Pharmacological prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Prevention and management of adverse events of endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure with the potential for a variety of adverse events, including acute pancreatitis, perforation, bleeding, and cardiopulmonary complications, which are well-established risk factors. It has become standard that patients undergoing ERCP are carefully selected based on appropriate indications. Once an ERCP is undertaken, preprocedure and intraprocedure risks should be assessed and appropriate risk-reducing modalities, such as prophylactic pancreatic stent placement and rectal indomethacin, should be used if patient or procedural factors suggest an increased risk of post-ERCP pancreatitis.

Efficacy of ENBD in the prevention of post-ERCP pancreatitis and hyperamylasemia in patients with common bile duct stones: an analysis of 65 cases

AIM: To investigate the value of endoscopic nasobiliary drainage (ENBD) in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and hyperamylasemia in patients with common bile duct stones.

METHODS: The clinical data of 141 patients with common bile duct stones, including 65 undergoing ENBD and 77 undergoing routine treatment, were retrospectively reviewed. The efficacy and complication rate were compared between the two groups.

RESULTS: Serum amylase levels at 2 and 24 h postoperatively were significantly lower in the ENBD group than in the routine treatment group (67.3 U/L ± 9.1 U/L vs 98.3 U/L ± 11.2 U/L, 89.5 U/L ± 13.0 U/L vs 126.2 U/L ± 14.2 U/L, both P < 0.01). The incidence of post-ERCP pancreatitis and hyperamylasemia was also significantly lower in the ENBD group than in the routine treatment group.

CONCLUSION: ENBD can effectively prevent the occurrence of post-ERCP pancreatitis and hyperamylasemia in patients with common bile duct stones.

Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review

The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.

Ectopic pancreaticobiliary drainage accompanied by proximal jejunal adenoma: A case report

A patient with obstructive jaundice was examined by multidetector row helical computed tomography (MDCT) and magnetic resonance imaging (MRI), and his common bile duct was observed to be leading into the distal portion of the horizontal duodenum with a pancreaticobiliary union outside the duodenal wall. A mass was also found in the proximal jejunum. All the above findings were confirmed by subsequent surgery, thus contrast-enhanced MDCT and MRI with appropriate image post-processing could provide non-invasive and accurate information regarding anatomy and lesions of the pancreaticobiliary duct and duodenal union, which may improve the feasibility of surgery and reduce postoperative complications.

Meta-analysis: octreotide prevents post-ERCP pancreatitis, but only at sufficient doses

BACKGROUND

Effects of octreotide on post-endoscopic retrograde cholangiopancreatography pancreatitis have been studied in many clinical trials. These trials have yielded inconclusive results. Results of more recent studies using larger doses, however, seem to be more optimistic.

AIM

To examine effects of octreotide at different doses on PEP.

METHODS

A comprehensive search of relevant databases, including Medline, Embase, the Cochrane Controlled Trials Register, the Cochrane Library and Science Citation Index yielded 18 randomized controlled trials (RCTs). Trials were divided into two groups according to the total dosage of octreotide: <0.5 mg (OCT1), > or =0.5 mg (OCT2). The rate of PEP was analysed using a fixed effect model.

RESULTS

At doses of > or =0.5 mg, octreotide reduced the rate of PEP. In the OCT2 group, analysis revealed a statistically significant difference on PEP between the octreotide group and the controls (3.4% vs. 7.5%, pooled OR = 0.45; 95% CI: 0.28-0.73; P = 0.001, NNT = 25). In the OCT1 group, the rate of PEP was similar between patients receiving octreotide and the controls (7.2% vs. 6.0%, pooled OR = 1.23; 95% CI: 0.80-1.91; P = 0.35).

CONCLUSION

Octreotide is effective in preventing PEP, but only at sufficient doses (> or =0.5 mg).

Does glyceryl nitrate prevent post-ERCP pancreatitis? A prospective, randomized, double-blind, placebo-controlled multicenter trial

OBJECTIVE

Acute pancreatitis is the most dreaded complication of ERCP. Two studies have shown a significant effect of glyceryl nitrate (GN) in preventing post-ERCP pancreatitis (PEP). We wanted to evaluate this promising effect in a larger study with a realistically precalculated incidence of PEP.

DESIGN/PATIENTS

A randomized, double-blind, placebo-controlled multicenter study including patients from 14 European centers was performed. A total of 820 patients were entered; 806 were randomized.

INTERVENTION

The active drug was transdermal GN (Discotrine/Minitran, 3M Pharma) 15 mg/24 hours; placebo (PL) was an identical-looking patch applied before ERCP. A total of 401 patients received GN; 405 received PL.

