Rectal Indomethacin plus Lactated Ringer's for Prophylaxis of Post-ERCP Pancreatitis in Children
1Department of Pediatric Gastroenterology, Çukurova University School of Medicine, Adana, Turkey.
Insights
This study found that combined rectal indomethacin and lactated Ringer's (LR) was safe for pediatric patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). However, this prophylaxis did not significantly reduce post-ERCP pancreatitis (PEP) or cholangitis rates.
Area of Science:
- Pediatric Gastroenterology
- Endoscopic Procedures
- Pharmacological Prophylaxis
Background:
- Limited pediatric data exists on prophylaxis for post-ERCP pancreatitis (PEP).
- This study addresses the need for effective PEP prevention strategies in children undergoing ERCP.
Purpose of the Study:
- To evaluate the effectiveness and safety of a combined rectal indomethacin and lactated Ringer's (LR) prophylaxis regimen.
- To assess the impact of this protocol on PEP and cholangitis rates in pediatric ERCP patients.
Main Methods:
- Retrospective review of pediatric ERCPs at a single tertiary center (2012-2025).
- Comparison of a standardized prophylaxis protocol (rectal indomethacin + LR) implemented post-2021 against a control group (pre-2021).
- Analysis included PEP, cholangitis, procedural complexity, stent use, and naive papilla status.
Main Results:
- 95 ERCPs in 75 children were analyzed (prophylaxis group: 38 procedures; control group: 65 procedures).
- PEP rates were 13.2% (prophylaxis) vs. 13.8% (control) (p=1.000); cholangitis rates were 5.3% vs. 7.7% (p=1.000).
- The combined regimen was feasible, well-tolerated, and associated with no treatment-related adverse events.
Conclusions:
- Combined rectal indomethacin and LR is safe and feasible for pediatric ERCP prophylaxis.
- This regimen did not significantly reduce PEP or cholangitis rates in the studied cohort.
- Larger, multicenter pediatric trials are needed to establish optimal PEP prophylaxis strategies.
Background And Study Aims:
Pediatric data on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prophylaxis remains limited. This study evaluated the effectiveness and safety of combined rectal indomethacin and lactated Ringer's (LR) as prophylaxis for PEP in children undergoing ERCP.
Patients And Methods:
We retrospectively reviewed all pediatric ERCPs performed at a single tertiary center (2012- 2025). The study group consisted of procedures performed after 2021, when a standardized prophylaxis protocol (100 mg rectal indomethacin before ERCP plus LR at 2.5 L·m-2, started 2 hours before and continued 6 hours after) was implemented. Procedures performed before 2021 served as the control group. Primary and secondary endpoints were the development of PEP and cholangitis, respectively. Analyses considered American Society for Gastrointestinal Endoscopy (ASGE) procedural complexity, stent placement/type, and naive papilla status.
Results:
Seventy-five children underwent 95 ERCPs (prophylaxis group: 23 patients/38 procedures; control group: 55 patients/65 procedures). Baseline demographic and procedural characteristics were similar between the prophylaxis and control groups. Post-ERCP pancreatitis developed in 13.2% of procedures in the prophylaxis group and 13.8% in the control group (RD -0.7%; 95% CI -18.5 to 19.9; p = 1.000). Cholangitis developed in 5.3% of procedures in the prophylaxis group and 7.7% in the control group (RD -2.4%; 95% CI -15.3 to 14.0; p = 1.000). Adjustment for stent type did not meaningfully alter the associations between prophylaxis and outcomes. All PEP cases were mild to moderate. No treatment-related adverse events-including indomethacin-associated gastrointestinal or renal complications, or fluid-overload events-were observed in either group.
Conclusions:
Combined rectal indomethacin plus LR was feasible and well tolerated in pediatric ERCP but did not significantly reduce PEP or cholangitis. These findings highlight the need for larger, multicenter pediatric trials to define optimal prophylaxis.
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