Relationship between post-ERCP pancreatitis and the change of serum amylase level after the procedure

Postprocedure serum amylase or lipase levels predict postendoscopic retrograde cholangiopancreatography pancreatitis: Meta-analysis of diagnostic test accuracy studies and utility assessment

OBJECTIVES

We aimed to clarify the clinical utility of measuring serum pancreatic enzymes after endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of predicting post-ERCP pancreatitis (PEP) by a meta-analysis of diagnostic test accuracy studies.

METHODS

Studies on the prediction accuracy of PEP by serum amylase or lipase measured at 2, 3, and 4 h after ERCP were collected. A literature search was performed in PubMed and the Cochrane Library database for studies published between January 1980 and March 2023. The quality of individual studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2. Data were analyzed using Meta-DiSc 2.0 software.

RESULTS

We searched the databases and identified 20 observational studies (12,313 participants). PEPs were defined according to criteria by Cotton or modified Cotton, revised Atlanta criteria, or the Japanese criteria. Meta-analysis of eight studies (4389 participants) showed a pooled sensitivity of 71.1% (95% confidence interval [CI] 56.1-82.5) and pooled specificity of 91.2% (95% CI 85.9-94.6) for the serum amylase cut-off value at 3 times the upper limit of normal (ULN). Another meta-analysis of five studies (1970 participants) showed a pooled sensitivity of 85.8% (95% CI 61.9-95.7) and pooled specificity of 85.3% (95% CI 81.9-88.1) for the serum lipase cut-off value at 3 times ULN.

CONCLUSION

Despite a high risk of bias due to various reference standards, this updated meta-analysis and the utility assessment by a decision tree showed the utility of serum amylase or lipase levels more than 3 times ULN measured 2-4 h after ERCP for predicting PEP.

Risk Factors for Post-Endoscopic Retrograde Cholangio-Pancreatography Pancreatitis in Children With Chronic Pancreatitis and Its Prediction Using 4-Hour Postprocedure Serum Amylase and Lipase Levels

BACKGROUND

Post-endoscopic retrograde cholangio-pancreatography pancreatitis (PEP) is seen in 3% to 16% of children undergoing therapeutic endoscopic retrograde cholangio-pancreatography (ERCP). We evaluated the risk factors of PEP and utility of 4-hour post-ERCP amylase and lipase for early prediction of PEP in children with chronic pancreatitis (CP).

MATERIALS AND METHODS

Thirty children with CP (boys 20, 14.3 [interquartile range, 9.3-16] years) who underwent 62 ERCP procedures were studied. Clinical and procedural details with outcome were noted. Serum amylase and lipase were measured before, 4 hours, and 24 hours after ERCP. Multivariate analysis was done to identify risk factors for PEP. Cutoff scores of 4-hour amylase and lipase were identified.

RESULTS

PEP occurred in 14.5% (9/62) of ERCP procedures (mild, 8; moderate, 1) with no mortality. On univariate analysis, endoscopic sphincterotomy ( P = 0.04), difficult cannulation ( P = 0.004), and prior PEP ( P = 0.036) were risk factors, while prior ERCP ( P = 0.04) was protective. Difficult cannulation (odds ratio, 5.83; 95% confidence interval, 1.329-25.592) was the independent risk factor on multivariate analysis overall and for first ERCP session alone. Amylase >3.3 times upper limit of normal (ULN) and lipase of >5 times ULN at 4 hours had best sensitivity and specificity for diagnosis of PEP. All cases with PEP were symptomatic by 6 hours and none had amylase/lipase <3 ULN at 4 hours. Amylase/lipase of <3 ULN at 4 hours could exclude PEP with good sensitivity (100%) and specificity (76% and 81%, respectively).

CONCLUSIONS

PEP occurred in 14.5% of procedures in children with CP, with difficult cannulation being the independent risk factor. Asymptomatic patients with 4-hour amylase/lipase <3 times ULN can be safely discharged.

Nafamostat Reduces the Incidence of post-ERCP Pancreatitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). As the management of pancreatitis is limited, clinical approaches focus on the prevention of post-ERCP pancreatitis (PEP). In theory, the serine protease inhibitor nafamostat can reduce circulating inflammatory mediators in pancreatitis. We aimed to investigate the effect of nafamostat in the prevention of PEP in this systematic review and meta-analysis. The protocol for this review was registered in PROSPERO (CRD42022367988). We systematically searched 5 databases without any filters on September 26, 2022. The eligible population was adult patients undergoing ERCP. We compared the PEP preventive effect of nafamostat to placebo. The main outcome was the occurrence of PEP. We calculated the pooled odds ratios (ORs), mean differences, and corresponding 95% confidence intervals (95% CIs) and multilevel model. The risk of bias was assessed using the Rob2 tool. Seven randomized controlled trials involving 2,962 patients were eligible for inclusion. Nafamostat reduced the overall incidence rate of PEP (20 mg, OR: 0.50, 95% CI: 0.30-0.82 and 50 mg, OR: 0.48, 95% CI: 0.24-0.96). However, the occurrence of mild PEP was significantly reduced only in the subgroup receiving 20 mg nafamostat (OR, 0.49, 95% CI: 0.31-0.77). Overall, nafamostat therapy reduced moderate PEP in high-risk patients (OR: 0.18, 95% CI: 0.0.4-0.84) and mild PEP in low-risk patients (OR: 0.32, 95% CI: 0.17-0.61). Nafamostat is an effective therapy in the prevention of mild post-ERCP pancreatitis. Further research is required to determine the cost-effectiveness of this therapy.

