams
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Marisa L Conte
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
| | - Gregory A Cote
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Peter B Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Evan L Fogel
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Martin L Freeman
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota
| | - Glen A Lehman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Mariam Naveed
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas
| | - Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - James M Scheiman
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Stuart Sherman
- Division of Gastroenterology, Indiana University Medical Center, Indianapolis, Indiana
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - B Joseph Elmunzer
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
| | | |
Collapse
|
2
|
Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events: post-ERCP pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:107-21. [PMID: 25442962 DOI: 10.1016/j.giec.2014.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), and not uncommonly is the reason behind ERCP-related lawsuits. Patients at high risk for PEP include young women with abdominal pain, normal liver tests, and unremarkable imaging. Procedure-related factors include traumatic and persistent cannulation attempts, multiple injections of the pancreatic duct, pancreatic sphincterotomy, and, possibly, use of precut sphincterotomy. Aggressive hydration, use of rectal indomethacin, and prophylactic pancreatic stenting can diminish the risk (and likely severity) of PEP. Though hugely beneficial, these measures do not supersede careful patient selection and technique.
Collapse
Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
| |
Collapse
|
3
|
Wu W, Faigel DO, Sun G, Yang Y. Non-radiation endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis during pregnancy. Dig Endosc 2014; 26:691-700. [PMID: 24861135 DOI: 10.1111/den.12307] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 04/07/2014] [Indexed: 12/19/2022]
Abstract
Gallstone diseases are common during pregnancy. In most cases, patients are asymptomatic and do not require any treatment. However, choledocholithiasis, cholangitis, and gallstone pancreatitis may potentially become life-threatening for both mother and fetus and often require urgent intervention. Although endoscopic retrograde cholangiopancreatography (ERCP) has become the standard technique for removing common bile duct stones, it is associated with ionizing radiation that could carry teratogenic risk. Non-radiation ERCP (NR-ERCP) is reported to be effective without incurring this risk. Two techniques have been described to confirm bile duct cannulation: bile aspiration and image guidance. With bile aspiration, biliary cannulation is confirmed by applying suction to the cannula to yield bile, thus confirming an intrabiliary position. Image guidance involves using ultrasound or direct visualization (choledochoscopy) to confirm selective biliary cannulation or duct clearance. Once cannulation is achieved, the stones are removed using standard ERCP techniques and tools. Case series and retrospective studies have reported success rates of up to 90% for NR-ERCP with complication rates similar to standard ERCP. Pregnancy outcomes are not adversely affected by NR-ERCP, but whether the avoidance of radiation carries benefit for the baby is unknown. Prospective comparative trials are lacking. NR-ERCP is technically demanding and should be attempted only by skilled biliary endoscopists in properly equipped and staffed health-care institutions, in a multidisciplinary setting.
Collapse
Affiliation(s)
- Wenming Wu
- Institute of Digestive Diseases, Chinese PLA General Hospital, Beijing, China; Department of Gastroenterology and Hepatology, General Hospital of Ji'nan Military Command Region, Ji'nan, China
| | | | | | | |
Collapse
|
5
|
Arain MA, Freeman ML. Pharmacologic prophylaxis alone is not adequate to prevent post-ERCP pancreatitis. Am J Gastroenterol 2014; 109:910-2. [PMID: 24896759 DOI: 10.1038/ajg.2014.123] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/04/2014] [Indexed: 12/11/2022]
Abstract
Post-ERCP pancreatitis (PEP) remains the most common complication following ERCP. Although once considered unpredictable, understanding patient and procedure-related risk factors, and measures such as pancreatic stent placement and pharmacoprophylaxis have been shown to substantially decrease the risk of PEP. In this issue of the Journal, the role of pharmacoprophylaxis is explored in a study comparing rectal indomethacin plus sublingual nitrates vs. rectal indomethacin alone. While showing improved efficacy, dual pharmacoprophylaxis does not appear adequate to obviate the importance of technique-related variables and pancreatic stents. Rather, a comprehensive approach is likely to be the most efficacious strategy to reduce PEP.
Collapse
Affiliation(s)
- Mustafa A Arain
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
6
|
Abstract
AIM: To compare the effects of new-type versus traditional non-steroid antiinflammtory drugs (NSAIDs) in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).
METHODS: One hundred and ninety-seven patients who underwent ERCP for choledocholithiasis between May 2012 and May 2013 were randomly divided into three groups: a lornoxicam group, a parecoxib group and a control group. Different drugs were applied for each group. Mean visual analogue score (VAS) and serum levels of amylase and C-reactive protein (CRP) were measured before ERCP and 4, 24 and 48 h after ERCP. Incidences of hyperamylasemia and PEP were observed.
RESULTS: The incidences of PEP in the lornoxicam group, parecoxib group and control group were 4.55%, 9.09% and 10.8%, respectively, and the difference was statistically significant between the parecoxib group and control group (P < 0.05), but not between the lornoxicam group and control group (P > 0.05). The incidences of post-ERCP hyperamylasemia in the parecoxib group and lornoxicam group were significantly lower than that in the control group (9.09%, 15.2% vs 21.5%, both P < 0.01). Serum CRP level at 4 h after ERCP was significantly lower in both treatment groups than in the control group (both P < 0.01). Mean VAS at 4 h after ERCP was significantly lower in both treatment groups than in the control group (both P < 0.01).
CONCLUSION: NSAIDs like lornoxicam and parecoxib can prevent the occurrence of hyperamylasemia induced by ERCP. Parecoxib could prevent the occurrence of PEP. Both drugs can alleviate pain and inflammatory reactions after the endoscopic procedure. As a new type of NSAIDs, selective cyclooxygenase-2 (COX-2) inhibitors might be more useful in preventing PEP.
Collapse
|