Risk Factors for Post-ERCP Pancreatitis in Pediatric and Young Adult Patients

Abstract

Objectives: Post-ERCP pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Limited existing data suggest that prophylactic pancreatic duct (PD) stenting in pediatric patients may increase the risk of PEP. The aim of this study is to identify factors associated with PEP in pediatric patients. Methods: Patients at a single institution who underwent ERCP between 2012 and 2020 were retrospectively reviewed. Patient and procedure-related factors were collected. Data were analyzed using Chi-square or Fisher exact tests as appropriate and Mann-Whitney-Wilcoxon tests. Results: Seven hundred thirty-six ERCPs were performed for 402 unique patients. Ninety-four cases were complicated by PEP (12.8%), of which 91 were mild and 3 were moderately severe. Pancreatic indication, native major papilla, PD cannulation and injection, and higher American Society for Gastrointestinal Endoscopy (ASGE) complexity were associated with PEP. A higher proportion of patients who received rectal indomethacin (65% vs 47%, P = 0.002), or who had placement of a prophylactic (31% vs 20%, P = 0.01) or therapeutic PD stent (37% vs 27%, P = 0.04) developed PEP; however, in a subgroup analysis of high-risk patients, this association was not persistent. A smaller proportion of PEP patients had PRSS1 mutation compared to non-PEP patients (22% vs 40%, P = 0.04). Conclusions: This study evaluates factors associated with developing PEP in a large pediatric cohort. A high rate of PEP was observed, likely secondary to higher rates of pancreatic indication and higher ASGE complexity scores compared to previously reported literature. Randomized prospective trials are needed to better define the utility of various interventions.

Risk Factors for Post–Endoscopic Retrograde Cholangio-Pancreatography Pancreatitis in Children With Chronic Pancreatitis and Its Prediction Using 4-Hour Postprocedure Serum Amylase and Lipase Levels

“…In children, retrospective studies have shown efficacy of intravenous ibuprofen 28 and ketorolac 29 in preventing PEP but rectal indomethacin has not been formally evaluated. Surprisingly, a recent retrospective study by Hassan et al 26 in children showed that patients with PEP were more likely to have received rectal indomethacin (OR, 2.1; 95% CI, 1.3-3.2; P = 0.002), but in the high-risk subgroup, no significant difference was found. In our study, rectal indomethacin was administered in all.…”

“…4,5 Studies by Troendle et al 4 and Giefer et al 5 in children suggested that prophylactic PD stent placement was associated with an increased risk of PEP. A recent study by Hassan et al, 26 in 736 children undergoing ERCP, reported that PEP occurred more often in the prophylactic PD stent group (OR, 1.8; 95% CI, 1.1-2.95; P = 0.01), although the significance disappeared on subgroup analysis of high-risk patients. The authors have speculated that perhaps pediatric patients are at a higher risk for pancreatic stent-related complications than adults due to age-related physiologic differences.…”

ERCP-related Adverse Events in Pediatric Patients: A 10-Years Single-Site Review

“…ESGE has identi ed patient-related risk factors for PEP as suspected sphincter of Oddi dysfunction, female sex, previous pancreatitis, previous PEP, while Procedure-related risk factors include di cult cannulation, pancreatic guidewire passages > 1, and pancreatic injection [4]. A study on children and young adults identi ed factors associated with the development of PEP, including procedural factors such as pancreatic duct injection, cannulation, and sphincterotomy, anatomic factors such as pancreas divisum, complexity scoring, and patient related factors such as a prior history of PEP [12]. The incidence of PEP in the general population is reported to be 3-10% [2], while in our study, the incidence was 14.2%, higher than reported in the literature.…”

Availability and utilization of endoscopic retrograde cholangiopancreatography at children's hospitals

“…Since its introduction in 1968, endoscopic retrograde cholangiopancreatography (ERCP) has evolved into an effective therapeutic modality for pancreaticobiliary disorders. Numerous studies show its safety and efficacy in children 1–10 …”