ࡱ> SUNOT#( F/ 0|DTimes New Romanl@v 0( 0DArialNew Romanl@v 0( 0" DWingdingsRomanl@v 0( 00DVerdanasRomanl@v 0( 0"@DSymbolsRomanl@v 0( 0 ` .  @n?" dd@  @@`` $5        DAXBEa' 00 ff3@8{ aʚ;2Nʚ;g4:d:dv 0zppp@ <4!d!d` 0LXA<4dddd` 0LXA<4BdBd` 0LXA? % KOMPLIKACIJE ERCP-a zDoc.dr.sc. }arko Babi KB Dubrava Zavod za gastroenterologiju&5UVOD ERCP je najinvazivnija endoskopska metoda Ukupne komplikacije do 4% (1,1%-11,9%) Varijacija u definiciji komplikacije (npr. pankreatitis iza ERCP-a)w#@k   UVOD Ukupna sigurnost procedure (openito) u endoskopiji ovisi o: Indikacijama Na inu sedacije i monitoringu Klini koj praksi Dijagostika ili terapija ? Opremljenosti Uvje~banosti endoskopi ara i tima*=ZZ=tQ   + UVOD INDIKACIJE za ERCP-poativati!!! , a to su: Koledokolitijaza }utica Proairen d. koledokus Akutni pankreatitis (bilijarni) Kolangitis Palijacija pankreatikobilijarnog karcinoma Uzimanje uzoraka tkiva (PHD, citologija) NIJE INDIKACIJA: Nebilijarni akutni pankreatitis Disfunkcija sfinktera Odii Neki bolesnici sa pseudocistama<EZ+[+   +F ( UVOD ,Prvenstveno terapijski ERCP !!! Rjeaavanje strikture i bilijarnog  curenja kod maligne bolesti bilijarnog sustava Rjeaavanje pankreati kog  curenja  wt+     6UVOD -naj eae komplikacije Akutni post ERCP pankreatitis Krvarenje Perforacija (GI/bilijarna) Pneumpoperitoneum, pneumoretroperitoneum, pneumotoraks, pneumomedijastinum, subkutani emfizem, Sepsa IM, aritmijeZ    "OPE KOMPLIKACIJE tReakcija na lijekove O2 saturacija Kardiopulmonarni incident Hemoragija i perforacija vezana uz prolazak instrumenta@  . 8KOMPLIKACIJE vezane uz pankreatikobilijarnu manipulaciju& )Pankreatitis Sepsa Hemoragija Perforacija4    DEFINICIJA KOMPLIKACIJE    N`TO PODI}E RIZIK ZA RAZVOJ KOMPLIKACIJA (\Od strane bolesnika: Dob? ( ipak nema utjecaja dob nego komorbiditet, kardiovask, NPL, sepsa, debljina itd.) Spol ( eai pankreatitis u ~ena) Disfunkcija sfinktera Odii Raniji post ERCP pankreatitis Sistemne bolesti (Cheng et al, Am J Gastroenterol 2006, Cotton P et al, Gastroint Endoscopy 2009)lS xJS*8  )   N`TO PODI}E RIZIK ZA RAZVOJ KOMPLIKACIJA (Zbog tehni kih uvijeta: Viae kanulacija (teakih) Sfinkterektomija p. maior i p. minor ( pankreatitis) sfinkterektomija op. rizik krvarenja Koli ina kontrasta Iskustvo endoskopi ara Stentiranje snizuje rizik post ERCP-pankreatitisa kao i kroni ni pankreatitis (Cheng et al, Am J Gastroenterol 2006, Cotton P et al, Gastroint Endoscopy 2009)S f3f &ff$ffyfS   /!     4SPRIJE AVANJA KOMPLIKACIJA Izvje~bani tim Skraivanje procedure Dobar monotoring Malo konrasta Samo terapijski ERCP Meikamenti N+     ` f3f3` ff̙` ___` ff` 3ff3f>?" dd@,?lPd@   Z l<@ d`"  n?" dd@   @@``@n?" dd@  @@``PR    @ ` ` p>>  (  ^N y   "yZ  S B7 C DEHFPv @?q 6 6 n(dx  G b q %(@"B y2   `G1?"  Txygֳgֳ ?"P  X Click to edit Master title style!!  T}gֳgֳ ?"``  R*   Ttgֳgֳ ?"`   T*    Tgֳgֳ ?"