• common bile duct stones
• endoscopic retrograde cholangiopancreatography
• meta-analysis
• pancreatitis
• risk factors

Endoscopic retrograde cholangiopancreatography (ERCP) is an indispensable procedure for the management of pancreaticobiliary diseases. Post-ERCP pancreatitis (PEP) is the most common serious adverse event. One risk factor of PEP is difficulty achieving biliary access. The conventional ERCP technique involves the cannulation of the bile duct via the ampulla of Vater, followed by sphincter incision using electrocautery. Conventionally, if the standard method fails then, precut techniques have been utilized as an alternative means of gaining biliary access. The needle-knife fistulotomy (NKF) technique involves identifying the intra-duodenal segment of the bile duct and uses a needle knife to incise directly into the bile duct. This is done above and away from the natural office, thus minimizing thermal damage which may result in PEP. Our recent prospective study of 50 patients demonstrated the safety and feasibility of the NKF precut technique as a primary means of gaining biliary access. The next step is to conduct a randomized controlled trial to compare the efficacy and safety of initial NKF to the standard cannulation in a non-selective patient population undergoing ERCP.

A randomized control trial of 538 consecutive, non-selective patients with pancreaticobiliary disease undergoing ERCP at a tertiary care center in Kingston, Ontario, Canada, will be conducted. Patients will be randomized to one of two treatment groups, standard cannulation or NKF. The primary outcome of the study will be the incidence of PEP. Secondary outcomes will include rate of successful cannulation of the common bile duct (CBD), time to successful cannulation, total procedure time, difficulty of cannulation, and incidence of complications.

This RCT will yield important answers regarding the efficacy and safety of initial NKF to the standard cannulation in a non-selective patient population undergoing ERCP. The results of our study could alter ERCP practices and outcomes if NKF is shown to reduce PEP risk.

ClinicalTrials.govNCT04559867. Registered on September 23, 2020

• ERCP
• Pancreatitis
• Post-ERCP pancreatitis

Acute pancreatitis is the most common iatrogenic dilemma of endoscopic retrograde cholangiopancreatography, and it is associated with significant morbidity and mortality. Several factors have been implicated in the pathogenesis of post-endoscopic retrograde cholangiopancreatography pancreatitis, and preventive measures were practiced accordingly. This study aims to refine the potential mechanisms that trigger post-endoscopic retrograde cholangiopancreatography pancreatitis and define the role of enteropeptidase in the pathogenesis of post-endoscopic retrograde cholangiopancreatography pancreatitis. Furthermore, address the role of a new novel medication known as SCO-792, a potent enteropeptidase inhibitor, in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

Post-endoscopic retrograde cholangiopancreatography pancreatitis is caused by premature activation of the pancreatic enzymes within the pancreatic parenchyma. This activation is either an autoactivation due to direct provocation of intra-acinar enzymes as a result of the procedure or due to activation by enterpeptidase, a rate-limiting enzyme. Endoscopic retrograde cholangiopancreatography interjects duodenal juice that is rich in enterokinase into the pancreatic-biliary tract, which in turn leads to intra-ductal activation of trypsinogen and subsequent enzymes. Given the vital role of enterokinase in initiating the pathogenesis of pancreatitis, enteropeptidase inhibition may prevent and reduce the severity of post-endoscopic retrograde cholangiopancreatography pancreatitis.

SCO-792, a novel enteropeptidase inhibitor, is developed by SCOHIA Pharma, and pre-clinical trials confirmed its efficacy in inhibiting enteropeptidase. Studies are needed to confirm the efficacy of enteropeptidase inhibitors in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis.

• acute pancreatitis
• enteropeptidase
• enteropeptidase inhibitor
• post-endoscopic retrograde cholangiopancreatography pancreatitis
• sco-792

• Lactated ringer’s
• Pancreatic duct stents
• Post-ERCP pancreatitis
• Rectal indomethacin
• Tacrolimus

The aim of this study was to assess the safety and efficacy of using needle-knife fistulotomy (NKF) as a primary cannulation technique in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with a native papilla.