RESULTS

Forty-seven patients had PEP (5.8%), 18 (4.5%) in the GN group and 29 (7.1%) in the PL group. The relative risk reduction of PEP in the GN group of 36% (95% CI, 11%-65%) compared with the PL group was not statistically significant (P = .11). Thirteen had mild pancreatitis (4 in the GN group, 9 in the PL group), 26 had moderate pancreatitis (9 in the GN group, 17 in the PL group), and 8 had severe pancreatitis (5 in the GN group, 3 in the PL group). Headache (P < .001) and hypotension (P = .006) were more common in the GN group. Significant variables predictive of PEP were not having biliary stones extracted; hypotension after ERCP; morphine, propofol, glucagon, and general anesthesia during the procedure; or no sufentanil during the procedure.

CONCLUSIONS

The trial showed no statistically significant preventive effect of GN on PEP. Because of a considerable risk of a type II error, an effect of GN may have been overlooked. (ClinicalTrials.gov ID: NCT00121901.).

Effects of nafamostat mesilate on the prevention of cerulein-induced acute pancreatitis

OBJECTIVES

Protease inhibitors showed protective effects on animal models of acute pancreatitis when administered before induction of pancreatitis, and results when administered after induction are uncertain. We assessed the effects of nafamostat mesilate in a mouse model of cerulein-induced pancreatitis comparing results of before and after induction.

METHODS

Cerulein was injected to mice intraperitoneally to induce pancreatitis, and they received intravenous nafamostat mesilate before and after induction. Serum concentrations of amylase and lipase, histological changes, and tissue expression of myeloperoxidase were measured. In addition, tissue activation of p38 mitogen-activated protein kinase (MAPK) and interleukin-6 was evaluated.

RESULTS

Development of pancreatitis was prevented by pretreatment with nafamostat mesilate. However, such effect was not shown when given after induction, although it partially suppressed myeloperoxidase expression and infiltration of inflammatory cells. Tissue expression of phospho-p38 MAPK was prominent in mice with pancreatitis and suppressed by pretreatment with nafamostat mesilate. Interleukin-6 expression was not influenced by either cerulein or nafamostat mesilate.

CONCLUSIONS

The development of pancreatitis was prevented by treating mice with nafamostat mesilate before induction, however, this finding was not observed if administered after injection of cerulein. Pretreatment with nafamostat mesilate suppressed activation of p38 MAPK.

Usefulness of axial planes of helical computed tomography for diagnosis of pancreaticobiliary maljunction in early infants with negative findings on magnetic resonance cholangiopancreatography

PURPOSE

Magnetic resonance cholangiopancreatography (MRCP) is not sufficient to detect pancreaticobiliary maljunction (PBM) in young infants because the main pancreatic duct is not visualized and respiratory artifacts occur. To our knowledge, there are no reports highlighting the diagnostic accuracy of evaluation using the axial planes of helical computed tomographic (CT) scanning with contrast medium instead of 3-dimensional (3D) reconstruction. The aim of this study was to describe our experience and the characteristics of 3 children with PBM diagnosed using the axial planes of helical CT with contrast medium, although they showed negative findings of PBM by MRCP, instead of 3D reconstruction.

METHODS

Three patients aged from 1 month to 3 years were diagnosed with PBM using the axial planes of helical CT with contrast medium though MRCP could not show the common channel and/or the entrance of the common channel into the duodenum.

RESULTS

In all 3 patients, PBM of the common channel was not revealed by MRCP. On the other hand, axial planes of contrast-enhanced helical CT scans showed PBM clearly.

CONCLUSIONS

Our experience suggests that axial planes of the contrast-enhanced helical CT scan comprise an accurate tool for the diagnosis of fusiform-type PBM and could replace MRCP in younger children. Further studies are necessary for better assessment of the potential advantages and pitfalls of this modality.

Somatostatin and gabexate for post-endoscopic retrograde cholangiopancreatography pancreatitis prevention: meta-analysis of randomized placebo-controlled trials

BACKGROUND AND AIM

Prior studies have suggested the efficacy of somatostatin and gabexate in post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis prevention. We examined this notion in our study.

METHODS

An extensive literature search led to the inclusion of seven homogeneous high-quality studies (Jadad score >or=4), involving 3,130 patients. The studies were grouped according to the drug's length of administration: given as an infusion for 12 h (groups SOM1 and GAB1 for somatostatin and gabexate, respectively); given as an infusion for less then 12 h (groups SOM2 and GAB2 for somatostatin and gabexate, respectively); and given as a bolus (group SOM3 for somatostatin, none identified for gabexate). Separate meta-analyses investigating post-procedural pancreatitis and hyperamylasemia rates were conducted in a random effects model.

