Post-ERCP pancreatitis and hyperamylasemia: patient-related and operative risk factors

Previous studies on the development of post-endoscopic retrograde cholangiopancreatography (post-ERCP) hyperamylasemia and pancreatitis have focused on different risk factors, either procedure- or patient-related, and also prognostic factors, such as amylase levels together with the occurrence of pancreatic-type pain, which might be implicated. The aim of this study is to identify possible predictive risk factors and also prognostic factors in order to better organize the treatment strategy.

During a 5-year period, 556 ERCP procedures were performed by the same operator. Of these, 43 procedures were excluded from the study. Data recorded from the procedures included both patient characteristics and procedure details. Patients were evaluated for pancreatic-type pain at 4 and 24 h after the procedure, and serum amylase levels were determined at 2 and 24 h after the procedure. Pancreatitis was diagnosed on the basis of both clinical and laboratory examination, while patients with hyperamylasemia were in a normal clinical condition but had high serum amylase levels.

Post-ERCP pancreatitis occurred after 17 procedures (3.3%) and hyperamylasemia after 85 procedures (16.5%). Patients who developed pancreatitis all had pancreatic-type pain together with amylase levels higher than 4-5 times the upper normal limit at 24 h after ERCP. There was a significant association between serum amylase levels and post-procedure pancreatic-type pain both at 4 h and 24 h after ERCP (P = 0.006). Age less than 50 years, history of relapsing pancreatitis, pancreatic duct opacification, and difficulty in obtaining bile duct cannulation all proved to be significant predictive risk factors for the development of either hyperamylasemia or pancreatitis. In contrast, additional procedures and sphincterotomy seemed to reduce the likelihood of both complications.

Serum amylase levels higher than 4 - 5 times the normal upper limit together with the existence of pancreatic-type pain, at 24 h after ERCP, strongly suggest the occurrence of pancreatitis. When any of the predictive risk factors coexist during a procedure it would be better either to abandon the procedure and try again later or, if the situation is urgent, to have earlier recourse to an alternative, such as precut or needle-knife papillotomy.