Role of Prophylactic Aggressive Hydration to Prevent Post-ERCP Pancreatitis

Lahore General Hospital126 enrolled

Overview

Endoscopic Retrograde Cholangiopancreatography, also called ERCP, is a procedure used to diagnose and treat disorders of the bile ducts and pancreas. A common and potentially serious complication after ERCP is post ERCP pancreatitis, which is inflammation of the pancreas that can cause abdominal pain, raised pancreatic enzymes, prolonged hospital stay, and increased health care costs. Several preventive approaches have been evaluated, but an optimal, simple strategy that can be applied consistently in routine practice remains uncertain. This randomized controlled trial was evaluated whether giving a higher amount of intravenous lactated Ringer's solution around the time of ERCP reduces the risk of post ERCP pancreatitis compared with standard hydration. Adults aged 18 to 70 years undergoing their first ERCP for choledocholithiasis, bile duct leak, or biliary obstruction were randomly allocated to standard hydration or aggressive hydration. Standard hydration consists of lactated Ringer's solution at 1.5 mL/kg/hour during ERCP and for 8 hours after the procedure. Aggressive hydration consisted of lactated Ringer's solution at 3 mL/kg/hour during ERCP, followed immediately by a 20 mL/kg bolus and then 3 mL/kg/hour for 8 hours, with reduction to 1.5 mL/kg/hour if pain is absent after 8 hours. The primary hypothesis was that aggressive hydration is more effective than standard hydration in preventing post ERCP pancreatitis. Post procedure serum amylase was measured at 12 and 24 hours, and pain was assessed using a visual analog scale at 4, 12, and 24 hours. The main outcome is post ERCP pancreatitis, defined by new or worsening abdominal pain with enzyme elevation more than three times the upper limit of normal at 24 hours and a hospital stay of at least 2 days. Secondary outcomes include isolated hyperamylasemia, post procedure pain, and length of hospital stay. The study was conducted over 12 months at the Department of Gastroenterology, Lahore General Hospital, Lahore, with a total sample size of 126 participants.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

PREVENTION

Masking

Interventions

Aggressive intravenous hydration with lactated Ringer's solutionOTHER

Lactated Ringer's solution at 3 mL/kg/hour during endoscopic retrograde cholangiopancreatography. Immediately after the procedure, 20 mL/kg bolus of lactated Ringer's solution. Then 3 mL/kg/hour for 8 hours. If no pain after 8 hours, rate reduced to 1.5 mL/kg/hour. Hydration discontinued once the patient can comfortably tolerate a regular diet

Standard intravenous hydration with lactated Ringer's solutionOTHER

Lactated Ringer's solution at 1.5 mL/kg/hour during endoscopic retrograde cholangiopancreatography. Continued at 1.5 mL/kg/hour for 8 hours after the procedure. If post endoscopic retrograde cholangiopancreatography pancreatitis develops, a 20 mL/kg bolus may be administered, followed by 3 mL/kg/hour, as per management protocol

Eligibility

Sex: ALLMin age: 18 YearsMax age: 70 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Patients aged between 18 to 70 years. * Both males and females. * Patients undergoing their first Endoscopic Retrograde Cholangiopancreatography (ERCP) for choledocholithiasis, bile duct leak, or biliary obstruction. Exclusion Criteria: * Patients who have previously undergone an ERCP, endoscopic sphincterectomy, or endoscopic papillary balloon dilatation. * Individuals with a known history of chronic pancreatitis, ongoing acute pancreatitis, or patients with gallstone pancreatitis or active cholangitis. * Patients with coagulopathy or those on anticoagulation therapy. * Pregnant or lactating women. * Substance abuse: Individuals with a history of alcohol or other substance abuse disorders. * Patients having hypernatremia or hyponatremia (Na \<130 or Na \>150 mEq/L) or Hyperkalemia (\>5.1 mEq/dL). * Specific organ dysfunctions: * Patients with organ dysfunctions including cardiac insufficiency (New York Heart Association Class II or above), respiratory insufficiency (oxygen saturation \<90%), renal insufficiency (creatinine clearance \<40 mL/min), or liver dysfunction. * Clinical signs of fluid overload, specifically peripheral or pulmonary edema, and ongoing hypotension, including those with sepsis. * Patients undergoing sphincterotomy as it reduces the risk of pancreatitis.

Outcomes

Primary Outcomes

Incidence of post endoscopic retrograde cholangiopancreatography pancreatitis

Post endoscopic retrograde cholangiopancreatography pancreatitis was diagnosed when new or worsening abdominal pain occurs after the procedure, with pancreatic enzyme elevation more than three times the upper limit of normal at 24 hours, and the clinical course requires hospital admission for at least 2 days.

Time frame: 24 hours after endoscopic retrograde cholangiopancreatography, with confirmation based on a hospital stay of at least 2 days

Secondary Outcomes

Frequency of isolated hyperamylasemia

Isolated hyperamylasemia was defined as serum amylase elevation more than three times the upper limit of normal during the first 24 hours after the procedure, without meeting criteria for post endoscopic retrograde cholangiopancreatography pancreatitis.

Time frame: 12 hours and 24 hours after endoscopic retrograde cholangiopancreatography

Post procedure abdominal pain severity assessed by Visual Analog Scale

Abdominal pain was assessed using a 0 to 10 Visual Analog Scale. Pancreatic pain will be defined as development of pain, or an increase in pain, of at least 3 points compared with pre procedure pain score, persisting during follow up.

Time frame: 4 hours, 12 hours, and 24 hours after endoscopic retrograde cholangiopancreatography

Length of hospital stay

Length of hospital stay was measured as the number of days from the day of endoscopic retrograde cholangiopancreatography to the day of discharge within 30 days.

Time frame: From day of endoscopic retrograde cholangiopancreatography until hospital discharge within 30 days