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It is currently unclear whether endoscopic papillary balloon dilation (EPBD) is associated with increased severe postendoscopic retrograde cholangiopancreatography pancreatitis (PEP)-related morbidity owing to conflicting reports. This study aimed to investigate whether EPBD increases the risk of PEP and hyperamylasemia. Clinical data of patients with choledocholithiasis, treated at the Second Affiliated Hospital of Harbin Medical University from January 2015 to December 2016 were analyzed. Patients were divided into the EPBD group and endoscopic sphincterotomy (EST)+EPBD group, and their characteristics and PEP and hyperamylasemia incidences were compared. Incidences related to dilated balloon diameter were also analyzed. There were no significant differences in patient characteristics and the incidences of PEP (2.6% vs. 0%; P=0.257) and hyperamylasemia (4.4% vs. 5.6%; P=0.954) between the 2 groups. Results were similar even with different balloon dilatations. EPBD without endoscopic sphincterotomy did not increase the risk of PEP and hyperamylasemia. It is a safe option for choledocholithiasis patients.

Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic tool in patients with hepato-pancreatobiliary diseases. In the present study, we sought to determine predictors of post-ERCP complications at our institution., Methods: A retrospective analysis of patients who underwent ERCP in between January 2010 and November 2011 was done. Demographics, indications, ERCP findings, success rate, complications and the need of repeat procedure were evaluated with special emphasis on the difficulty in cannulation procedure, the primary etiology of the disease (benign/malign) and age. Chi-square analysis was applied for statistical analysis. The differences were considered statistically significant, if the p value was less than 0.05., Results: A total of 112 ERCP was performed in 81 patients. Thirty-eight were male (46.9 %) and 43 were female (53.1%). Mean age was 61.3 (range 17-88), and 31 patients was seventy years and older (38.3 %). Complications were detected in 28 patients (34.6 %). Nine cases with difficult or unsuccessful cannulation (69.2 %) had complications (p=0.001). Patients with benign diseases showed less complications (21/70), in comparison with those with malignancies (7/11) (30 % vs. 63.6 %, respectively; p<0.05). Complication rate in patients 70 years and older was 32.2 % (n=10) compared to 35.3 % in patients younger than 70 (n= 18) (p<0.05)., Conclusion: Risk factors such as difficult or incomplete cannulation and malignancy are considered as possible predisposing factors for complications. Age is an independent factor., Key Words: Endoscopic cholangiopancreatography, Risk factors.

Background: It is yet not clear whether differences in the contrast medium may affect post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP)., Aim: The aim of this study was to evaluate the rate of PEP between high osmolality contrast medium (HOCM) and iso osmolar medium (IOCM) in a prospective, randomized, controlled trial., Methods: Patients who were scheduled to undergo a diagnostic or therapeutic procedure under ERCP guidance were included. Patients were excluded from this study if they (1) were < 20 years old; (2) had acute or active pancreatitis; (3) had previously undergone ERCP; (4) had surgical altered upper gastrointestinal tract anatomy; or (5) refused to be involved in this study., Results: Seventy-five patients were randomly assigned to the IOCM group, and 71 patients were assigned to the HOCM group. PEP occurred in 27 patients (18.5%). Although there were no significant differences, the severe grade of PEP was more frequent in the HOCM group than in the IOCM group (p = 0.08). The results of the multivariate analyses for PEP were not identified as independent risk factors. Also, independent risk factors of hyperamylasemia were performing pre-cut. In subgroup analyses, HOCM was an independent risk factor for hyperamylasemia., Conclusions: In conclusion, HOCM may play a role in the development of PEP and in PEP severity grade., (© 2019 S. Karger AG, Basel.)

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with risk of complications. Methods to facilitate ductal cannulation may reduce complications. Intraduodenal acid infusion is a physiological approach to stimulate secretin release in human body and may facilitate cannulation. The objective of this study was to investigate the effect of intraduodenal acid infusion on pancreatic duct cannulation during ERCP., Methods: It was a single center, double-blind, randomized controlled trial. Consecutive patients undergoing first ERCP for pancreatic diseases were randomized toreceive 50 mL acetic acid intraduodenal infusion at ERCP (acetic acid group) or 50 mL saline (control group). The primary outcome, difficult cannulation rate (cannulation time >5 min), in the two groups was compared., Results: Two hundred ten patients were included in the final analysis (105 in each group). The difficult cannulation rate were 39.1% in the control group and 20.9% in the acetic acid group, and the difference was statistically significant (P = 0.004). The overall successful deep cannulation rate was 89.5% and 85.7%, respectively (P = 0.402). The cannulation time was remarkably shortened (182 vs 286 s, P = 0.018), and the cannulation attempts were significantly decreased (3.4 vs 4.4, P = 0.008). The fluoroscopy time was also significantly reduced (60 vs 86 s, P = 0.028). The incidence of post-ERCP pancreatitis and hyperamylasemia was comparable (7.6% vs 10.5% and 10.5% vs 19.1%, P > 0.05)., Conclusion: Intraduodenal acetic acid infusion can significantly decrease difficult pancreatic cannulation rate, facilitate pancreatic duct cannulation, and reduce radiation exposure (ClinicalTrials.gov number, NCT02800772)., (© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Aim: To investigate the location to which a pancreatic stent should be inserted to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP)., Methods: Over a ten-year period at our hospital, 296 patients underwent their first ERCP procedure and had a pancreatic stent inserted; this study included 147 patients who had ERCP performed primarily for biliary investigation and had a pancreatic stent inserted to prevent PEP. We divided these patients into two groups: 131 patients with a stent inserted into the pancreatic head (head group) and 16 patients with a stent inserted up to the pancreatic body or tail (body/tail group). Patient characteristics and ERCP factors were compared between the groups., Results: Pancreatic amylase isoenzyme (p-AMY) levels in the head group were significantly higher than those in the body/tail group [138.5 (7.0-2086) vs 78.5 (5.0-1266.5), P = 0.03] [median (range)]. No cases of PEP were detected in the body/tail group [head group, 12 (9.2%)]. Of the risk factors for post-ERCP hyperamylasemia (≥ p-AMY median, 131 IU/L), procedure time ≥ 60 min [odds ratio (OR) 2.65, 95%CI: 1.17-6.02, P = 0.02) and stent insertion into the pancreatic head (OR 3.80, 95%CI: 1.12-12.9, P = 0.03) were identified as independent risk factors by multivariate analysis., Conclusion: Stent insertion up to the pancreatic body or tail reduces the risk of post-ERCP hyperamylasemia and may reduce the risk of PEP., Competing Interests: Conflict-of-interest statement: We have no financial relationships to disclose.

