الفهرس 
Introduction and aim of the workOnly 14 pages are availabe for public view
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Abstract
Summary, Conclusions and Recommendations
The pancreas is a secretory structure with an internal hormonal role (endocrine) and an external digestive role (exocrine). Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems.
ERCP is used primarily to diagnose and treat conditions of the bile ducts and main pancreatic duct, including gallstones, inflammatory strictures (scars) and cancer. The reported incidence of ERCP-specific complications ranges from 5% to 40%. The most common complication is acute pancreatitis with an overall incidence of 2-10 %, which can reach even 30 % in the presence of certain risk factors. Acute pancreatitis is the most common complication after ERCP.
The mechanisms that lead to post-ERCP pancreatitis (PEP) are complex and not fully understood. Post ERCP pancreatitis is believed to be multi-factorial involving a combination of chemical, enzymatic, mechanical and thermal factors. Nonsteroidal anti-inflammatory drugs (NSAIDs) are believed to play an important role in the pathogenesis of acute pancreatitis. NSAIDs are inexpensive and easily administered and had an important role in the prevention of post ERCP pancreatitis.
This work is designed to evaluate and investigate the effects of using different drugs on reducing the frequency and severity of Post-ERCP pancreatitis. This study was conducted on 150 randomized patients with extrahepatic cholestasis subjected to ERCP. The patients were selected from Tropical Medicine Department and General Surgery Department of Minia University Hospital. The patients were divided into 2 groups (Placebo and Drug group): group I was the placebo group (included 30 patients). group II was the drug group (included 120 patients and subdivided into 4 sub-groups. group IIa was Allopurinol-treated patients, group IIb was Indomethacin-treated patients, group IIc was Epinephrine- treated patients and finally, group IId was Somatostatin-treated patients. These drugs were given before the beginning of ERCP except the epinephrine which sprayed on the papilla during ERCP.
All patients in this study were subjected to full history taking, full clinical examination, Laboratory investigations, ultrasonography is performed before ERCP and triphasic computed tomography (CT) abdomen was done to all patients before ERCP to confirm data of abdominal ultrasonography. Another triphasic CT abdomen was done after ERCP to cases that develop upper quadrant pain with hyperamylasemia to report degree of pancreatitis. Standard informed consent was obtained from all patients for ERCP. After ERCP, the patients were followed up for possible complications by clinical examination and investigation.
The use of allopurinol led to a significant reduction in the incidence of acute pancreatitis (40% vs 63% in placebo-treated controls). The rectal route of indomethacin administration appears effective for preventing PEP (7% vs 63% in placebo-treated group). According to the subgroup analysis, it significantly prevented pancreatitis compared with other drugs. Rectal indomethacin reduced the incidence of post-ERCP hyperamylasemia at different times (6 hours, 24 and 48 hours).
There was also a trend towards reduced frequency of abdominal pain in the Indomethacin group, and this was significantly different from the placebo group and other drugs subgroups. An intravenous infusion of somatostatin before ERCP, reduced the incidence of post-ERCP pancreatitis (37% vs 63% in placebo-treated controls,). However it was not reduced the incidence of post-ERCP hyperamylasemia. There was also a reduced frequency of abdominal pain in the somatostatin group, although this was not significantly different from the placebo group or other subtype drug group.
Risk factors for PEP were evaluated in the current study using univariate analysis we found that female sex, biliary sphinctrotomy, knife precut were significant independent risk factor for PEP. Also use of rectal Indomethacin has a definite beneficial and significant role in preventing PEP. Multivariate analysis model further showed that these two factors [female sex, Knife precut] were the independently indicators for PEP.
Conclusions and Recommendations
1- Post ERCP pancreatitis is the most common complication after ERCP.
2- Female sex, biliary sphinctrotomy and Knife precut were significant independent risk factor for post ERCP pancreatitis.
3- The incidence of post-ERCP acute pancreatitis can be reduced by giving an inexpensive 100-mg Indomethacin suppository immediately following the endoscopic procedure and reach significance in univariate or multivariate analysis as a protective agent against PEP.
The results of our study emphasize the need for future researches on the effect of other drugs in the prevention of post ERCP pancreatitis. Holding seminars for all doctors of ERCP units all over the country to get knowledge about the usefulness of giving indomethacin and other protective drugs to decrease the incidence of post ERCP pancreatitis.