Pancreas

Open journal

ISSN 2471-142X

Delayed Onset Post-ERCP Pancreatitis (DOPE-P)

Vishal Khurana*

Vishal Khurana, MBBS, MD, DM, MNAMS

Consultant, Department of Gastroenterology, Metro Heart Institute with Multispeciality, Faridabad, Haryana, India; E-mail: vishdoc24@gmail.com

Post Endoscopic retrograde cholangiopancreatography (ERCP) Pancreatitis (PEP) is defined as new onset or worsening of pain abdomen after ERCP with an elevation of pancreatic enzymes (amylase/lipase) more than 3 times upper limit of normal after 24 hours of procedure and prolongation of hospital stay/planned admission.1,2,3 The overall incidence of PEP is estimated to be 3-10%.1,2,3 Various risk factors found in multivariate trials are divided into patient-related risk factor (prior PEP, female sex, young patient, normal bilirubin, previous recurrent pancreatitis, suspected sphincter of Oddi dysfunction, absence of chronic pancreatitis) and procedure-related risk factors (difficult cannulation i.e. >10 minutes cannulation time, repetitive pancreatic duct guide wire cannulation, pancreatic duct contrast injection, pancreatic sphincterotomy, endoscopic papillary large-balloon dilatation of an intact sphincter). Placement of prophylactic pancreatic stents (PPSs) usually advocated in high-risk patients and reduced PEP rate by 60-80%.4,5 3 Fr stents have higher migration rate and hence 5 Fr stents are superior to 3 Fr. Studies have shown that if placement of pancreatic stent is attempted but fails risk of PEP increases.6

There is scarce data available on incidence and severity of delayed onset post ERCP pancreatitis (DOPE-P).7,8 DOPE-P is defined as the development of features of pancreatitis after the first 24 hrs of ERCP. It can occur in two situations: either early migration of prophylactic pancreatic duct (PD) stent within first day of ERCP or after endoscopic removal of PD stent. A retrospective cohort study of 230 patient undergoing PPS removal has shown 3% incidence of pancreatitis after pancreatic stent removal. Statistical significant risk factors found in this study were use of 5 fr a stent, stent with internal flange and history of PEP after initial ERCP.8 Probable etiology of DOPE-P is trauma to PD caused by stent removal. There is a need for a prospective trial for incidence, severity and prevention of DOPE-P. Judicious use of PPS in the only high-risk ERCP with slow removal of PPS within 5-10 days or pharmacoprophylaxis with rectal Nonsteroidal anti-inflammatory drug (NSAIDs), if stent removal done after 10 days, it may theoretically decrease the incidence of DOPE-P. Guidelines recommends evaluation of self-migration of PPS within 5-10 days of placement and endoscopic removal if stent do not migrate with 5-10 days.1

CONFLICTS OF INTEREST

None.

1. Dumonceau JM, Andriulli A, Elmunzer BJ, et al. Prophylaxis of post-ERCP pancreatitis: European society of gastrointestinal endoscopy (esge) guideline – updated june 2014. Endoscopy. 2014; 46(9): 799-815. doi: 10.1055/s-0034-1377875

2. ASGE Standards of Practice Committee, Anderson MA, Fisher L, Jain R, et al. Complications of ERCP. Gastrointest Endosc. 2012; 75(3): 467-73. doi: 10.1016/j.gie.2011.07.010

3. ASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, Muthusamy VR, et al. Adverse events associated with ERCP. Gastrointest Endosc. 2017; 85(1): 32-47. doi: 10.1016/j.gie.2016.06.051

4. Mazaki T, Masuda H, Takayama T. Prophylactic pancreatic stent place- ment and post-ERCP pancreatitis: A systematic review and meta-analysis. Endoscopy. 2010; 42: 842-853. doi: 10.1055/s-0030-1255781

5. Choudhary A, Bechtold ML, Arif M, et al. Pancreatic stentsfor prophylaxis against post-ERCP pancreatitis: A meta-analysis and systematic review. Gastrointest Endosc. 2011; 73: 275-282. doi: 10.1016/j.gie.2010.10.039

6. Choksi NS, Fogel EL, Cote GA, et al. The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement. Gastrointest Endosc. 2015; 81(1): 150-155. doi: 10.1016/j.gie.2014.07.033

7. Freeman ML. Use of Prophylactic Pancreatic Stents for the Prevention of Post-ERCP Pancreatitis. Gastroenterol Hepatol (N Y). 2015; 11(6): 420-422. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843038/

8. Moffatt DC, Coté GA, Fogel EL, et al. Acute pancreatitis after removal of retained prophylactic pancreatic stents. Gastrointest Endosc. 2011; 73(5): 980-986. doi: 10.1016/j.gie.2011.01.012

 

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