This prospective feasibility study enrolled 50 patients between December 2018 and June 2019. The procedure was performed by two expert endoscopists (R.B. and L.H.). The primary outcome was the incidence of post-ERCP pancreatitis. Other variables assessed included the success rate of cannulation of the common bile duct (CBD), time to successful cannulation, and incidence of adverse events.

Between December 2018 and June 2019, 50 patients enrolled in the study. The mean age was 63.4 years (standard deviation 18.1), and there were 26 females. Indications included biliary obstruction secondary to malignancy (n = 14) and choledocholithiasis (n = 36). Successful cannulation of the CBD through the fistulotomy occurred in 49/50 cases. The time to successful cannulation was 5.1 minutes (range 0.5 to 23 minutes). Mild acute pancreatitis occurred in two cases (4%). Post-ERCP bleeding occurred in three patients (6%)

In this pilot study, NKF was used as the primary biliary access technique and it was demonstrated that it appears to be at least as safe as the traditional access technique with a sphinctertome. However, its role as a primary cannulation technique requires further investigation with multicenter, randomized control studies.

• Endoscopy
• Gastroenterology
• Hepatology

• Southeastern academic medical organization

• ERCP complications
• Endoscopic retrograde cholangiopancreatography
• Indomethacin
• Pancreatic duct stent
• Post-ERCP pancreatitis

• Acute pancreatitis
• Endoscopic retrograde cholangiopancreatography
• Post endoscopic retrograde cholangiopancreatography pancreatitis

• Post-endoscopic retrograde cholangiopancreatography pancreatitis
• biliary brushing cytology
• inverse probability of treatment weighting
• propensity score
• risk factor

• Clinical guideline
• Endoscopic retrograde cholangiopancreatography (ERPC)
• Post-ERCP pancreatitis

Background: Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP). Although, somatostatin (SOM) has been used in the prevention of post-ERCP pancreatitis (PEP), the efficacy of SOM remains inconsistent.

Methods: Electronic databases, including PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), and the Science Citation Index were searched to retrieve relevant studies. Details of the study population, including patients’ characteristics, sample size, regimen of drug administration and incidence of PEP, hyperamylasemia and abdominal pain were extracted by two investigators. Data were analyzed with Review Manager 5.3 software.

Results: Eleven randomized controlled trials, enrolling a total of 4192 patients, were included in the meta-analysis. After data were pooled, we observed decreased incidence of ERCP-induced outcomes, such as PEP (RR = 0.63, 95% CI: 0.40, 0.98; P = 0.04) and hyperamylasemia (RR = 0.75, 95% CI: 0.66, 0.84; P < 0.001) in patients treated with SOM than those with placebo. Subgroup analysis by ethnicity found decreased incidence of PEP and hyperamylasemia in Asia only. Subgroup analysis by treatment schedule and dosage revealed decreased incidence of PEP and hyperamylasemia when SOM were treated with a single bolus or long-term infusion, or at dose above 3000 μg. We did not observed efficacy of SOM on abdominal pain in pooled or subgroup analysis.

Conclusion: This meta-analysis of patients undergoing ERCP showed reduced incidence of PEP and hyperamylasemia when SOM was administrated with single bolus, long-term infusion, or high dosage. More data are needed to confirm our findings.

• endoscopic retrograde cholangiopancreatography
• hyperamylasemia
• meta-analysis
• pancreatitis
• somatostatin

Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP) and may cause significant morbidity and even death. There is no effective prophylactic intervention for patients with average risk yet. This study aims to investigate preventive effect of aggressive hydration for post-ERCP pancreatitis.

