Post ERCP Pancreatitis

POST-ERCP
PANCREATITIS
Std. Tran Quang Dat
Group: Byakko
OBJECTIVES
1. Review ERCP
2. Know about the adverse events following ERCP
3. Recognize, diagnose, and manage Post-ERCP pancreatits
Keywords
1. Endoscopic retrograde cholangiopancreatography (ERCP)
2. Post-ERCP Pancreatitis (PEP)
3. Sphincterotomy
4. Sphincter of Oddi dysfunction (SOD)
References
Review of ERCP
Introduction
ERCP is a combined endoscopic and fluoroscopic procedure allowing for
radiologic visualization and therapeutic interventions when indicated.
History
ERCP was first introduced in 1968 and has undergone development
over the past five decades.
Dr. William McCune Dr. Itaru Oi Petter B. Cotton

(1909 – 1998)
Uses of ERCP
Diagnosis Therapeutic uses

• Cholangiopancreatoscopy • Sphincterotomy
• Biopsy • Stent placement
• Brush cytology • Stone removal
• Intraductal ultrasound
Biopsy Intraductal ultrasound
Equipment
Adverse Events
of ERCP
Epidemiology
• Overall AEs from ERCP rates 6.8%
• 1/4 of these events requires intervention, blood transfusions, or
prolonged hospitalization
• Mortality rate is about 0.3%
• Common AEs includes:
• Pancreatitis (3.5%)
• Infection (1.4%)
• GI Bleeding (1.3%)
• Other complications (1.3%)
Why “Adverse Events”
but not “Complications”?
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Complication Definition
“The word "complication" describes an undesired outcome. It carries
no implication of negligence, since bad things can happen despite
exquisite care.
Herein lies the crucial importance of fully informed consent, by which
the patient accepts the full range of possible outcomes-good and bad.”
-P. B. Cotton-
Adverse Events Definition
• Prevents completion of the planned procedure (because of an event,
and not simply for technical reasons), or
• Within 14 days, has clinical results that need treatment involving:
o Unplanned or prolonged hospital admission, or
o Another procedure (requiring sedation or anesthesia), or
o Consultation with other specialist.
Definitions for PEP
The first consensus definition for PEP was developed by
P. B. Cotton (1991):
PEP is defined as a clinical syndrome consistent with:

1. Clinical presentation of pancreatitis
2. Amylase more than 3 times the upper limit of normal
3. Requiring > 1 night of hospitalization.
Definitions for PEP
The second definition is in the 2012 revised Atlanta Classification of

