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ERCP-Induced Pancreatitis in Primary Sclerosing Cholangitis: Risk Factors and Proposed Scoring System for Guiding Prophylactic Pancreatic Stent Therapy

2008; Elsevier BV; Volume: 67; Issue: 5 Linguagem: Inglês

10.1016/j.gie.2008.03.327

1097-6779

Ferga C. Gleeson, Todd H. Baron, Felicity Enders, Gregory J. Gores, Andrea A. Gossard, Christopher J. Gostout, Keith D. Lindor, Bret T. Petersen, Mark Topazian, Michael J. Levy,

Biliary and Gastrointestinal Fistulas

Background: In the setting of PSC, ERCP is often performed for diagnostic and/or therapeutic intent. While prior studies have identified risk factors for ERCP-induced pancreatitis (EIP), the prognostic value of these risk factors has not been adequately studied in patients with PSC. Aims: In patients with PSC undergoing ERCP: 1) to identify patient and procedural factors associated with EIP, and 2) to develop a scoring system to identify patients at increased risk of EIP who may benefit from pancreatic duct (PD) stenting. Methods: A prospectively maintained database was reviewed to identify all PSC patients who had undergone ERCP procedures over 5 ½ years. Patient and procedure related potential risk factors for EIP were analyzed. EIP was defined per the 1991 consensus workshop guidelines. Statistical Methods: A logistic regression model was performed to estimate the odds ratio associated with each variable. Parameter estimates were calculated in order to design a logistic odds equation for EIP. ROC analysis was used to evaluate an alternative risk score to aid patient selection most likely to benefit from prophylactic PD stenting. Results: 869 ERCP procedures were performed on 375 patients with PSC (67% male; mean age 47.9 ± 14.5). A median of 2 procedures, [range 1-14] was performed. EIP developed in 15 (1.7%) patients. EIP rates were not influenced biliary cytology brushing, dilation, stone extraction, intraductal ultrasonography, intraluminal brachytherapy, photodynamic therapy, or biliary stent insertion or exchange. The prevalence of EIP was less in a subgroup with prior performance of an endoscopic sphincterotomy (ES) (p = 0.002). Multivariate analysis identified 3 risk factors associated with EIP, including: native papilla with ES (OR 5, 95% CI 1-9), native papilla without ES (OR 6, 95% CI 2-24), and intraductal biopsy (OR 10, 95% CI 2-62). A risk score was applied to each procedure, assigning 1 point for age <40Y or native papilla ES performance and 2 points for either performance of intraductal biopsy or, if no ES performed on a native papilla. The magnitude of this score could range from 0 to 5. ROC curve analysis [AUC 0.85] demonstrated that a risk score ≥3 had an 80% EIP accuracy. Conclusion: Prognostic variables can be used to determine the risk of EIP in patients with PSC. A predictive risk score of ≥3 indicates an increased risk of EIP. Prophylactic PD stents may be beneficial in this subgroup. Our data indicate that performance of ES provides a protective influence during subsequent exams and should be considered during an index exam for patients likely to undergo repeat ERCP.