Pre-ERCP Rectal indomethacin is MORE effective than Post-procedure - LANCET - RCT

Multicentre - single blinded RCT across 6 centres in China

2600 patients with average and high-risk for pancreatitis, randomly assigned to: 

Universal rectal indomethacin 100mg 30min before procedure  OR   post-ERCP selective rectal indomethacin in high-risk patients only

23% trainee participation, 15% patients required dual wire or pre-cut

Only 18% high-risk patients also received pancreatic stent (discretionary to endoscopists)

In high-risk patients, pre-procedure indomethacin reduced overall and Mod-sev pancreatitis by half (6% and 1% vs 12% and 2%)

In Avg-risk patients, pre-procedure indomethacin reduced overall and Mod-severe pancreatitis by half (3% and 1% vs 6% and 2%) compared to no indomethacin


Overall, pre-procedure rectal indomethacin was MORE effective than post-procedure indomethacin in high-risk patients, and was MORE effective than no indomethacin in average risk patients.


DOI: http://dx.doi.org/10.1016/S0140-6736(16)30310-5

Comments

Post a Comment

Popular posts from this blog

Pancreatic Cyst

Image
 MCN - (Mother cyst) >95% in pre-menopausal women Mostly in body and tail of pancreas Thick-walled cyst, lined by Ovarian type stroma. Cyst contains mucinous / hemorrhagic material. Does not communicate with PD (unlike IPMN) 10-20% have in-dwelling cancer One review found - no dysplasia in cysts <3 cm in size LN mets is rare. Distal pancreatectomy usually suffices.  Doesnt result in metachronous lesions. Surveillance isnt really necessary SCA - (Grandmother cyst) 75% of SCAs seen in post-menopausal women Can be anywhere in pancreas Honeycombing, with tiny cysts containing clear fluid distributed around central scarring. Central scarring may bear calcification in 30% cases Microcystic SCAs can undergo degeneration and become macrocystic variants zero risk of malignancy, but they can continue to grow and cause obstructive symptoms SPN - (daughter lesion) - Solid Pseudopapillary Neoplasm 90% of lesion occur in young women, in teens / twenties Anywhere  in pancreas Solid / Solid-cys
Read more

Pancreatic cyst fluid examiantion

  CEA Levels:   CEA >192 is 60% sensitive and 90% specific for mucinous cysts (ipmn/mcn) This was based on a study of 70 lesions in 2004 and has stuck till date   CEA < 5 has excellent negative predictive value for mucinous cysts   CEA > 5, therefore can still be a mucinous neoplasm and needs to be taken in context. Other markers such as Ca 72-4, CA 19-9, CA 15-3, CA 125 have lower accuracy than CEA   Amylase levels: ·        Amylase < 250 IU/L is highly unlikely to be connected to PD (eg  SCA) ·        MCN usually have very low / low amylase (one study suggested it has similar amylase to ipmn)   Glucose: ·        Glucose is very low in mucinous tumors & pseudocysts (those with communication to PD)– usually less than 2.8 mmol/l     Glucose < 2.8 mmol/l has Sens/Spec of 90/90 ( more accurate)  compared to CEA >192 (sens/spec 60/90) for identification of mucinous cysts
Read more

Iron deficiency anaemia

IDA   Ferritin: (BSG 2021 / UTD)   Ferritin is the universal intracellular protein containing Iron – a soluble and non-toxic form. It is the primary iron storage protein in prokaryotes and eukaryotes. Ferritin w/o iron is called apo-ferritin . Each ferritin molecule can store up to 4,500 atoms of iron within it.     Iron deficiency anaemia:   1)     Low MCH is more sensitiv e for Iron deficiency than Low MCV. 2)     Low Ferritin is single most important serological marker of IDA. Serum ferritin assessed by assays is usually apo-ferritin, but reflects intra-cellular ferritin stores in RES (macrophages in liver, spleen, LN etc ) in absence of inflammation.   Fe < 15 – indicative of absent iron stores Fe <45 – indicative of low iron stores   In anaemia of chronic disease / CHF  - TSat <20% with Fe <100 is suggestive of Fe deficiency     Fe > 150 unlikely to represent low iron stores even in face of inflammation .   3)     Transf
Read more