`   T* (   0 "  RClick to edit Master text styles Second level Third level Fourth level Fifth level!    S`  Hd޽h? ? f3f3 Soaring=   @ A(   N t   "tZ   S BsC5 DEHFPv @?3 r4 rv$[I_l3HxF 3 %(@" "2   C CRENGCJRQ1? `TO`TR`TO`TRR`TRR"t  TNgֳgֳ ?"/O  X Click to edit Master title style!!  T@gֳgֳ ?"pp   [#Click to edit Master subtitle style$$  TDgֳgֳ ?"``  R*   TL=gֳgֳ ?"`   T*   T`gֳgֳ ?"`   T* `  Hd޽h? ?  f3f3 0p$(  pr p S \ /O  r p S ] pp   H p 0޽h ? f3f3  `t$(  tr t S P   r t S    H t 0޽h ? f3f3  p$(  r  S x P   r  S 4   H  0޽h ? f3f3  $(  r  S P   r  S <   H  0޽h ? f3f3  $(  r  S P   r  S |   H  0޽h ? f3f3  x$(  xr x S T`    r x S    H x 0޽h ? f3f3  $(  r  S X/P   r  S T   H  0޽h ? f3f3  $(  r  S @   r  S :   H  0޽h ? f3f3*  W*O*CC)(  r  S ?`@   r  S P@   'L 5 # 0&N 5  5N >  >  <$$o \ , "   `  0>N >   >   <\b$o mMild : "" `   0>N "   "   <$!o q Moderate :  ""  `  0"N "5  "5  <pA"$4o oSevere : "" `  0"5N >Q  >Q  <u$- c Bleeding ,   "   `  0>QN >Q  >Q3  <{b- eClinical evidence of bleeding (ie, not just endoscopic); Hb level drop <3 g; no need for transfusion ,e e"  f`  0>QN "Q  "QL  <!- ~Transfusion: d"4 units; no angiographic intervention or surgery ,? ?"  @`  0"QN "5Q  "5QP  <ІA"4- Transfusion: e"5 units or intervention (angiographic or surgical) ,A A" B`  0"5QN >  >  <$ f Perforation ,   "   `   0>`N > ! > " <0b &Possible, or only very slight leak of fluid or contrast dye; treatable by fluids and suction for d"3 d ,f f" g` # 0>N " $ ": % <4! lAny definite perforation treated medically for 4 10 d ,6 6" 7` & 0"N "5 ' "5 ( <A"4 PMedical treatment for more than 10 d or intervention (percutaneous or surgical) ,P P" Q` ) 0"5N W> * W> + <ԣ${ g Pancreatitis ,   "   ` , 0W>N >W - >W  . <0b{ >Clinical pancreatitis; amylase at least 3 times normal at more than 24 h after the procedure requiring admission or prolongation of planned admission to 2 3 d , "   ` / 0>WN W" 0 W"0 1 <({! bPancreatitis requiring hospitalization of 4 10 d ,1 1" 2` 2 0W"7N "W5 3 "W5q 4 <̵A"{4 Pancreatitis requiring hospitalization for more than 10 d, or hemorrhagic pancreatitis, phlegmon or pseudocyst, or intervention (percutaneous drainage or surgery) , "   ` 5 0"W5N > 6 > 7 <x$9g rInfection (cholangitis) , "   ` 8 0>N > 9 > : <b9g |">38C at 24 48 h , " ` ; 0>N " < "8 = <p9!g jFebrile or septic illness requiring >3 d of hospital treatment or endoscopic or percutaneous intervention ,j j"   k` > 0"N "5 ? "5 @ <A"94g rSeptic shock or surgery , " ` A 0"5Z B s *5  C BA (Cotton P et al, Gastroint Endoscopy 2009))NH  0޽h ? f3f3'} ||Pg|(  R  s *?x IzF E x  p  z@ B u B u@  R  <y$$c \ , " ` Q 0@  T  < $c \ , " ` S 0W@ j  Vj N Yu  $F   6ĂYu Severity (% of complications) X &&& r  BY  6Y[ >` U 0j @  X   < $w u Complication :   "" ` W 0@  Z   <w Total (% of total procedures) : "" ` Y 0@ y \y   <䘦Uw mMild : "" ` [ 0y@ yq  ^yq    < M w q