Risk factors for post-ERCP pancreatitis

We read with great interest the article by Williams et al. [1]. The authors attempted to identify the principal risk factors for endoscopic retrograde cholangiopancreatography (ERCP) complication in a large-scale, prospective multicenter study. As expected, post-ERCP pancreatitis was more frequent than any other complication. Univariable analysis identified eight factors associated with post-ERCP pancreatitis, including pancreatic duct injections. Our endoscopy unit is one of the high-volume ERCP centers in Turkey, performing approximately 80 procedures a month. Based on our personal experience, we would like to raise two issues related to the Williams data and post-ERCP pancreatitis.

The unnecessary pancreatic duct injection during selective biliary cannulation is one of the major risk factors for post-ERCP pancreatitis, as confirmed by the Williams study [1]. To avoid this injection, we gain access to the bile duct with a soft-tipped guide wire, perform a selective cannulation using a standard papillotome if the direction of the guide wire suggests the biliary system, and then inject contrast to visualize the biliary ducts. By following the direction of the guide wire, accidental pancreatic cannulation and injection are avoided. The superiority of this method over the conventional injection method for preventing post-ERCP pancreatitis has been shown in controlled studies [2] [3]. I wonder whether Williams and colleagues recorded which method was used for biliary cannulation in the study centers, and whether the cannulation method affected the post-ERCP pancreatitis.

Secondly, in a prospective study on assessment of risk factors related to post-ERCP pancreatitis, we observed that the incidence of pancreatitis was higher and the course of pancreatitis was more severe among patients with diabetes mellitus compared with age- and sex-matched patients without diabetes. We have managed two patients with necrotizing pancreatitis following ERCP in the past year, both of whom were diabetic. The issue is still under investigation even in our unit: our interim data suggested to us that diabetes mellitus might be an independent risk factor for post-ERCP pancreatitis. I would like to ask the authors whether they searched their data in this respect.

Competing interests: None

References

• 1 Williams E J, Taylor S, Fairclough P. et al . Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study.  Endoscopy. 2007;  39 793-801
• 2 Artifon E L, Sakai P, Cunha J E. et al . Guidewire cannulation reduces risk of post-ERCP pancreatitis and facilitates bile duct cannulation.  Am J Gastroenterol. 2007;  102 2147-2153
• 3 Lella F, Bagnolo F, Colombo E, Bonassi U. A simple way of avoiding post-ERCP pancreatitis.  Gastrointest Endosc. 2004;  59 830-834