review of literature on clinical pancreatology - The Pancreapedia

endoscopic retrograde cholangiopancreatography 170 patients were enrolled andrandomized to two groups: a study group (n=85) who received 300 mg <strong>of</strong> oral allopurinol at15 h and 3 h before endoscopic retrograde cholangiopancreatography (ERCP) and a controlgroup (n=85) receiving an oral placebo at the same times. Main Outcome Measurementsincluded serum amylase levels and the number severity <strong>of</strong> the episodes <strong>of</strong> pancreatitis.Serum amylase levels were classified as normal (< 150 IU/L) or hyperamylasemia (> 151IU/L). Episodes <strong>of</strong> pancreatitis were classified following Ranson's criteria and CT severityindex. Distribution <strong>of</strong> benign pathology was similar between groups. Hyperamylasemia wasmore common in the control group. Mild pancreatitis developed in two patients from the studygroup (2.3 %) and eight (9.4 %) from control group, which was a significant difference; sevenepisodes were observed in high-risk patients <strong>of</strong> the control group (25 %) and one in theallopurinol group (3 %). Significant risk factors for post-procedure pancreatitis were precutsphincterotomy, pancreatic duct manipulation, and multiple procedures. There were nodeaths or side effects. It was concluded that allopurinol before ERCP decreased theincidences <strong>of</strong> hyperamylasemia and pancreatitis in patients submitted to high-risk procedures[211].Sprayed epinephrine as prophylaxisEpinephrine sprayed on the papilla may reduce papillary edema and thus prevent acutepancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The aim <strong>of</strong> onestudy was to determine the efficacy <strong>of</strong> this technique for prevention <strong>of</strong> post- ERCPpancreatitis. It was randomized the patients to have 10 ml <strong>of</strong> either 0.02 percent epinephrine(epinephrine group) or saline (control group) sprayed on the papilla after diagnostic ERCPand prospectively analyzed the occurrence <strong>of</strong> post-ERCP pancreatitis between the groups.There was no significant difference between the groups with regard to visualization <strong>of</strong> the bileduct and/or the main and accessory pancreatic ducts, presence <strong>of</strong> pancreatic acinarization,number <strong>of</strong> injections into the pancreatic duct, total volume <strong>of</strong> contrast used, and procedureduration. Overall, post-ERCP pancreatitis occurred in 4 <strong>of</strong> the 370 patients (1 %). Theincidence <strong>of</strong> pancreatitis tended to be higher in the control group (4/185) than in theepinephrine group (0/185), but this was not a statistically significant difference. Furtherstudies on the efficacy <strong>of</strong> this technique in patients at high risk for pancreatitis, and on othervolumes and/or concentrations <strong>of</strong> epinephrine, are warranted [212].Interleukin-10 as prophylaxisPancreatitis is the most common major complication <strong>of</strong> endoscopic retrogradecholangiopancreatography (ERCP). Inflammatory cytokines are released during acutepancreatitis. Interleukin-10 (IL-10) is a potent inhibitor <strong>of</strong> cytokines and has been shown toattenuate pancreatitis in animal models and pilot human studies. One study aimed todetermine whether prophylactic IL-10 administration reduces the frequency or severity <strong>of</strong>post-ERCP pancreatitis in high-risk patients. A randomized, multicenter, double-blind,placebo-controlled study was conducted. Patients received IL-10 at a dose <strong>of</strong> either 8 or 20microg/kg or placebo as a single intravenous injection 15 to 30 minutes before ERCP.Standardized criteria were used to diagnose and grade the severity <strong>of</strong> postprocedurepancreatitis. A total <strong>of</strong> 305 <strong>of</strong> the planned total enrollment <strong>of</strong> 948 patients were randomized.There was a 15, 22, and 14 percent incidence <strong>of</strong> post-ERCP pancreatitis in the IL-10 (8microg/kg), IL-10 (20 microg/kg), and placebo treatment groups, respectively. Due toapparent lack <strong>of</strong> efficacy, the study was terminated at an interim analysis [213].Antibiotics as prophylaxisIt was determined the prophylactic effect <strong>of</strong> antibiotics on post-endoscopic retrogradecholangiopancreatography (ERCP) cholangitis or sepsis reduction in randomized controlledtrials. Databases including MEDLINE, EMBASE, Cochrane Library, and Science CitationIndex updated to June 2007 were searched. Main outcome measure was post-ERCPcholangitis or sepsis. Seven trials were identified, and a total <strong>of</strong> 1389 patients were included;post-ERCP cholangitis occurred in 5.8 percent <strong>of</strong> controls (41/705) versus 3.4 percent <strong>of</strong>