Moderate :  "" ` ] 0yq @ q   `q     <褦  w oSevere : "" ` _ 0q  @  B  b B   <  w nFatal : "" ` a 0 B @  d  <$ bOverall , " ` c 0@  f  <T  462 (4.0) H  "&" ` e 0@ y hy  <U c 335 (73) ,   "  ` g 0y@ yq  jyq   <x¦M  b78 (17) , " ` i 0yq @ q   lq    <Ǧ   a42 (9) , " ` k 0q  @  B  n B   <Dͦ   `7 (2) , " ` m 0 B @  p  <`Ҧ$ g Pancreatitis ,   " ` o 0@  r  <צ  304 (2.6) H  "&" ` q 0@ y ty  <ަU  229 (75) B  "  "  "` s 0y@ yq  vyq   <M  b57 (19) , " ` u 0yq @ q   xq    <0   a17 (6) , " ` w 0q  @  B  z B   <   b1 (0.3) , " ` y 0 B @    |    <,$/   c Bleeding ,   " ` { 0  @    ~    </   c 40 (0.3) ,   " ` } 0  @  y   y   </ U  b22 (55) , " `  0 y @ y q  y q   </ M  a9 (23) , " `  0y q @ q  q   <  /  a9 (23) , " `  0q @  B   B    < /   `0 (0) , " `  0 B @       ! <$C q  d Infection ,   " `  0  @       " <C q  c 38 (0.3) ,   " `  0  @  y   y  # <"C Uq  b29 (76) , " `  0 y @ y q  y q  $ <D(C M q  a5 (13) , " `  0y q @ q   q   % <- C q  `2 (5) , " `  0q  @   B    B  & <1 C  q  |2 (5) H "&f" `  0  B @     ' <`8$  bCardiac , " `  0 @     ( <=  c 10 (0.1) ,   " `  0 @  y  y ) <B U `5 (5) , " `  0 y@ y q  y q  * <H M  `0 (0) , " `  0y q @ q  q  + <`M   a2 (20) , " `  0q @  B   B  , <TR    q3 (30) < "& `  0 B @   - <0X$ d Pulmonary ,   " `  0@   . <|] b9 (0.1) , " `  0@ y y / <cU a6 (67) , " `  0y@ yq  yq  0 < hM  a2 (22) , " `  0yq @ q   q   1 <hm   a1 (11) , " `  0q  @  B   B  2 <4r   `0 (0) , " `  0 B @   3 <|w$) lBowel perforation , " `  0@   4 <|) c 12 (0.1) ,   " `  0@ y y 5 <)U a4 (33) , " `  0y@ yq  yq  6 <0)M  `0 (0) , " `  0yq @ q   q   7 <X )  a7 (58) , " `  0q  @  B   B  8 < )  |1 (8) H "&" `  0 B @   9 <$= pSphincter perforation , " `  0@   : <= \4 , " `  0@ y y ; <=U `0 (0) , " `  0y@ yq  yq  < <ܧ=M  a1 (25) , " `  0yq @ q   q   = < =  a3 (75) , " `  0q  @  B  ´ B  > < =  `0 (0) , " `  0 B @ - Ĵ- ? <d$Q nMedication reaction , " ` ô 0-@ - ƴ- @ <Q \6 , " ` Ŵ 0-@ -y ȴ-y A <0QU b6 (100) , " ` Ǵ 0-y@ y-q  ʴy-q  B <QM  `0 (0) , " ` ɴ 0y-q @ q -  ̴q -  C < Q  `0 (0) , " ` ˴ 0q - @  -B  δ -B  D < Q  `0 (0) , " ` ʹ 0 -B @ A дA E <<$e d Phlebitis ,   " ` ϴ 0A@ A ҴA F <e \2 , " ` Ѵ 0A@ Ay ԴAy G <eU b2 (100) , " ` Ӵ 0Ay@ yAq  ִyAq  H <eM  `0 (0) , " ` մ 0yAq @ q A  شq A  I < e  `0 (0) , " ` ״ 0q A @  AB  ڴ AB  J < e  `0 (0) , " ` ٴ 0 AB @ u ܴu K <$#Q `Other , " ` ۴ 0u@ u ޴u L <#Q c 37 (0.3) ,   " ` ݴ 0u@ yu yu M <#UQ b32 (86) , " ` ߴ 0yu@ yq u yq u N <$ #M Q a4 (11) , " `  0yq u@ q  u q  u O < # Q `1 (3) , " `  0q  u@  B u  B u P <H # Q `0 (0) , " `  0 B uZ  s *E x  6UP (Cotton P et al, Gastroint Endoscopy 2009))NH  0޽h ? f3f3G FFWWF(    6@G^VN___PPT90(@@ JOverall complications of endoscopic sphincterotomy and related mortality ZJ0!0 Hcc c(#$0n %q  # #" P%q   <?Dq  > @`  B?%qD > @`HB  C %q%HB  C  q HB  C % HB   C q%q rp P  3 #" Pk)    <X?P > @`HB   C HB   C PPHB  C PHB  C P> ` # #"F: `+  <?"