Immediate prediction of post-ERCP pancreatitis: a novel approach using serum trypsin

As trypsin activation occurs early in the pathogenesis of pancreatitis, evaluating serum trypsin (TRY) may allow immediate prediction of post-ERCP pancreatitis (PEP). This study aims to evaluate the diagnostic performance of TRY measurement for predicting PEP.

This multicenter prospective observational study was conducted at 12 tertiary centers in Japan. Serum TRY, amylase (AMY), pancreatic-type AMY (P-AMY), and lipase (LIP) were measured before ERCP, immediately post-procedure (0 h), and 2 h post-procedure. Predictive performances of pancreatic enzymes for PEP were evaluated using receiver operating characteristic (ROC) analysis, Youden's index, and DeLong's test.

PEP was identified in 48 of the 463 patients analyzed (10.3%). The optimal 0-h TRY cut-off was 2043 ng/mL, yielding an area under the ROC curve (AUC) of 0.83 (68.7% sensitivity, 84.6% specificity), significantly higher than those of 0-h AMY (AUC 0.74, p = 0.002), 0-h P-AMY (0.78, p = 0.007), or 0-h LIP (0.80, p = 0.048). At 2-h, TRY showed an AUC of 0.89, superior to 2-h AMY (0.84) and comparable to 2-h P-AMY (0.89) and 2-h LIP (0.90). When cutoffs were set as 2 × , 2.5 × and 3 × of the upper limit of normal, TRY consistently showed higher sensitivity than AMY or P-AMY. TRY showed the earliest and steepest post-procedural increase among all enzymes in patients with PEP.

TRY measured immediately after ERCP provides significantly better early prediction of PEP than conventional enzymes. Rapid measurement of TRY may enable immediate risk stratification, potentially improving clinical outcomes.