Delayed Onset Post-ERCP Pancreatitis (DOPE-P)

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.

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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