RESULTS

Pancreatitis analyses yielded significant risk differences for the SOM1, SOM3 and GAB1 groups. The resulting values were 7.7% (95% confidence intervals [CI][3.4 to 12.0], P < 0.0001), 8.2% (95% CI [4.4 to 12.0], P < 0.0001) and 5.2% (95% CI [1.1 to 9.4], P = 0.01), respectively. No statistically significant risk differences were observed for the SOM2 and GAB2 groups: -2.3% (95% CI [-5.2 to 0.5], P = 0.11) and -1.1% (95% CI [-3.8 to 1.6], P = 0.41), respectively. Hyperamylasemia analyses yielded significant risk differences for the SOM1 and SOM3 groups (P = 0.017 and 0.001, respectively), although not for the SOM2, GAB1 and GAB2 groups (P = 0.44, 0.49 and 0.47, respectively).

CONCLUSIONS

Somatostatin administered as a bolus seems to be an efficacious measure of post-ERCP pancreatitis prevention, reducing pancreatitis and hyperamylasemia rates, and being applicable to clinical practice. Further study is required before its introduction into routine care.

Pancreatic-stent placement for prevention of post-ERCP pancreatitis: a cost-effectiveness analysis

BACKGROUND

Controlled trials support pancreatic-stent placement as an effective intervention for the prevention of post-ERCP acute pancreatitis in high-risk patients.

OBJECTIVE

To perform a decision analysis to evaluate the most cost-effective strategy for preventing post-ERCP pancreatitis.

DESIGN

Cost-effectiveness analysis.

SETTING

Patients undergoing ERCP.

INTERVENTIONS

Three competing strategies were evaluated in a decision analysis model from a third-party-payer perspective in hypothetical patients undergoing ERCP. In strategy I, none of the patients had pancreatic-stent placement. Strategy II had only those patients identified to be at high risk for post-ERCP, and, in strategy III, all patients underwent prophylactic stent placement. Probabilities of developing post-ERCP pancreatitis and the risk reduction by placement of a pancreatic stent were obtained from published information. Cost estimates were obtained from Medicare reimbursement rates.

MAIN OUTCOME MEASUREMENTS

Incremental cost-effectiveness ratio (ICER) of different strategies.

RESULTS

Strategy I was the least-expensive strategy but yielded the least number of life years. Strategy II yielded the highest number of years of life, with an ICER of $11,766 per year of life saved, and strategy III was dominated by strategy II.

LIMITATIONS

Indirect costs and pharmacologic prophylaxis were not considered in this analysis.

CONCLUSIONS

Pancreatic-stent placement for the prevention of post-ERCP pancreatitis in high-risk patients is a cost-effective strategy.

Risk for post-ERCP pancreatitis after needle knife precut sphincterotomy following repeated cannulation attempts

GOALS

The aim of this study was to determine the risk and identify the factors associated with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients who undergo needle knife precut sphincterotomy (NKS). In addition, we evaluated the effect of gabexate for the prevention of post-ERCP pancreatitis.

BACKGROUND

NKS, after repeated cannulation attempts during ERCP, is known to increase the risk of post-ERCP pancreatitis. However, the specific risk factors for post-ERCP pancreatitis have not been identified, and the preventive role of protease inhibitors, such as gabexate, has not yet been established.

STUDY

The medical records of 200 patients who underwent NKS, after repeated cannulation attempts during ERCP, were reviewed retrospectively. The potential risk factors for post-ERCP pancreatitis were investigated. The effect of gabexate infused after the ERCP procedure was also evaluated.

RESULTS

Thirteen (6.5%) patients out of 200 developed post-ERCP pancreatitis. Sex, age, the presence of pancreatitis at procedure, underlying disease, direction of the sphincterotomy, success or failure of cannulation after NKS, diameter of common bile duct, pancreatic duct status, and the presence of acinar filling were not associated with the risk of pancreatitis. Gabexate infusion after ERCP increased the incidence of ERCP-associated pancreatitis.

CONCLUSIONS

We could not identify any risk factors associated with the development of post-ERCP pancreatitis in patients who underwent NKS after repeated cannulation attempts during ERCP. However, gabexate administered after the ERCP procedure was found to increase the incidence of pancreatitis.

Effects of thalidomide in experimental models of post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND

Tumor necrosis factor-alpha (TNF-alpha) plays a central role in the pathogenesis of acute pancreatitis and related systemic complications. The authors hypothesized that it may also play an important role in the development of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The aim of the study was to evaluate the effectiveness of thalidomide, an immunomodulator that exerts an inhibitory action on TNF-alpha by enhancing mRNA degradation, in reducing post-ERCP pancreatitis in a rat model.