Objective: To perform a meta-analysis of all available studies on the effect of prophylactic somatostatin administration on prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and post-ERCP hyperamylasemia (PEHA)., Methods: Electronic databases, including PubMed, EMBASE, the Cochrane library, and the Science Citation Index were searched to retrieve relevant trials. Randomized, placebo-controlled trials in adult patients that compared somatostatin versus placebo in prevention of PEP were included. Meta-analysis was performed using a random-effects model to assess the ratios of PEP, PEHA and post-ERCP abdominal pain., Results: Total ratio of PEP of somatostatin group was significantly lower than that of placebo group. For the short-term injection or bolus injection there were no heterogeneity and no significance between the ratio of PEP of somatostatin group and placebo group. For the long-term injection subgroup there was heterogeneity, and the ratio of PEP of somatostatin group was significantly lower than that of placebo group. There was no significance between the ratio of PEP of somatostatin group and placebo group for the low-risk PEP subgroup, while the ratio of PEP of somatostatin group was significantly lower than that of placebo group for the high-risk PEP subgroup. The ratio of PEP of somatostatin group was significantly lower than that of placebo group for the long-term injection high-risk PEP subgroup. There was no significance between the ratio of PEHA of somatostatin group and placebo group for the short-term injection subgroup or bolus injection subgroup. The ratio of PEHA of somatostatin group was significantly lower than that of placebo group for the long-term injection subgroup. The total ratio of post-ERCP abdominal pain of somatostatin group was significantly lower than that of placebo group. The funnel plot of incidence of PEP and PEHA showed no asymmetry with a negative slope., Conclusion: Prophylactic use of long-term injection of somatostatin can significantly reduce the incidence of PEP, PEHA and post-ERCP abdominal pain for the high-risk PEP patients, while it is not necessary to be used for the low-risk PEP patients., (Copyright © 2018 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Aim: To determine the efficacy of rectally administered naproxen for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP)., Methods: This double-blind randomized control trial conducted from January 2013 to April 2014 at the Gastrointestinal and Liver Diseases Research Center in Rasht, Iran. A total of 324 patients were selected from candidates for diagnostic or therapeutic ERCP by using the simple sampling method. Patients received a single dose of Naproxen (500 mg; n = 162) or a placebo (n = 162) per rectum immediately before ERCP. The overall incidence of PEP, incidence of mild to severe PEP, serum amylase levels and adverse effects were measured. The primary outcome measure was the development of pancreatitis onset of pain in the upper abdomen and elevation of the serum amylase level to > 3 × the upper normal limit (60-100 IU/L) within 24 h after ERCP. The severity of PEP was classified according to the duration of therapeutic intervention for PEP: mild, 2-3 d; moderate 4-10 d; and severe, > 10 d and/or necessitated surgical or intensive treatment, or contributed to death., Results: PEP occurred in 12% (40/324) of participants, and was significantly more frequent in the placebo group compared to the naproxen group (P < 0.01). Of the participants, 25.9% (84/324) developed hyperamylasemia within 2 h of procedure completion, among whom only 35 cases belonged to the naproxen group (P < 0.01). The incidence of PEP was significantly higher in female sex, in patients receiving pancreatic duct injection, more than 3 times pancreatic duct cannulations, and ERCP duration more than 40 min (Ps < 0.01). There were no statistically significant differences between the groups regarding the procedures or factors that might increase the risk of PEP, sphincterotomy, precut requirement, biliary duct injection and number of pancreatic duct cannulations. In the subgroup of patients with pancreatic duct injection, the rate of pancreatitis in the naproxen group was significantly lower than that in the placebo (6 patients vs 23 patients, P < 0.01, RRR = 12%, AR = 0.3, 95%CI: 0.2-0.6). Naproxen reduced the PEP in patients with ≥ 3 pancreatic cannulations (P < 0.01, RRR = 25%, AR = 0.1, 95%CI: 0.1-0.4) and an ERCP duration > 40 min (P < 0.01, RRR = 20%, AR = 0.9, 95%CI: 0.4-1.2)., Conclusion: Single dose of suppository naproxen administered immediately before ERCP reduces the incidence of PEP.

Unlabelled: Endoscopic retrograde cholangiopancreatography (ERCP) is an effective tool in the diagnostics and treatment of bile duct diseases. Although minimally invasive, the procedure is associated with a risk of complications, with acute pancreatitis being the most serious. In recent years, high hopes have been placed on pharmacological prevention of acute pancreatitis after ERCP. The aim of the study was assessment of the efficacy of low-molecular-weight heparin and somatostatin in combination with diclofenac in the prevention of acute pancreatitis after ERCP., Material and Methods: The study enrolled three groups of 30 patients diagnosed with cholelithiasis; group I: patients who received low-molecular-weight heparin prior to ERCP, group II: patients who received somatostatin and diclofenac, group III: control group. The study assessed the incidence of acute pancreatitis, hyperamylasemia and increased CRP levels., Results: Acute pancreatitis was observed in 13.3% of group I patients, 10% of group II patients and 16.7% of group III patients (no statistical significance). Hyperamylasemia was observed in 16.7% of group I patients, 16.7% of group II patients and 43.3% of group III patients. These differences were statistically significant. No significant differences were found in the occurrence of increased CRP levels among the study groups., Conclusions: No significant reduction in the occurrence of acute pancreatitis after ERCP was observed in patients who received pharmacological prophylaxis. A significant reduction in the occurrence of hyperamylasemia was found in drug-treated patients.

Unlabelled: Endoscopic retrograde cholangiopancreatography (ERCP) is the most important non-surgical procedure in serious pancreatic and biliary diseases, still burdened with the risk of severe complications. The objective of the study was to distinguish factors which could increase the risk of occurrence of ERCP complication in the form of pancreatitis., Material and Methods: The study included 452 patients who had undergone ERCP. Patients' records were retrospectively analyzed from the aspect of demographic data, indications for the procedure, type and course of the procedure, type and severity of complications, width of the common bile duct (CBD), concomitant diseases and administered medicines which might increase the risk of complications., Results: In 35 patients (7.7%) a complication occurred in the form of pancreatitis (AP). A severe course was confirmed in 11 patients (31%). Cholelithiasis constituted approximately 2/3 of indications for ERCP. AP after ERCP was significantly more often observed in the group of patients aged under 40 (22.9% vs 8.6%; p<0.05). Narrow biliary ducts (3-8 mm) were the factor increasing the frequency of development of AP (25.9% vs 45%; p<0.05). Death occurred in 5 patients (1.1%), including 4 patients (0.96%) in the group without complications, and in 1 patient (2.85%) with complicated AP., Conclusions: ERCP is a very valuable procedure in clinical treatment; however, it is burdened with the risk of complications, such as AP, bleeding, or duodenal perforation. A group especially exposed to the risk of complications in the form of AP are young patients aged under 40 with a narrow CBD.