Early prediction of post-ERCP pancreatitis by post-procedure amylase and lipase levels: A systematic review and meta-analysis

Background and study aims  Post-ERCP pancreatitis (PEP) is the most common complication attributed to the procedure, its incidence being approximately 9.7 %. Numerous studies have evaluated the predictive efficacy of post-procedure serum amylase and lipase levels but with varied procedure-to-test time intervals and cut-off values. The aim of this meta-analysis was to present pooled data from available studies to compare the predictive accuracies of serum amylase and lipase for PEP. Patients and methods  A total of 18 studies were identified after a comprehensive search of various databases until June 2021 that reported the use of pancreatic enzymes for PEP. Results  The sample size consisted of 11,790 ERCPs, of which PEP occurred in 764 (6.48 %). Subgroups for serum lipase and amylase were created based on the cut-off used for diagnosing PEP, and meta-analysis was done for each subgroup. Results showed that serum lipase more than three to four times the upper limit of normal (ULN) performed within 2 to 4 hours of ERCP had the highest pooled sensitivity (92 %) for PEP. Amylase level more than five to six times the ULN was the most specific serum marker with a pooled specificity of 93 %. Conclusions  Our analysis indicates that a lipase level less than three times the ULN within 2 to 4 hours of ERCP can be used as a good predictor to rule out PEP when used as an adjunct to patient clinical presentation. Multicenter randomized controlled trials using lipase and amylase are warranted to further evaluate their PEP predictive accuracy, especially in high-risk patients.

Impact of laparoscopic cholecystectomy on the complexity of endoscopic retrograde cholangiopancreatography

BACKGROUND AND OBJECTIVES

A scarce number of researches discussed the impact of cholecystectomies on the anatomy of common bile duct (CBD) and intern if this will affect the difficulty of endoscopic retrograde cholangiopancreatography (ERCP). The objective of present study was to assess the impact of complicated cholecystectomy on the complexity and safety of the ERCP procedure.

STUDY DESIGN

A total of 100 patients were enrolled after meeting the following inclusion criteria - study group (group A): 50 patients with previous history of complicated laparoscopic cholecystectomy and control group (group B): 50 patients with previous noncomplicated laparoscopic cholecystectomy. ERCP was performed and complexity was judged by a number of cannulation attempts, ERCP time, pancreatic cannulation and post-ERCP pancreatitis.

RESULTS

The study revealed prolonged ERCP procedure duration in noncomplicated cholecystectomy (24.2 ± 8.5 min) and it was significantly more prolonged in complicated cholecystectomy (39.6 ± 10.7 min; P = 0.03). The trials of cannulation attempts were significantly higher in the study group with complicated cholecystectomy (P = 0.009). Pancreatic duct cannulation was frequently higher in the complicated cholecystectomy group (P = 0.03). Difficult or failed stone extraction was significantly prevalent in the complicated cholecystectomy group and the occurrence of post-ERCP pancreatitis (PEP) was significantly higher than the control group.

CONCLUSION

ERCP after complicated laparoscopic cholecystectomy is more complex with increased duration liability of complications.

Randomized trial of high-dose rectal diclofenac suppository and epinephrine spray on duodenal papilla for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIMS

High-dose rectal diclofenac suppository and epinephrine spray on duodenal papilla during endoscopic retrograde cholangiopancreatography (ERCP) may reduce the incidence of post-ERCP pancreatitis. We performed randomized trial to compare the effect of combination of rectal diclofenac and epinephrine spray on papilla (group A) vs. combination of rectal diclofenac with saline spray (group B) for prevention of post-ERCP pancreatitis.

METHODS

We performed a double-blind trial at tertiary care center from April 2018 to May 2020 on 882 patients with naive papilla undergoing ERCP. The patients were randomly assigned to groups, A (n=437) or B (n=445). All patients received a single dose of rectal diclofenac 100 mg within 30 minutes before ERCP; 20 mL of diluted epinephrine 0.02% (group A) or saline (group B) was then sprayed on the duodenal papilla at the end of ERCP. The primary outcome was to compare incidence of post-ERCP pancreatitis (PEP) in two groups.

RESULTS

The groups had similar baseline characteristics. PEP developed in 28 patients in group A (6.4%) and 35 patients in group B (7.9%) (relative risk, 1.1; 95% CI, 0.87-1.39; p=0.401).

CONCLUSION

Our study showed that addition of epinephrine spray on duodenal papilla did not reduce the risk of post-ERCP pancreatitis. There is need for further studies to evaluate the role of different concentrations of epinephrine spray on papilla for prevention of post-ERCP pancreatitis.

TRIAL REGISTRATION

Clinical Trials Registry- India (CTRI/2018/04/013396).

