The synergistic impact of NSAIDs and aggressive hydration therapy on the rate of post-ERCP pancreatitis in high risk and low risk patients.
Gastroenterology and Hepatology from Bed to Bench,
9 December 2020
Background: The main complication of Endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). Patients according to demographic characteristics and underlying issues or the reason of ERCP indication are categorized as high risk or low risk patients. Previous investigations represented the effective role of NSAIDS or hydration therapy before the ERCP in reduction PEP. Nevertheless, there is no available evidence about the evaluation the synergistic effects of NSAIDS and hydration therapy, separately sorted by the risk assessment of PEP in different groups of patients.
Method: This study included 281 eligible participants after exclusion. The patients according to demographic characteristics and co-morbidities were divided to high risk and low risk participants. High risk group was divided randomly to two subgroups. both of them received NSAIDs (100 mg rectal Diclofenac). In one group received standard hydration (1.5mg/kg/hr), another group received aggressive hydration (3mg/kh/h). Low risk group received standard hydration. One of its subgroups received NSAID, other not. The efficacy of these preventions were compared between 4 subgroups.
Result: the mean age was 59.85±17.17. The amylase and lipase 8 hours after ERCP were significantly higher in high risk group with standard hydration (P=0.00). amylase, lipase 8 hours, between two low risk subgroups, NSAIDs had no significant effect (P=0.38, P=0.95, respectively). After adjustment based on cannulation, manipulation and duration time, the results had no change (P=0.64, P=0.19, P=0.61).
Conclusion: the aggressive hydration could significantly decrease the risk of PEP. However, still, the low risk group exposed lowest risk of PEP. NSAIDS, could not alone help to decrease the rate PEP in low risk groups. Overall, it seems hydration and NSAIDs therapy had synergistic outcome in high risk patients.
- Keywords: Endoscopic retrograde cholangiopancreatography (ERCP), post ERCP pancreatitis.
2. Committee ASoP, Anderson MA, Fisher L, Jain R, Evans JA, Appalaneni V, et al. Complications of ERCP. Gastrointestinal endoscopy. 2012;75(3):467-73.
3. Kochar B, Akshintala VS, Afghani E, Elmunzer BJ, Kim KJ, Lennon AM, et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review by using randomized, controlled trials. Gastrointestinal Endoscopy. 2015;81(1):143-9.e9.
4. Wu D, Wan J, Xia L, Chen J, Zhu Y, Lu N. The Efficiency of Aggressive Hydration With Lactated Ringer Solution for the Prevention of Post-ERCP Pancreatitis: A Systematic Review and Meta-analysis. Journal of clinical gastroenterology. 2017;51(8):e68-e76.
5. Sotoudehmanesh R, Ali-Asgari A, Khatibian M, Mohamadnejad M, Merat S, Sadeghi A, et al. Pharmacological prophylaxis versus pancreatic duct stenting plus pharmacological prophylaxis for prevention of post-ERCP pancreatitis in high risk patients: a randomized trial. Endoscopy. 2019;51(10):915-21.
6. Choudhary A, Bechtold ML, Arif M, Szary NM, Puli SR, Othman MO, et al. Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc. 2011;73(2):275-82.
7. Patai Á, Solymosi N, Mohácsi L, Patai Á V. Indomethacin and diclofenac in the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis of prospective controlled trials. Gastrointest Endosc. 2017;85(6):1144-56.e1.
8. Dumonceau JM, Andriulli A, Elmunzer BJ, Mariani A, Meister T, Deviere J, et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014. Endoscopy. 2014;46(9):799-815.
9. Smeets XJNM, da Costa DW, Fockens P, Mulder CJJ, Timmer R, Kievit W, et al. Fluid hydration to prevent post-ERCP pancreatitis in average- to high-risk patients receiving prophylactic rectal NSAIDs (FLUYT trial): study protocol for a randomized controlled trial. Trials. 2018;19(1):207-.
10. Sagi SV, Schmidt S, Fogel E, Lehman GA, McHenry L, Sherman S, et al. Association of greater intravenous volume infusion with shorter hospitalization for patients with post-ERCP pancreatitis. J Gastroenterol Hepatol. 2014;29(6):1316-20.
11. Shaygan-Nejad A, Masjedizadeh AR, Ghavidel A, Ghojazadeh M, Khoshbaten M. Aggressive hydration with Lactated Ringer's solution as the prophylactic intervention for postendoscopic retrograde cholangiopancreatography pancreatitis: A randomized controlled double-blind clinical trial. J Res Med Sci. 2015;20(9):838-43.
12. Zhang ZF, Duan ZJ, Wang LX, Zhao G, Deng WG. Aggressive Hydration With Lactated Ringer Solution in Prevention of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis: A Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol. 2017;51(3):e17-e26.
