Determination of the effectiveness of epinephrine spray on the papillae in preventing pancreatitis after endoscopic retrograde cholangiopancreatography

Karami, Mohammad; Salemi, Bahman; Shafigh Ardestani, Mohammad

Determination of the effectiveness of epinephrine spray on the papillae in preventing pancreatitis after endoscopic retrograde cholangiopancreatography

Authors

¹ Departments of Gastroenterology and Hepatology, Shahrekord University of Medical Science, Shahrekord, Iran

² Department of Internal Medicine, Shahrekord University of Medical Science, Shahrekord, Iran

Abstract

Background: As the most common complication of endoscopic retrograde cholangiopancreatography (ERCP) is acute pancreatitis, researchers have paid due attention to minimize this complication using various drugs, one of which is epinephrine. Therefore, the present study aimed at evaluating the effectiveness of epinephrine spray on the papilla in preventing post-ERCP pancreatitis (PEP).
Materials and Methods: The present double-blind clinical trial was performed on 164 patients undergoing ERCP. Patients in both groups received 50 mg rectal suppository as usual before ERCP. Then, during ERCP, epinephrine or normal saline was sprayed topically on the major papillae. After the intervention, patients were evaluated in terms of the incidence of PEP.
Results: The results of the present study revealed that the incidence of PEP in the epinephrine and control groups was 2.4% and 4.9%, respectively (P > 0.05). There was no significant difference between the two groups in terms of the incidence of bleeding after ERCP, number of accidental pancreatic duct cannulation, the increase in vision during common bile duct cannulations, the need for precut sphincterotomy, and the number of hospitalization days (P > 0.05). In addition, the chance of developing PEP was lower and higher in patients with higher ages (odds ratio [OR]: 0.86; P = 0.030) and biliary sludge (OR: 4.97; P = 0.042), respectively.
Conclusion: As compared with indomethacin alone (control group), it seems that the administration of epinephrine can be effective in reducing the incidence of PEP, although this relationship was not recognized to be significant in this study and only the age and the presence of sludge had a negative and positive relationship with the incidence of PEP, respectively.