The prognostic value of serum and urine amylase levels and blood count parameters in assessing the risk of post-endoscopic pancreatitis development

Introduction

Detection of post-endoscopic pancreatitis (PEP) in the first hours after endoscopic retrograde cholangiopancreatography (ERCP) can limit its consequences, while excluding it can provide safe discharge of the patient. Therefore, a simple, clinically available test is needed for this purpose.

Aim

The assessment of the risk of PEP development based on serum and urine amylase levels and parameters included in blood counts 4 h after ERCP.

Material and methods

The study included 398 patients after therapeutic ERCP. Four hours after the procedure was completed, serum and urine amylase levels and blood count parameters were analysed.

Results

The optimal serum amylase level for PEP detection was 516 UI/l, with ACC = 0.94, sens. 77.8%, spec. 0.95; positive predictive value (PPV) 0.412, negative predictive value (NPV) 0.98, positive likelihood factor (LR+) 14.93, and negative likelihood factor (LR-) 0.23. The serum amylase level for exclusion of PEP was 184 UI/l with ACC 0.79, sens. 0.83, spec. 0.79, PPV 0.16, NPV 0.99, and LR- 0.21. The optimal urine amylase level for detection and exclusion (based on Youden index) was 575 UI/l, sens. 83.33%, spec. 81.3%, PPV 0.172, NPV 0.99, LR+ 4.44, and LR- 0.20.

Conclusions

Serum amylase levels above 516 UI/l at 4 h after ERCP should be an indication for further observation in hospital, and levels below 184 UI/l may justify safe discharge of the patient. Additional determinations of urine amylase levels and parameters included in blood counts do not improve the diagnostic capacity for the detection or exclusion of PEP risk.

Preventive and therapeutic significance of octreotide combined with lansoprazole on post-ERCP pancreatitis and its effect on serum amylase, inflammatory factors and immune function

The study aimed to investigate the preventive and therapeutic significance of octreotide combined with lansoprazole on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and its effects on serum amylase (AMS), inflammatory factors and immune function. A total of 132 patients who underwent ERCP in Shaoxing People's Hospital (Shaoxing, China) were enrolled in the study and allocated into two groups: The study group (octreotide plus lansoprazole, 68 cases) and the control group (octreotide alone, 64 cases). The incidence of PEP and post-ERCP hyperamylasemia (PEH), the concentrations of serum AMS, interleukin-17 (IL-17) and tumor necrosis factor-α (TNF-α), as well as the T-lymphocyte population in peripheral blood were detected. The AMS levels in the study group were significantly lower than those in the control group at 6 and 24 h after treatment (P<0.001). The incidence of PEP and PEH, symptom disappearance time and hospital stay in the study group were significantly lower than those in the control group after treatment (P<0.05). The levels of IL-17 and TNF-α in the study group were significantly lower than those in the control group after treatment (all P<0.05). The percentage of CD3⁺, CD4⁺, CD8⁺ cells and the ratio of CD4⁺/CD8⁺ in the study group were significantly higher than those in the control group after treatment (all P<0.05). The results indicated that octreotide combined with lansoprazole reduces AMS levels and the incidence of PEP, alleviates inflammation and improves the immune function.

The milestone for preventing post-ERCP pancreatitis using novel simplified predictive scoring system: a propensity score analysis

BACKGROUND

Post-ERCP pancreatitis (PEP) with trans-papillary approach remains a major issue, and the multi-factorial etiology can lead to the development of unpredictable PEP. Therefore, the early identification of PEP is highly desirable to assist with the health cost containment, the reduction in unnecessary admissions, earlier appropriate primary care, and intensive care for preventing progression of severe pancreatitis. This study aimed to establish a simplified predictive scoring system for PEP.

METHODS

Between January 1, 2012, and December 31, 2019, 3362 consecutive trans-papillary ERCP procedures were retrospectively analyzed. Significant risk factors were extracted by univariate, multivariate, and propensity score analyses, and the probability of PEP in the combinations of each factor were quantified using propensity score analysis. The results were internally validated using bootstrapping resampling.

RESULTS

In the scoring system with four stratifications using combinations of only five extracted risk factors, the very high-risk group showed 28.79% (95% confidence interval [CI], 18.30%-41.25%; P < 0.001) in the predicted incidence rate of PEP, and 9.09% (95% CI, 3.41%-18.74%; P < 0.001) in that of severe PEP; although the adjusted prevalence revealed 3.74% in PEP and 0.90% in severe PEP, respectively. The prediction model had an area under the curve of 0.86 (95% CI, 0.82-0.89) and the optimism-corrected model as an internal validation had an area under the curve of 0.81 (95% CI, 0.77-0.86).

CONCLUSIONS

We established and validated a simplified predictive scoring system for PEP using five risk factors immediately after ERCP to assist with the early identification of PEP.

Emerging Therapies to Prevent Post-ERCP Pancreatitis

PURPOSE OF REVIEW

The aim of this review is to evaluate emerging, novel therapies for the prevention of post-ERCP pancreatitis.

