Hepatic Failure/GI/Endocrine Emergencies
Endoscopic retrograde cholangiopancreatography (ERCP)
Although many gallstones are passed through the duodenum and lost in the stool without causing
harm to the patient, gallstones that are not cleared can cause an obstruction in some patients in
either the biliary tree or the pancreatic duct, which can lead to severe AP or cholangitis.
ii.
An ERCP, together with a sphincterotomy, may be used to extract gallstones from the pancreatic
ducts or biliary tree.
iii.
There is considerable risk with ERCP, including bleeding and the potential to worsen AP
because of manipulation of the pancreas. Because of this risk, the most recent 2024 ACG
guidelines suggest medical therapy over early ERCP in patients with acute biliary pancreatitis
without cholangitis.
iv.
Eight randomized controlled trials have evaluated the effectiveness of early ERCP in reducing
the risk of complications in patients with gallstone AP. A limitation of these studies is that many
did not exclude acute cholangitis, which is an indication for ERCP without AP. A systematic
review controlling for patients with cholangitis found no benefit of early ERCP (mortality OR
0.67; 95% CI, 0.26–1.75).
AP is the most common complication of ERCP. Although the incidence of post-ERCP
pancreatitis has decreased significantly during the past few decades, post-ERCP pancreatitis
continues to occur in 2%–4% of patients.
| (a) | Rectal NSAIDs (i.e., 100 mg of indomethacin) after an ERCP can be given to patients at |
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high risk of post-ERCP pancreatitis.
| (b) | In a multicenter randomized controlled trial of 600 high-risk patients undergoing |
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ERCP, 100 mg of rectal indomethacin (administered as two 50-mg suppositories given
immediately post-ERCP) reduced the incidence of AP compared with placebo (9.2% vs.
16.9%, p=0.005) and, specifically, the development of moderate to severe AP (4.4% vs.
8.8%, p=0.03).
Infection
Pancreatic and non-pancreatic infections contribute to mortality in patients with AP. The primary
infectious concern with AP is infected necrotizing pancreatitis, which confers a high mortality
rate (about 30%); thus, patients with severe acute necrotizing pancreatitis are at highest risk of
pancreatic infections.
The role of prophylactic antibiotics is controversial in AP.
Early randomized trials showed a potential benefit in the reduction of infectious complications,
particularly central line–related bloodstream infections, pulmonary infections, urinary
infections, and pancreatic infections; however, the studies were unblinded, and the benefit was
mostly confined to patients with severe AP.
ii.
In more recent literature with higher-quality trials, the benefit of prophylactic antibiotic is
unsupported. A systematic review of 10 randomized controlled trials showed a trend toward
reduced mortality with prophylactic antibiotics (OR 0.66; 95% CI, 0.42–1.04); however, the
mortality benefit was lost among the subgroup of recent studies (after 2002: OR 0.85; 95% CI,
0.52–1.80). Similarly, there was no difference in risk of infected necrosis in more recent trials
(OR 0.81; 95% CI, 0.44–1.49).
According to the available information, use of prophylactic antibiotics to prevent the development
of infected pancreatic necrosis is not recommended at this time.
| d. | For patients who have not improved after 7–10 days of hospitalization with pancreatic necrosis, an |
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infection should be suspected, and empiric antibiotics should be initiated at that time. Because of
penetration issues, carbapenems, fluoroquinolones, metronidazole, or high-dose cephalosporins
may be preferred; however, guidelines now also recommend piperacillin-tazobactam for severe
AP, despite intermediate penetration..