Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Table 1 Mild, moderate, and severe acute pancreatitis as delineated by the revised Atlanta classification and the post-endoscopic retrograde cholangiopancreatography pancreatitis-specific Cotton criteria

Revised Atlanta classification		Cotton criteria
Mild	Requires 2 out of 3: Epigastric abdominal pain; amylase/lipase > 3 × normal limit; abdominal image findings; no organ failure; no local or systemic complications	New or worsened abdominal pain and amylase > 3 × upper limit of normal within 24 h after the procedure and requiring hospital stay/extension by 2-3 d
Moderate	Transient organ failure (resolves within 48 h). Local or systemic complications without persistent organ failure	All the above with requiring 4-10 d hospitalization
Severe	Persistent organ failure (> 48 h). Single/multiple organ failure	> 10 d hospitalization or requiring intervention. Development of a complication (pseudocyst, necrosis) or Need for surgical intervention

Table 2 Reported patient-, procedure-, and operator-related risk factors for post- endoscopic retrograde cholangiopancreatography pancreatitis

Risk factors for post-ERCP pancreatitis by category
Patient-related	Procedure-related	Operator-related
Sphincter of Oddi dysfunction	Pancreatic sphincterotomy	Endoscopist inexperience
Age (young or old)	Recent sphincter of Oddi manometry	Lower ERCP case volume
Normal bilirubin	Difficult biliary cannulation	Poor fluoroscopic imaging
Female sex	Papillary balloon dilation	Aggressive attempts at cannulation
History of PEP	Numerous pancreatic duct cannulations	Poor ancillary services
History of pancreatitis	Inadvertent/high-pressure pancreatography	Unfamilarity with preventative methods

PEP: Post endoscopic retrograde cholangiopancreatography pancreatitis; ERCP: Endoscopic retrograde cholangiopancreatography.