Objective: With an increased use of endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP complications have attracted much attention. We aimed to identify independent risk factors of post-ERCP pancreatitis (PEP) and hyperamylasemia, and to develop a simple scoring system of the factors contributing to the clinical prevention against PEP., Methods: A retrospective single-center analysis was performed in 4234 ERCP procedures between September 2007 and December 2012. Patient-related and procedure-related risk factors for PEP and post-ERCP hyperamylasemia were identified by univariate and multivariate regression analyses. A scoring system was developed based on the independent risk factors., Results: PEP occurred in 226 (5.3%) ERCP procedures and hyperamylasemia in 774 (18.3%) procedures. Female gender (odds ratio [OR] 1.449), first-time ERCP (OR 1.745), latent jaundice (OR 1.917), difficult cannulation (OR 3.317) and pancreatography (OR 1.823) were all proven to be significant risk factors for predicting PEP. In addition, difficult cannulation (OR 1.990) and pancreatography (OR 2.009), age <60 years (OR 1.294), prior diabetes (OR 0.614), biliary duct stent placement (OR 1.884) and nasobiliary drainage (OR 1.613) were associated with developing hyperamylasemia. Prophylactic pancreatic duct stent (PS) might prevent against PEP in significantly high-risk patients (score ≥6)., Conclusions: Both patient-related and procedure-related risk factors are important for predicting PEP and post-ERCP hyperamylasemia. Technical procedures, for example, PS, are necessary to prevent PEP in patients at the highest risk., (© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.)

Background and Study Aim: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains the most common complication of ERCP. Somatostatin may inhibit pancreatic secretion and has been tested for PEP prophylaxis. However, the results of previous studies are inconsistent. The aim of the current study was to investigate whether somatostatin can reduce the incidence of PEP., Patients and Methods: The study was a multicenter, open-label, randomized controlled trial. A total of 908 patients with normal amylase levels who were undergoing ERCP were randomized to receive somatostatin 250 μg bolus injection before ERCP and 250 μg/hour intravenous infusion for 11 hours after ERCP (somatostatin group) or no somatostatin treatments (control group). The incidences of PEP and hyperamylasemia were compared in the two groups., Results: The full analysis set included 900 patients (445 in the somatostatin group, 455 in the control group). PEP developed in 34 patients (7.5 %) in the control group (95 % confidence interval [CI] 5.4 % - 10.3 %) and in 18 patients (4.0 %) in the somatostatin group (95 %CI 2.6 % - 6.3 %; P = 0.03). Hyperamylasemia occurred in 46 patients (10.1 %) in the control group (95 %CI 7.7 % - 13.2 %) and in 27 patients (6.1 %) in the somatostatin group (95 %CI 4.2 % - 8.7 %; P = 0.03). No perforation or death occurred during the study., Conclusions: This study showed that somatostatin was effective and safe for the prevention of PEP and hyperamylasemia in ERCP patients.(ClinicalTrials.gov number, NCT01431781)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: To evaluate short-type-single-balloon enteroscope (SBE) with passive-bending, high-force transmission functions for endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anastomosis., Methods: Short-type SBE with this technology (SIF-Y0004-V01; working length, 1520 mm; channel diameter, 3.2 mm) was used to perform 50 ERCP procedures in 37 patients with Roux-en-Y anastomosis. The rate of reaching the blind end, time required to reach the blind end, diagnostic and therapeutic success rates, and procedure time and complications were studied retrospectively and compared with the results of 34 sessions of ERCP performed using a short-type SBE without this technology (SIF-Y0004; working length, 1520 mm; channel diameter, 3.2 mm) in 25 patients., Results: The rate of reaching the blind end was 90% with SIF-Y0004-V01 and 91% with SIF-Y0004 (P = 0.59). The median time required to reach the papilla was significantly shorter with SIF-Y0004-V01 than with SIF-Y0004 (16 min vs 24 min, P = 0.04). The diagnostic success rate was 93% with SIF-Y0004-V01 and 84% with SIF-Y0004 (P = 0.17). The therapeutic success rate was 95% with SIF-Y0004-V01 and 96% with SIF-Y0004 (P = 0.68). The median procedure time was 40 min with SIF-Y0004-V01 and 36 min with SIF-Y0004 (P = 0.50). The incidence of hyperamylasemia was 6.0% in the SIF-Y0004-V01 group and 14.7% in the SIF-Y0004 group (P = 0.723). The incidence of pancreatitis was 0% in the SIF-Y0004-V01 group and 5.9% in the SIF-Y0004 group (P > 0.999). The incidence of gastrointestinal perforation was 2.0% (1/50) in the SIF-Y0004-V01 group and 2.9% (1/34) in the SIF-Y0004 group (P > 0.999)., Conclusion: SIF-Y0004-V01 is useful for ERCP in patients with Roux-en-Y anastomosis and may reduce the time required to reach the blind end.

Background and Study Aims: Meta-analyses suggest that an intravenous bolus or a high dose continuous infusion of somatostatin reduces the incidence of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). Clinical guidelines, however, do not recommend this prophylaxis. The aim of this randomized, double-blind clinical trial was to evaluate the effect of somatostatin on the incidence of post-ERCP pancreatitis., Patients and Methods: Patients undergoing ERCP at a single center were randomized to either intravenous bolus of somatostatin followed by a short (4-hour) continuous infusion, or to a similar placebo regimen. The primary outcome was post-ERCP pancreatitis, defined as abdominal pain with an amylase level at least three times higher than the upper limit of normality 24 hours after the ERCP and requiring admission for at least 2 days., Results: A total of 510 patients were enrolled (255 patients per group) and all completed follow-up. The main indications for ERCP were choledocholithiasis (62 %), and biliary malignant stricture (31 %). Post-ERCP pancreatitis occurred in 19 patients (7.5 %) in the somatostatin group and 17 patients (6.7 %) in the placebo group (relative risk [RR] 1.12, 95 % confidence interval [95 %CI] 0.59 - 2.1; P = 0.73). The number of cases of moderate or severe acute pancreatitis was similar in the somatostatin (2.4 %) and the placebo (3.5 %) groups (RR 0.67, 95 %CI 0.24 - 1.85, P = 0.43). No side effects were observed related to the use of somatostatin., Conclusions: Administration of an intravenous bolus of somatostatin followed by a short continuous infusion does not reduce the incidence of post-ERCP pancreatitis. Clinical Trials.gov number: NCT01060826., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: To assess the effectiveness of pancreatic stents for preventing pancreatitis in high-risk patients after endoscopic retrograde cholangiopancreatography (ERCP)., Methods: PubMed, Embase, Science Citation Index, and Cochrane Controlled Trials Register were searched to identify relevant trials published in English. Inclusion and exclusion criteria were used to screen for suitable studies. Two reviewers independently judged the study eligibility while screening the citations. The methodological quality of the included trials was assessed using the Jadad scoring system. All results were expressed as OR and 95%CI. Data were analyzed using Stata12.0 software., Results: Ten eligible randomized controlled trials were selected, including 1176 patients. A fixed-effects model in meta-analysis supported that pancreatic duct stents significantly decreased the incidence of post-ERCP pancreatitis (PEP) in high-risk patients (OR = 0.25; 95%CI: 0.17-0.38; P < 0.001). Pancreatic stents also alleviated the severity of PEP (mild pancreatitis after ERCP: OR = 0.33; 95%CI: 0.21-0.54; P < 0.001; moderate pancreatitis after ERCP: OR = 0.30; 95%CI: 0.13-0.67; P = 0.004). The result of severe pancreatitis after ERCP was handled more rigorously (OR = 0.24; 95%CI: 0.05-1.16; P = 0.077). Serum amylase levels were not different between patients with pancreatic stents and control patients (OR = 1.08; 95%CI: 0.82-1.41; P = 0.586)., Conclusion: Placement of prophylactic pancreatic stents may lower the incidence of post-ERCP pancreatitis in high-risk patients and alleviate the severity of this condition.