METHODS

A total of 200 mg/kg thalidomide was given intragastric once a day (total 8 days) before the experimental models of post-ERCP pancreatitis were established. After 24 h, histology and edema of pancreas, serum amylase, and TNF-alpha mRNA in the pancreatic tissue were evaluated.

RESULTS

Intraductal contrast infusion caused increases in serum amylase, edema, histological grade, and TNF-alpha mRNA of pancreas. The prophylactic use of thalidomide significantly reduced serum amylase, pancreatic edema and the histologic grade of pancreatitis accompanied by a decrease in mRNA expression of TNF-alpha in the pancreatic tissue.

CONCLUSIONS

Prophylactic intragastric administration of thalidomide provides a protective effect in post-ERCP pancreatitis. The mechanism of the protective effects of thalidomide seems to be the reduction of expression of TNF-alpha mRNA in pancreatic tissue.

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Pharmacological prevention and treatment of acute pancreatitis: where are we now?

Acute pancreatitis is a disease of increasing prevalence, unchanged mortality over many decades, and limited treatment strategies. Progress has been made in developing therapies that reduce the rate of endoscopic retrograde cholangiopancreatography (ERCP)-associated pancreatitis and in preventing infected pancreatic necrosis with intravenous carbapenems. Attempts at reducing pancreatic enzyme output or inhibiting the activity of digestive enzyme proteases have not yielded encouraging results - nor have anti-inflammatory strategies for the treatment of acute pancreatitis been found to be effective so far. Future therapeutic options that are presently being developed or under investigation attempt to restore pancreatic secretory function, interfere with inflammatory pathways in a more effective manner, or inhibit digestive enzyme proteases more selectively.

Clinical trial of gabexate in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis

The objective of the present study was to determine the efficacy of prophylactic administration of gabexate for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, hyperamylasemia and pancreatic pain. Patients scheduled for ERCP were randomized into two groups in a double-blind manner: the patients in the gabexate group were treated with continuous intravenous infusion of 300 mg gabexate dissolved in 500 mL Ringer's solution at 111 mL/h, starting 30 min before the endoscopic maneuvers and continuing up to 4 h after them; placebo group patients were treated only with Ringer's solution also starting 30 min before the endoscopic maneuvers and continuing up to 4 h. Data for 193 patients were analyzed. The incidence of post-ERCP pancreatitis was 3 patients (3.1%) in the gabexate group and 10 (10.5%) in the placebo group (P = 0.040). The incidence of hyperamylasemia was 33 patients (33.7%) in the gabexate group and 42 (43.7%) in the placebo group (P = 0.133). The incidence of pancreatic pain was 15 patients (15.3%) in the gabexate group and 28 (29.5%) in the placebo group (P = 0.018). The results suggest that a 4.5-h infusion of gabexate (for a total of 300 mg) could prevent post-ERCP pancreatitis and pancreatic pain.

Trypsin mediates nociception via the proteinase-activated receptor 2: a potentially novel role in pancreatic pain

BACKGROUND & AIMS

The pathogenesis of pain in pancreatitis remains poorly understood. We hypothesized that trypsin, a key inflammatory mediator in this condition, can also activate nociceptive neurons via the proteinase-activated receptor 2.

METHODS

Double immunohistochemical staining of T8 to T12 dorsal root ganglia sections was performed with antibodies against proteinase-activated receptor 2 and vanilloid receptor 1, a marker for primary nociceptive neurons. In vivo nociceptive activity was measured by FOS immunoreactivity in thoracic spinal dorsal horn segments after intrapancreatic administration of proteinase-activated receptor 2 agonists. Pain behavior was assessed by visceromotor reflex activity in response to noxious stimulation of the pancreas with proteinase-activated receptor 2 agonists.

RESULTS

Proteinase-activated receptor 2 was expressed by virtually all nociceptive neurons in thoracic dorsal root ganglia. Intraductal trypsin, in subinflammatory concentrations, activated spinal dorsal horn neurons in a dose-dependent manner, as measured by FOS expression. Both trypsin and a proteinase-activated receptor 2-specific peptide agonist induced a behavioral pain response when infused into the pancreatic duct of awake rats. Preinfusion of the pancreatic duct with proteinase-activated receptor 2-specific activating peptide desensitized the response to trypsin.

CONCLUSIONS

Our findings suggest a novel proteinase-activated receptor 2-mediated role for trypsin in the pathogenesis of pancreatic pain and one that is independent of its inflammatory effect.

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