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A RELIABLE PREDICTION RULE OF POST-ERCP PANCREATITIS IN BILIARY ERCP FOR PATIENTS WITH INTACT PAPILLA

Koichi Fujita 1,2, Unknown Unknown 2, Hisakazu Matsumoto 3, Masanori Asada 4, Hiroko Nebiki 5, Keiji Hanada 6, Takaaki Eguchi 7, Kengo Matsumoto 8, Satoshi Yamada 9, Akihito Okazaki 10, Ken Hirao 11, Kazuya Matsumoto 12, Toru Maruo 13, Mamoru Takenaka 14, Takeshi Tomoda 15, Akira Kurita 2, Toshiharu Ueki 13, Takumi Onoyama 12, Toshiro Katayama 2, Takashi Kawamura 16, Hirofumi Kawamoto 17

Affiliations

1 Yodogawa Christian Hospital, Osaka, Japan

2 Medical Research Institute Kitano Hospital, PIIF Tazuke Kofukai, Osaka, Japan

3 Japanese Red Cross Wakayama Medical Center, Wakayama, Japan

4 Japanese Red Cross Osaka Hospital, Osaka, Japan

5 Osaka City General Hospital, Osaka, Japan

6 Onomichi General Hospital, Onomichi, Japan

7 Osaka Saiseikai Nakatsu Hospital, Osaka, Japan

8 Toyonaka Municipal Hospital, Toyonaka, Japan

9 Kobe City Medical Center West Hospital, Kobe, Japan

10 Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan

11 Hiroshima City Hiroshima Citizens’ Hospital, Hiroshima, Japan

12 Tottori University Faculty of Medicine, Yonago, Japan

13 Fukuoka University Chikushi Hospital, Chikushino, Japan

14 Kinki University, Osaka-sayama, Japan

15 Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan

16 Kyoto University, Kyoto, Japan

17 Kawasaki Medical School, General Medical Center, Okayama, Japan

Summary

AI Generated

A multicenter prospective cohort study of 3739 patients developed and validated a scoring system to predict post-ERCP pancreatitis risk in biliary ERCP, identifying eleven factors that stratify patients into low-risk, intermediate-risk, and high-risk groups with PEP incidences of 1.6%, 6.0%, and 17.7%, respectively.

Post-ERCP pancreatitis occurred in 6.9% of 3739 patients enrolled at 36 hospitals in West Japan between April 2017 and March 2018, with 258 cases including 201 mild, 39 moderate, 17 severe, and 1 fatal.
Eleven factors were identified in multivariable analysis: seven risk factors (age under 50, female sex, cannulation time over 20 minutes, guidewire insertion into pancreatic duct, intraductal ultrasonography, biopsy, and total procedure time over 60 minutes) and four protective factors (ASA 3, cholangitis, hypoamylasemia, and main pancreatic duct obstruction at the pancreatic head).
The scoring model achieved an AUC of 0.721 with bootstrap-corrected AUC of 0.728, stratifying patients into three risk groups with PEP incidences ranging from 1.6% in low-risk patients to 17.7% in high-risk patients scoring 4 points or higher.
This material is most relevant for endoscopists performing ERCP who need to estimate individual patient risk and determine the intensity of preventive measures.

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Abstract

Introduction

Post-ERCP pancreatitis (PEP) is the most important adverse event of ERCP. In order to make a decision to take adequate preventive measures, it is necessary to estimate the risk of PEP in individual cases. Several models have been reported to predict PEP, but these models do not have high generalizability.

Aims & Methods

The aim of this study is to develop a reliable prediction rule for PEP in biliary ERCP for patients with intact papilla.
We had conducted a multicenter prospective cohort study which investigated the incidence of adverse events of biliary ERCP in patients with intact papilla (1). This study is a sub-analysis of the cohort study. A total of 3739 patients were prospectively enrolled at 36 hospitals of the Biliopancreatic Study Group of West Japan between April 2017 and March 2018. Exclusion criteria were acute pancreatitis, altered gastrointestinal anatomy, and an ASA physical status greater than 3.
The primary outcomes were the incidence of PEP. The diagnosis and severity of PEP were defined by the lexicon for endoscopic adverse events (2). Patient-related factors, operator-related factors, procedure-related factors and preventative measures were accumulated.
Multivariable logistic regression analysis with stepwise methods were used to identify predictors for PEP and a scoring model was developed based on their β coefficients.
The performance of the model was evaluated based on area under the receiver-operating characteristic curve (AUC), calibration and clinical adequacy. In addition, internal validity was assessed using the bootstrap method by sampling with replacements for 2000 iterations.