Context: Acute pancreatitis is the most common complication in ERCP, and some risk factors were associated with the development of hyperamylasemia and post-ERCP pancreatitis., Objectives: identifying new factors associated with the development of hyperamylasemia or post-ERCP pancreatitis in patients attended at our center., Material and Methods: A (retrospective) cohort study was carried out in 170 patients on which a diagnostic-therapeutic ERCP was done due to biliopancreatic disease. 67 patients developed hyperamylasemia (39.4%) and 6 post-ERCP pancreatitis (3.5%). The following diagnostic criteria were applied: Hyperamylasemia: increase in the serum amylase level above the normal value (90 I/U). Acute post-ERCP pancreatitis: clinical: continuous abdominal pain for over 24 hours and biochemical: elevation of amylase3 times above normal value (90 U/I)., Results: The number of cannulations more than 4 (19 patients), (p=0.006; RR= 3.00) was associated significantly with the development of hyperamylasemia and the placing of biliary stent (14 patients), (p=0.00; RR= 0.39) was a protective factor. The factors associated with the development of post-ERCP pancreatitis were related with the patient (peridiverticular location of the papilla (p=0.00; RR= 2.00) and the sphincter of Oddi dysfunction (p=0.000; RR=1.20)., Conclusion: Technical factors were associated with the development of hyperamylasemia, however, the factors associated with the development of post-ERCP pancreatitis in our universe of study were related mainly with the patient.

Objectives: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is diagnosed on the basis of pancreatic pain and hyperamylasemia. However, because the diagnosis of abdominal pain is not objective, there may be some cases of painless pancreatitis among patients with post-ERCP hyperamylasemia (PEH). We reviewed the computed tomography (CT) findings of PEH cases to determine the incidence of painless pancreatitis., Methods: Between July, 2005 and December, 2011, CT was performed in 91 patients with hyperamylasemia 18 h after ERCP. We reviewed the CT findings and graded the severity of pancreatitis according to the Balthazar grading system. Grades C, D, and E were defined as pancreatitis., Results: Thirty-four patients (37%) had pancreatitis according to the CT findings. There was a significant difference in the serum amylase levels between the positive- and negative-CT finding groups (1306 ± 833 vs. 786 ± 315 IU/L, respectively; p = 0.0012). Receiver operating characteristic curve analysis showed that the amylase cut-off value for discriminating between the 2 groups was 795 IU/L (6.36 times the upper normal limit)., Conclusions: Thirty-seven percent of PEH patients had painless pancreatitis. CT is useful to determine pancreatitis in patients taking analgesics, steroids, or anti-immunological drugs and those with diabetes mellitus and 18-h serum amylase levels of >6 times the normal upper limit., (Copyright © 2013 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Objective: Pancreatitis is the most common and serious complication of endoscopic retrograde cholangiopancreatography (ERCP). Several studies have compared contrast media (CM) with different osmolalities, but the results are conflicting. We conducted this study to clarify the difference between 2 CM used in ERCP., Methods: Five hundred and seventy-six patients were examined by using ERCP in our hospital during 2010. Out of these, 56 patients were enrolled in this study. We investigated the incidence of post ERCP pancreatitis (PEP) and hyperamylasemia. Serum amylase levels were compared in the 2 groups., Results: Twenty-seven patients were treated with iodixanol and 29 with diatrizoate meglumine Na. The rate of PEP in the diatrizoate meglumine Na group and iodixanol group was 0% (0/29) and 7.4% (2/27), respectively (P = 0.228). The rate of hyperamylasemia was 10.3% (3/29) and 14.8% (4/27), respectively (P = 0.70). There were no significant differences between two groups for amylase levels pre-procedure (P = 0.082), 3 h post procedure (P = 0.744), or next morning (P = 0.265)., Conclusions: There were no significant differences in the rates of PEP or hyperamylasemia between CMs in ERCP. We believe it is unnecessary to use the more expensive low osmolality CM in ERCP to prevent PEP.

Objectives: The mechanism of pancreatitis development following endoscopic papillary balloon dilation (EPBD) remains unknown. Antegrade dilation with percutaneous transhepatic papillary balloon dilation (PTPBD) allows the removal of bile duct stones or fragments during percutaneous choledochoscopic lithotomy, with less mechanical trauma to the papilla than with EPBD-mediated stone removal., Methods: A total of 56 patients with bile duct stones underwent antegrade dilation with PTPBD from March 2006 to February 2011. A total of 208 patients with common bile duct stones underwent retrograde dilation with EPBD during the same period. The conditions of papillary balloon dilation were identical in both groups. The frequencies of pancreatitis and hyperamylasemia were compared in both groups., Results: Pancreatitis occurred in 14 (6.7%) of 208 patients in the EPBD group (mild, nine; moderate, four; severe, one). There was no case of pancreatitis among 56 patients in the PTPBD group (P < 0.05). Hyperamylasemia developed in significantly more patients treated in the EPBD group (62, 29.8%) compared with the PTPBD group (4, 7.1%; P < 0.05). Complete bile duct clearance was achieved in 98.2% of PTPBD group and 97.1% of EPBD group., Conclusions: The rates of post-procedural pancreatitis and hyperamylasemia were significantly higher after retrograde dilation with EPBD than after antegrade dilation with PTPBD for the removal of bile duct stones. Although the mechanism of pancreatitis following papillary balloon dilation remains unclear, post-EPBD pancreatitis may be associated with procedures before and after balloon dilation similar to mechanical lithotripsy rather than balloon dilation itself., (© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Objective: To study the feasibility and risk of endoscopic retrograde cholangiopancreatography (ERCP) for children in clinic, and to evaluate the effects of ERCP in diagnosis and treatment of the pancreatic diseases in children., Method: Totally 98 patients under 14 years of age who underwent ERCP from 1994 to 2011 were enrolled in the study. The data of diagnosis, anesthesia type, treatments, and postoperative complications were collected., Result: The 98 patients were 4 to 14 years old, of whom 32 cases suffered from acute pancreatitis (30 cases with biliary disease and 2 with hyperlipidemia); 42 cases had chronic pancreatitis, of whom 36 had calculus of pancreatic duct, pancreatic pseudocyst was seen in 6 cases. Pancreas divisum was found in 20 cases, choledochopancreatic junction anomaly in 6 cases,and annular pancreas in 1 case. The operations of dissection of pancreatic duct and biliary duct, calculus removal, insertion of endoprosthesis and draining tube in pancreatic duct or biliary duct were performed. No patients died from ERCP complications. In observation of postoperative complications, acute pancreatitis after ERCP occurred in 1 case, with the incidence rate of 1%, 1 case had bleeding (1%), and 5 cases had hyperamylasemia (5%). All the complications were cured within 1 week. The average hospital stay was 5.51 d., Conclusion: ERCP is useful and safe in children under suitable condition of doctors and equipments, and no high rates of complications were observed.