RECENT FINDINGS

Rectal indomethacin reduces the risk of pancreatitis in low- and average-risk patients, who comprise the majority of patients undergoing ERCP. An 8-h protocol of aggressive lactated Ringer's reduces the risk of pancreatitis in average-risk patients. Sublingual nitrate may provide additional benefit to rectal NSAIDs in preventing PEP. A tacrolimus trough > 2.5 ng/mL was recently shown to be associated with a lower risk of PEP in liver transplant patients undergoing ERCP. Routine usage of rectal indomethacin in all patients undergoing ERCP reduces the risk of PEP. Pancreatic-duct stents reduce the risk of PEP in high-risk patients. There is emerging data that aggressive hydration with lactated Ringer's and nitrates may further reduce PEP. Tacrolimus is a promising potential agent to prevent PEP but needs further clinical study.

Diagnostic Value of Serum Amylase Levels Indicating Computed Tomography-Defined Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective Multicenter Observational Study

OBJECTIVE

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis involves persistent serum amylase levels of 3 times or more the standard upper limit. However, these criteria were mostly based on retrospective studies and not necessarily supported by diagnostic imaging. Our prospective study aimed to investigate cutoff serum amylase levels suggesting post-ERCP pancreatitis using computed tomography as the criterion standard.

METHODS

We prospectively followed 2078 cases. Computed tomography was performed in patients whose serum amylase levels exceeded the institutional upper limit 12 to 24 hours after ERCP. Two expert radiologists blindly assessed the images and judged the presence or absence of pancreatitis. Correlations between serum amylase levels with pancreatitis were investigated using receiver operating characteristic analysis.

RESULTS

Amylase levels increased in 416 (23.2%) of 1789 cases included, and 350 cases were analyzed using computed tomography. Post-endoscopic retrograde cholangiopancreatography pancreatitis was diagnosed in 12.0% (214/1789). The cutoff amylase levels for judging pancreatitis after 12 to 24 hours was 2.75 times higher than the institutional upper limit, with an area under the curve of 0.77.

CONCLUSIONS

The appropriate cutoff serum amylase level for judging post-ERCP pancreatitis at 12 to 24 hours after ERCP was 2.75 times higher than the institutional upper limit. These results may clarify the definition of post-ERCP pancreatitis.

Three-hour post-ERCP amylase level: a useful indicator for early prediction of post-ERCP pancreatitis

Background

To evaluate the value of the 3-h post-ERCP serum amylase level for early prediction of post-ERCP pancreatitis (PEP).

Method

A study of 206 patients performed ERCP (Encoscopic Retrograde Cholangio-Pancreatography) at a single centre was done from Jan. 2011 to Nov. 2016. The serum amylase or lipase level was measured at 3 h after ERCP. The patients with PEP were recorded. ROC curves were used to statistically analyze the data: The enrolled patients were divided into two groups according to gender, then we analyzed the data respectively. We comprehensively evaluated the predictive value of PEP by 3-h post-ERCP serum amylase level based on the results above.

Results

Two hundred six patients (92 males, 114 females) were enrolled. PEP occurred in 21 patients (10.19%) among them. The median time to discharge was 7 days (min = 1d, max = 13d) after the procedure. In the 206 patients, the 3-h post-ERCP pancreatic amylase level was used as the test variable, and the PEP occurrence as the state variable to plot the ROC curve. The area under the curve (AUC) was 0.816, and was statistically significant (P < 0.001). The standard error (SE) was 0.0507, the 95% confidence interval (CI) was 0.756–0.866, and the optimal cut-off value was 351 U/L (sensitivity 76.19%, specificity 83.24%, positive likelihood ratio 4.55, negative likelihood ratio 0.29, Youden index 59.43%). Of the 206 patients, there were 83 patients with both 3-h post-ERCP amylase level and lipase level detected, and the ROC curves were plotted for both serum amylase and lipase respectively. The ROC curve matched-pair testing was carried out: The areas under the ROC curves were statistically significant. (P < 0.001) The area under the ROC curve for the 3-h post-ERCP lipase was 0.778, the 95% confidence interval was 0.673–0.862, and optimal cut-off value was 1834 U/L. The area under the ROC curve for the 3-h post-ERCP serum amylase was 0.780, and the 95% confidence interval was 0.676–0.864. The optimal cut-off is 380 U/L, and there was no statistically significant difference between the two for diagnostic accuracy. According to gender, 206 patients were divided into 2 groups, and the ROC curves were drawn respectively. Based on statistical analysis, there was no statistically significant difference in the diagnostic accuracy of the two groups. In the male group, 436 U/L serum amylase provided the greatest diagnostic accuracy with sensitivity (SE) of 70.5%, specificity (SP) of 89.2%, positive predictive value (PPV) 87.5%, and negative predictive value (NPV) 78.1%. Whereas, in the female group, 357 U/L serum amylase provided the greatest diagnostic accuracy with sensitivity of 76.9%, specificity of 81.2%, positive predictive value of 80.4%, negative predictive value of 77.9%.

Conclusions

1. The 3-h post-ERCP serum amylase level is a useful measurement for predicting post-ERCP pancreatitis. 2. There was no significant difference between serum amylase and lipase 3-h post-ERCP for predicting PEP. 3. There was no statistically significant difference between male and female using the 3-h post-ERCP serum amylase level to predict PEP. For female, the optimal cut-off value was 357 U/L, whereas male 436 U/L .

