Peri-Procedural Aggressive Hydration for Preventing Post-ERCP Pancreatitis

Acute pancreatitis is an inflammation of the pancreas. Gallstones block the flow of pancreatic juices into the duodenum. Digestive enzymes become active in pancreas, where they destroy healthy tissue.
Peri-procedural aggressive hydration is associated with significantly decreased rates of post-ERCP pancreatitis (PEP) and appears to be a safe and effective strategy for PEP prevention.

Post-endoscopic retrograde cholangiopancreatography (ERCP) is a necessary diagnostic and therapeutic procedure for the investigation and intervention of pancreato-biliary pathologies.

Peri-procedural aggressive hydration is associated with significantly decreased rates of post-ERCP pancreatitis (PEP) and appears to be a safe and effective strategy for PEP prevention, according to a study published in Pancreatology.

Although peri-procedural intravenous hydration is suggested to decrease PEP risk, the quality of supporting evidence remains poor. This meta-analysis was used to investigate the hypothesis that aggressive hydration (AH) with normal saline or Ringer’s lactate (RL) could be used to reduce risk of PEP. Randomized, controlled studies through January 2019 comparing AH to standard hydration (SH) for PEP prevention were found using CINAHL, Clinical Key, Clinical Trials. gov, EMBASE, Google Scholar, International Standard Randomized Trial Number registry, Pubmed, and secondary sources. Two reviewers assessed the quality of the studies based on Cochrane Handbook Recommendations. The random-effects model was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI). The primary endpoint was acute pancreatitis.

For this meta-analysis, a total of 9 randomized controlled trials (RCTs) with 2094 participants were included, of whom 165 (7.9%) developed PEP. No significant heterogeneity was found between the RCTs (I²=31%). PEP incidence was significantly lower in AH participants (5.1%, n=108 of 969) compared with SH participants (11.1%, n=57 of 1125). The number of individual patients needing to receive AH to prevent one episode of PEP was 17. AH reduced PEP incidence by half when compared with SH (OR,  0.44; 95% CI, 0.28-0.69; P =.0004), as well as decreased the incidence of post-ERCP hyperamylasemia (OR, 0.51; 95% CI, 0.34-0.77; P =.001) and length of stay by 1 day (mean difference, −0.89 d; P =.00002). No significant between-group differences were seen in adverse events related to fluid overload (OR, 1.29; 95% CI, 0.16-10.69; P =.81) or post-ERCP abdominal pain (OR, 0.35; 95% CI, 0.08-1.58; P =.17). Results were not affected by statistical models of heterogeneity or alternative effect measures.

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Limitations to the meta-analysis included using research abstracts, a lack of information on secondary outcomes and adverse event rates, the use of variable rates of fluid hydration, varied definitions of PEP, and not being able to analyze other outcomes such as mortality, cost associated with hospitalization and effect of hydration strategy on severity of pancreatitis.

Overall, study investigators conclude that the “meta-analysis shows that aggressive hydration can be a supportive measure to rectal NSAIDs, and pancreatic stent in patients with low risk for volume overload. More research in the form of randomized controlled trials is needed to further elucidate the role of the type of the hydration fluid and the rate of the fluid. Also, the safety of aggressive hydration in the particularly subset of patients at high risk for volume overload should be explored.”


Radadiya D, Devani K, Arora S, et al. Peri-procedural aggressive hydration for post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis prophylaxsis: Meta-analysis of randomized controlled trials [published online July 30, 2019]. Pancreatology. doi: 10.1016/j.pan.2019.07.046