Acute pancreatitis associated with endoscopic retrograde cholangiopancreatography: Systematic evaluation of 99,483 procedures with qualitative meta-analysis

Objective: To evaluate the literature regarding the frequency and risk factors involved in endoscopic retro-grade cholangiography (ERCP) - associated pancreatitis (EAP) and to perform qualitative meta-analysis. Methods: Pub Med access on January 21, 2007 using the word ERCP without language barrier for the years 1996 - 2006 was performed. Papers dealing with post-ERCP pancreatitis were located on Pub Med. More articles were added after visual evaluation of citations on ERCP and studying the references following key publications. Summary sheets were prepared for visual evaluation. Methods of qualitative research such as diagramming, theme repetition without serious contradiction, theme saturation and investigator reflexivity were used. The frequency of EAP was calculated; the risk factors for EAP were estimated as also the endoscopic and pharmacologic interventions to prevent EAP. Results: Pub Med yielded 6140 citations on ERCP in many languages. The total number of ERCP procedures evaluated was 99483. EAP occurred in 4535 (4.5%) cases. Gender information was available in 34951 cases; 20062 (57%) were women. The mean age was 55.6 years. Osmolality and concentration of contrast media had no role in EAP. Of the pharmacologic methods, somatostatin, ulinastatin, gabexate, interleukin -10 and indomethacin showed promise although there were contradictory reports. Of the mechanical methods prophylactic pancreatic stent (PPS) was found to be effective but has important caveats. Many risk factors for EAP were identified and have been discussed. Conclusions: EAP occurs in 4.5% cases of ERCP. Some pharmacologic methods and PPS showed promise in preventing EAP. The evaluation of risk factors and proper selection of patients for ERCP may help reduce the frequency and severity of EAP.