Usefulness of serum lipase for early diagnosis of post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is new onset acute pancreatitis after ERCP. This complication is sometimes fatal. As such, PEP should be diagnosed early so that therapeutic interventions can be carried out. Serum lipase (s-Lip) is useful for diagnosing acute pancreatitis. However, its usefulness for diagnosing PEP has not been sufficiently investigated.

AIM

This study aimed to retrospectively examine the usefulness of s-Lip for the early diagnosis of PEP.

METHODS

We retrospectively examined 4192 patients who underwent ERCP at our two hospitals over the last 5 years. The primary outcomes were a comparison of the areas under the receiver operating characteristic (ROC) curves (AUCs) of s-Lip and serum amylase (s-Amy), s-Lip and s-Amy cutoff values based on the presence or absence of PEP in the early stage after ERCP via ROC curves, and the diagnostic properties [sensitivities, specificities, positive predictive values (PPV), and negative predictive value (NPV)] of these cutoff values for PEP diagnosis.

RESULTS

Based on the eligibility and exclusion criteria, 804 cases were registered. Over the entire course, PEP occurred in 78 patients (9.7%). It occurred in the early stage after ERCP in 40 patients (51.3%) and in the late stage after ERCP in 38 patients (48.7%). The AUCs were 0.908 for s-Lip [95% confidence interval (CI): 0.880-0.940, P < 0.001] and 0.880 for s-Amy (95%CI: 0.846-0.915, P < 0.001), indicating both are useful for early diagnosis. By comparing the AUCs, s-Lip was found to be significantly more useful for the early diagnosis of PEP than s-Amy (P = 0.023). The optimal cutoff values calculated from the ROC curves were 342 U/L for s-Lip (sensitivity, 0.859; specificity, 0.867; PPV, 0.405; NPV, 0.981) and 171 U/L for s-Amy (sensitivity, 0.859; specificity, 0.763; PPV, 0.277; NPV, 0.979).

CONCLUSION

S-Lip was significantly more useful for the early diagnosis of PEP. Measuring s-Lip after ERCP could help diagnose PEP earlier; hence, therapeutic interventions can be provided earlier.

Serum lipase as a biomarker for early prediction and diagnosis of post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND

Lipase is one of the diagnostic criteria for acute pancreatitis; however, the value of serum lipase in the early prediction and diagnosis for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis remains controversial.

AIMS

We evaluate the 3-h post-ERCP serum amylase and lipase activities for early prediction of postoperative pancreatitis (PEP) and compare the 24-h post-ERCP serum amylase and lipase activities in the diagnosis of PEP.

METHODS

Clinical information of patients who underwent ERCP from January 2017 to December 2018 at our hospital were retrospectively reviewed. Receiver operating characteristic (ROC) curves were performed for 3-h and 24-h post-ERCP serum amylase and lipase activities to evaluate predictive and diagnostic values, respectively.

RESULTS

A total of 498 cases with ERCP were finally enrolled, in which 36 cases of PEP were confirmed. ROC curves for 3-h post-ERCP amylase and lipase activities depicted areas under the curve (AUCs) of 0.88 (P < 0.001, 95% confidence intervals [CI] 0.82-0.93) and 0.90 (P < 0.001, 95% CI 0.86-0.93), respectively. The difference showed no significance using Z test (Z = 0.69, P > 0.05). AUCs for 24-h amylase and lipase activities were 0.83 (P < 0.001, 95% CI 0.77-0.89) and 0.94 (P < 0.001, 95% CI 0.90-0.99), respectively, and the difference was significant (Z = 3.04, P < 0.05).

CONCLUSIONS

For early prediction of PEP, 3-h post-ERCP serum lipase activity is at least as good as that of amylase. For diagnosis of PEP, 24-h post-ERCP serum lipase is a much better indicator than that of amylase. Together, this study suggests that serum lipase should be given priority in the early prediction and diagnosis of PEP.

Serum amylase and lipase levels for prediction of postendoscopic retrograde cholangiopancreatography pancreatitis

Background:

The aim of the present study was to assess 2- and 4-h postendoscopic retrograde cholangiopancreatography (ERCP) serum amylase and lipase levels for prediction of post-ERCP, pancreatitis (PEP), and their predictive cutoff values.

Materials and Methods:

In this cross-sectional study, we evaluated serum amylase and lipase levels before the procedure, 2 h and 4 h after the procedure, and in patients with persisting abdominal pain, 24 h afterward. A total of 300 adult patients who underwent ERCP procedures from March 2014 to June 2015 in referral hospital in Isfahan were studied. The receiver operating characteristic analysis was applied to determine the predictive score of amylase and lipase levels for PEP 2 and 4 h after ERCP.

Results:

The 2-h serum amylase cutoff values of 241 IU/L (normal range: 28–100 IU/L) had a very high negative predictive value (NPV) (98.7%) but a poor positive predictive value (49.2%) for prediction of PEP (area under curve [AUC]: 0.947; 95% confidence interval [CI]: 0.914–0.979). Based on our results, the patients might be considered for supportive therapy of PEP with the 4-h serum amylase above the cut point of 839.5 IU/L with a specificity of 95.1% (AUC: 0.978; 95% CI: 0.964–0.992). In addition, the 2- and 4-h serum lipase levels at cut points of 216 IU/L (AUC: 0.954; 95% CI: 0.931–0.977) and 656.5 IU/L (AUC: 0.966; 95% CI: 0.945–0.986) (normal value <60 IU/L), respectively, had the best sensitivity (97.1%) and high NPVs (99.6%) for exclusion of PEP.

