Reactive Pancreatitis Following Endoscopic Retrograde Cholangiopancreatography: Diagnosis, Prevention and Treatment

Objective: to study the risk factors, clinical, laboratory, and functional manifestations, course, prevention, treatment, and outcome of reactive pancreatitis (RP) following endoscopic retrograde cholangiopancreatography (ERCP).

Subjects and methods: A study group comprised 207 patients (156 males and 51 females; mean age, 54.5±12.7 years) treated at the N. N. Burdenko Main Military Hospital and undergone ERCP with and without papillosphincterotomy (PST). The patients’ status, the presence and pattern of subjective and objective symptoms and laboratory parameters (blood amylase, urinary diastase, leukocytosis) were dynamically estimated after ERCP.

Results: 58 (28.0%) patients developed post-ERCP RP, the severe course of pancreatitis being observed in 4.3%. There were no cases of pancreatic necrosis or fatal outcomes. RP was significantly more common in females, persons under 50 years of age, patients with chronic pancreatitis, cholelithiasis, or major duodenal papillary abnormalities (duodenal papillitis, choledochal stricture), choledocholithiasis, in the absence of the dilated common bile duct. RP less frequently occurred in patients only when adequate or combined PST had been performed. RP was characterized by an acute course, with a significant pain syndrome occurring, by altered health status, fever, hyperamylasemia, and leukocytosis within the first-second days following ERCP, and delayed urinary diastase elevation. Just after ERCP, all the patients were given a combination of octreotide and a protease inhibitor to prevent RP. The efficiency of prevention was directly confirmed by the fact that there were no cases of pancreatic necrosis and fatal outcomes. To treat RP, the authors gave a combination of antisecretory agents, protease inhibitors (contrycal, ingitril), antibacterial drugs (cephalosporins, fluoroquinolones), and proton pump inhibitors during starvation, in the use of analgesics and spasmolytics, and during active infusion therapy. In all cases RP was benign and ended with the patients recovery 5—14 days after initiation of the therapy.

Conclusion: ERCP is a serious endoscopic operation characterized by a high risk of life-threatening complications (first of all RP). Before ERCP, the risk factors of RP should be assessed. All patients to undergo ERCP need a complex RP prevention including endoscopy, drugs, and intensive monitoring. In evolving RP, early multimodality therapy comprising antisecretory drugs, protease inhibitors, antibiotic therapy, analgesia, infusion therapy, and starvation.

1. Клинические лекции по гастроэнтерологии и гепатологии / Под ред. Калинина А. В., Хазанова А. И. 2. М.: Типография ГВГК им. Н. И. Бурденко; 2002. 208—298.

2. Маев И. В., Казюлин А. Н., Кучерявый Ю. А. Хронический панкреатит. М.: Медицина; 2005.

3. Манцеров М. П. Возможности ретроградной холангиопанкреатографии в диагностике и лечении патологии панкреатобилиарной системы и пути повышения ее эффективности: дис. … канд. мед. наук. М. 2004.

4. Ayub K., Imada R., Slavin J. Endoscopic retrograde cholangiopancreatography in gallstone associated acute pancreatitis. Cochrane Database Syst. Rev. 2004; 4: CD003630.

5. Freeman L. Adverse outcomes of endoscopic retrograde cholangiopancreatography. Rev. Gastroenterol. Dis. 2002; 2: 147—168.

6. Murray W. Reducing the incidence and severity of post ERCP pancreatitis. Scand. J. Surg. 2005; 94: 112—116.

7. Савельев В. С., Филимонов М. И., Гельфанд Б. Р., Бурневич С. З. Деструктивный панкреатит: алгоритм диагностики и лечения. Consilium-medicim. 2000; 6: 5—11.

8. Бескосный А. А., Снытко Н. П., Кирсов П. П. и др. Постэндоскопический ретроградный панкреатохолангиографический панкреатит. www.smolensk.ru/user/sgma/kaphedr/gospchir/stat/1.htm

9. Christensen M., Matzen P., Schulze S., Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc. 2004; 60: 721—731.

10. Loperfido S., Angelini G., Benedetti G. et al. Major early complications from diagnostic and terapeutic ERCP: a prospectivi multicenter study. Gastrointest. Endos. 1998; 7: 1—10.

11. Masci E., Mariani A., Curioni S., Testoni P. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a metaanalysis. Endoscopy 2003; 35: 830—834.

12. Chen C., Sherman S., Watkins J. et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am. J. Gastroenterol. 2006; 101: 139—147.

13. Wilson M., Tweedle D., Martin D. Comon bile diameter and complications of endoscopic sphincterotomy. Br. J. Surg. 1992; 79: 1346—1347.

14. Pezzilli R., Romboli E., Compana D., Corinaldesi R. Mechanisms involved in the onset of post-ERCP pancreatitis. JOP. J. Pancreas (online) 2002; 3: 162—168.

15. Akashi R., Kiyozumi T., Tanaka T. et al. Mechanism of pancreatitis caused by ERCP. Gastrointest. Endosc. 2002; 55: 50—54.

16. Freeman M. Role of Pancreatic Stents in Prevention of Post-ERCP Pancreatitis. JOP. J Pancreas (Online) 2004; 5: 322—327.

17. Testoni P. Pharmacological Prevention of Post-ERCP Pancreatitis: The Facts and the Fiction. JOP. J. Pancreas (Online) 2004; 5: 171—178.

18. Testoni P. Preventing Post-ERCP Pancreatitis: Where are we? JOP. J. Pancreas (Online) 2003; 4: 22—32.

19. Andriulli A., Solmi L., Loperfido S. et al. Prophylaxis of ERCP-related pancreatitis: a randomized, controlled trial of somatostatin and gabexate mesylate. Clin. Gastroenterol. Hepatol. 2004; 2: 713—718.

20. Andriulli A., Leandro G., Niro G. et al. Pharmacologic treatment can prevent pancreatic injury after ERCP: a mete-analysis. Gastrointest. Endosc. 2000; 51: 1—7.

21. Testoni P., Bagnolo F., Andriulli A. et al. Octreotide 24-h prophylaxis in patients at high risk for post-ERCP pancreatitis: results of a multicenter, randomized, controlled trial. Aliment Pharmacol. Ther. 2001; 15: 965—972.

22. Seta T., Noguchi Y., Shimada T. et al. Treatment of acute pancreatitis with protease inhibitors: a meta-analysis. Eur. J Gastroenterol. Hepatol. 2004; 16: 1287—1293.

23. Fan W., Wang Q., Li Q. Preventive effect of 5-fluorouracil on post-ERCP pancreatitis. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2004; 29: 201—203.

24. Villatoro E, Larvin M, Bassi C. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. The Cochrane database of sys. rev. 2003; 4: CD002941.

25. Рациональная фармакотерапия заболеваний органов пищеварения/ Под ред. Ивашкина В. Т. М.: Литтера. 334—350.