Aim: To compare the efficacy, complications and post-procedural hyperamylasemia in endoscopic pre-cut conventional and needle knife sphincterotomy., Methods: We performed a retrospective analysis of two pre-cut sphincterotomy (PS) techniques, pre-cut conventional sphincterotomy (PCS), and pre-cut needle knife (PNK). The study included 143 patients; the classic technique was used in 59 patients (41.3%), and the needle knife technique was used in 84 patients (58.7%). We analyzed the efficacy of bile duct access, the need for a two-step procedure, the rates of complications and hyperamylasemia 4 h after the procedure, "endoscopic bleeding" and the need for bleeding control. Furthermore, to assess whether the anatomy of the Vater's papilla, indications for the procedure or the need for additional procedures could inform the choice of the PS method, we evaluated the additive hyperamylasemia risk 4 h after the procedure with respect to the above mentioned variables., Results: The bile duct access efficacy with PNK and PCS was 100% and 96.6%, respectively, and the difference between the two groups was not significant (P = 0.06). However, the needle knife technique required two-step access significantly more often, in 48.8% vs 8.5% of cases (P < 0.0001). The only complication noted was post-ercp pancreatitis (PEP), which was observed in 4/84 (4.8%) and 2/59 (3.4%) patients submitted to PNK and PSC, respectively; the difference between the two procedures was not significant (P = 0.98). An analysis of other consequences of the techniques yielded the following results in the PNK and PCS groups: hyperamylasemia 4 h after the procedure > 80 U/L, 41/84 vs 23/59 (P = 0.32); hyperamylasemia 4 h after the procedure > 240 U/L, 19/84 vs 11/59 (P = 0.71); pancreatic pain, 13/84 vs 7/59 (P = 0.71); endoscopic bleeding, 10/84 vs 8/59 (P = 0.97); and the need for bleeding control, 10/84 vs 7/59 (P = 0.79). In the next part of the study, we analyzed the influence of the method chosen on the risk of hyperamylasemia with respect to an indication for endoscopic retrograde cholangiopancreatography, papillary anatomy and concomitant procedures performed. We determined that the hyperamylasemia risk was increased by more than threefold [odds ratio (OR) = 3.38; P = 0.027] after PCS in patients with a flat Vater's papilla and more than fivefold (OR = 5.3; P = 0.049) after the PNK procedure in patients who required endoscopic homeostasis., Conclusion: PCS and PNK do not differ in terms of efficacy or complication rates, but PNK is more often associated with the necessity for a two-step procedure.

Background/aims: This study was designed to determine whether bile aspiration before contrast injection cholangiogram prevent of post-ERCP cholangitis, liver function worsening, cholecystitis and pancreatitis., Methods: One hundred and two patients in the bile aspiration group before contrast injection from December 1, 2008 to December 30, 2009 and 115 patients in the conventional control group from January 1, 2010 to June 30, 2010 were analyzed. The incidence of post-ERCP cholangitis, liver function worsening, cholecystitis, pancreatitis, and hyperamylasemia only were compared between these two groups., Results: In the 102 patients with the bile aspiration group, post-ERCP cholangitis in 3 patients (2.9%), liver function worsening in 4 patients (3.9%), cholecystitis and pancreatitis in none, and hyperamylasemia only in 6 patients (5.8%) occurred. In the 115 patients with control group, post-ERCP cholangitis in 1 patient (0.4%), liver function worsening in 9 patients (7.8%), cholecystitis in none, pancreatitis in 3 patients (2.6%), hyperamylasemia only in 10 patients (8.6%) developed. The two groups did not significantly differ in terms of the incidence of post-ERCP cholangitis, liver function worsening, pancreatitis, and hyperamylasemia only (p>0.05)., Conclusions: Initially bile juice aspiration just before contrast injection into the bile duct rarely prevented post-ERCP cholangitis, liver function worsening, and pancreatitis in patients with the extrahepatic bile duct obstruction.

Background and Aims: ERCP during pregnancy is always challenging for the entire team performing the endoscopic intervention. In this study techniques and different interventional aspects used at several centres about the clinical experience on ERCP in pregnant women are analyzed., Patients and Methods: the practice on ERCP in pregnant women in six centres during a period of ten years is reported., Results: eleven patients were included in the study. Mean age was 30.6 years. Indication for ERCP was always symptomatic common bile duct stone (CBDS) disease. Before the procedure abdominal ultrasound was performed at all times and magnetic resonance cholangiopancreatography in four occasions. Conscious sedation by means of midazolam and fentanyl or meperidine was applied. Sphincterotomes and guidewires were used for bilary cannulation. Sometimes, rapid exchange platforms with short-length guidewires controlled by the same endoscopist were employed. Biliary cannulation was confirmed in 9 occasions by bile aspiration. In five procedures, a mean of 30 seconds of fluoroscopy was used, both to verify cannulation and to corroborate complete CBDS clearance. These patients had the pelvic zone protected with a lead shield and radiation dose was measured. Ten biliary sphincterotomies were performed followed by CBDS extraction. Two plastic stents were inserted. Relief of biliary obstruction was attained in all circumstances. Only one patient had hyperamylasemia after ERCP. All pregnant women had healthy foetuses with normal deliveries., Conclusions: with experience, ERCP appears to be a safe technique during pregnancy. With simple measures fluoroscopic time can be diminished or even abolished. It seems that ERCP during pregnancy is underused in our working areas, although it has shown to be a useful technique for relieving biliary obstruction.

