Is There a Way to Prevent Pancreatitis After ERCP?
Aggressive intravenous hydration with lactated Ringer’s solution reduces the incidence of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP), but is not associated with volume overload, according to a pilot study published in the February issue of Clinical Gastroenterology and Hepatology.
Pancreatitis is the leading complication of ERCP, causing considerable morbidity and even death. Researchers have attempted to reduce post-ERCP pancreatitis with a number of agents (octreotide, corticosteroids, protease inhibitors), but these have not been successful.
Hydration is one of the most important factors in treatment of acute pancreatitis of any etiology. Clinical studies of fluid resuscitation in patients with acute pancreatitis have associated hemoconcentration and decreased systemic perfusion with increased risk of pancreas necrosis and poor outcomes.
James Buxbaum et al. performed a clinical trial to investigate whether aggressive intravenous hydration with lactated Ringer’s solution reduced the incidence of post-ERCP pancreatitis. Patients who were undergoing their first ERCP were randomly assigned to groups that received aggressive hydration with lactated Ringer’s solution (3 mL/kg/h during the procedure, a 20-mL/kg bolus after the procedure, and 3 mL/kg/h for 8 hours after the procedure) or standard hydration with the same solution (1.5 mL/kg/h during and for 8 hours after the procedure).
None of the 39 patients who received aggressive hydration developed pancreatitis after ERCP, compared with 4 of 23 (17%) of patients who received standard hydration. Hyperamylasemia (an excess of the pancreatic enzyme amylase in the blood) developed in 23% of patients who received aggressive hydration vs 39% of those who received standard hydration.
Only 8% of patients who received aggressive hydration experienced increased epigastric pain, compared with 22% of those who received standard hydration. No patients had evidence of volume overload.
Buxbaum et al. say that these findings are important because markers of inadequate fluid resuscitation (increased hematocrit, creatinine, and blood urea nitrogen) are associated with organ failure.
The authors propose that the aggressive fluids act, at least in part, by attenuating pancreatic inflammation. Lactate can stimulate an anti-inflammatory immune response, and lactated Ringer’s solution is less likely than saline to induce metabolic acidosis, which might also account for its protective effects. Furthermore, studies have shown that prophylactic administration of fluids is more effective in preventing tissue damage than administration after pancreatitis has developed.
Buxbaum et al. warn that these results should be interpreted with caution, as this was a pilot study designed primarily to assess feasibility and safety of aggressive hydration and to inform design of future trials. Larger randomized trials are needed to confirm the findings and determine whether aggressive hydration reduces the severity of post-ERCP pancreatitis, if it does develop.
In an editorial that accompanies the article, B. Joseph Elmunzer says these findings set the stage for larger trials evaluating, in outpatients, a regimen of aggressive fluid delivery followed by a bolus that can be delivered over a reasonable timeframe in the recovery area.
Elmunzer adds that it is important that post-ERCP pancreatitis be defined according to standard consensus criteria, and the impact of aggressive IVFR on moderate and severe post-ERCP pancreatitis be the central focus.