Inside Tract
July 2015

Recognizing a post-procedure reaction can save dollars and lives.

A journal article authored by Johns Hopkins physicians and researchers says that the absence of a systemic inflammatory response to a common endoscopic procedure could lead to shorter hospital stays and increased health care savings.

In the March issue of the journal Pancreatology, author and director of the Johns Hopkins Pancreatitis Center Vikesh Singh and his colleagues wrote that systemic inflammatory response syndrome, or SIRS, following endoscopic retrograde cholangiopancreatography, or ERCP, is an accurate, inexpensive and easy-to-obtain predictor of a severe form of a condition that frequently leads to long inpatient stays.

When patients develop or have SIRS on the second day after their ERCP, Singh says they’re at high risk to develop severe acute pancreatitis, and this results in a long hospitalization.

On the other hand, patients who don’t have a SIRS reaction are almost a sure bet to tolerate the procedure with no trouble. Recognizing those patients, says Singh, could reduce costs by eliminating unnecessary hospitalizations.

Studying data from 12 years of Johns Hopkins Hospital admissions for post-ERCP pancreatitis, Singh says the condition isn’t common, but it is dangerous—and preventable.

Almost one in 10 outpatients develops pancreatitis after the procedure. “That’s a pretty high complication rate,” says Singh. Most of the cases fall into the mild to moderate range of disease severity and are hard to predict.

But Singh and his Johns Hopkins co-authors say that SIRS is a reliable predictor of which patients are likely to develop severe acute post-ERCP pancreatitis and, just as importantly, which patients are not.

ERCP uses endoscopy and X-rays to diagnose and treat problems of the biliary and pancreatic ductal systems. The endoscopist accesses the system through the major duodenal papilla. Most patients tolerate the procedure with very few problems. “But to get where you’re going, there can be a fair bit of trauma to the pancreas,” Singh says. “In some patients, that trauma can cause some edema, which can block the pancreatic duct.”

When patients begin to show a systemic reaction to ERCP, Singh recommends the prophylactic insertion of a rectal suppository of a nonsteroidal anti-inflammatory and/or placement of a pancreatic stent to prevent the duct blockage that leads to pancreatitis.

Using SIRS as a predictor of post-ERCP pancreatitis has great implications for how long a patient needs to stay in the hospital. Singh says that patients who develop severe post-ERCP pancreatitis often require hospital stays of 10 or more days. “For so many reasons, that’s what we’re trying to avoid,” says Singh. “This is a simple marker that gives us a lot of information.”

A SIRS diagnosis, says Singh, requires only a combination of a few vital signs and a laboratory measure that’s likely already in place.

“You can usually look at the vital signs that have already been done,” he says. “Patients are probably getting a leukocyte count anyway as part of their routine daily labs.”

Singh has done other research on SIRS and its predictive power.

“The negative predictive value of SIRS is almost perfect in this case,” says Singh. “If you don’t have that systemic inflammatory response after ERCP, we can be pretty sure you won’t develop severe pancreatitis either.”

To see a video of Vikesh Singh discussing treatment options for pancreatitis, please visit http://bit.ly/pancreatitis_treatments.