In a double-blind controlled setting, 150 patient were randomly assigned to receive either aggressive hydration with lactated Ringer's solution (3 mL/kg/h during ERCP, followed by a 20 mL/kg bolus and 3 mL/kg/h for 8 h after the procedure, n = 75) or standard amount of hydration (1.5 mL/kg/h during and for 8 h after ERCP, n = 75). Patients were observed for volume overload as well as pancreatic pain and serum levels of amylase at baseline and 2, 8, and 24 h after ERCP. Post-ERCP pancreatitis was defined as hyperamylasemia (level of amylase >300) and pancreatic pain during the 24 h follow-up. Hyperamylasemia and pancreatic pain were the secondary end points.

Mean age of the patients was 50.8 ± 13.5 years. Most of the patients were female (66%). Pancreatitis developed in 21 patients, including 22.7% of patients receiving standard hydration and 5.3% patients receiving aggressive hydration (P = 0.002). Hyperamylasemia was detected in 44.0% of patients receiving standard hydration and 22.7% of patients aggressive hydration (P = 0.006). The pancreatic pain was reported by 5.3% of patients receiving aggressive hydration and 37.3% of patients receiving standard hydration (P ≤ 0.005).

Aggressive hydration with lactated Ringer's solution may effectively prevent post-ERCP pancreatitis as well as hyperamylasemia and pancreatic pain in patients with average risk.

• Aggressive hydration
• endoscopic retrograde cholangiopancreatography
• pancreatitis
• prevention

AIM: To determine whether or not the use of antioxidant supplementation aids in the prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis.

METHODS: A systematic review of randomized controlled trials (RCTs) was made to evaluate the preventive effect of prophylactic antioxidant supplementation in post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The inclusion criteria included: acute post-endoscopic retrograde cholangiopancreatography pancreatitis in adults; randomized clinical trials with the use of any antioxidant as an intervention compared with placebo, to reduce PEP. The outcome measure was the incidence and severity of PEP. Twelve RCTs involving 3110 patients since 1999 were included. The antioxidants used were selenite, β-carotene, and pentoxifylline (each one in one trial), N-acetylcysteine (NAC) in three trials, and allopurinol in six trials. The group of patients treated with NAC received different doses; either oral or intravenous, and allopurinol-treated patients received five different oral doses in two different administration periods. The results are expressed with raw numbers, proportions, as well as mean and standard deviations. The incidence of pancreatitis between groups was analyzed with Pearson’s χ² test or Fisher’s exact test (F). The main outcome is expressed as relative risks and 95%CI.

RESULTS: The incidence of pancreatitis in all antioxidant treatment groups was 8.6%, whereas it was 9.7% in the control group. The antioxidants used were selenite, β-carotene, and pentoxifylline (each one in one trial), NAC in three trials, and allopurinol in six trials. In allopurinol trials, three different dosifications were used; two trials reported a low dosage (of less than 400 mg), two trials reported a moderate dose (600 mg) and the remaining two employed higher doses (more than 900 mg). Supplementation was not associated with a significant reduction in the incidence of PEP [relative risk (RR) = 0.93; 95%CI: 0.82-1.06; P = 0.28]. In addition, the incidences of PEP in patients treated with allopurinol and those treated with other antioxidants were similar to that observed in patients who received the placebo (RR for trials with allopurinol, 0.92; 95%CI: 0.78-1.08; P = 0.31) and, with the use of other antioxidants, the incidence of PEP was 8.9%, whereas it was 9.7% in the control group (RR = 0.95; 95%CI: 0.77-1.18; P = 0.19).

CONCLUSION: Antioxidant supplementation shows no beneficial effect on the incidence of PEP. There is a lack of robust trials to support the use of antioxidants for prevention.

