Efficacy of low dose rectal diclofenac for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: Propensity score-matched analysis

Fatty Liver, Statin Therapy, and the Risk of Hypertriglyceridemic Acute Pancreatitis: A Retrospective Study

OBJECTIVES

Identifying patients with severe hypertriglyceridemia (HTG) who are prone to developing hypertriglyceridemic pancreatitis (HTGP) is essential for facilitating preventative interventions. This research aims to explore which part of the HTG patients is easy to develop into HTGP.

MATERIALS AND METHODS

An observational cohort study was conducted in patients with serum triglycerides (TGs) ≥ 5.65 mmol/L. Propensity score matching (PSM) and logistic regression were used to adjust for potential confounding factors. Receiver operating characteristic (ROC) curves were applied to evaluate the predictive potential for HTGP.

RESULTS

A total of 283 patients were included finally with a PSM cohort consisting of 55 HTGP matched with 77 non-HTGP. In multivariate logistic regression analysis, fatty liver (FL) (odds ratio, 2.535; P = 0.019) showed statistically significant association with HTGP, whereas statin use was correlated with a lower rate of HTGP (odds ratio, 0.203; P = 0.009). Finally, the ROC analysis showed that the TGs threshold thought to be causal of HTGP in patients with FL was significantly lower (9.31 vs 14.67 mmol/L) than that in patients without FL.

CONCLUSIONS

Although with lower TGs levels, patients with FL are much more prone to generate HTGP, and our findings suggest a potential role of statin as protective agents against HTGP.

Update on the management of acute pancreatitis

PURPOSE OF REVIEW

This review provides insight into the recent advancements in the management of acute pancreatitis.

RECENT FINDINGS

Moderate fluid resuscitation and Ringer's lactate has advantages above aggressive fluid resuscitation and normal saline, respectively. A normal "on-demand" diet has a positive effect on recovery from acute pancreatitis and length of hospital stay. A multimodal pain management approach including epidural analgesia might reduce unwarranted effects of opiate use. A more targeted use of antibiotics is starting to emerge. Markers such as procalcitonin may be used to limit unwarranted antibiotic use. Conversely, many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear. Delay of drainage as much as is possible is advised since it is associated with less procedures. If drainage is required, clinicians have an expanding arsenal of interventional options to their disposal such as the lumen-apposing metal stent for transgastric drainage and (repeated) necrosectomy. Immunomodulation using removal of systemic cytokines or anti-inflammatory drugs is an attractive idea, but up to now the results of clinical trials are disappointing. No additional preventive measures beside non-steroidal anti-inflammatory drugs (NSAIDs) can be recommended for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

SUMMARY

More treatment modalities that are less invasive became available and a trend towards less aggressive treatments (fluids, starvation, interventions, opiates) of acute pancreatitis is again emerging. Despite recent advancements, the pathophysiology of specific subgroup phenotypes is still poorly understood which reflects the disappointing results of pharmacological and immunomodulatory trials.

Efficacy of pancreatic duct stenting to prevent postendoscopic retrograde cholangiopancreatography pancreatitis after covered self-expandable metal stent deployment

OBJECTIVES

Although covered self-expandable metal stents (CSEMSs) are associated with the risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis due to pancreatic duct (PD) orifice obstruction, they are often used for biliary drainage treatment in malignant biliary obstruction (MBO). This study aimed to investigate the efficacy of PD stenting in preventing post-ERCP pancreatitis after CSEMS implantation.

METHODS

This retrospective cohort study analyzed 554 patients with transpapillary CSEMS for MBO. Patients with noninitial deployment, benign disease, CSEMS deployment above the papilla, surgically altered anatomy, uncovered self-expandable metal stents, multiple thin self-expandable metal stents, and unavailable procedure videos were excluded. Logistic regression analysis estimated the association between PD stenting and post-ERCP pancreatitis incidence. We adjusted for age, sex, pancreatitis history, prophylactic rectal nonsteroidal anti-inflammatory drug use, naïve papilla, MBO etiology, and prolonged biliary cannulation time.

RESULTS

Among 554 patients, 67 (12.1%) experienced post-ERCP pancreatitis. Post-ERCP pancreatitis was recorded in 13.7% of patients in the non-PD stenting and 4.3% in the PD stenting groups. Pancreatic duct stenting was associated with lower risks of post-ERCP pancreatitis (odds ratio [OR] 0.28; 95% confidence interval [CI] 0.099-0.79; P = 0.028). In multivariable analysis, the association between PD stenting and lower post-ERCP pancreatitis incidence was consistent (OR 0.19; 95% CI 0.062-0.58; P = 0.0034).

CONCLUSIONS

Pancreatic duct stenting could reduce the risk of post-ERCP pancreatitis after CSEMSs.

Rectal administration of low-dose diclofenac does not reduce post-endoscopic retrograde cholangiopancreatography pancreatitis: a propensity score matching analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a popular technique; however, post-ERCP pancreatitis (PEP) remains a major adverse event. The administration of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) is reportedly effective in preventing PEP. However, the recommended dose varies and the efficacy of low-dose rectal NSAIDs remains unclear. Therefore, we decided to investigate the effectiveness of low-dose rectal diclofenac on PEP prevention, using propensity score matching.