Keywords

References

1.	ASGE Training Committee; Jorgensen J, Kubiliun N, Law JK, Al-Haddad MA, Bingener-Casey J, et al. Endoscopic Retrograde Cholangiopancreatography (ERCP): Core curriculum. Gastrointest Endosc 2016;83:279-89.
2.	Georgieva SD. Actual role of ERCP in a diagnostic and therapeutically algorithm in a in some biliary tract disease. Varna Med Forum 2017;6:34-9.
3.	Tryliskyy Y, Bryce GJ. Post-ERCP pancreatitis: Pathophysiology, early identification and risk stratification. Adv Clin Exp Med 2018;27:149-54.
4.	Alcivar-Leon M, Nieto-Orellana I, Jara-Alba ML, Marriott-Diaz E, Serrano-Suarez A, Garzon-Cercado N, et al. Risk factors for ERCP-related complications: A prospective multicenter study in Guayaquil, Ecuador: 2742. Official J Am College of Gastroenterol 2017;112:S1486.
5.	Zhou W, Li Y, Zhang Q, Li X, Meng W, Zhang L, et al. Risk factors for postendoscopic retrograde cholangiopancreatography pancreatitis: A retrospective analysis of 7,168 cases. Pancreatology 2011;11:399-405.
6.	Hatami B, Kashfi SM, Abbasinazari M, Nazemalhosseini Mojarad E, Pourhoseingholi MA, Zali MR, et al. Epinephrine in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A preliminary study. Case Rep Gastroenterol 2018;12:125-36.
7.	Matsushita M, Takakuwa H, Shimeno N, Uchida K, Nishio A, Okazaki K. Epinephrine sprayed on the papilla for prevention of post-ERCP pancreatitis. J Gastroenterol 2009;44:71-5.
8.	Beltz S, Sarkar A, Loren DE, Andrel J, Kowalski T, Siddiqui AA. Risk stratification for the development of post-ERCP pancreatitis by sphincter of Oddi dysfunction classification. South Med J 2013;106:298-302.
9.	Sotoudehmanesh R, Khatibian M, Kolahdoozan S, Ainechi S, Malboosbaf R, Nouraie M. Indomethacin may reduce the incidence and severity of acute pancreatitis after ERCP. Am J Gastroenterol 2007;102:978-83.
10.	Khoshbaten M, Khorram H, Madad L, Ehsani Ardakani MJ, Farzin H, Zali MR. Role of diclofenac in reducing post-endoscopic retrograde cholangiopancreatography pancreatitis. J Gastroenterol Hepatol 2008;23:e11-6.
11.	Yoo KS, Huh KR, Kim YJ, Kim KO, Park CH, Hahn T, et al. Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: A prospective, randomized, double-blind, controlled trial. Pancreas 2011;40:181-6.
12.	Yoo YW, Cha SW, Kim A, Na SY, Lee YW, Kim SH, et al. The use of gabexate mesylate and ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Gut Liver 2012;6:256-61.
13.	Prat F, Amaris J, Ducot B, Bocquentin M, Fritsch J, Choury AD, et al. Nifedipine for prevention of post-ERCP pancreatitis: A prospective, double-blind randomized study. Gastrointest Endosc 2002;56:202-8.
14.	Schwartz JJ, Lew RJ, Ahmad NA, Shah JN, Ginsberg GG, Kochman ML, et al. The effect of lidocaine sprayed on the major duodenal papilla on the frequency of post-ERCP pancreatitis. Gastrointest Endosc 2004;59:179-84.
15.	Xu LH, Qian JB, Gu LG, Qiu JW, Ge ZM, Lu F, et al. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis by epinephrine sprayed on the papilla. J Gastroenterol Hepatol 2011;26:1139-44.
16.	Zhang H, Cho J, Buxbaum J. Update on the prevention of post-ERCP pancreatitis. Curr Treat Options Gastroenterol 2018;16:428-40.
17.	Kamal A, Akshintala VS, Talukdar R, Goenka MK, Kochhar R, Lakhtakia S, et al. A Randomized trial of topical epinephrine and rectal indomethacin for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients. Am J Gastroenterol 2019;114:339-47.
18.	Ohashi A, Tamada K, Tomiyama T, Wada S, Higashizawa T, Gotoh Y, et al. Epinephrine irrigation for the prevention of pancreatic damage after endoscopic balloon sphincteroplasty. J Gastroenterol Hepatol 2001;16:568-71.
19.	Shi N, Deng L, Altaf K, Huang W, Xue P, Xia Q. Rectal indomethacin for the prevention of post-ERCP pancreatitis: A meta-analysis of randomized controlled trials. Turk J Gastroenterol 2015;26:236-40.
20.	Inamdar S, Han D, Passi M, Sejpal DV, Trindade AJ. Rectal indomethacin is protective against post-ERCP pancreatitis in high-risk patients but not average-risk patients: A systematic review and meta-analysis. Gastrointest Endosc 2017;85:67-75.
21.	Puig I, Calvet X, Baylina M, Isava Á, Sort P, Llaó J, et al. How and when should NSAIDs be used for preventing post-ERCP pancreatitis? A systematic review and meta-analysis. PLoS One 2014;9:e92922.
22.	Döbrönte Z, Szepes Z, Izbéki F, Gervain J, Lakatos L, Pécsi G, et al. Is rectal indomethacin effective in preventing of post-endoscopic retrograde cholangiopancreatography pancreatitis? World J Gastroenterol 2014;20:10151-7.
23.	Döbrönte Z, Toldy E, Márk L, Sarang K, Lakner L. Effects of rectal indomethacin in the prevention of post-ERCP acute pancreatitis. Orv Hetil 2012;153:990-6.
24.	van Ooijen B, Ouwendijk RJ, Kort WJ, Zijlstra FJ, Vincent JE, Wilson JH, et al. Raised plasma thromboxane B2 levels in experimental acute necrotizing pancreatitis in rats. The effects of flunarizine, dazoxiben, and indomethacin. Scand J Gastroenterol 1988;23:188-92.
25.	Elmunzer BJ, Higgins PD, Saini SD, Scheiman JM, Parker RA, Chak A, et al. Does rectal indomethacin eliminate the need for prophylactic pancreatic stent placement in patients undergoing high-risk ERCP? Post hoc efficacy and cost-benefit analyses using prospective clinical trial data. Am J Gastroenterol 2013;108:410-5.
26.	Katsinelos P, Fasoulas K, Paroutoglou G, Chatzimavroudis G, Beltsis A, Terzoudis S, et al. Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: A randomized, double-blind, placebo-controlled trial. Endoscopy 2012;44:53-9.
27.	Sotoudehmanesh R, Eloubeidi MA, Asgari AA, Farsinejad M, Khatibian M. A randomized trial of rectal indomethacin and sublingual nitrates to prevent post-ERCP pancreatitis. Am J Gastroenterol 2014;109:903-9.
28.	Gross V, Leser HG, Heinisch A, Schölmerich J. Inflammatory mediators and cytokines – New aspects of the pathophysiology and assessment of severity of acute pancreatitis? Hepatogastroenterology 1993;40:522-30.
29.	Choksi NS, Fogel EL, Cote GA, Romagnuolo J, Elta GH, Scheiman JM, et al. The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement. Gastrointest Endosc 2015;81:150-5.

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