• Antioxidant drugs
• Endoscopic retrograde cholangiopancreatography
• Pancreatitis
• Prophylaxis

• Antioxidants/therapeutic use
• Chi-Square Distribution
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Evidence-Based Medicine
• Humans
• Incidence
• Pancreatitis/diagnosis
• Pancreatitis/epidemiology
• Pancreatitis/prevention & control
• Randomized Controlled Trials as Topic
• Risk Factors
• Treatment Outcome

• endoscopic retrograde cholangiopancreatography
• pancreatitis
• somatostatin

Endoscopic retrograde cholangiopancreatography (ERCP) is the essential first modality for common bile duct (CBD) stone therapy. The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy (EST). Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted. There are many reports regarding endoscopic papillary balloon dilation (EPBD) utilizing a small balloon (< 10 mm) instead of EST for the removal of small CBD stones. In contrast, two cases of mortality due to post-ERCP pancreatitis (PEP) were reported after an EPBD clinical trial in the Western world, and the psychological barrier caused by these incidences hinders the use of this technique in Western countries. Endoscopic papillar large balloon dilation (EPLBD), which is used to treat large CBD stones, was not widely adopted when first introduced due to concerns about perforation and severe pancreatitis from the use of a large balloon (12-20 mm). However, as experience with this procedure accumulates, the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD. This report reviews whether EPBD and EPLBD, two procedures that use balloon dilation but differ in terms of indications and concept, contribute to the occurrence of PEP.

• Post-endoscopic retrograde cholangiopancreatography pancreatitis
• Endoscopic papillary balloon dilation
• Endoscopic papillary large balloon dilation
• Common bile duct stone

• Acute Disease
• Catheters
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/instrumentation
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholangiopancreatography, Endoscopic Retrograde/mortality
• Choledocholithiasis/diagnosis
• Choledocholithiasis/therapy
• Dilatation/adverse effects
• Equipment Design
• Humans
• Pancreatitis/diagnosis
• Pancreatitis/etiology
• Pancreatitis/mortality
• Risk Factors
• Severity of Illness Index
• Treatment Outcome

Somatostatin has been extensively studied for the prophylaxis of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). However, the results remain controversial. The present retrospective cohort study aimed to investigate the efficacy of pre- and post-ERCP somatostatin administration in the prevention of post-ERCP pancreatitis (PEP). All ERCP procedures performed at one hospital between January 2009 and December 2012 were reviewed. They were divided into three groups based on somatostatin administration: pre-ERCP som group (somatostatin administration: 0.25 mg/h for 24 h, starting 1 h prior to ERCP), post-ERCP som group (somatostatin administration: 0.25 mg/h for 24 h, starting immediately following ERCP), and control group (no somatostatin administration). Out of a total of 304 cases, 81 received pre-ERCP somatostatin; 126 received post-ERCP somatostatin and 97 were not administered somatostatin. Pre-ERCP somatostatin was effective in reducing the incidence of PEP compared with that in the control group (4.9 vs. 16.5%; P=0.017). This benefit was significant in high-risk patients (8.9 vs. 26.0%; P=0.035), but not in low-risk patients (0 vs. 6.4%; P=0.254). Post-ERCP somatostatin was not effective in preventing PEP in high- or low-risk patients. In conclusion, pre-ERCP somatostatin may be effective in reducing the risk of PEP in high-risk patients, but not in low-risk patients. Post-ERCP somatostatin did not reveal a benefit in high- or low-risk patients. However, large randomized controlled trials are required to further confirm these findings.

• post-endoscopic retrograde cholangiopancreatography pancreatitis
• prevention
• retrospective study
• somatostatin

• gabexate mesylate
• meta-analysis
• post-endoscopic retrograde cholangiopancreatography pancreatitis
• prevention
• randomized controlled trial

• Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
• Benzamidines
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Guanidines/therapeutic use
• Humans
• Pancreatitis/etiology
• Pancreatitis/prevention & control
• Protease Inhibitors/therapeutic use
• Randomized Controlled Trials as Topic

• Anti-inflammatory agents, non-steroidal
• Cholangiopancreatography, endoscopic retrograde
• Pancreatitis
• Prevention and control

• Acute Disease
• Administration, Rectal
• Animals
• Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
• Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Humans
• Pancreatitis/etiology
• Pancreatitis/prevention & control
• Treatment Outcome

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Pancreatic duct stent insertion after ERCP has been widely accepted as the standard of care for the prevention of this complication in high-risk patients. Unfortunately, the placement of pancreatic stents requires higher level of endoscopic expertise and is not always feasible due to anatomic considerations. Therefore, effective non-invasive pharmacologic prophylaxis remains appealing, particularly if it is inexpensive, easily administered, has a low risk side effect profile and is widely available. There have been multiple studies evaluating potential pharmacologic candidates for post-ERCP pancreatitis (PEP) prophylaxis, most of them yielding disappointing results. A recently published large, multi-center, randomized controlled trial reported that in high risk patients a single dose of rectal indomethacin administered immediately after the ERCP significantly decreased the incidence of PEP compare to placebo.

