Combined rectal indomethacin and intravenous saline hydration in post-ERCP pancreatitis prophylaxis
Hesham El Makhzangy1, Saeed Samy2, Mohammad Shehata3
1Endemic Medicine Department, Faculty of Medicine, Cairo University, Egypt.
Insights
Combining rectal indomethacin with aggressive intravenous (IV) saline hydration effectively prevents post-ERCP pancreatitis (PEP). This combined approach is superior to indomethacin alone for preventing PEP after endoscopic retrograde cholangiopancreatography (ERCP).
Area of Science:
- Gastroenterology
- Endoscopic Procedures
- Pancreatology
Background:
- Post-ERCP pancreatitis (PEP) is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP).
- Effective prevention strategies for PEP are limited, with non-steroidal anti-inflammatory drugs (NSAIDs) being a primary option.
- Aggressive hydration is considered beneficial in acute pancreatitis due to hemoconcentration and hypoperfusion.
Purpose of the Study:
- To evaluate the clinical effectiveness of combining indomethacin with aggressive saline hydration for preventing PEP.
- To compare the efficacy of this combined regimen against indomethacin alone in a patient cohort undergoing ERCP.
Main Methods:
- A cross-sectional study involving 120 patients undergoing their first ERCP.
- Patients were randomly assigned to receive either indomethacin alone or indomethacin plus intravenous (IV) saline hydration (10 ml/kg/h for 2 hours post-ERCP).
- Risk factors for PEP and outcomes were analyzed in both groups.
Main Results:
- PEP occurred in 8% of patients receiving indomethacin alone versus 0% in the combined indomethacin-hydration group (p=0.022).
- Patient-related risk factors for PEP included older age, higher pre-ERCP urea, and less choledocholithiasis.
- Factors during ERCP associated with PEP included increased biliary cannulation attempts, accidental pancreatic duct cannulation, longer cannulation time, precut knife use, transpancreatic sphincterotomy, and longer procedure time.
Conclusions:
- Aggressive IV saline hydration combined with rectal indomethacin significantly enhances PEP prevention compared to indomethacin monotherapy.
- This combined strategy offers a more effective prophylactic measure against post-ERCP pancreatitis.
Background And Study Aim:
Acute pancreatitis (AP) is a potentially life-threatening complication of endoscopic retrograde cholangiopancreatography (ERCP). There is a lack of effective measures to prevent post-ERCP pancreatitis (PEP), except NSAIDs. Aggressive hydration for AP can be considered, given the frequency of hemoconcentration, hypovolemia, and hypoperfusion in pancreatitis. We aimed to clarify the clinical utility of combined indomethacin and saline hydration for preventing PEP.
Patients And Method:
In this cross-sectional study, 120 patients undergoing ERCP for the first time at the Gastrointestinal Endoscopy Unit and Liver Unit Kasralainy (GIELUKA) were enrolled and then randomly allocated into two groups: indomethacin and indomethacin-hydration groups. Intravenous (IV) saline was given to the latter at a rate of 10 ml/kg/h after the ERCP for 2 h.
Results:
The age of the studied patients was 43.8 ± 14.9 years, with 55% of them being female. The patient-related risk factors for PEP were older age (p = 0.039), higher pre-ERCP urea level (p = 0.032), and less choledocholithiasis (p = 0.028). The patients with PEP had a higher frequency of biliary cannulation attempts (p = 0.004) and accidental pancreatic duct cannulation (p = 0.003), required a longer cannulation time (p = 0.021), had undergone precut knife and transpancreatic sphincterotomy at a higher rate (p = 0.032; and p = 0.001, respectively), and had a significantly longer procedure time (p = 0.006). PEP occurred in only five patients in the indomethacin group, while it did not occur in the indomethacin-hydration group (8% vs. 0%, p = 0.022). Serum amylase and lipase elevation 2 h after ERCP were predictors of PEP. However, serum amylase only was significantly lower 2 h post-ERCP in the indomethacin-hydration group than in the indomethacin group (p = 0.045). Moreover, abdominal pain and vomiting on the first day of ERCP were good predictors of PEP.
Conclusion:
Aggressive IV saline hydration with rectal indomethacin can more effectively prevent PEP than indomethacin alone.
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