By Patrick Smith

An endoscopic procedure to treat diseases of the pancreatobiliary tract has brought relief to hundreds of thousands of patients in the decades since its introduction. Endoscopic retrograde cholangiopancreatography (ERCP) combines endoscopy and fluoroscopy to allow gastroenterologists to see inside the pancreas and its ducts.

However, a large number of patients experience a painful and sometimes dangerous inflammation of the pancreas following ERCP, even when the procedure is otherwise successful. Post-ERCP pancreatitis (PEP) occurs in as many as 15% of patients in the United States. In addition to the $200 million it adds to American health care expenses each year, PEP can lead to serious complications, such as pancreatic necrosis and even organ failure.

Johns Hopkins gastroenterologists Vikesh Singh and Venkata Akshintala are studying PEP’s poorly understood causes and pathophysiology in hopes of making the procedure safer and preventing pancreatitis more often.

During the procedure, the endoscopist uses a guide wire to access the pancreas via the major duodenal papilla, which is the primary drain for the secretion of bile and other digestive enzymes. The delicate, intricate nature of the papilla, along with anatomy that can vary from one patient to the next, can make the procedure especially difficult.

“One of the reasons that ERCP is no longer used very often for diagnostic purposes is the risk of post-procedure pancreatitis,” Akshintala explains. “We’ve turned mostly to magnetic resonance cholangiopancreatography and endoscopic ultrasound to perform diagnostics, and reserve the ERCP for only the therapeutic indications.”

Akshintala adds that therapeutic ERCP has become increasingly complex. “We’re able to do more with ERCP, but we’ve also seen the number of PEP-related hospital admissions rise about 15% since the decrease in number of diagnostic ERCPs.”

Akshintala says there are numerous risk factors associated with post-ERCP pancreatitis. Difficult or failed cannulation, pancreatic sphincterotomy and multiple guidewire passes into the pancreatic duct are only a few of the factors that put ERCP patients at risk.

Selecting the right patient for ERCP is an important way to minimize risk of pancreatitis, he says.

“Women are more likely to experience PEP,” he says. “Also, patients under 50, patients who have disorders of the sphincter of Oddi and patients with a history of acute pancreatitis are at higher risk.”

Akshintala says most endoscopists use a combination of strategies to prevent PEP. For patients at low risk of developing PEP, a stent placed in the pancreatic duct can help maintain patency and prevent buildup of pressure. In addition, high-volume intravenous fluids can help lessen the risk of PEP.

Patients at medium-to-high risk for PEP can benefit from peri-procedure rectal administration of nonsteroidal anti-inflammatory drugs, says Akshintala.

Akshintala and Singh say that the identification of better PEP prevention should be the emphasis of future research in the field.

“We’ll look for better pharmacological options, a refinement in procedural techniques, and improved risk stratification approaches,” says Akshintala. “We also encourage personalized prophylactic strategies for each patient, since risk is so uniquely individual. The primary approach to PEP prevention should be through careful patient selection, appropriate ERCP technique and the use of recommended PEP prophylaxis strategies.”