Conclusion:

Measurements of serum amylase and lipase 2- and 4-h post-ERCP might be useful in prediction of PEP.

Prediction of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Using 4-Hour Post-Endoscopic Retrograde Cholangiopancreatography Serum Amylase and Lipase Levels

Early post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prediction may allow safe same-day outpatients discharge after ERCP and earlier proper management. This study aimed to assess the usefulness of the 4-hour post-ERCP serum amylase and lipase levels for PEP early prediction and to investigate predictive cut-off values for 4-hour post-ERCP serum amylase and lipase levels for safe discharge and urgent initiation of resuscitation. The data of 516 consecutive patients with native papilla who underwent ERCP between January 2013 and August 2014 were retrospectively reviewed. Serum amylase and lipase levels were measured before, and 4 and 24 hours after ERCP. PEP occurred in 16 (3.1%) patients. The receiver-operator characteristic curve for 4-hour post-ERCP serum amylase and lipase levels showed that the areas under the curve were 0.919 and 0.933, respectively, demonstrating good test performances as predictors for PEP (both P values < 0.001). The amylase level > 1.5 × the upper limit of reference (ULR) was found useful for PEP exclusion with a sensitivity of 93.8%, while 4 × ULR was found useful to guide preventive therapy with the best specificity of 93.2%. Similarly, the lipase level 2 × ULR showed best sensitivity, while 8 × ULR had the best specificity. Logistic regression analysis showed that 4-hour post-ERCP amylase level > 4 × ULR, lipase level > 8 × ULR, precut sphincterotomy, and pancreatic sphincterotomy were significant predictors for PEP. In conclusion, 4-hour post-ERCP amylase and lipase levels are useful early predictors of PEP that can ensure safe discharge or prompt resuscitation after ERCP.

Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis

BACKGROUND

The treatment of people with acute abdominal pain differs if they have acute pancreatitis. It is important to know the diagnostic accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis, so that an informed decision can be made as to whether the person with abdominal pain has acute pancreatitis. There is currently no Cochrane review of the diagnostic test accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis.

OBJECTIVES

To compare the diagnostic accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase, either alone or in combination, in the diagnosis of acute pancreatitis in people with acute onset of a persistent, severe epigastric pain or diffuse abdominal pain.

SEARCH METHODS

We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase.

SELECTION CRITERIA

We included all studies that evaluated the diagnostic test accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis. We excluded case-control studies because these studies are prone to bias. We accepted any of the following reference standards: biopsy, consensus conference definition, radiological features of acute pancreatitis, diagnosis of acute pancreatitis during laparotomy or autopsy, and organ failure. At least two review authors independently searched and screened the references located by the search to identify relevant studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies. The thresholds used for the diagnosis of acute pancreatitis varied in the trials, resulting in sparse data for each index test. Because of sparse data, we used -2 log likelihood values to determine which model to use for meta-analysis. We calculated and reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) for each cutoff, but have reported only the results of the recommended cutoff of three times normal for serum amylase and serum lipase, and the manufacturer-recommended cutoff of 50 mg/mL for urinary trypsinogen-2 in the abstract.

MAIN RESULTS

Ten studies including 5056 participants met the inclusion criteria for this review and assessed the diagnostic accuracy of the index tests in people presenting to the emergency department with acute abdominal pain. The risk of bias was unclear or high for all of the included studies. The study that contributed approximately two-thirds of the participants included in this review was excluded from the results of the analysis presented below due to major concerns about the participants included in the study. We have presented only the results where at least two studies were included in the analysis.Serum amylase, serum lipase, and urinary trypsinogen-2 at the standard threshold levels of more than three times normal for serum amylase and serum lipase, and a threshold of 50 ng/mL for urinary trypsinogen-2 appear to have similar sensitivities (0.72 (95% CI 0.59 to 0.82); 0.79 (95% CI 0.54 to 0.92); and 0.72 (95% CI 0.56 to 0.84), respectively) and specificities (0.93 (95% CI 0.66 to 0.99); 0.89 (95% CI 0.46 to 0.99); and 0.90 (95% CI 0.85 to 0.93), respectively). At the median prevalence of 22.6% of acute pancreatitis in the studies, out of 100 people with positive test, serum amylase (more than three times normal), serum lipase (more than three times normal), and urinary trypsinogen (more than 50 ng/mL), 74 (95% CI 33 to 94); 68 (95% CI 21 to 94); and 67 (95% CI 57 to 76) people have acute pancreatitis, respectively; out of 100 people with negative test, serum amylase (more than three times normal), serum lipase (more than three times normal), and urinary trypsinogen (more than 50 ng/mL), 8 (95% CI 5 to 12); 7 (95% CI 3 to 15); and 8 (95% CI 5 to 13) people have acute pancreatitis, respectively. We were not able to compare these tests formally because of sparse data.

