Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

Abstract

One of the most frequent and serious complications of endoscopic retrograde cholangiopancreatography (ERCP) is acute pancreatitis. The aim of this study was to evaluate the preventive effect of low-dose heparin (unfractionated or low-molecular-weight heparin) on post-ERCP pancreatitis (PEP) and its side-effects by a systematic review and meta-analysis of clinical trials. Searching PubMed and EMBASE, up to August 2011, two independent reviewers systematically identified prospective clinical trials detecting the effect of prophylactic low-dose heparin on the incidence of PEP, severe PEP, and post-ERCP hemorrhage complications. Four clinical trials fulfilled our selection criteria, with three prospective randomized and one nonrandomized. A meta-analysis of these clinical trials was then performed. A total of 1438 patients were included. Meta-analysis of these trials indicated that there was no significant association between the use of heparin and the reduction of PEP [relative risk (RR) 0.67, 95% confidence interval (CI): 0.44-1.03, P=0.07] and severe PEP (RR 0.62, 95% CI: 0.15-2.60, P=0.51). However, low-dose heparin did not increase the incidence of post-ERCP hemorrhage complications (RR 0.84, 95% CI: 0.34-2.03, P=0.69). This meta-analysis did not demonstrate a statistically significant benefit of prophylactic heparin use for the prevention of post-ERCP pancreatitis. More multicenter trials involving a larger number of patients are needed to show a possible prevention effect of PEP from heparin and its related compounds.

The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications

“…Moreover, heparin in a complex with antithrombin or heparin cofactor II is able to reduce activity of trypsin and chymotrypsin as well as the conversion of trypsinogen into trypsin [171,172]. Various experimental studies have shown the anti-inflammatory effect of heparin, administered both in a protective and therapeutic manner in AP [171,173,174,175,176,177,178]. Earlier studies have been summarized by Hackert et al in 2004 [179].…”

“…Neither of the studies demonstrated reduced AP or SAP ratios in the treatment groups. A meta-analysis [177] performed in 2011 that included the four trials cited above (1438 patients in total) did not show significant benefit of prophylactic heparin in prevention of post-ERCP pancreatitis (relative risk 0.67, 95% confidence interval 0.44–1.03, p = 0.07) or post-ERCP SAP (relative risk 0.62, 95% confidence interval 0.15–2.60, p = 0.51). There were no differences between unfractioned and low molecular weight heparin.…”

Prevention of post-ERCP pancreatitis

“…A meta-analysis of four trials (1438 patients) demonstrated no benefit for prophylactic heparin in prevention of post-ERCP pancreatitis [83] . Magnesium sulphate (intravenous) is currently being studied as a calcium-antagonist and hence, a prophylactic agent against post-ERCP pancreatitis [84] .…”

Chinese expert consensus on perioperative medications for endoscopic retrograde cholangiopancreatography (ERCP)

“…Other drugs that have been evaluated include glucocorticoids, 76 interleukin (IL)-10, 77 heparin, 78 antioxidants, [79][80][81] and agents that lower the pressure of sphincter of Oddi, such as botulinum toxin, lidocaine, and nifedipine [82][83][84][85] . The trials on these drugs did not show clinical efficacy in lowering the incidence of PEP.…”