TorontoGiFellow

 Source: British society / UK-PSC guidelines -  10.1136/gutjnl-2018-317993 ERCP in PSC 1) All patients should receive broad-spectrum antibiotics for 3-5 days 2) Dominant stricture (clinically significant stricture) is defined as a stricture causing functional narrowing - either 1) biochemically (cholestatic LFT), 2) radiologically (upstream dilatation), 3) symptomatically (pruritius). The BSG guideline doesnt mention size criteria for definition of dominant stricture. 3) Obtain cytology from dominant strictures ( sensitivity 50%) every time 4) Balloon dilatation of stricture is thought to retard progression of liver disease by reducing cholestatic injury 5) Stenting is associated with high rates of cholangitis / stent occlusion, as well as pancreatitis. All guidelines recommend against routine stenting in patients with PSC. Dominant stricutre need management with periodic balloon dilatation only without stenting Other things PSC: British guidelines suggest: Annual ultrasound ...

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

 DOI:  10.1097/MPA.0000000000002090 Consecutive 321 patients with native papilla,  were randomly assigned to Pancreatic stent, 50mg rectal diclofenac or stent + diclofenac at a single centre in Japan from 2014 to 2019. Pancreaitc injection performed in nearly half of all patients! 75% of all patients were considered high risk (either F<40, difficult cannulation, pancreatic cannulation, pancreatic injection, pre-cut, pancreatic sphincteortomy, balloon sphincteroplasty, IDUS, choledochoscopy)  Procedure time was >30 mins in half of all patients. 5 patients in total developed pancreatitis (all mild), with no difference in any of the 3 sub-groups.