• Non-steroidal anti-inflammatory drugs
• Indomethacin
• Post-endoscopic retrograde cholangiopancreatography pancreatitis
• Acute pancreatitis

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Only a few pharmacologic agents have been shown to have potential efficacy for the prophylactic treatment of post-ERCP pancreatitis (PEP). The aim of this study was to determine whether prophylactic gabexate and ulinastatin can decrease the incidence of PEP.

From January 2005 to April 2010, 1,679 patients undergoing ERCP treatment were consecutively enrolled in the study. After selective exclusion, a total of 1,480 patients were included in the analysis. The patients were separated into 3 groups according to the prophylactic administration of gabexate (593 patients), ulinastatin (229 patients), or saline solution (658 patients) and analyzed retrospectively. The primary outcome measurements were the incidence of pancreatitis and hyperamylasemia.

PEP occurred in 21 of the 593 (3.5%) patients who received gabexate, 16 of the 229 (7.0%) patients who received ulinastatin, and 48 of the 658 (7.3%) patients who received a saline solution. The incidence of PEP was significantly different between the gabexate and ulinastatin or saline solution groups (p<0.05).

Gabexate prophylaxis is effective in preventing PEP. However, there is no difference in the beneficial effects of the prophylactic administration of ulinastatin and a saline solution.

• Endoscopic retrograde cholangiopancreatography
• Gabexate
• Pancreatitis
• Ulinastatin

• Acute Disease
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Dose-Response Relationship, Drug
• Gastrointestinal Agents/administration & dosage
• Gastrointestinal Agents/therapeutic use
• Hormones/administration & dosage
• Hormones/therapeutic use
• Humans
• Models, Statistical
• Octreotide/administration & dosage
• Octreotide/therapeutic use
• Pancreatitis/etiology
• Pancreatitis/prevention & control
• Somatostatin/administration & dosage
• Somatostatin/therapeutic use

Double balloon enteroscopy (DBE) is a new technique, first published and introduced into clinical practice in 2001 by Yamamoto, the inventor of this outstanding method. DBE allows complete visualization, biopsy and treatment of the small bowel. Nowadays, we have some experience of this method for evaluation of the complication rate. Severe complications are described in 1%-1.7% of patients. Acute pancreatitis is a rare complication of the investigation. The incidence of acute pancreatitis after diagnostic DBE is 0.3% in most studies. More than 50 cases of acute pancreatitis have been described in the literature so far. On the contrary, hyperamylasemia after DBE seems to be a rather common condition. Association with acute pancreatitis is supposed to be possible, but not obligatory. The causal mechanism of post-DBE acute pancreatitis is uncertain, and there are several theories in the literature. The most probable cause seems to be a mechanical straining of the endoscope with over-tube on the pancreas or in the papillary area.

• Double balloon endoscopy
• Gastrointestinal endoscopy
• Small intestine
• Hyperamylasemia
• Acute pancreatitis

The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.

• Cholangiopancreatography endoscopic retrograde
• Adverse effects
• Pancreatitis
• Prevention and control/therapy
• Risk assessment
• Risk factors
• Ampulla of vater
• Sphincter of oddi
• Humans

• Endoscopic retrograde cholangiopancreatography
• Gabexate
• Hyperamylasemia
• Nafamostat
• Pancreatitis

AIM: To assess the efficacy of intramuscular diclofenac and fluid replacement for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

METHODS: A prospective, placebo-controlled study was conducted in 80 patients who underwent ERCP. Patients were randomized to receive parenteral diclofenac at a loading dose of 75 mg followed by the infusion of 5-10 mL/kg per hour isotonic saline over 4 h after the procedure, or the infusion of 500 mL isotonic saline as placebo. Patients were evaluated clinically, and serum amylase levels were measured 4, 8 and 24 h after the procedure.

