Efficacy of Epinephrine Injection in Preventing Post-ERCP Pancreatitis

Background: Rectal indomethacin or a topical spray of epinephrine to the papilla of Vater has each shown efficacy alone in the prevention of post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We supposed that a submucosal epinephrine injection would be more effective and longer acting than a topical epinephrine spray and therefore would further reduce the incidence of PEP. Patients and Methods: A retrospective analysis was conducted of 412 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2017 and December 2019. These patients were divided into 2 groups: the indomethacin group and the indomethacin plus the submucosal epinephrine injection group. The incidence rates and severity of PEP, post-ERCP hyperamylasemia, other outcomes, and any other adverse events were compared between the groups. Results: Baseline demographic and clinical characteristics and procedure-related parameters were similar between the 2 groups. The incidence of PEP was 0.4% in the epinephrine group compared with 5.1% in the indomethacin group ( P <0.001). Post-ERCP hyperamylasemia occurred in 24.6% of patients in the indomethacin group, whereas 7.6% of patients in the epinephrine group developed this condition; the difference was significant ( P <0.001). Postsphincterotomy bleeding occurred in 5 patients, all of whom were in the indomethacin group ( P <0.001). Other adverse events, including arrhythmias, acute coronary events, stroke, or hypertension were not significantly different between the 2 groups. Conclusion: Addition of a submucosal epinephrine injection in conjunction with rectal indomethacin significantly reduced the incidence of PEP, post-ERCP hyperamylasemia, and postsphincterotomy bleeding.