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Role of vitamin C and rectal indomethacin in preventing and alleviating post-endoscopic retrograde cholangiopancreatography pancreatitis: a clinical study

  • Amir Sadeghi (Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences) ;
  • Rana Jafari-Moghaddam (Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences) ;
  • Sara Ataei (Department of Clinical Pharmacy, School of Pharmacy, Hamadan University of Medical Sciences) ;
  • Mahboobe Asadiafrooz (Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences) ;
  • Mohammad Abbasinazari (Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences)
  • Received : 2022.06.05
  • Accepted : 2022.06.27
  • Published : 2023.03.30

Abstract

Background/Aims: This study aimed to determine whether vitamin C in addition to indomethacin decreases the occurrence and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) occurrence and severity. Methods: This randomized clinical trial included patients undergoing ERCP. The participants were administered either rectal indomethacin (100 mg) plus an injection of vitamin C (500 mg) or rectal indomethacin (100 mg) alone just before ERCP. The primary outcomes were PEP occurrence and severity. The secondary amylase and lipase levels were determined after 24 hours. Results: A total of 344 patients completed the study. Based on intention-to-treat analysis, the PEP rates were 9.9% for indomethacin plus vitamin C plus indomethacin and 15.7% for indomethacin alone. Regarding the per-protocol analysis, the PEP rates were 9.7% and 15.7% in the combination and indomethacin arms, respectively. There was a remarkable difference between the two arms in PEP occurrence and severity on intention-to-treat and per-protocol analyses (p=0.034 and p=0.031, respectively). The post-ERCP lipase and amylase concentrations were lower in the combination arm than in the indomethacin alone arm (p=0.034 and p=0.029, respectively). Conclusions: Vitamin C injection in addition to rectal indomethacin reduced PEP occurrence and severity.

Keywords

References

  1. Pereira P, Costa-Moreira P, Macedo G. Cholangiopancreatoscopy: expanding the diagnostic indications of endoscopic retrograde cholangiopancreatography. J Gastrointestin Liver Dis 2020;29:445-454. https://doi.org/10.15403/jgld-1268
  2. Johnson KD, Perisetti A, Tharian B, et al. Endoscopic retrograde cholangiopancreatography-related complications and their management strategies: a "scoping" literature review. Dig Dis Sci 2020;65:361-375. https://doi.org/10.1007/s10620-019-05970-3
  3. Bhatt H. Post-endoscopic retrograde cholangiopancreatography pancreatitis: an updated review of current preventive strategies. Clin Exp Gastroenterol 2021;14:27-32. https://doi.org/10.2147/CEG.S276361
  4. Bozkurt S, Guner A, Kadioglu H, et al. The effects of different mechanisms on the development of post-ERCP pancreatitis in an ERCP model in rats. Turk J Gastroenterol 2013;24:469-475. https://doi.org/10.4318/tjg.2013.0654
  5. Mohammad Alizadeh AH, Abbasinazari M, Hatami B, et al. Comparison of rectal indomethacin, diclofenac, and naproxen for the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis. Eur J Gastroenterol Hepatol 2017;29:349-354. https://doi.org/10.1097/MEG.0000000000000787
  6. Abbasinazari M, Mohammad Alizadeh AH, Moshiri K, et al. Does allopurinol prevent post endoscopic retrograde cholangio-pancreatography pancreatitis? A randomized double blind trial. Acta Med Iran 2011;49:579-583.
  7. Katsinelos P, Kountouras J, Paroutoglou G, et al. Intravenous N-acetylcysteine does not prevent post-ERCP pancreatitis. Gastrointest Endosc 2005;62:105-111. https://doi.org/10.1016/S0016-5107(05)01574-9
  8. Raty S, Sand J, Pulkkinen M, et al. Post-ERCP pancreatitis: reduction by routine antibiotics. J Gastrointest Surg 2001;5:339-345; discussion 345. https://doi.org/10.1016/S1091-255X(01)80059-7
  9. Hatami B, Kashfi SM, Abbasinazari M, et al. Epinephrine in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a preliminary study. Case Rep Gastroenterol 2018;12:125-136. https://doi.org/10.1159/000479494
  10. Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2020;52:127-149. https://doi.org/10.1055/a-1075-4080
  11. Bopanna S, Nayak B, Prakash S, et al. Increased oxidative stress and deficient antioxidant levels may be involved in the pathogenesis of idiopathic recurrent acute pancreatitis. Pancreatology 2017;17:529-533. https://doi.org/10.1016/j.pan.2017.06.009
  12. Duarte TL, Lunec J. Review: when is an antioxidant not an antioxidant? A review of novel actions and reactions of vitamin C. Free Radic Res 2005;39:671-686.
  13. Scott P, Bruce C, Schofield D, et al. Vitamin C status in patients with acute pancreatitis. Br J Surg 1993;80:750-754. https://doi.org/10.1002/bjs.1800800632
  14. Siriwardena AK, Mason JM, Balachandra S, et al. Randomised, double blind, placebo controlled trial of intravenous antioxidant (n-acetylcysteine, selenium, vitamin C) therapy in severe acute pancreatitis. Gut 2007;56:1439-1444. https://doi.org/10.1136/gut.2006.115873
  15. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-111. https://doi.org/10.1136/gutjnl-2012-302779
  16. Cotton PB, Eisen G, Romagnuolo J, et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. Gastrointest Endosc 2011;73:868-874. https://doi.org/10.1016/j.gie.2010.12.036
  17. Armstrong JA, Cash N, Soares PM, et al. Oxidative stress in acute pancreatitis: lost in translation? Free Radic Res 2013;47:917-933. https://doi.org/10.3109/10715762.2013.835046
  18. Thiruvengadam NR, Kochman ML. Emerging therapies to prevent post-ERCP pancreatitis. Curr Gastroenterol Rep 2020;22:59.
  19. Bonham MJ, Abu-Zidan FM, Simovic MO, et al. Early ascorbic acid depletion is related to the severity of acute pancreatitis. Br J Surg 1999;86:1296-1301. https://doi.org/10.1046/j.1365-2168.1999.01182.x
  20. Mohseni Salehi Monfared SS, Vahidi H, Abdolghaffari AH, et al. Antioxidant therapy in the management of acute, chronic and post-ERCP pancreatitis: a systematic review. World J Gastroenterol 2009;15:4481-4490. https://doi.org/10.3748/wjg.15.4481
  21. Gooshe M, Abdolghaffari AH, Nikfar S, et al. Antioxidant therapy in acute, chronic and post-endoscopic retrograde cholangiopancreatography pancreatitis: an updated systematic review and meta-analysis. World J Gastroenterol 2015;21:9189-9208. https://doi.org/10.3748/wjg.v21.i30.9189
  22. Koseoglu H, Solakg_lu T, Basaran M, et al. Risk factors for post-ERCP pancreatitis: it depends on the ERCP indication. Acta Gastroenterol Belg 2020;83:598-602.