AUTHORS' CONCLUSIONS

As about a quarter of people with acute pancreatitis fail to be diagnosed as having acute pancreatitis with the evaluated tests, one should have a low threshold to admit the patient and treat them for acute pancreatitis if the symptoms are suggestive of acute pancreatitis, even if these tests are normal. About 1 in 10 patients without acute pancreatitis may be wrongly diagnosed as having acute pancreatitis with these tests, therefore it is important to consider other conditions that require urgent surgical intervention, such as perforated viscus, even if these tests are abnormal.The diagnostic performance of these tests decreases even further with the progression of time, and one should have an even lower threshold to perform additional investigations if the symptoms are suggestive of acute pancreatitis.

The "Scope" of Post-ERCP Pancreatitis

Pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography, with the potential for clinically significant morbidity and mortality. Several patient and procedural risk factors have been identified that increase the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Considerable research efforts have identified several pharmacologic and procedural interventions that can drastically affect the incidence of PEP. This review article addresses the underlying mechanisms at play for the development of PEP, identifying patient and procedural risk factors and meaningful use of risk-stratification information, and details current interventions aimed at reducing the risk of this complication.

Combination of two-hour post-endoscopic retrograde cholangiopancreatography amylase levels and cannulation times is useful for predicting post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM

To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography (ERCP) serum amylase levels and other factors for predicting post-ERCP pancreatitis.

METHODS

This was a retrospective, single-center cohort study of consecutive patients who underwent ERCP from January 2010 to December 2013. Serum amylase levels were measured 2 h post-procedure, and patient- and procedure-related pancreatitis (PEP) risk factors were analyzed using a logistic model.

RESULTS

A total of 1520 cases (average age 72 ± 12 years, 60% male) were initially enrolled in this study, and 1403 cases (725 patients) were ultimately analyzed after the exclusion of 117 cases. Fifty-five of these cases developed PEP. We established a 2 h serum amylase cutoff level of two times the upper limit of normal for predicting PEP. Multivariate analysis revealed that a cannulation time of more than 13 min [odds ratio (OR) 2.28, 95%CI: 1.132-4.651, P = 0.0210] and 2 h amylase levels greater than the cutoff level (OR = 24.1, 95%CI: 11.56-57.13, P < 0.0001) were significant predictive factors for PEP. Forty-seven of the 55 patients who developed PEP exhibited 2 h amylase levels greater than the cutoff level (85%), and six of the remaining eight patients who developed PEP (75%) required longer cannulation times. Only 2 of the 1403 patients (0.14%) who developed PEP did not exhibit concerning 2 h amylase levels or require longer cannulation times.

CONCLUSION

These findings indicate that the combination of 2 h post-ERCP serum amylase levels and cannulation times represents a valuable marker for identifying patients at high risk for PEP.

Insulin Resistance as a Novel Risk Factor for Post-ERCP Pancreatitis: A Pilot Study

BACKGROUND AND AIMS

The relationship between insulin resistance and post-ERCP pancreatitis (PEP) is not known. We aimed to determine the relation between pre-ERCP insulin resistance and risk of PEP, and to evaluate the relationship of insulin resistance with well-established risk factors for PEP.

METHODS

Consecutive patients who underwent ERCP with the diagnosis of choledocolithiasis between January and December 2013 were enrolled in this prospective study. Pre-procedural insulin resistance state and other risk factors were evaluated according to PEP development.

RESULTS

Pancreatitis developed in 16 (11.3 %) of 141 ERCP procedure. Homeostasis model assessment of insulin resistance (HOMA-IR) levels was found statistically significantly higher in patients who developed PEP than the ones who did not (3.37 ± 0.8 vs. 2.38 ± 1.4, p < 0.001). Common bile duct (CBD) diameter of the patients developing PEP was found significantly lower than the non-PEP group (10.1 ± 4 vs. 13.4 ± 4.5 mm, p = 0.01). Mean procedure time was 33.5 min in PEP group and 27.9 min in non-PEP group (p = 0.006). HOMA-IR (OR 2.39), procedure time (OR 1.15), and CBD diameter (OR 0.82) were independent predictors of PEP development.

CONCLUSIONS

The presence of insulin resistance is an important risk factor for PEP, and these data can be used as a considerable clue to predict the risk of PEP before ERCP and to decrease related morbidity.

Predicting post-endoscopic retrograde cholangiopancreatography pancreatitis using the 4-h serum lipase level

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex therapeutic procedure that is complicated by pancreatitis in 3-5% of cases. The aim of this study is to determine whether a 4-h post-ERCP serum lipase level is superior to the serum amylase level in predicting the occurrence of post-ERCP pancreatitis (PEP).

METHODS

We performed a retrospective review of prospectively collected data on 543 consecutive patients undergoing therapeutic ERCP at a single centre. Serum lipase and amylase levels were measured at 4-h post-procedure and were recorded as a factor of the upper limit of normal: amylase factor (AF) and lipase factor (LF). Sensitivity and specificity were compared using receiver-operating characteristics and the Youden index (YI).

