Risk factors of pancreatitis after endoscopic sphincterotomy. Review of literature and practical remarks based on approximately 10,000 ERCPs

Abstract

Post-endoscopic pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Depending on the presence of risk factors, PEP can occur in 4,1% to about 43% of patients. According to the European Society of Gastrointestinal Endoscopy (ESGE) guidelines, only three to patient-associated risk factors have been identified: suspected sphincter of Oddi dysfunction (SOD) (OR 4.09), female gender (OR 2.23), and previous pancreatitis (OR 2.46). Another three procedure-associated factors include cannulation attempt duration > 10 minutes (OR 1.76), more than one pancreatic guidewire passage (OR 2.77, CI: 1.79 - 4.30), and pancreatic injection (OR 2.2, CI: 1.60 - 3.01). Importantly, analyses of cumulative risk due to coexistence of several factors emphasize the importance of female sex, difficult cannulation, CBD diameter <5 mm, young age, and many other factors. Unfortunately, studies performed to date have included only small numbers of patients with several co-existing risk factors. Therefore, further analysis of other risk factors and the cumulative risk related to their co-occurrence is necessary. Based on current evidence, special care must be given to patients with several risk factors. Also, care should be given to proper qualification of patients, use of guidewires, early pre-cut incision, protective Wirsung's duct stenting, and rectal NSAID administration.

Risk Factors and Clinical Impacts of Post-Pancreatectomy Acute Pancreatitis After Pancreaticoduodenectomy: A Single-Center Retrospective Analysis of 298 Patients Based on the ISGPS Definition and Grading System

“…Nahm et al ( 7 ) reported that the acinar cell density at the pancreatic resection margin can better describe the residual pancreas than “texture,” and the density of acinar was significantly associated with PPAP. Univariate analysis showed that PPAP was more likely to take place in females, and female is also one of the independent risk factors for PEP ( 38 ). Women have a higher percentage of body fat than men, which makes the pancreas softer; hpwever, gender did not show statistical difference in multivariate analysis in this study.…”

Split-dose or hybrid nonsteroidal anti-inflammatory drugs and N-acetylcysteine therapy for prevention of post-retrograde cholangiopancreatography pancreatitis

“…Although ERCP should be a safe procedure for the vast majority of patients, postprocedural complications may arise, among which acute pancreatitis is the most frequently reported. The mean estimated incidence of this complication is 4%-5.5%, representing a wide range of rates reported in the various studies - from as low as 0.4% up to 40%, depending on the presence of various risk factors[1-3].…”

“…Regarding the risk factors for post-ERCP pancreatitis (PEP), most studies have reported young age, normal serum bilirubin level, personal history of acute PEP, female sex, difficult cannulation of the papilla, injection of contrast agent in the pancreatic duct, and excessive use of the guidewire[1,2,4-6,9-13]. Studies on the prophylaxis of acute PEP have identified pancreatic stent placement as having the highest efficiency in preventing this event in high-risk patients, and consequently this method has been recommended by some guidelines[11-13].…”