Putting Out the 'Fire' of Post-ERCP Pancreatitis: Let It Rain!

David A. Johnson, MD


December 05, 2016

A Feared Adverse Event

Pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is the most commonly feared adverse event for this procedure. It can result in significant morbidity and, rarely, mortality. Additionally, it is a common cause of endoscopy-related lawsuits against gastroenterologists.

Although the use of pancreatic stent placement in high-risk patients has been well accepted, a role for the use of rectal indomethacin as prophylaxis for patients at both average- and high risk for postprocedure pancreatitis has recently been emphasized. Results from a preliminary pilot study[1] suggested that the use of aggressive intravenous fluid resuscitation can also have a prophylactic role. The use of lactated Ringer's (LR) solution has had better results than normal saline in acute pancreatitis, which is attributed to a more favorable acid-base result, limiting premature zymogen activation.

Vigorous Periprocedural Hydration With Lactated Ringer's Solution Reduces the Risk of Pancreatitis After Retrograde Cholangiopancreatography in Hospitalized Patients

Choi JH, Kim HJ, Lee BU, Kim TH, Song IH
Clin Gastroenterol Hepatol. 2016 Jun 14. [Epub ahead of print]

Study Summary

The first study of note is a prospective, multicenter, randomized controlled trial from three high-volume ERCP centers in Korea.

Choi and colleagues evaluated patients aged 18-75 years who were to have their first ERCP (native papilla). No trainees were involved in any of the ERCPs. Patients were randomly assigned to vigorous intravenous LR at 3 mL/kg/h during ERCP, 8 hours after ERCP, and a postprocedure bolus of 10 mL/kg; or to standard LR at 1.5 mL/kg/h during ERCP and for 8 hours after ERCP.

For both average- and high-risk patients, post-ERCP pancreatitis (PEP) was lower in the vigorous group (4.3%) compared with the standard group (9.8%). Nonvigorous hydration was identified as a risk by univariate and multivariate analysis. Vigorous hydration was superior for patients at high risk.

A limitation of this study was that all patients were hospitalized for at least 24 hours, making this somewhat difficult to extrapolate to a procedure that is typically performed as an outpatient.


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