Combined rectal indomethacin and intravenous saline hydration in post-ERCP pancreatitis prophylaxis

Abstract

Background and study aim: Acute pancreatitis (AP) is a potentially life-threatening complication of endoscopic retrograde cholangiopancreatography (ERCP). There is a lack of effective measures to prevent post-ERCP pancreatitis (PEP), except NSAIDs. Aggressive hydration for AP can be considered, given the frequency of hemoconcentration, hypovolemia, and hypoperfusion in pancreatitis. We aimed to clarify the clinical utility of combined indomethacin and saline hydration for preventing PEP.

Patients and method: In this cross-sectional study, 120 patients undergoing ERCP for the first time at the Gastrointestinal Endoscopy Unit and Liver Unit Kasralainy (GIELUKA) were enrolled and then randomly allocated into two groups: indomethacin and indomethacin-hydration groups. Intravenous (IV) saline was given to the latter at a rate of 10 ml/kg/h after the ERCP for 2 h.

Results: The age of the studied patients was 43.8 ± 14.9 years, with 55% of them being female. The patient-related risk factors for PEP were older age (p = 0.039), higher pre-ERCP urea level (p = 0.032), and less choledocholithiasis (p = 0.028). The patients with PEP had a higher frequency of biliary cannulation attempts (p = 0.004) and accidental pancreatic duct cannulation (p = 0.003), required a longer cannulation time (p = 0.021), had undergone precut knife and transpancreatic sphincterotomy at a higher rate (p = 0.032; and p = 0.001, respectively), and had a significantly longer procedure time (p = 0.006). PEP occurred in only five patients in the indomethacin group, while it did not occur in the indomethacin-hydration group (8% vs. 0%, p = 0.022). Serum amylase and lipase elevation 2 h after ERCP were predictors of PEP. However, serum amylase only was significantly lower 2 h post-ERCP in the indomethacin-hydration group than in the indomethacin group (p = 0.045). Moreover, abdominal pain and vomiting on the first day of ERCP were good predictors of PEP.

Conclusion: Aggressive IV saline hydration with rectal indomethacin can more effectively prevent PEP than indomethacin alone.

Keywords: ERCP; Hydration; Indomethacin; Pancreatitis; Saline.