Lactated Ringer’s Solution in Combination with Rectal Indomethacin

Post written by Shaffer R. S. Mok, MD, MBS, from Cooper University Hospital.

The present fund of knowledge available for the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is growing. With available data evaluating rectal indomethacin and early studies assessing lactated ringer’s (LR) infusion, we felt it necessary to study the combination of these therapies for the prevention of post-ERCP pancreatitis.

Mok_fig1
Figure 2. The incidence of the primary outcome of post-ERCP pancreatitis. Bars from left to right indicate NS + placebo (Pl), NS + IND, LR + Pl, and LR + IND groups. The difference between the NS + Pl versus LR + IND group was significant (P = .04). ns, Not significant; NS, normal saline solution; IND, indomethicin; LR, lactated Ringer’s solution; Pl, placebo; PEP, post-ERCP pancreatitis.

Despite existing data regarding lactated ringer’s infusion to prevent post-ERCP pancreatitis, the present preventative fluid strategies do not fit the endoscopy unit workflow in the United States. We felt it important not only to evaluate the combination of indomethacin with LR, but also to validate preventative measure that were more applicable to the endoscopists in the US. Therefore, we tested a fluid strategy involving 1 liter infused prior to ERCP.

Mok_fig2
Figure 3. The incidence of secondary outcome readmission rates. Bars from left to right indicate NS + placebo (Pl), NS + IND, LR + Pl, and LR + IND groups. The difference between the NS + Pl versus LR+IND group was significant (P = .03). ns, Not significant; NS, normal saline solution; IND, indomethicin; LR, lactated Ringer’s solution; Pl, placebo.

Our study was a randomized, prospective, double-blinded placebo controlled trial of 196 patients undergoing ERCP at a tertiary care center. All subjects were at high risk for post-ERCP pancreatitis, either by demographic or endoscopic characteristics. There were an equal number of pancreatic stents placed in all groups. Patients were randomized to undergo preventative strategies with normal saline with placebo, normal saline with indomethacin, LR with placebo, or LR with indomethacin. When comparing our groups, we found that LR with indomethacin led to lower rates of post-ERCP pancreatitis and readmission when compared with normal saline with placebo.

Our hope is that this simple strategy of LR with indomethacin prior to ERCP will improve the safety of ERCP for both the advanced endoscopist and their patients.

Find the article abstract here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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