Tenner_edit.qxp 4/10/07 4:31 pm Page 62
Pancreatitis
Prevention and Treatment of Post-endoscopic Retrograde
Cholangiopancreatography Pancreatitis
a report by
Nison Badalov, MD and Scott Tenner, MD, MPH
Maimonides Medical Center, State University of New York
Acute pancreatitis is the most common and feared complication of of the pancreatic duct (PD) and instillation of intra-ductal contrast often
endoscopic retrograde cholangiopancreatography (ERCP) and is associated result in a transient increase in the serum amylase and lipase with no clinical
with substantial morbidity and occasional mortality. The mechanisms that lead significance. Combining these two common findings (pain and elevation in
to post-ERCP pancreatitis are complex and not fully understood. Rather than amylase and lipase) may lead to a patient suffering from gas pain being
having a single pathogenesis, post-ERCP pancreatitis is believed to include inappropriately diagnosed with post-ERCP pancreatitis. Obviously, this
chemical, hydrostatic, enzymatic, mechanical, and thermal factors. A number would lead to an extraordinary number of patients appearing to have mild
of risk factors acting independently or in concert have been proposed as disease who, in fact, do not have pancreatic inflammation. Perhaps this is
predictors of post-ERCP pancreatitis.
1–4
These include patient- and procedure- the reason why many large studies suggest that post-ERCP pancreatitis is a
related factors. Investigators have attempted to identify endoscopic or less severe disease. This may also explain why the incidence of post-ERCP
pharmacological interventions that might reduce the incidence of pancreatitis pancreatitis varies greatly among studies: from 2 to 30%.
1,2,5
following ERCP. The purpose of this review is to describe the advances in
preventing the occurrence and severity of post-ERCP pancreatitis. Due to the lack of specificity of pain and the elevations of amylase/lipase in
patients who have undergone ERCP, imaging becomes the most important
Identification of Post-endoscopic Retrograde criterion in determining the diagnosis of post-ERCP pancreatitis. Post-ERCP
Cholangiopancreatography Pancreatitis pancreatitis should be suspected in any patient who develops pain within six
Regardless of the etiology, the diagnosis of acute pancreatitis requires two of hours of the procedure. It is much less likely to develop after 12 hours from
the three following criteria:
5
abdominal pain (symptoms) consistent with the the procedure. In the setting of pain, the presence of elevated amylase/lipase
diagnosis; an amylase and/or lipase greater than three times the upper limit of should lead to radiologic imaging to confirm the diagnosis.
normal; and/or imaging consistent with the diagnosis—computed tomography
(CT) and/or magnetic resonance imaging (MRI). Although these criteria provide Risk Factors for Developing Post-endoscopic Retrograde
accuracy in the diagnosis of acute pancreatitis in almost all other etiologies, in Cholangiopancreatography Pancreatitis
post-ERCP pancreatitis many patients will have two of these criteria in the Identification of the risk factors for post-ERCP pancreatitis is essential for
absence of acute pancreatitis, pain, and an elevation of amylase and lipase. recognizing high-risk cases in which ERCP should be avoided if possible, or
Often patients have pain following ERCP in the absence of pancreatitis due in which protective endoscopic or pharmacological interventions should be
to the large amounts of air insufflated during the procedure. This air results considered. Risk factors for developing post-ERCP pancreatitis have been
in bowel distention and painful spasm. In addition to pain, asymptomatic assessed in various studies and include patient-, procedure-, and operator-
elevations in amylase and/or lipase often occur following ERCP. Cannulation related factors.
2
Table 1 describes the various factors that increase the risk
of post-ERCP pancreatitis. The patient-related factors include: young age;
female gender; suspected sphincter of Oddi dysfunction (SOD); recurrent
Nison Badalov, MD, is a second-year gastrointestinal Fellow at
Maimonides Medical Center, State University of New York,
pancreatitis; prior history of post-ERCP pancreatitis; and patients with
Brooklyn. Dr Badalov is actively involved in research into normal bilirubin. The procedure-related factors include: PD injection;
pancreatic disorders.
difficult cannulation; pancreatic sphincterotomy; pre-cut access; and
balloon dilatation. The operator or technical factors are controversial.
Although, intuitively, a high volume should have lower rates, studies in
general do not show this to be true. However, trainee (fellows) participation
has been shown to be a significant risk factor for the development of post-
Scott Tenner, MD, MPH, serves as Director of Medical Education ERCP pancreatitis. In general, the more likely a patient is to have an
and Research at Maimonides Medical Center, and Associate
abnormal common bile duct and/or pancreatitic duct, the less likely that
Professor of Medicine at the State University of New York Health
Sciences Center. Dr Tenner is also a Governor for the American
patient is to develop post-ERCP pancreatitis. Cheng and colleagues
3
created
College of Gastroenterology, and Vice President of the New York a 160-variable database that prospectively evaluated over 1,000 patients
Society for Gastrointestinal Endoscopy. Dr Tenner has been
from 15 highly respected centers in the Midwest. Their study emphasized
actively involved in research into pancreatic disease, authoring
over 200 papers, chapters and, abstracts on acute pancreatitis.
the role of patient factors, including age, SOD, prior history of post-ERCP
pancreatitis, and technical factors, including number of PD injections, minor
papilla sphincterotomy, and operator experience.
62 © TOUCH BRIEFINGS 2007
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100