Background and Aim: Wire-guided cannulation (WGC) might increase the biliary cannulation rate and decrease the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We assessed the learning curve for WGC in therapeutic biliary ERCP (study 1) and compared WGC and conventional contrast-assisted cannulation (CC) by a matched case-control study (study 2)., Methods: Prospectively collected data of 500 therapeutic biliary ERCP cases (250 consecutive cases of WGC and 250 matched controls of CC) were retrospectively studied. Rate and time of biliary cannulation, total procedure time, PEP, and hyperamylasemia were analyzed., Results: In study 1, biliary cannulation by WGC was successful in 96% of the first 50 cases, with a median time to cannulation of 3 min. Rates of hyperamylasemia were within 10% after 100 WGC. In study 2, there were no significant differences in the overall cannulation rate and PEP between WGC and CC, but the total procedure time was shorter in WGC (30 vs 35 min, P = 0.059). Rates of hyperamylasemia and the change in serum amylase levels was lower (9% vs 14%, P = 0.069, and + 62.8 U/L vs+ 169.5 U/L, P = 0.043) in WGC, which was more prominent in experienced endoscopists (9% vs 17%, P = 0.025, and + 68.9 U/L vs+ 229.3 U/L, P = 0.014)., Conclusions: The introduction of WGC was effective in the first 50 cases and did not increase the rate of PEP in biliary therapeutic ERCP., (© 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.)

Background and Aim: Pancreatitis remains a serious complication after endoscopic retrograde cholangiopancreatography (ERCP). The efficacy of prophylactic pancreatic duct stent placement to prevent post-ERCP pancreatitis in patients at high risk has been established in several randomized controlled trials. The aim of this study was to investigate the frequency and risk factors of post-ERCP pancreatitis in patients who had undergone prophylactic pancreatic duct stenting., Patients and Methods: Between July 2002 and January 2010, ERCP-related procedures were performed in 9192 cases of pancreatobiliary diseases at seven institutions. Among them, 414 patients (246 men, 168 women; mean age, 68 yr; age range, 22-91 yr) at high risk of post-ERCP pancreatitis who had undergone prophylactic pancreatic duct stenting were included in this study. The stent used in the present study was a 5-Fr stent with a single duodenal pigtail, which is made of soft polyethylene and has no flange (Pit-stent: Cathex, Co., Ltd., Tokyo, Japan). The pancreatic duct stent was placed via the channel of the duodenoscope over a guidewire with the assistance of fluoroscopy at the end of the procedure. The frequency and risk factors of post-ERCP pancreatitis were investigated. Post-ERCP pancreatitis was defined based on the consensus criteria., Results: Therapeutic ERCP was performed in 52% of the patients. Indications for prophylactic pancreatic duct stenting were as follows: difficult cannulation of the bile duct, 192; pancreatic duct cytology/biopsy, 95; precut sphincterotomy, 40; pancreatic sphincterotomy, 29; female gender, 28; papillectomy, 25; sphincter of Oddi dysfunction, 12; history of pancreatitis, 10. Hyperamylasemia at 18-24 h after ERCP was observed in 64% (267 patients) of the patients. Pancreatitis occurred in 9.9% (41 patients: mild, 37; moderate, 2; severe, 2). Univariate analysis revealed intraductal papillary mucinous neoplasm (IPMN) of the pancreas to be the only significant risk factor for pancreatitis (OR 2.9, 95% CI 1.2, 7.1). Multivariate analysis also showed IPMN to be the only risk factor for pancreatitis (OR 3.1, 95% CI 1.2, 7.8). The mean diameter of the pancreatic head duct in patients with IPMN who developed post-ERCP pancreatitis was significantly smaller than that in those who did not develop pancreatitis (3.0 ± 1 mm vs 4.7 ± 2.6 mm, p=0.0037)., Conclusion: Post-ERCP pancreatitis developed in 9.9% of the patients at high risk who had undergone prophylactic pancreatic duct stenting. Since the majority of cases of post-ERCP pancreatitis were mild, pancreatic duct stenting may contribute to lessening the severity of pancreatitis. The present results suggest that IPMN without a dilated pancreatic head duct is a possible risk factor for post-ERCP pancreatitis after prophylactic pancreatic duct stenting.

Objectives: The role of prophylactic ulinastatin in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is debated. A meta-analysis of all published randomized clinical trials was performed to evaluate the efficacy of ulinastatin on post-ERCP pancreatitis., Methods: Searches were conducted in multiple databases composed of PubMed, EMBASE, the Cochrane Library, the Science Citation Index Expanded, and the China National Knowledge Infrastructure series full-text database. Primary outcome was post-ERCP pancreatitis, with or without hyperamylasemia., Results: Seven randomized clinical trials fulfilling the inclusion criteria were selected for meta-analysis, 5 comparing ulinastatin with placebo and 2 for ulinastatin versus gabexate. The incidence of post-ERCP pancreatitis was reduced by ulinastatin (odds ratio, 0.53; 95% confidence interval, 0.31-0.89; P = 0.02; test for heterogeneity: I = 0%; P = 0.51), so was the event of hyperamylasemia (odds ratio, 0.42; 95% confidence interval, 0.30-0.59; P < 0.00001; test for heterogeneity: I = 13%; P = 0.33). Subsequent sensitivity and subgroup analyses produced conflicting results., Conclusions: Ulinastatin shows to be of value on preventing post-ERCP pancreatitis and hyperamylasemia for patients in average risk, when given intravenously at a dose of not less than 150,000 U, just before ERCP. More high-quality trials are needed for further confirmation.

Aim: To assess the efficacy of allopurinol to prevent hyperamylasemia and pancreatitis after endoscopic retrograde cholangiopancreatography (PEP)., Methods: One hundred and seventy patients were enrolled and randomized to two groups: a study group (n = 85) who received 300 mg of oral allopurinol at 15 h and 3 h before endoscopic retrograde cholangiopancreatography (ERCP) and a control group (n = 85) receiving an oral placebo at the same times. Main Outcome Measurements included serum amylase levels and the number severity of the episodes of pancreatitis. Serum amylase levels were classified as normal (< 150 IU/L) or hyperamylasemia (> 151 IU/L). Episodes of PEP were classified following Ranson's criteria and CT severity index., Results: Gender distribution was similar between groups. Mean age was 53.5 +/- 18.9 years for study group and 52.8 +/- 19.8 years for controls. Also, the distribution of benign pathology was similar between groups. Hyperamylasemia was more common in the control group (P = 0.003). Mild PEP developed in two patients from the study group (2.3%) and eight (9.4%) from control group (P = 0.04), seven episodes were observed in high-risk patients of the control group (25%) and one in the allopurinol group (3.3%, P = 0.02). Risk factors for PEP were precut sphincterotomy (P = 0.02), pancreatic duct manipulation (P = 0.002) and multiple procedures (P = 0.000). There were no deaths or side effects., Conclusion: Oral allopurinol before ERCP decreased the incidences of hyperamylasemia and pancreatitis in patients submitted to high-risk procedures.