RESULTS: The two groups were matched for age, sex, underlying disease, ERCP findings, and type of treatment. The overall incidence of pancreatitis was 7.5% in the diclofenac group and 17.5% in the placebo group (12.5% in total). There were no significant differences in the incidence of pancreatitis and other variables between the two groups. In the subgroup analysis, the frequency of pancreatitis in the patients without sphincter of Oddi dysfunction (SOD) was significantly lower in the diclofenac group than in the control group (P = 0.047).

CONCLUSION: Intramuscular diclofenac and fluid replacement lowered the rate of pancreatitis in patients without SOD.

• Endoscopic retrograde cholangiopancrea-tography
• Pancreatitis
• Diclofenac
• Nonsteroidal anti-inflammatory drugs
• Fluid replacement

AIM: To assess the efficacy of allopurinol to prevent hyperamylasemia and pancreatitis after endoscopic retrograde cholangiopancreatography (PEP).

METHODS: One hundred and seventy patients were enrolled and randomized to two groups: a study group (n = 85) who received 300 mg of oral allopurinol at 15 h and 3 h before endoscopic retrograde cholangiopancreatography (ERCP) and a control group (n = 85) receiving an oral placebo at the same times. Main Outcome Measurements included serum amylase levels and the number severity of the episodes of pancreatitis. Serum amylase levels were classified as normal (< 150 IU/L) or hyperamylasemia (> 151 IU/L). Episodes of PEP were classified following Ranson’s criteria and CT severity index.

RESULTS: Gender distribution was similar between groups. Mean age was 53.5 ± 18.9 years for study group and 52.8 ± 19.8 years for controls. Also, the distribution of benign pathology was similar between groups. Hyperamylasemia was more common in the control group (P = 0.003). Mild PEP developed in two patients from the study group (2.3%) and eight (9.4%) from control group (P = 0.04), seven episodes were observed in high-risk patients of the control group (25%) and one in the allopurinol group (3.3%, P = 0.02). Risk factors for PEP were precut sphincterotomy (P = 0.02), pancreatic duct manipulation (P = 0.002) and multiple procedures (P = 0.000). There were no deaths or side effects.

CONCLUSION: Oral allopurinol before ERCP decreased the incidences of hyperamylasemia and pancreatitis in patients submitted to high-risk procedures.

• Endoscopic retrograde cholangiopancreatography
• Hyperamylasemia
• Acute pancreatitis
• Oral allopurinol
• Risk factors

AIM: To examine the prophylactic effect of glyceryl trinitrate on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and hyperamylasemia.

METHODS: Patients scheduled for ERCP were randomly divided into study group and placebo group. Patients in study group and placebo group were treated with 5 mg glyceryl trinitrate and 100 mg vitamin C, respectively, 5 min before endoscopic maneuvers.

RESULTS: A total of 74 patients were enrolled in the final analysis. Post-ERCP pancreatitis occurred in 3 patients (7.9%) of the study group and 9 patients (25%) in the placebo group (P = 0.012). Hyperamylasemia occurred in 8 patients of the study group (21.1%) and 13 patients (36.1%) of the placebo group (P = 0.037).

CONCLUSION: Glyceryl trinitrate before ERCP can effectively prevent post-ERCP and hyperamylasemia.