METHODS

This single-center retrospective study included 401 patients who underwent ERCP between July 2015 and March 2020. After December 2016, we administered rectal diclofenac within 30 min before the ERCP procedure as widely as possible. Patients were divided into those who did (diclofenac group) and did not (control group) receive rectal diclofenac. Patients weighing ≥ 50 kg were administered a 50 mg dose, while those weighing < 50 kg were administered a 25 mg dose. The incidence and severity of PEP in the two groups were assessed by propensity score matching analysis.

RESULTS

Among 401 patients undergoing ERCP, 367 fulfilled the inclusion criteria. Overall, 187 patients received rectal diclofenac (diclofenac group) and 180 did not (control group). After propensity score matching, 105 pairs were selected for evaluation. Overall, seven (6.7%) patients in the diclofenac group and 10 (9.5%) in the control group developed PEP (P = 0.45). Moderate or severe PEP occurred in four (3.8%) patients in the diclofenac group and six (5.7%) in the control group (P = 0.52).

CONCLUSIONS

The administration of low-dose rectal diclofenac could not reduce the incidence and severity of PEP.

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

Prophylaxis is important for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), which is the most common and serious complication of ERCP. Although the current guidelines include independent patient- and procedure-related risk factors for PEP and available PEP prophylactic measures, the synergistic effect of these risk factors on PEP should also be considered, given that patients often harbor multiple risk factors. Furthermore, a combination of prophylactic measures is often selected in clinical practice. However, established methods estimating the synergistic effect of independent risk factors on PEP incidence are lacking, and evidence on the impact of combining prophylactic measures on PEP should be discussed. Selection of appropriate candidate patients for ERCP is also important to reduce the incidence of PEP associated with unnecessary ERCP. ERCP indications in patients with asymptomatic common bile duct stones (CBDSs) and in those with suspected CBDSs with no imaging-based evidence of stones are controversial. Further studies are warranted to predict the synergistic effect of independent risk factors on PEP, determine the best prophylactic PEP measures, and identify appropriate candidates for ERCP in patients with asymptomatic CBDSs and those with suspected CBDSs.

Post-ERCP Pancreatitis: Prevention, Diagnosis and Management

Endoscopic retrograde cholangiopancreatography (ERCP) carries a post-ERCP pancreatitis (PEP) rate of 2–10%, which could be as high as 30–50% in high-risk cases. PEP is severe in up to 5% of cases, with potential for life-threatening complications, including multi-organ failure, peripancreatic fluid collections, and death in up to 1% of cases. The risk of PEP is potentially predictable and may be modified with pharmacological measures and endoscopist technique. This review covers the definition, epidemiology and risk factors for PEP, with a focus on the latest evidence-based medical and endoscopic strategies to prevent and manage PEP.

Multicenter prospective cohort study of adverse events associated with biliary endoscopic retrograde cholangiopancreatography: Incidence of adverse events and preventive measures for post-endoscopic retrograde cholangiopancreatography pancreatitis

OBJECTIVES

The reported incidence of adverse events (AEs) in endoscopic retrograde cholangiopancreatography (ERCP) varies between 2.5% and 14%. The aim of this study was to evaluate the incidence and severity of AEs in biliary ERCP and to specify the risk factors and preventive measures for post-ERCP pancreatitis (PEP).

METHODS

Patients with biliary disease with intact papilla were prospectively enrolled at 36 hospitals between April 2017 and March 2018. The primary outcomes were the incidence and severity of AEs.

RESULTS

A total of 16,032 ERCP procedures were performed at the 36 hospitals during the study period and 3739 patients were enrolled. The overall incidence of AEs was 10.1% and ERCP-related mortality was 0.08%. PEP developed in 258 cases (6.9%), bleeding in 33 (0.9%), instrumental AEs in 17 (0.5%), infections in 37 (1.0%), cardiovascular AEs in eight (0.2%), pulmonary AEs in eight (0.2%), drug reaction AE in one (0.03%), pain in 15 (0.4%), and other AEs in 15 (0.4%). Multivariable analysis showed significant risk factors for PEP were: female of younger age, pancreatic guidewire-assisted biliary cannulation, temporary guidewire insertion into the pancreatic duct, total procedure time >60 min, and post-ERCP administration of non-steroidal anti-inflammatory drugs. Effective preventive measures were prophylactic pancreatic stenting (PPS) and epinephrine spraying onto the papilla.

CONCLUSIONS

In patients with intact papilla who underwent biliary ERCP, the incidence of AEs was 10.1% and the mortality was 0.08%. PPS and epinephrine spraying may prevent PEP.

REGISTRATION

This study was registered in the University Hospital Medical Information Network (UMIN000024820).

Application of non-steroidal anti-inflammatory drugs in prevention of pancreatitis after endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most important methods for the clinical diagnosis and treatment of biliary and pancreatic diseases. Post-ERCP pancreatitis (PEP) is the most common complication. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in clinical prevention of PEP, but the application standards are not unified. This article reviews the progress in the research of the preventive effect of different types of NSAIDs on PEP, their administration routes, timing, and dosage, and combination with other drugs, as well as the preventive effect of NSAIDs in different risk stratification populations, and points out that indomethacin and diclofenac are the most commonly used types of NSAIDs, which should be given at 100 mg via rectal administration before ERCP in all non-selected patients with no contraindications.