Objectives: To investigate the potential risk factors for endoscopic retrograde cholangiopancreatography (ERCP) complications and to identify whether the risk factors are different for pancreatitis and asymptomatic hyperamylasemia., Methods: Consecutive ERCP procedures were studied at 14 centers in China from May 2006 to April 2007. The complications after the patients' first-only procedures were evaluated. Multivariate analysis based on the first-only procedures was used to identify the risk factors., Results: A total of 3,178 procedures were performed on 2,691 patients. Overall, complications developed in 213 (7.92%) patients, pancreatitis in 116 (4.31%), and asymptomatic hyperamylasemia in 396 (14.72%). In the multivariate analysis, female gender (adjusted odds ratios (ORs): 1.52, 95% confidence interval (CI): 1.14-2.02, P=0.004), periampullary diverticulum (OR: 2.02, 95% CI: 1.49-2.73, P<0.001), cannulation time >10 min (OR: 1.51, 95% CI: 1.08-2.10, P=0.016), > or =1 pancreatic deep wire pass (OR: 1.80, 95% CI: 1.33-2.42, P<0.001), and needle-knife precut (OR: 2.70, 95% CI: 1.42-5.14, P=0.002) were risk factors for overall complications. Female gender (OR: 1.84, 95% CI: 1.25-2.70, P=0.002), age < or =60 year (OR: 1.59, 95% CI: 1.06-2.39, P=0.025), cannulation time>10 min (OR: 1.76, 95% CI: 1.13-2.74, P=0.012), > or =1 pancreatic deep wire pass (OR: 2.77, 95% CI: 1.79-4.30, P<0.001), and needle-knife precut (OR: 4.34, 95% CI: 1.92-9.79, P<0.001) were risk factors for pancreatitis. Cannulation time>10 min (OR: 1.96, 95% CI: 1.52-2.54, P<0.001), > or =1 pancreatic deep wire pass (OR: 2.24, 95% CI: 1.74-2.89, P<0.001), needle-knife precut (OR: 2.34, 95% CI: 1.32-4.14, P=0.004), and major papilla pancreatic sphincterotomy (OR: 1.71, 95% CI: 1.23-2.37, P=0.001) were risk factors for asymptomatic hyperamylasemia., Conclusions: Patient-related factors are as important as procedure-related factors in determining high-risk predictors for post-ERCP overall complications and pancreatitis. However, the risk factors for asymptomatic hyperamylasemia may be mostly procedure related.

Objectives: Patients undergoing therapeutic endoscopic retrograde cholangiopancreatography (ERCP) are at a higher risk of developing post-ERCP pancreatitis than patients undergoing diagnostic ERCP. The aim of this study was to evaluate the effectiveness of somatostatin in preventing post-therapeutic ERCP pancreatitis., Methods: This placebo-controlled, double-blind, randomized study involved 391 patients in 3 hospitals who required therapeutic ERCP. Patients were assigned to receive either somatostatin or placebo. The incidence of pancreatitis and hyperamylasemia after performing ERCP was compared between the somatostatin and placebo groups., Results: Pancreatitis occurred in statistically significantly fewer ERCP patients who received somatostatin (7/193: 3.6%) than placebo (19/198: 9.6%; P = 0.02). With regard to the individual ERCP procedures, statistically significant reductions in post-ERCP pancreatitis were seen in patients treated with somatostatin who had stoneremoval (P = 0.04) and endoscopic papillary balloon dilation (P= 0.03). The incidence of hyperamylasemia was lower in the somatostatin group (7.8%) than in the placebo group (12.6%), although this difference was not statistically significant (P > 0.05)., Conclusions: A significantly lower incidence of post-ERCP pancreatitis occurred in patients who received somatostatin prophylaxis. This finding suggests that the administration of somatostatin is useful in preventing pancreatitis in patients undergoing therapeutic ERCP.

Objectives: Previous studies have shown that ulinastatin may be effective at preventing pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, routine administration of ulinastatin is unlikely to be cost-effective. So the aim of this prospective study was to evaluate the effectiveness of low-dose ulinastatin at preventing pancreatitis in patients at high risk of post-ERCP pancreatitis., Methods: A total of 227 patients (mean age, 63 years; 54% men) were randomized to receive placebo (n = 108) or active drug (n = 119) immediately after ERCP and received active drug (100,000 U of ulinastatin) or placebo. Occurrence of post-ERCP pancreatitis and hyperamylasemia were compared between the 2 groups., Results: The overall incidence of pancreatitis was 6.2%, and no significant differences were observed between placebo- and ulinastatin-treated patients in terms of the frequencies of pancreatitis (5.6% vs 6.7%), abdominal pain, or hyperamylasemia. Pancreatic duct acinarization, papillectomy of ampulla of Vater adenoma, difficult cannulation, and female sex were identified as risk factors for pancreatitis in univariate analysis., Conclusions: Low-dose prophylactic treatment with ulinastatin immediately after ERCP did not show a beneficial influence on the incidence of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

Aim: To investigate if transnasal endoscopic retrograde cholangiopancreatography (n-ERCP) using an ultrathin forward-viewing scope may overcome the disadvantages of conventional oral ERCP (o-ERCP) related to the large-caliber side-viewing duodenoscope., Methods: The study involved 50 patients in whom 25 cases each were assigned to the o-ERCP and n-ERCP groups. We compared the requirements of esophagogastroduodenoscopy (EGD) prior to ERCP, rates and times required for successful cannulation into the pancreatobiliary ducts, incidence of post-procedure hyperamylasemia, cardiovascular parameters during the procedure, the dose of a sedative drug, and successful rates of endoscopic naso-biliary drainage (ENBD)., Results: Screening gastrointestinal observations were easily performed by the forward-viewing scope and thus no prior EGD was required in the n-ERCP group. There was no significant difference in the rates or times for cannulation, or incidence of hyperamylasemia between the groups. However, the cannulation was relatively difficult in n-ERCP when the scope appeared U-shape under fluoroscopy. Increments of blood pressure and the amount of a sedative drug were significantly lower in the n-ERCP group. ENBD was successfully performed succeeding to the n-ERCP in which mouth-to-nose transfer of the drainage tube was not required., Conclusion: n-ERCP is likely a well-tolerable method with less cardiovascular stress and no need of prior EGD or mouth-to-nose transfer of the ENBD tube. However, a deliberate application is needed since its performance is difficult in some cases and is not feasible for some endoscopic treatments such as stenting.

Introduction: Chronic pancreatitis is defined as chronic inflammatory lesion of pancreatic parenchyma leading to destruction and fibrosis of exocrine pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) is the most sensitive and specific method for detection of morphological alterations in chronic pancreatitis. ERCP is inevitably associated to post-ERCP acute pancreatitis, as well as hyperamilasemia., Study Aim: This study aims to determine frequency of post-ERPC pancreatitis and asymptomatic hyperamilasemia., Study Methods: We have studied 160 patients who underwent ERCP in Institute of Digestive Diseases, Clinical Centre of Serbia in Belgrade. Data regarding cholecystectomy, papillotomy, peripapillary diverticulosis, Oddi's sphincter hypertension, choledoch canulation and diameter, Wirsung duct canulation, minor duodenal papilla patency, anomalies of BP junction, as well as chronic pancreatitis has been analysed and correlated with eventual development of post-ERCP pancreatitis and asymptomatic hyperamilasemia., Results: Asymptomatic hyperamilasemia was determined in 51 subjects (31.9%), while pancreatitis has been developed in 5 patients (3.1%) subsequent to ERCP. It has been proofed that Wirsung duct canulation plays significant role in development of post-ERCP complications., Conclusion: Although numerous factors may potentially contribute to development of post-ERCP pancreatitis, none of them, with the exception of Wirsung duct canulation, has been determined to play significant role in development of these complications.

