A0019 - Native vs Non-Native Papilla: Defining and Mitigating the Post-ERCP Pancreatitis Risk

Sunday, October 23, 2022

5:00 PM – 7:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Linda Huang, MD

University of Southern California
Los Angeles, CA

Linda Huang, MD¹, Patrick W. Chang, MD¹, James L. Buxbaum, MD¹, Jin Sun Kim, MD¹, Jonathan Sadik, MD¹, Karam Ashouri, MD¹, Jennifer Phan, MD¹, Ara B. Sahakian, MD², Jacques Van Dam, MD, PhD¹, Bruce Zweiban, MD³
¹University of Southern California, Los Angeles, CA; ²Keck School of Medicine, University of Southern California, Los Angeles, CA; ³Kaiser Permanente, Panorama City, CA

Introduction: Pancreatitis occurs in approximately 5-10% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) making it the most common adverse event of an endoscopic procedure. While it has been proposed that native papilla increases the risk of post-ERCP pancreatitis (PEP), this risk has not been quantified and strategies to prevent PEP in this subset of patients is undefined.

Methods: As part of an ongoing randomized clinical trial at Los Angeles County Hospital (Clinicaltrials.gov: NCT03087656), we captured patient characteristics and procedural factors including the anatomy, procedural complexity score, use of rectal indomethacin, and volume of fluids administered for patients both included and excluded from the trial. The primary predictor was the presence of a native or non-native papilla. The primary outcome was the development of PEP. We used a bivariate regression model to determine whether prophylactic rectal indomethacin and aggressive hydration ( >3.5L of fluids/24 hours) mitigated the risk of PEP.

Results: From October 2019 to December 2021, we evaluated 416 cases of ERCP. PEP developed following 25 procedures (overall incidence 6.0%), of which 22 had a native papilla (unadjusted OR 4.1; 95% CI 1.3-12.8). On multivariate analysis adjusting for the ERCP complexity score, patients with a native papilla were more likely to develop PEP (OR 5.4; 95% CI 1.6-17.9). Rectal indomethacin was used in 268 procedures, aggressive hydration in 283 procedures, and both maneuvers in 211 procedures (Table 1). Native papilla remained a compelling risk factor in patients who received rectal indomethacin (adjusted OR 6.0; 95% CI 1.2-30.6), aggressive hydration (adjusted OR 7.8; 95% CI 1.6-39.0), and the combination (adjusted OR 9.0; 95% CI 1.1-77.3).

Discussion: Patients with a native papilla are significantly more likely to develop PEP regardless of procedural complexity. This association remained in the setting of rectal indomethacin use and aggressive hydration. This study emphasizes the need to develop and study preventative measures particularly in patients undergoing their first ERCP.

	N	PEP in Native Papilla (n=262)	PEP in Non-Native Papilla (n=154)	Univariate OR (95% CI)	Multivariate OR (95% CI)
Total Cohort	416	22	3	4.1 (1.3-12.8)	5.4 (1.6-17.9
Rectal Indomethacin	268	18	2	3.8 (0.9-16.7)	6.0 (1.2-30.6)
Aggressive Hydration	283	19	1	6.0 (1.2-29.4)	7.8 (1.6-39.0)
Indomethacin + Hydration	211	16	1	5.7 (0.7-44.1)	9.0 (1.1-77.3)

Table: Table 1: Post-ERCP Pancreatitis in Native versus Non-Native Papilla; Overall Cohort and Subset Receiving Prophylactic Measures

Disclosures:

Linda Huang indicated no relevant financial relationships.

Patrick Chang indicated no relevant financial relationships.

James Buxbaum: Boston Scientific – Consultant.

Jin Sun Kim indicated no relevant financial relationships.

Jonathan Sadik indicated no relevant financial relationships.

Karam Ashouri indicated no relevant financial relationships.

Jennifer Phan: Boston Scientific – Consultant. Noah – Consultant. Olympus – Consultant.

Ara Sahakian: Boston Scientific – Consultant. Cook Medical – Consultant. Noah Medical – Consultant. Olympus – Consultant.

Jacques Van Dam indicated no relevant financial relationships.

Bruce Zweiban indicated no relevant financial relationships.

Linda Huang, MD¹, Patrick W. Chang, MD¹, James L. Buxbaum, MD¹, Jin Sun Kim, MD¹, Jonathan Sadik, MD¹, Karam Ashouri, MD¹, Jennifer Phan, MD¹, Ara B. Sahakian, MD², Jacques Van Dam, MD, PhD¹, Bruce Zweiban, MD³. A0019 - Native vs Non-Native Papilla: Defining and Mitigating the Post-ERCP Pancreatitis Risk, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.