We thank Zammit SC et al. [1] for their interest in and comments on our article [2]. In our study, nine of 10 cases complicated by pancreatitis were in patients with
suspected sphincter of Oddi dysfunction. These procedures were performed prior to
the publication by Elmunzer BJ et al. of the randomized trial of rectal indomethacin
to prevent post-endoscopy retrograde cholangiopancreatography (ERCP) pancreatitis
[3]. In regard to post-oral double balloon enteroscopy (DBE) pancreatitis, in our experience,
the incidence was 1.7 % to 2 % [4]
[5]. We noticed that it was more common in patients who were female, of shorter height,
and who had a history of prior abdominal surgery [4]. Importantly, we noticed that the incidence was related to the depth of insertion
of the DBE [5]. We have encountered virtually no pancreatitis episodes since we stopped pursuing
unidirectional oral DBE to reach the cecum in non-ERCP cases.
We are intrigued by the experience shared in the letter where patients who received
rectal indomethacin prior to oral DBE appeared to have lower mean amylase levels post-DBE
compared to those patients who did not receive it and that the approach might have
decreased incidence of clinical pancreatitis [1]. We should point out that the pathogenesis of acute pancreatitis in the DBE-ERCP
setting is likely different from that for DBE done for general purposes in normal
anatomy. In Roux-en-Y gastric bypass, the major or minor papilla are not in direct
contact with the scope or its balloons, and intestinal pleating is not likely to compress
the pancreas or its blood flow. Therefore, evidence of lower amylase levels and reduction
in pancreatitis with rectal indomethacin when DBE is performed for common indications
may not apply to DBE done to facilitate ERCP. It would be interesting to see if, indeed,
rectal indomethacin would decrease clinical pancreatitis in patients undergoing oral
DBE in a prospective randomized clinical trial. Meanwhile, we have already used rectal
indomethacin in patients who we feel are at higher risk of post-DBE pancreatitis.