• Glyceryl trinitrate
• Cholangiopancreatography
• Endoscopic retrograde
• Pancreatitis

The aim of the present review is to summarize the current knowledge regarding pharmacological prevention and treatment of acute pancreatitis (AP) based on experimental animal models and clinical trials. Somatostatin (SS) and octreotide inhibit the exocrine production of pancreatic enzymes and may be useful as prophylaxis against Post Endoscopic retrograde cholangiopancreatography Pancreatitis (PEP). The protease inhibitor Gabexate mesilate (GM) is used routinely as treatment to AP in some countries, but randomized clinical trials and a meta-analysis do not support this practice. Nitroglycerin (NGL) is a nitrogen oxide (NO) donor, which relaxes the sphincter of Oddi. Studies show conflicting results when applied prior to ERCP and a large multicenter randomized study is warranted. Steroids administered as prophylaxis against PEP has been validated without effect in several randomized trials. The non-steroidal anti-inflammatory drugs (NSAID) indomethacin and diclofenac have in randomized studies showed potential as prophylaxis against PEP. Interleukin 10 (IL-10) is a cytokine with anti-inflammatory properties but two trials testing IL-10 as prophylaxis to PEP have returned conflicting results. Antibodies against tumor necrosis factor-alpha (TNF-α) have a potential as rescue therapy but no clinical trials are currently being conducted. The antibiotics beta-lactams and quinolones reduce mortality when necrosis is present in pancreas and may also reduce incidence of infected necrosis. Evidence based pharmacological treatment of AP is limited and studies on the effect of potent anti-inflammatory drugs are warranted.

• Acute pancreatitis
• Diclofenac
• Gabexate
• Indomethacin
• Interleukin-10
• Necrotizing pancreatitis
• Nitrogen oxides
• Octreotide
• Protease inhibitors
• Somatostatin

• Amylases/blood
• Animals
• Aspartate Aminotransferases/blood
• C-Reactive Protein/metabolism
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Contrast Media/toxicity
• Female
• Hydrostatic Pressure
• Iohexol/analogs & derivatives
• Iohexol/toxicity
• L-Lactate Dehydrogenase/blood
• Pancreas/drug effects
• Pancreas/pathology
• Pancreatic Ducts/drug effects
• Pancreatitis, Acute Necrotizing/chemically induced
• Pancreatitis, Acute Necrotizing/enzymology
• Pancreatitis, Acute Necrotizing/pathology
• Rats
• Rats, Sprague-Dawley
• Sodium Chloride/pharmacology

Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The only way to prevent this complication is to avoid an ERCP all together. Because of the risks involved, a careful consideration should be given to the indication for ERCP and the potential risk/benefit ratio of the test. Once a decision to perform an ERCP is made, the procedure should be carried out with meticulous care by an experienced endoscopist, and with a minimum of pancreatic duct opacification. Several pharmacologic agents have been tested, but to date the most important method of reducing post ERCP pancreatitis is the placement of pancreatic stent. Pancreatic stents should be placed in all patients at high risk of this complication such as those undergoing pancreatic sphincterotomy, pancreatic duct manipulation and intervention, and patients with suspected sphincter of Oddi dysfunction. Pancreatic stents should be also considered in patients requiring precut sphincterotomy to gain biliary access.

• Post endoscopic retrograde cholangiopancreatography pancreatitis
• Somatostatin
• Gabexate
• IL-10
• Pancreatic stents
• Aspirating catheter
• Sphincter of Oddi dysfunction

• Acute Disease
• Animals
• Anti-Inflammatory Agents/therapeutic use
• Antioxidants/therapeutic use
• Cholangiopancreatography, Endoscopic Retrograde
• Gabexate/therapeutic use
• Humans
• Interleukin-10/therapeutic use
• Pancreas
• Pancreatitis/prevention & control
• Postoperative Complications/prevention & control
• Serine Proteinase Inhibitors/therapeutic use
• Somatostatin/therapeutic use
• Stents

