Z Gastroenterol 2014; 52 - A51
DOI: 10.1055/s-0034-1376111

What explains the contradictory results of nonsteroidal anti-inflammatory drugs (NSAIDS) in prophylaxis for Post-ERCP Pancreatitis (PEP)?

Á Patai 1, N Solymosi 2, VÁ Patai 3
  • 11st Department of Medicine and Gastroenterology, Sopron Elizabeth Teaching Hospital, Sopron
  • 2Department of the Physics of Complex Systems, Eötvös Loránd University, Budapest
  • 32nd Department of Medicine, Semmelweis University, Budapest

Background: The 2010 ESGE guideline recommended the use of NSAIDs for prophylaxis of PEP, but this recommendation was not accepted widely. Controversies were raised by publications in which NSAIDs were found ineffective against PEP. After a thorough literature overview, we concluded that NSAIDs seem to be ineffective in cases with too many cannulation attempts and early precut can prevent from unsuccessful trials.

Aim of our study was to test our biliary intubation protocol with early precut and to find those patients benefiting from the use of NSAIDs for prevention of PEP.

Methods: A total of 539 patients with intact papilla undergoing ERCP according to our preconceived protocol at our Department of Gastroenterology were included into a randomized, prospective, double blind clinical trial to study the effect of rectally administered 100 mg indomethacin within 1 hour before ERCP for the prevention of PEP. Number of cannulation attempts were restricted: in phase I 5 trials were allowed to reach deep intubation of common bile duct (CBD), in phase II 5 or fewer wire-guided attempts were performed and after 10 unsuccessful trials precut (phase III) was prescribed.). For the univariate analysis of outcome (PEP) two-tailed Fisher exact test was used. A p value of < 0.05 was considered significant.

Results: In 70.3% of patients biliary intubation was successful in phase I, PEP rate was low and indomethacin was ineffective (7.4% in the placebo group and 5.2% in the indomethacin group, p = 0.406). In phase II success rate increased up to 83.5%, and PEP rate rose up to 8.7%, the effect of indomethacin was significant (11.9% vs. 5.4%, p = 0.018). Applying early precut success rate of biliary cannulation increased up to 98.1% and overall indomethacin diminished the frequency of PEP from 13.8% to 6.7% (p = 0.007).

Conclusions: Early precut resulted in a high success rate of biliary intubation. Rectally administered 100 mg indomethacin was ineffective in cases with easy intubation, but it was very effective for prevention of PEP in cases with difficult cannulation.