Objectives: Since the introduction of endoscopic retrograde cholangiopancreatology (ERCP) in clinical use, pancreatitis has become a common complication of ERCP. Octreotide is an inhibitor of pancreatic enzyme secretions. Several studies have evaluated the effect of octreotide on the incidence of clinical pancreatitis after ERCP, but with different results. The aim was to determine the efficacy of prophylactic administration of octreotide for the prevention of post-ERCP pancreatitis (PEP) and hyperamylasemia., Methods: In this study, patients with scheduled ERCP were randomized to receive either octreotide (0.3 mg) via intramuscular injection or a placebo. The study was conducted in 12 digestive endoscopic units in China. Patients were randomized into two groups: an octreotide group (N = 414) and a control group (N = 418). In the octreotide group, octreotide (0.3 mg) was dissolved in 500 mL of 0.9% saline solution and administered by continuous intravenous infusion, beginning 1 h before endoscopic examination and continued for 6 h thereafter; 0.1 mg of octreotide was injected subcutaneously at 6 and 12 h after the intravenous injection was stopped. The control group was given a placebo intravenously. The end point was the development of acute pancreatitis., Results: The overall incidence of acute pancreatitis was 3.85%; this included 2.42% (10/414) in the octreotide group and 5.26% (22/418) in the control group (P = 0.046). The overall incidence of hyperamylasemia was 14.9%; 12.32% (51/414) in the octreotide group and 17.46% (73/418) in the control group (P = 0.041). No side effects were found., Conclusion: The results indicate that octreotide can prevent PEP and hyperamylasemia.

Background and Study Aims: Several drugs have been used for the prevention of post-ERCP pancreatitis with conflicting results and no data referring to the routine use of a pharmacological prophylaxis have been published up to now. Aim of the study was to evaluate the frequency of post-ERCP pancreatitis and costs in a series of consecutive patients who have undergone ERCP procedures before and after the introduction of a routine prophylaxis with gabexate in all cases., Patients and Methods: Data from 1312 patients who underwent ERCP procedures without gabexate prophylaxis and from 1149 consecutive patients with 1g i.v. gabexate, were retrospectively evaluated during a 6-year period. Patients were also subdivided in standard- and high-risk subjects, on the basis of patient- and technique-related risk factors: 984 subjects (39.9%) had one or more conditions that placed them at high risk for post-ERCP pancreatitis., Results: Post-ERCP pancreatitis was reported in 76 out of 2461 patients (3.1%). The frequency of pancreatitis appeared significantly reduced in the gabexate period in comparison with before gabexate in overall cases (2.2% versus 3.9%; p=0.019); however, the reduction was significant only for high-risk patients (3.8% versus 7.3%; p=0.001). Severe hyperamylasaemia at 4-6h and 24h after the procedure was also significantly reduced only in high-risk patients (p=0.001). Routine prophylaxis with gabexate appeared cost-effective in high-risk patients., Conclusions: Routine gabexate prophylaxis was associated with a significant reduction of post-ERCP pancreatitis rate, severe hyperamylasaemia and hospitalisation-related costs only in high-risk patients. However, gabexate appeared unable to reduce the incidence of severe pancreatitis.

Background: Acute pancreatitis (AP) represents the main complication after endoscopic retrograde cholangiopancreatopgraphy (ERCP) and appears in 1% to 10% of the cases. The incidence increases in patients with opacification and instrumentation of pancreatic duct and it varies according to the indications of the procedure and the intervention performed. Risk factors for this complication include history of pancreatitis, difficult canulation, pancreatic acinar opacity, Oddi sphincter hypertension and sphincterotomy., Objective: Evaluate the efficacy of rectal indometacine to reduce the incidence of hyperamylasemia and AP post-ERCP., Methods and Materials: Control clinical trial simple blind perfomed between June and December of 2004. One hundred seventeen patients were included in the study. They were randomly assigned in two groups: 1) study group (n = 61, 52%), 100 mg of rectal indomethacin was administered 2 hours previous to the procedure and, 2) control group (n = 56, 47.8%) received placebo (glycerine suppository). Hyperamylasemia was diagnosed with levels > 151 U/L and AP with levels > 600 U/L and characteristically abdominal pain., Results: Gender distribution was of 79 (67.5%) women and 38 (32.5%) men. Mean age was of 54.2 +/- 18.8 years for the study group and 50.1 +/- 18.1 years for the control group. After ERCP, 12 patients (10.2%) of the study group and 19 (16.2%) of control group presented hyperamylasemia (p = 0.09). AP was present in 3 patients (2.5%) in the study group and 8 patients (6.8%) of the control group (p = NS). There was no mortality in our study., Conclusion: The use of 100 mg of rectal indomethacine previous to ERCP decreases the risk of hyperamylasemia and AP. However, these differences did not reach statistical significance, probably because a greater sample of patients was needed.

Aim: Acute pancreatitis (AP) is the most common and often severe complication of endoscopic retrograde cholangiopancreatography (ERCP). The early step in the pathogenesis of acute pancreatitis is probably the capillary endothelial injury mediated by oxygen-derived free radicals. N-acetylcysteine - a free radical scavenger may be potentially effective in preventing post-ERCP acute pancreatitis and it is also known that N-acetylcysteine (ACC) can reduce the severity of disease in experimental model of AP., Methods: One hundred and six patients were randomly allocated to two groups. Fifty-five patients were given N-acetylcysteine (two 600 mg doses orally 24 and 12 h before ERCP and 600 mg was given iv, twice a day for two days after the ERCP). The control group consisted of 51 patients who were given iv. isotonic saline twice a day for two days after the ERCP. Serum and urine amylase activities were measured before ERCP and 8 and 24 h after the procedure. The primary outcome parameter was post-ERCP acute pancreatitis and the secondary outcome parameters were differences between groups in serum and urine amylase activity., Results: There were no significant differences in the rate of post-ERCP pancreatitis between two groups (10 patients overall, 4 in the ACC group and 6 in the control group). There were also no significant differences in baseline and post-ERCP serum and urine amylase activity between ACC group and control group., Conclusion: N-acetylcysteine fails to demonstrate any significant preventive effect on post-ERCP pancreatitis, as well as on serum and urine amylase activity.

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.