RESULTS

A total of 506 procedures were considered for analysis. PEP occurred in 19 patients (3.8%). A LF of <10 was useful for the exclusion of PEP with a sensitivity of 100% and a specificity of 94%, YI = 0.94. In contrast, an AF <3 yielded a sensitivity of 79% and specificity of 94%, YI = 0.73.

CONCLUSION

Serum lipase measured at 4-h post-ERCP better excludes PEP than serum amylase measured at the same time point. Patients with a LF <10 may be safely considered for same-day discharge.

Chemerin: a new biomarker to predict postendoscopic retrograde cholangiopancreatography pancreatitis

INTRODUCTION

Individuals with increased visceral adiposity are considered to be more sensitive and more prone to severe acute pancreatitis because of the inflammatory microenvironment they have. We hypothesized that insulin resistance, adipokines, and proinflammatory cytokines that markedly affect the course of pancreatitis can contribute toward development of postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) and aimed to investigate the association between PEP risk and preprocedural serum vaspin, chemerin, tumor necrosis factor α, interleukin-6 (IL-6) levels, and homeostasis model assessment of insulin resistance.

PATIENTS AND METHODS

Eighty-two patients with a diagnosis of choledocholithiasis and 30 controls were enrolled. Preprocedural chemerin, vaspin, IL-6, and well-known PEP risk factors were compared between PEP and non-PEP groups.

RESULTS

The mean age of the patients was 56.3±14.4 years; 52 patients were women. Adipocytokine levels, BMIs, and waist circumferences of the patient group were found to be higher than those of the controls. Total cannulation success and the mean procedure time were 82.9% and 28.7±8.8 min, respectively. PEP developed in 12 (14.6%) patients. Chemerin levels in the PEP group were higher than those in the non-PEP group (580.2±172.5 vs. 392.2±168.2 ng/ml, P<0.01). Insulin resistance was higher in the PEP group than the non-PEP group (P=0.001), but there was no significant difference between PEP and non-PEP groups in terms of preprocedural vaspin, tumor necrosis factor α, IL-6, and C-reactive protein levels. According to logistic regression analysis, increased chemerin levels, homeostasis model assessment of insulin resistance 2.5 or greater, and pancreatic duct cannulation were found to be independent risk factors for PEP [odds ratio (OR)=1.006, P=0.006; OR=4.57, P=0.05; OR=6.54, P=0.02].

CONCLUSION

Elevated serum chemerin levels and insulin resistance are independent risk factors of PEP development.

Rapid urinary trypsinogen-2 test strip in the diagnosis of pancreatitis after endoscopic retrograde cholangiopancreatography

OBJECTIVES

The aim of this prospective study was to evaluate the diagnostic value of the rapid urinary trypsinogen-2 test strip in post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

METHODS

A total of 150 patients were tested with the urinary trypsinogen-2 test strip and serum levels of amylase and lipase before ERCP and 3 hours after ERCP. The diagnostic value of urinary trypsinogen-2 strip test compared with that of serum amylase and lipase was analyzed.

RESULTS

Post-ERCP pancreatitis was diagnosed in 13 (8.7%) of 150 patients. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of urinary trypsinogen-2 dipstick test at 3 hours after ERCP are 84.6%, 97.1%, 73.3%, 98.5%, and 96%, respectively. At the cutoff level of 3 times the upper reference limit, the negative predictive values of amylase and lipase were comparable to that urinary trypsinogen-2 strip test; however, their positive predictive values (42.9% and 36.4%, respectively) were markedly lower than that of urinary trypsinogen-2 test (73.3%).

CONCLUSIONS

The urinary trypsinogen-2 dipstick test is a useful test for early diagnosis of post-ERCP pancreatitis. A negative urinary dipstick test at 3 hours after the procedure rules out post-ERCP pancreatitis with a high probability and allows of early discharge plan.

Assessment of trypsinogen-2 levels as an early diagnostic for post-endoscopic retrograde cholangiopancreatography pancreatitis

OBJECTIVES

The objective of the present study was to assess the use of serum trypsinogen-2 (TRY-2) measurements in early diagnosis of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

In this prospective study, investigation 1 involved collection of blood serum both before and at 2, 4, and 18 hours after ERCP, whereas investigation 2 involved collection before and 1, 2, 3, 4, 6, and 18 hours after ERCP. Total amylase, pancreatic amylase, and TRY-2 levels were measured from serum samples, and values from patients with pancreatitis after ERCP were compared to those from healthy control patients after ERCP.

RESULTS

In investigation 1, 8 of the 68 cases examined were diagnosed as post-ERCP pancreatitis. In the healthy group, total- and pancreatic-amylase levels peaked 4 hours after ERCP, and TRY-2 levels peaked at 2 hours after ERCP. In contrast, cases of post-ERCP pancreatitis demonstrated prolonged periods of high total-amylase, pancreatic-amylase, and TRY-2 levels. In investigation 2, none of the 23 cases was diagnosed as post-ERCP pancreatitis: Pancreatic amylase levels peaked 4 to 6 hours after ERCP and TRY-2 levels peaked 1 hour after ERCP.

CONCLUSION

These results suggest that TRY-2 is a more sensitive marker than amylase, and it can be useful in early diagnosis of post-ERCP pancreatitis.