13. Mok SRS, Ho HC, Shah P, Patel M, Gaughan JP, Elfant AB. Lactated Ringer's solution in combination with rectal indomethacin for prevention of post-ERCP pancreatitis and readmission: a prospective randomized, double-blinded, placebo-controlled trial. Gastrointest Endosc. 2017;85(5):1005-13.
14. Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy. 2007;39(9):793-801.
15. Li G-Z, Wang F, Fang J, Zha H-L, Zhao Q. Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Evidence from 1786 Cases. Med Sci Monit. 2018;24:8544-52.
16. Lee YK, Yang MJ, Kim SS, Noh CK, Cho HJ, Lim SG, et al. Prediction of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Using 4-Hour Post-Endoscopic Retrograde Cholangiopancreatography Serum Amylase and Lipase Levels. Journal of Korean medical science. 2017;32(11):1814-9.
17. Testoni PA, Caporuscio S, Bagnolo F, Lella F. Twenty-four-hour serum amylase predicting pancreatic reaction after endoscopic sphincterotomy. Endoscopy. 1999;31(2):131-6.
18. Coté GA. Intravenous Hydration for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterology. 2014;146(2):581-2.
19. Radadiya D, Devani K, Arora S, Charilaou P, Brahmbhatt B, Young M, et al. Peri-Procedural Aggressive Hydration for Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis Prophylaxsis: Meta-analysis of Randomized Controlled Trials. Pancreatology. 2019;19(6):819-27.
20. Choi JH, Kim HJ, Lee BU, Kim TH, Song IH. Vigorous Periprocedural Hydration With Lactated Ringer's Solution Reduces the Risk of Pancreatitis After Retrograde Cholangiopancreatography in Hospitalized Patients. Clin Gastroenterol Hepatol. 2017;15(1):86-92.e1.
21. Hamada T, Nakai Y, Isayama H, Koike K. Toward routine use of non-steroidal anti-inflammatory drugs for patients undergoing endoscopic retrograde cholangiopancreatography. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society. 2017;29(3):291-3.
22. Hosseini M, Shalchiantabrizi P, Yektaroudy K, Dadgarmoghaddam M, Salari M. Prophylactic Effect of Rectal Indomethacin Administration, with and without Intravenous Hydration, on Development of Endoscopic Retrograde Cholangiopancreatography Pancreatitis Episodes: A Randomized Clinical Trial. Archives of Iranian medicine. 2016;19(8):538-43.
23. Del Olmo Martínez L, Velayos Jiménez B, Almaraz Gómez A. Rectal diclofenac does not prevent post-ERCP pancreatitis in consecutive high-risk and low-risk patients. Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva. 2018;110(8):505-9.
24. Feng Y, Navaneethan U, Zhu X, Varadarajulu S, Schwartz I, Hawes R, et al. Prophylactic rectal indomethacin may be ineffective for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in general patients: A meta-analysis. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society. 2017;29(3):272-80.
25. Lyu Y, Cheng Y, Wang B, Xu Y, Du W. What is impact of nonsteroidal anti-inflammatory drugs in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of randomized controlled trials. BMC gastroenterology. 2018;18(1):106.
26. Uçar R, Biyik M, Uçar E, Polat İ, Çifçi S, Ataseven H, et al. Rectal or intramuscular diclofenac reduces the incidence of pancreatitis afterendoscopic retrograde cholangiopancreatography. Turkish journal of medical sciences. 2016;46(4):1059-63.
27. Khoshbaten M, Khorram H, Madad L, Ehsani Ardakani MJ, Farzin H, Zali MR. Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis. J Gastroenterol Hepatol. 2008;23(7 Pt 2):e11-6.
28. Tryliskyy Y, Bryce GJ. Post-ERCP pancreatitis: Pathophysiology, early identification and risk stratification. Advances in clinical and experimental medicine : official organ Wroclaw Medical University. 2018;27(1):149-54.
29. de la Morena Madrigal EJ, Rodríguez García Mª I, Galera Ródenas AB, Pérez Arellano E. Biliary cannulation effectiveness and pancreatitis risk using two early precut techniques. Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva. 2018;110(2):74-81.
30. Gong B, Hao L, Bie L, Sun B, Wang M. Does precut technique improve selective bile duct cannulation or increase post-ERCP pancreatitis rate? A meta-analysis of randomized controlled trials. Surgical endoscopy. 2010;24(11):2670-80.
31. Katsinelos P, Gkagkalis S, Chatzimavroudis G, Beltsis A, Terzoudis S, Zavos C, et al. Comparison of three types of precut technique to achieve common bile duct cannulation: a retrospective analysis of 274 cases. Dig Dis Sci. 2012;57(12):3286-92.
- Abstract Viewed: 0 times