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Pancreatitis
were seen in the guidewire group compared with eight cases in the standard The relationship of HCT to severity implies that the opposite is also true.
contrast group (p<0.001). Cannulation success rates between the standard Early vigorous intravenous hydration for the purpose of intravascular
contrast and guidewire techniques were comparable: 98.5 versus 97.5%. resuscitation is of utmost importance. The goal is to decrease the HCT
hemodilution. Too often, patients with acute pancreatitis are given
Treatment of the Complication
In general, post-ERCP pancreatitis should be managed similarly to other
etiologies of acute pancreatitis. The management of patients with acute
The management of patients with acute
pancreatitis is complicated by the inability to distinguish mild from severe
disease during the early stages. The height of elevation of serum amylase/
pancreatitis is complicated by the
lipase does not correlate with severity. Prospective systems using clinical
inability to distinguish mild from severe
criteria have been developed to determine severity in patients with acute
pancreatitis, such as the Ranson, Imrie, Acute Physiology, and Chronic
disease during the early stages.
Health Evaluation (APACHE) Score. Unfortunately, these systems are
cumbersome, requiring multiple measurements. Additionally, the systems
are not accurate until 48 hours after presentation. Close monitoring for suboptimal intravenous hydration. Acute pancreatitis typically results in
signs of organ dysfunction is paramount. What appears to be mild post- significant intravascular losses. Intravenous hydration should be at least
ERCP pancreatitis can easily develop into a life-threatening disease. 250–300cc per hour and titrated to the HCT. Pain control, monitoring for
early and late infections, and questions regarding nutrition apply to these
Early intensive care to prevent complications would require the early patients as they do for those with acute pancreatitis. Further discussion
identification of patients with severe disease or at risk of developing severe here is limited, but can be found in other reviews on the management of
disease. Older age (>55 years), obesity (body mass index (BMI) >30), organ acute pancreatitis.
5,40
failure at admission, and pleural effusion and/or infiltrates are risk factors for
severity that should be noted early.
5
Patients with these characteristics may Summary
require treatment in a highly supervised area, such as a step-down unit or Multiple studies have shown that patient-related factors are as important
an intensive care unit. as technical factors in predicting the risk of acute pancreatitis following
ERCP. Risk stratification will allow endoscopists to identify more effectively
Hematocrit (HCT) is the best laboratory marker to follow in monitoring patients who are at risk. ERCP should be avoided in patients with a low
patients with acute pancreatitis. The role of HCT in determining severity is likelihood of pathology (stones, strictures, masses) as complications appear
related to hemoconcentration. As the inflammatory process progresses early to be inversely proportional. Multiple studies have failed to adequately
in the course of the disease, there is an extravasation of protein-rich identify a drug that consistently prevents post-ERCP pancreatitis in all
intravascular fluid into the peritoneal cavity, resulting in hemoconcentration. patients. However, until effective, safe, and low-cost prophylactic drugs are
The decreased perfusion pressure into the pancreas leads to microcirculatory definitively identified and made available, selective use in high-risk groups
changes that lead to pancreatic necrosis. An admission HCT of >47% may be warranted. The best strategy for prevention of post-ERCP
and/or a failure of the admission HCT to decrease at 24 hours have been pancreatitis appears to be avoiding the procedure and judicious placement
shown to be predictors of necrotizing pancreatitis. of pancreatic duct stents in high-risk patients. ■
1. Freeman ML, Guda NM, Gastrointest Endosc, 2004;59:845–64. 1998;93:61–5. 28. Tarnasky PR, Palesch YY, Cunningham JT, et al., Gastroenterology,
2. Freeman ML, DiSario JA, Nelson DB, et al., Gastrointest Endosc, 16. Sherman S, Blaut U, Watkins JL, et al., Gastrointest Endosc, 1998;115:1518–24.
2001;54:425–34. 2003;58:23–9. 29. Elton E, Howell DA, Parsons WG, et al., Gastrointest Endosc,
3. Cheng CL, Am J Gastroenterol, 2006;101:139–47. 17. Murray B, Carter R, Imrie C, et al., Gastroenterology, 2003;124: 1998;47:240–49.