Results

PEP developed in 258 cases (6.9%), 201 mild, 39 moderate, 17 severe and 1 fatal. Significant factors with adjusted odds ratios (OR) in multivariate analysis were under 50 years old (OR: 1.78 [95% confidence interval (CI), 1.10-2.79]), female (OR: 1.33 [95% CI, 1.02-1.73]), ASA 3 (OR: 0.62 [95% CI, 0.39-0.95]), cholangitis (OR: 0.72 [95% CI, 0.52-0.98]), hypoamylasemia (OR: 0.62 [95% CI, 0.37-0.97]), obstruction of the main pancreatic duct (MPD) at the pancreatic head (OR: 0.41 [95% CI, 0.22-0.71]), cannulation time > 20 min (OR: 1.43 [95% CI, 1.03-1.97]), guidewire insertion into pancreatic duct (OR: 2.88 [95% CI, 2.17-3.82]), intraductal ultrasonography (IDUS) (OR: 1.49 [95% CI, 1.00-2.17]), biopsy (OR: 1.51 [95% CI, 1.00-2.23]) and total procedure time > 60 min (OR:1.64 [95% CI, 1.17-2.28]).
A scoring system was constructed from the eleven clinical variables as below. Under 50 years old: 2 points, female: 1 point, ASA 3: -2 points, cholangitis: -1 point, hypoamylasemia: -1 point, obstruction of the MPD at the pancreatic head: -2 points, cannulation time > 20 min: 1 point, guidewire insertion into pancreatic duct: 3 points, IDUS: 1 point, biopsy: 1 point and total procedure time > 60 min: 2 points. The points were added up to a total score that predicts the risk of pancreatitis.
AUC of this scoring model was 0.721. A bootstrap analysis revealed a corrected AUC of 0.728 (95%CI: 0.697 - 0.759).
When all cases were divided into three groups; a low-risk group (scoring -1 points or fewer), an intermediate-risk group (between 0 and 3 points) and a high-risk group (more than 4 points), the incidence of PEP were 1.6% (17/1048), 6.0% (121/2012) and 17.7% (120/679), respectively.

Conclusion

This scoring model is useful for predicting and stratifying the risk of PEP in individual cases. Aggressive preventive measures are recommended for patients in the high-risk group with a score of 4 or higher.

References

1. Fujita K, Yazumi S, Matsumoto H, Asada M, Nebiki H, Matsumoto K, et al. Multicenter prospective cohort study of adverse events associated with biliary endoscopic retrograde cholangiopancreatography: Incidence of adverse events and preventive measures for post-endoscopic retrograde cholangiopancreatography pancreatitis. Dig Endosc. 2022;34(6):1198-204.
2. Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71(3):446-54.

Conference

UEG Week Copenhagen 2023

Topics

Hepatobiliary

Submission format

Abstract

Session

Biliopancreatic endoscopy: ERCP or EUS? (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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Can I trust elastography and blood-based non-invasive tests in case of ongoing drinking or active inflammation? Yes or no?

Annalisa Cespiati 1, Ansgar Lohse 2

Affiliations

1 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy

2 University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

Summary

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

Session

Avoid inflammation and intoxication: Management of autoimmune and alcohol-related liver disease

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Shellie Radford 1

Affiliations

1 None, None, United Kingdom

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Abstract

Event

UEG Week Barcelona 2026

Topics

Nurses

Session

Education of patients and staff

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Elisa Pose 1

Affiliations

1 Hospital Clínic of Barcelona - IDIBAPS, Barcelona, Spain

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Abstract

Event

UEG Week Barcelona 2026

Topics

Primary Care

Session

Public health aspects related to GI and steatotic liver disease (SLD)

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

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Abstract

Event

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Topics

Primary Care Small Intestine & Nutrition

Session

Beyond calories: Managing complications and refeeding syndrome in clinical nutrition support

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2026: United European Gastroenterology Journal 2026; 14 (S1)

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Luca Havelda 1

Affiliations

1 Semmelweis University, Budapest, Hungary

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

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Primary Care Small Intestine & Nutrition

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UEG Week Barcelona 2026

Topics

Nurses

Session

Innovative approaches in liver disease management – in cooperation with EASL nurses and AHP taskforce

Citation

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