Pancreatitis is the most common complication after endoscopic retrograde cholangio-pancreatography (ERCP); the reported incidence of this complication varies from less than 1% to 40%, but a rate of 4%-8% is reported in most prospective studies involving non-selected patients. Differences in criteria for defining pancreatitis, methods of data collection, and patient populations (i.e. number of high-risk patients included in the published series) are factors that are likely to affect the varying rates of post-ERCP pancreatitis. The severity of post-ERCP pancreatitis (PEP) can range from a minor inconvenience with one or two days of added hospitalization with full recovery to a devastating illness with pancreatic necrosis, multiorgan failure, permanent disability, and even death. Although, most episodes of PEP are mild (about 90%), a small percentage of patients (about 10%) develop moderate or severe pancreatitis. In the past, PEP was often viewed as an unpredictable and unavoidable complication, with no realistic strategy for its avoidance. New data have aided in stratification of patients into PEP risk categories and new measures have been introduced to decrease the risk of PEP. As most ERCPs are performed on an outpatient basis, the majority of patients will not develop PEP and can be discharged. Alternatively, early detection of those patients who will go on to develop PEP can guide decisions regarding hospital admission and aggressive management. In the last decade, great efforts have been addressed toward prevention of this complication. Points of emphasis have included technical measures, pharmacological prophylaxis, and patient selection. This review provides a comprehensive, evidence-based assessment of published data on PEP and current suggestions for its avoidance.

• Endoscopic retrograde cholangiopan-creatography
• Post-ERCP pancreatitis

• Amylases/blood
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Humans
• Lipase/blood
• Pancreas/enzymology
• Pancreas/pathology
• Pancreatitis/blood
• Pancreatitis/etiology
• Pancreatitis/prevention & control
• Predictive Value of Tests
• Risk Factors

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography and the benefit of its pharmacological treatment is unclear. Although prophylactic use of gabexate for the reduction of pancreatic injury after ERCP has been evaluated, the discrepancy about gabexate's beneficial effect on pancreatic injury still exists. This study aimed to evaluate the effectiveness and safety of gabexate in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

We employed the method recommended by the Cochrane Collaboration to perform a meta-analysis of randomized controlled trials (RCTs) of gabexate in the prevention of post-ERCP pancreatitis (PEP) including three RCTs conducted in Italy and one in China.

All of the four RCTs were of high quality. When the RCTs were analyzed, odds ratios (OR) for gabexate mesilate were 0.67 [95% CI (0.31~1.47), p = 0.32] for PEP, 3.78 [95% CI (0.62~22.98), p = 0.15] for severe PEP, 0.68 [95% CI (0.19~2.43), p = 0.56] for the case-fatality of PEP, 0.88 [95% CI (0.72~1.07), p = 0.20] for post-ERCP hyperamylasemia, 0.69 [95% CI (0.39~1.21), p = 0.19] for post-ERCP abdominal pain, thus indicating no beneficial effects of gabexate on acute pancreatitis, the death rate of PEP, hyperamylasemia and abdominal pain. No evidence of publication bias was found.

Gabexate mesilate can not prevent the pancreatic injury after ERCP. It is not recommended for the use of gabexate mesilate in the prophylaxis of PEP.

• Acute Disease
• Adult
• Aged
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Female
• Humans
• Male
• Middle Aged
• Pancreatitis/etiology
• Retrospective Studies
• Severity of Illness Index

• Analgesics/therapeutic use
• Anti-Inflammatory Agents/therapeutic use
• Antifibrinolytic Agents/therapeutic use
• Antioxidants/therapeutic use
• Humans
• Pancreatitis, Acute Necrotizing/drug therapy
• Pancreatitis, Acute Necrotizing/prevention & control
• Randomized Controlled Trials as Topic
• Treatment Outcome

• Ampulla of Vater
• Bile Duct Diseases/pathology
• Bile Duct Diseases/therapy
• Common Bile Duct Diseases/therapy
• Constriction, Pathologic
• Humans
• Pancreatic Diseases/therapy
• Sphincterotomy, Endoscopic/instrumentation
• Stents

• Acute Disease
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Clinical Trials as Topic
• Humans
• Pancreatitis/drug therapy
• Pancreatitis/etiology
• Pancreatitis/prevention & control
• Risk Factors