4. Mehta SN, Pavone E, Barkun JS, et al., Endoscopy, 1998;30: 1786–91. 30. Patel R, Tarnasky P, Hennessy WS, et al., Gastrointest Endosc,
457–63. 18. Khoshbaten M, Khorram H, Madad L, J Gastroenterol Hepatol, 1999;49:AB80.
5. Banks PA, Freeman ML, Am J Gastroenterol, 2006;101:2379–400. epub Aug 7, 2007. 31. Vandervoort J, Soetikno RM, Montes H, et al., Gastrointest Endosc,
6. Clemens JA, Bulkley GB, Cameron JL, et al., Gastroenterology, 19. Sotoudehmanesh R, Khatibian M, Kolahdoozan S, Am J 1999;49:322–7.
1991;100:A270. Gastroenterol, 2007;102:978–83. 32. Aizawa T, Ueno N, Gastrointest Endosc, 2001;54:209–13.
7. Budzyska A, Marek T, Nowak A, et al., Endoscopy, 2001;33: 20. Sudhindran S, Bromwich E, Edwards PR, Br J Surg, 33. Fogel EL, Eversman D, Jamidar P, et al., Endoscopy, 2002;34:
766–72. 2001;88:1178–82. 280–85.
8. Katsinelos P, Kountouras J, Chatzis J, et al., Gastrointest Endosc, 21. Moreto M, Zaballa M, Casado I, Gastrointest Endosc, 34. Norton ID, Gostout CJ, Baron TH, et al., Gastrointest Endosc,
2005;61(3):407–15. 2003;57:1–7. 2002;56:239–43.
9. Mosler P, Sherman S, Marks J, Gastrointest Endosc, 2005;62(2): 22. Kaffles AJ, Bourke MJ, Ding S, Alrubaie A, et al., Gastrointest 35. Fazel A, Quadri A, Catalano MF, et al., Gastrointest Endosc,
251–2. Endosc, 2006;64:351–7. 2003;57:291–4.
10. Milewski J, Rydzewska G, Degowska M, et al., World J 23. Messori A, Rampazzo R, Scroccaro G, et al., Dig Dis Sci, 36. Freeman ML, Overby C, Qi D, Gastrointest Endosc, 2004;5:8–14.
Gastroenterol, 2006;12:3751–5. 1995;40(4):734–8. 37. Catalano MF, Linder JD, Chak A, et al., Gastrointest Endosc,
11. Katsinelos P, Kountouras J, Paroutoglou G, et al., Gastrointest 24. Cavallini G, Tittobello A, Frulloni L, et al., N Engl J Med, 2004;59:225–32.
Endosc, 2005;62:105–11. 1996;335:919–23. 38. Harewood GC, Pochron NL, Gostout CJ, Gastrointest Endosc,
12. Wiener GR, Geenen JE, Hogan WJ, Catalano MF, Gastrointest 25. Andriulli A, Leandro G, Federici T, et al., Gastrointest Endosc, 2005;62:367–70.
Endosc, 1995;42:579–83. 2007;65:624–32. 39. Lella F, Bagnolo F, Colombo E, Bonassi U, Gastrointest Endosc,
13. Kwanngern K, Tiyapattanaputi P, Wanitpukdeedecha M, 26. Smithline A, Silverma W, Rogers D, et al., Gastrointest Endosc, 2004;59:830–34.
Navicharern P, J Med Assoc Thai, 2005;88:S4:S42–45. 1993;39:652. 40. Tenner S, Am J Gastroenterol, 2004;99:2489–94.
14. De Palma GD, Tatanzano C, Am J Gastroenterol, 1999;94:982–5. 27. Sherman S, Earle DT, Bucksot L, et al., Gastrointest Endosc,
15. Dumot JA, Conwel DL, O’Connor JB, et al., Am J Gastroenterol, 1996;43:A489.
66 US GASTROENTEROLOGY REVIEW 2007
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