Antisecretory agents for prevention of post-ERCP pancreatitis: rationale for use and clinical results

Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Over the past decade, there has been notable research on the use of various prophylactic agents in preventing post-ERCP pancreatitis. The most widely investigated drug is the antisecretory agent somatostatin and its analogue octreotide. Both agents are potent inhibitors of exocrine secretion of the pancreas, which plays an important role in the pathogenesis of acute pancreatitis by causing autodigestion of pancreas. In addition, somatostatin and octreotide appear to have anti-inflammatory and cytoprotective effects, both of which may be protective against post-ERCP pancreatitis. Furthermore, somatostatin has been shown to relax the sphincter of Oddi, whereas octreotide increases the basal pressure of the sphincter. Several randomized controlled trials have evaluated the efficacy of somatostatin and octreotide in reducing post-ERCP pancreatitis. The results of these trials vary due to different patient populations and experimental designs. Overall, the available evidence suggests that somatostatin reduces the incidence of post-ERCP pancreatitis, whereas octreotide does not. Whether the difference in efficacy between the two drugs is related to their differential effects on sphincter of Oddi motility or is due to other reasons remains unclear. Although there is some evidence supporting the use of somatostatin in reducing the frequency of post-ERCP pancreatitis, it is widely agreed that generalized treatment of all patients undergoing ERCP with prophylactic somatostatin may not be cost-effective. Further studies should focus on the elucidation of the most cost-effective dosage regimen of somatostatin and it efficacy in patients at high risk for post-ERCP pancreatitis.