acute pancreatitis, requires two of three features:
1. Abdominal pain consistent with acute pancreatitis
2. Serum lipase or amylase greater than three
times the upper limit of normal and
3. Characteristic findings of acute pancreatitis on contrast-enhanced
CT scan, MRI, or transabdominal ultrasound
Severity Grading for PEP
Pathogenesis of PEP
• Poorly understood, numerous theories have been proposed.
• Many potential mechanisms includes: mechanical, chemical,
hydrostatic, enzymatic, microbiologic, and thermal.
• The common endpoint is the activation of inflammatory pathways.
• This cascade can be limited to local inflammation or initiate SIRS.
Risk factors for
PEP
Patient-related Technique-
factors related factors
Patient-related Factors
Definite Likey No
• Suspected of SOD • Female gender • Small CBD
• Young age • Absence of CBD diameter
• History of previous stone • Sphincter of Oddi
PEP manometry
• Normal bilirubin
Definite Likey No
PEP manometry
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“On a total of 7524 female patients, the incidence of post-ERCP/ES
pancreatitis in women was nearly double that found in men (4.04 %
compared with 2.07%, P < 0.001).”
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Definite Likey No
PEP manometry
Sphincter of Oddi (SO)
• A complex smooth muscle structure
surrounding the terminal common bile
duct, main pancreatic duct and the
common channel
• The high-pressure zone ranges from
4 to 10 mm in length
• The SO regulates the flow of bile and
pancreatic exocrine juice, prevents
duodenum-to-duct reflux and
maintains a sterile intraductal milieu
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Sphincter of Oddi Dysfunction
• SOD is a subgroup of Biliary dyskinesia
• Occur both in patients with or without a gallbladder
• Most commonly diagnosed in patients with postcholecystectomy
symptoms
• SOD is considered a complex disorder due to its confusing definition
and wide range of clinical presentations
• SOD is currently diagnosed based on the Rome criteria (Rome IV)
Diagnosis for SOD
Diagnostic Criteria for Functional Biliary Sphincter of Oddi Disorder
1. Criteria for biliary pain
2. Elevated liver enzymes or dilated bile duct, but not both
3. Absence of bile duct stones or other structural abnormalities
Supportive Criteria
4. Normal amylase/lipase
5. Abnormal sphincter of Oddi manometry
6. Hepatobiliary scintigraphy
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Sphincter of Oddi manometry
Suspected of SOD factor
• SOD poses a formidable risk for pancreatitis after any kind of ERCP,
whether diagnostic, manometric, or therapeutic
• Suspicion of SOD independently triples the risk of PEP to about 10% -
30%
• SOD is most often suspected in women
Definite Likey No
PEP manometry
THE END OF PART 1
THANK YOU FOR LISTENING
BYAKKO LOVES YOU
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References
1. Meseeha M, Attia M. Endoscopic Retrograde Cholangiopancreatography. [Updated
2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493160/
2. Baron TH, Kozarek RA, Carr-Locke DL. ERCP. Elsevier; 2019.
3. Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP
complications: a systematic survey of prospective studies. Am J Gastroenterol.
2007;102(8):1781-1788. doi:10.1111/j.1572-0241.2007.01279.x
4. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and
their management: an attempt at consensus. Gastrointest Endosc. 1991;37(3):383-
393. doi:10.1016/s0016-5107(91)70740-2
5. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events:
report of an ASGE workshop. Gastrointest Endosc. 2010;71(3):446-454.
doi:10.1016/j.gie.2009.10.027
References
1. Thaker AM, Mosko JD, Berzin TM. Post-endoscopic retrograde cholangiopancreatography
pancreatitis. Gastroenterol Rep (Oxf). 2015;3(1):32-40. doi:10.1093/gastro/gou083
2. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary
sphincterotomy. N Engl J Med. 1996;335(13):909-918.
doi:10.1056/NEJM199609263351301
3. Trap R, Adamsen S, Hart-Hansen O, Henriksen M. Severe and fatal complications after
diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering
public hospitals. Endoscopy. 1999;31(2):125-130. doi:10.1055/s-1999-13659
4. Masci E, Mariani A, Curioni S, Testoni PA. Risk factors for pancreatitis following
endoscopic retrograde cholangiopancreatography: a meta-analysis. Endoscopy.
2003;35(10):830-834. doi:10.1055/s-2003-42614
5. Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES. Rome IV. Gallbladder and
Sphincter of Oddi Disorders. Gastroenterology. Published online February 19, 2016.
doi:10.1053/j.gastro.2016.02.033
Technique-related Factors
Define Likely No
• Difficult or failed at • > 2 ERCP cases/week • Small CBD diameter

cannulation for each endoscopists • Sphincter of Oddi
• Pancreatic duct wire • Trainee involvement manometry
passage • Biliary sphincterotomy
• Pancreatic
sphincterotomy
• Balloon dilation of
intact biliary sphincter
• Precut sphincterotomy
• Metallic biliary stent
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Factors to Reduce Risk of PEP
• Guidewire cannulation (instead of using contrast injection)
• Pancreatic stent placement
• Balloon dilation of the biliary sphincter
• Pure cutting current
Pancreatic stent placement
Pancreatic stent placement
Balloon dilation of the biliary sphincter
Pharmacotherapy for PEP
• Gabexate (a protease inhibitor) or somatostatin
• Rectal NSAIDs (indomethacin)
Prevention for PEP
• Avoid performing ERCP for marginal indications
• Intraoperative laparoscopic cholangiography, MRCP, and endoscopic
ultrasonography are safer alternatives for diagnosing billary pathology
• the use of normal saline before and continuing after the procedure
• The use of NSAIDs before every ERCP
Diagnosis for PEP
• as for any other cause of acute pancreatitis
• obtaining serum amylase or lipase within a few hours after the
procedure in patients who are at high risk, and for those who have
postprocedural abdominal pain
• If serum amylase or lipase:
• normal, the probability of developing pancreatitis is very low
• if the pancreatic enzymes are significantly elevated (>3 times
• upper limits of normal)
Thank you so much for listening
Byakkos love you

Post ERCP Pancreatitis

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POST-ERCP

Dr. William McCune Dr. Itaru Oi Petter B. Cotton

Diagnosis Therapeutic uses

PEP is defined as a clinical syndrome consistent with:

The second definition is in the 2012 revised Atlanta Classification of

• Difficult or failed at • > 2 ERCP cases/week • Small CBD diameter

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