Endoscopists now have concrete guidance to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, according to James Buxbaum, MD, associate professor of medicine at the University of Southern California and lead author on the ASGE guideline on post-ERCP pancreatitis prevention strategies. Dr. Buxbaum discusses how endoscopists can incorporate these guidelines into their practice during Digestive Disease Week® (DDW) 2024.
“Post-ERCP pancreatitis is by far the most frequent complication of ERCP, and it has been accepted as part of the procedure,” says Dr. Buxbaum. “Endoscopists need to be aware that they can prevent and mitigate this. These strategies should be top-of-mind when they’re considering the procedure.”
Approximately 10% of patients who undergo ERCP develop post-ERCP pancreatitis (PEP), which can cause pain, hospitalization, organ failure and even death.
These are the first such guidelines published by the ASGE. The guideline panel, consisting of experts in gastroenterology, endoscopy and systematic reviews, along with a patient advocate, based their recommendations on a sequence of meta-analyses of clinical studies performed over the past decade. The guidelines also include considerations such as cost effectiveness, patient preferences and health equity.
Dr. Buxbaum highlights some of the key recommendations for endoscopists.
Rectal NSAIDs should be considered for most patients.
The data are clear — most patients undergoing ERCP should receive prophylactic rectal non-steroidal anti-inflammatory drugs (NSAIDs). The guidelines show that rectal NSAIDs reduce the risk of pancreatitis by approximately half. Early studies focused on high-risk patients; however, more recent data has shown that rectal NSAIDs reduce the risk of PEP in lower-risk patients as well. Due to their low cost and low risk of side effects, rectal NSAIDs are recommended for all patients undergoing ERCP, unless contraindicated.
While rectal indomethacin was used in many of the trials, Dr. Buxbaum notes that endoscopists could consider other NSAIDs if cost is an issue. “The cost of rectal indomethacin has gone up considerably since many of these trials were done,” he says. “But there are ways to reformulate other types of NSAIDs to administer them in a preventative manner.”
More data are needed on the cost-effectiveness of aggressive hydration.
The guidelines show that aggressive hydration can reduce the overall risk of PEP by half but had no impact on the risk of severe pancreatitis. Intravenous fluids are generally inexpensive and may be available in areas that do not have access to rectal NSAIDs, though Dr. Buxbaum stresses that the overall cost-effectiveness of aggressive hydration is not clear.
“The original strategy for aggressive hydration was to keep patients overnight,” Dr. Buxbaum says. “That has cost implications. We need more evidence on the optimal timing of this approach.”
Pancreatic stents are recommended for high-risk patients.
The guidelines recommend that pancreatic stents be placed in high-risk patients to reduce the risk of PEP. Prophylactic pancreatic ductal stents reduced the risk of PEP by 65% according to the guideline meta-analysis and was the only intervention shown to reduce the risk of severe PEP. Despite this, pancreatic stents are used in less than 10% of high-risk patients.
“Placing pancreatic stents requires additional training,” says Dr. Buxbaum. “We need to train our gastroenterology fellows well if they’re doing ERCP. This is a key preventive measure.”
“Consider the risk of a patient, and act accordingly” Dr. Buxbaum concludes. “Always keep in mind if there is a way to prevent pancreatitis. For low-risk ERCP, we should think about rectal indomethacin or rectal NSAIDs. In high-risk cases, consider placing a pancreatic stent.”
Dr. Buxbaum’s oral presentation, “Preventing post-ERCP Pancreatitis” on Monday, May 20, at 10:05 a.m. EDT is part of the session “Guidelines in Action: A Case-Based Approach to Recent ASGE Guidelines.”
