What is impact of nonsteroidal anti-inflammatory drugs in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of randomized controlled trials

Lyu, Yunxiao; Cheng, Yunxiao; Wang, Bin; Xu, Yueming; Du, Weibing

doi:10.1186/s12876-018-0837-4

Cited by 49 publications

(32 citation statements)

References 51 publications

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“…The RCT by Levenick et al that did not demonstrate a beneficial effect of NSAIDs in consecutive patients undergoing ERCP [88] has received many comments and criticisms. Four of the most recent meta-analyses confirmed that this study is an outlier among the RCTs that assessed the effect of NSAIDs in patients at average risk for PEP [79,80,89,90]. Therefore, also considering logistical reasons as well as the benefit of pre-ERCP as compared with post-ERCP administration of NSAIDs (see below), and the fact that patients may become at high risk for PEP during ERCP, we recommend routine administration of NSAIDs.…”

Section: Recommendationmentioning

confidence: 80%

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2019

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Main Recommendations Prophylaxis 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before endoscopic retrograde cholangiopancreatography (ERCP) in all patients without contraindications to nonsteroidal anti-inflammatory drug administration.Strong recommendation, moderate quality evidence. 2 ESGE recommends prophylactic pancreatic stenting in selected patients at high risk for post-ERCP pancreatitis (inadvertent guidewire insertion/opacification of the pancreatic duct, double-guidewire cannulation).Strong recommendation, moderate quality evidence. 3 ESGE suggests against routine endoscopic biliary sphincterotomy before the insertion of a single plastic stent or an uncovered/partially covered self-expandable metal stent for relief of biliary obstruction.Weak recommendation, moderate quality evidence. 4 ESGE recommends against the routine use of antibiotic prophylaxis before ERCP.Strong recommendation, moderate quality evidence. 5 ESGE suggests antibiotic prophylaxis before ERCP in the case of anticipated incomplete biliary drainage, for severely immunocompromised patients, and when performing cholangioscopy.Weak recommendation, moderate quality evidence. 6 ESGE suggests tests of coagulation are not routinely required prior to ERCP for patients who are not on anticoagulants and not jaundiced.Weak recommendation, low quality evidence. Treatment 7 ESGE suggests against salvage pancreatic stenting in patients with post-ERCP pancreatitis.Weak recommendation, low quality evidence. 8 ESGE suggests temporary placement of a biliary fully covered self-expandable metal stent for post-sphincterotomy bleeding refractory to standard hemostatic modalities.Weak recommendation, low quality evidence. 9 ESGE suggests to evaluate patients with post-ERCP cholangitis by abdominal ultrasonography or computed tomography (CT) scan and, in the absence of improvement with conservative therapy, to consider repeat ERCP. A bile sample should be collected for microbiological examination during repeat ERCP.Weak recommendation, low quality evidence.

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Section: Recommendationmentioning

confidence: 80%

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2019

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“…On occasion, an urgent ERP may need to done to place a pancreatic stent or replace a migrated stent in an attempt to modify the course of an evolving PEP and hasten recovery[109]. Peri-procedure rectal indomethacin 100 mg[110, 111, 112, 113] and post procedure intravenous lactated Ringer’s solution[114] have also been shown to reduce the risk of PEP.…”

Section: Managementmentioning

confidence: 99%

Identification and management of pancreas divisum

Gutta

Fogel

Sherman

2019

Expert Review of Gastroenterology & Hepatology

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Pancreas divisum, the most common congenital malformation of the pancreas, occurs due to a failure of fusion of the ductal systems of the dorsal and ventral pancreatic buds in the seventh week of intra-uterine life. This leads to a dominant dorsal pancreatic duct draining though the minor papilla and a small ventral pancreatic duct draining through the major papilla. The prevalence in western populations is about 10% and more than 95% of these patients are without pancreatic symptoms, with the anomaly found incidentally on abdominal imaging for an unrelated indication. The etiological role and clinical significance of pancreas divisum in relation to pancreatic disease has not yet been clearly defined, but may predispose to pancreatic disease in co-existence with other factors. Secretin-enhanced Magnetic Resonance Cholangiopancreatography is the non-invasive imaging modality of choice to identify pancreas divisum. Patients may be offered minor papilla therapy when they present with recurrent acute pancreatitis, severe acute pancreatitis and can be considered for therapy in the setting of chronic pancreatitis and chronic abdominal pain of pancreatic origin. Minor papilla endotherapy (sphincterotomy and/or stenting) via Endoscopic Retrograde Cholangiopancreatography and minor papilla surgical therapy have comparable outcomes with endotherapy typically considered first-line due to a favorable adverse event profile. The response to therapy is variable with maximal benefit seen in patients with recurrent acute pancreatitis and least with chronic pancreatic-type abdominal pain. Data supporting either therapy are of low quality as they are predominantly retrospective with a sub-optimal follow up period. Surgical options including a pancreatojejunostomy (Puestow or Frey procedure) or a total pancreatectomy with auto-islet cell transplantation may be considered in a subset of patients.

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“…In recent years, rectal NSAIDs were proved to be effective in average-risk and high-risk patients. [ 28 , 29 ] Rectal NSAIDs are cheap and of low risk. Meta-analyses showed that the overall rates of adverse events in the NSAIDs groups versus control groups were found no significant difference, as well as the specific complications such as gastrointestinal bleeding, renal dysfunctions and anal itching.…”

Section: Discussionmentioning

confidence: 99%

Rectal nonsteroidal anti-inflammatory drugs and pancreatic stents in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients

Shou-Xin¹,

Han²,

Fan-Guo³

et al. 2020

Medicine

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Background: 100 mg rectal nonsteroidal anti-inflammatory drugs (NSAIDs) and pancreatic stents both significantly reduce the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Direct comparison of randomized controlled trials (RCTs) between them in high-risk patients is absent. We conducted this network meta-analysis to indirectly compare the efficacies of 100 mg rectal NSAIDs and pancreatic stents in preventing post-ERCP pancreatitis (PEP) in high-risk patients and help us decide which is preferred in clinical practice. Methods: A comprehensive search was done to identify RCTs published in English full-text. Interventions included 100 mg rectal NSAIDs (diclofenac or indomethacin) and pancreatic stents. Only studies with high-risk patients of PEP were included. Meta-analyses of NSAIDs and pancreatic stents were conducted respectively. A network meta-analysis using the Bayesian method was performed. Results: We included 14 RCTs, 8 on pancreatic stents and 6 on 100 mg rectal NSAIDs in high-risk patients. There was no direct comparison between them. After excluding an outlier study on NSAIDs (n = 144), meta-analyses showed they both significantly and statistically reduced the incidence of PEP in high-risk patients (pancreatic stents: n = 8 studies, random-effects risk ratio (RR)0.41, 95%CI 0.30–0.56, I 2 = 0%; NSAIDs: n = 5 studies, random-effects RR 0.37, 95%CI 0.25–0.54, I 2 = 0%). And network meta-analysis showed efficacy of 100 mg rectal NSAIDs was equal to pancreatic stents (random-effects RR 0.94, 95%CI 0.50–1.8). Conclusions: The efficacy of 100 mg rectal NSAIDs (diclofenac or indomethacin) seems equally significant to pancreatic stents in preventing PEP in high-risk patients. Considering the cost-effectiveness and safety, 100 mg diclofenac or indomethacin may be preferred.

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What is impact of nonsteroidal anti-inflammatory drugs in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of randomized controlled trials

Cited by 49 publications

References 51 publications

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Identification and management of pancreas divisum

Rectal nonsteroidal anti-inflammatory drugs and pancreatic stents in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients

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