Comparative effectiveness of aggressive intravenous fluid resuscitation with lactated Ringer’s solution and rectal indomethacin therapy in the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a double blind randomised controlled clinical trial

Abstract

IntroductionThere is growing evidence indicating the aggressive intravenous fluid resuscitation (IVFR) can decrease the rate of pancreatitis; however, to the best of our knowledge it has not been well studied in a post-endoscopic retrograde cholangiopancreatography (post-ERCP) setting.AimTo compare the effects of aggressive IVFR and rectal indomethacin (RI) in preventing pancreatitis after ERCP.Material and methodsThis is a double blind randomised controlled clinical trial on 186 patients undergoing ERCP in Ahvaz, Iran. The inclusion criteria were ERCP for standard clinical indications such as choledocholithiasis, bile duct leak, and biliary obstruction. The IVFR group (n = 62) received a bolus of 20 ml/kg of body weight lactated Ringer’s solution (LRS) immediately after ERCP, followed by 3 ml/kg/h maintenance for 8 h. The RI group (n = 62) received 50 mg rectal indomethacin immediately before procedure and 12 h after ERCP. The control group (n = 62) did not receive any treatment.ResultsPost-ERCP pancreatitis in IVFR, rectal indomethacin, and control groups occurred in 8 (12.9%), 16 (25.8%), and 20 (32.3%) patients (p = 0.036). Pancreatic pain was reported in 13 (21%), 21 (33.9%), and 27 (43.5%) patients in the IVFR, RI, and control group (p = 0.046). The serum amylase level increased over 24 h after intervention in all three groups. The mean serum amylase level 8 h after intervention in the IVFR patients was lower than the RI and control groups.ConclusionsIntravenous fluid resuscitation with LRS was more effective in preventing post-ERCP pancreatitis in comparison to the rectal indomethacin and control group.

Nonsteroidal anti-inflammatory drug effectivity in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

“…Table 1 shows the included studies in alphabetical order, year, country of publication, route of administration, dose, and type of NSAIDs. Of the 26 RCTs, diclofenac was used in 12[ 10 - 21 ], indomethacin in 10[ 7 , 22 - 30 ], COX-2 inhibitors in 2[ 6 , 31 ], and other NSAIDs in 2[ 32 , 33 ]. Table 2 shows the included studies in alphabetical order, type of substance used (comparison) and number ( n ), and time of NSAID administration.…”

Risk Factors for Post-Endoscopic Retrograde Pancreatography Pancreatitis: A Retrospective Chart Review in a Regional Hospital in Japan

“…Although PEP has a very guarded prognosis and may be fatal in some cases, most previous studies were performed in high-volume centers [16,17]. Although these risk factors are consistently reported in the medical guidelines and references, complete prevention of PEP has not been achieved because of the possible presence of other underlying risk factors for PEP [18][19][20][21].…”

Comparison of the therapeutic methods (pharmacologic and nonpharmacologic) on prevention of post-ERCP pancreatitis: A systematic review and meta-analysis

“…About the type of drugs, diclofenac (hajikhani, senol) 29,30 , and rectal indometacin (masjedizadeh, hosseini, elmuzar, MOk ) [31][32][33][34] were used as NSAIDS in five studies.…”

“…The patients in the control group received rectal glycerin, 32 normal saline alone, 30 or no treatment at all. 33 In three studies, patients received the treatment 30 minutes to two hours before the ERCP procedure. 29,32,34 In the other three studies, the intervention was done in the timespan of immediately after the procedure to two hours.…”