`H@8___PPT9@ g1.44(!" d   +  <x? "H@8___PPT9@ g1.54(!" d   +  <8z?t" H@8___PPT9@ g1.74(!" d   K  <\+?"tXPH___PPT9*"@ wPercent6(!" d  *  </? `"H@8___PPT9@ f104(!" d   *  <+? "H@8___PPT9@ f354(!" d   +  <\3?t "H@8___PPT9@ g1294(!" d   J  <@E? t"XPH___PPT9*"@ vNumber6(!" d  J  <M?^ ` XPH___PPT9*"@ vSepsis6(!" d  +  <TQ? `^ H@8___PPT9@ g2.14(!" d   +  < T? ^ H@8___PPT9@ g2.04(!" d   +  <X?t ^ H@8___PPT9@ g3.04(!" d   K  <h? t^ XPH___PPT9*"@ wPercent6(!" d  *  <l? ` H@8___PPT9@ f164(!" d   *  <o?  H@8___PPT9@ f484(!" d   +   <0i?t H@8___PPT9@ g2344(!" d   J ! <s? t XPH___PPT9*"@ vNumber6(!" d  L " <(? ` XPH___PPT9*"@ xBleeding6 (!" d  + # <V?= ` H@8___PPT9@ g4.74(!" d   + $ < V? =  H@8___PPT9@ g5.44(!" d   + % <V?t= H@8___PPT9@ g1.94(!" d   K & <V?= t XPH___PPT9*"@ wPercent6(!" d  * ' <V?&`= H@8___PPT9@ f354(!" d   + ( <_? &= H@8___PPT9@ g1274(!" d   + ) <D_?t& = H@8___PPT9@ g1484(!" d   J * <x_?&t= XPH___PPT9*"@ vNumber6(!" d  R + < _?x`&XPH___PPT9*"@ ~ Pancreatitis6 (!" d    + , <_?b`xH@8___PPT9@ g7464(!" d   , - <_? bxH@8___PPT9@ h23474(!" d   , . <_?tb xH@8___PPT9@ h77294(!" d   J / <X_?btxXPH___PPT9*"@ vNumber6(!" d  L 0 <D_?`bXPH___PPT9*"@ xPatients6 (!" d  ` 1 < _?`XPH___PPT9*"@ Prospective monocenter study6(!" d  a 2 <(%_? XPH___PPT9*"@ Prospective multicenter study6(!" d  d 3 <-_?t XPH___PPT9*"@  Retrospective multicenter review6!(!" d    I 4 <._?tXPH___PPT9*"@ uStudy6(!" d  Y 5 <x2_?`XPH___PPT9*"@ Rabenstein et al 19986(!" d  V 6 < 7_? XPH___PPT9*"@ Freeman et al 19966(!" d  U 7 <@;_?t XPH___PPT9*"@ Cotton et al 19916(!" d  J 8 <dA_?tXPH___PPT9*"@ vAuthor6(!" d  ZB 9 s *1 ?`ZB : s *1 ?`TB ; c $g  ?ZB < s *1 ?``ZB = s *1 ?`TB > c $g  ?ttTB ? c $g  ?  TB @ c $g  ?ZB A s *1 ?`ZB B s *1 ?b`bZB C s *1 ?x`xTB D c $g  ?tbtxTB E c $g  ? b xTB F c $g  ?bxZB G s *1 ?&`&ZB H s *1 ?= `= TB I c $g  ?t&t TB J c $g  ? & TB K c $g  ?& ZB L s *1 ? ` ZB M s *1 ? ` ZB N s *1 ? ` TB O c $g  ?t t^ TB P c $g  ? ^ TB Q c $g  ? ^ ZB R s *1 ?^ `^ ZB S s *1 ? ` ZB T s *1 ?"`"TB U c $g  ?t tTB V c $g  ? TB W c $g  ? H  0޽h ? 3380___PPT10.E )E!EDDD(    <_^VN___PPT90(@@ dRisk factors for post-ERCP pancreatitis identified by multivariate analysis in prospective studies Zd0 0 bccc,LB 0 # #"RF!0c  <,_?@{0XPH___PPT9*"@ !Failed clearing of biliary stones4"(" d! !p  <L_?@ {XPH___PPT9*"@ Pre-cut sphincterotomy4(" d .N  <t_?@  XPH___PPT9*"@ z Age under 604 (" d   y  <H_?  @0jbZ___PPT9<4@@  1.8 percentB (" d  "*  <P_? 0H@8___PPT9@ f21032(" d  a   < _?p 0XPH___PPT9*"@ Diagnostic and therapeutic ERCP4 (" d S   <_?0 p0XPH___PPT9*"@ Multicenter study4(" d R   <Y_? 00XPH___PPT9*"@ ~Masci et al 20014(" d L   <t^_?@]  XPH___PPT9*"@ x Female sex4 (" d   i   <a_?@ ] XPH___PPT9*"@ %Previous laparoscopic cholecystectomy4&(" d% %T  <f_?@  XPH___PPT9*"@ Pancreas divisum4(" d   <xk_?@  XPH___PPT9*"@ :Sphincterotomy frequency of the endoscopist (<40 per year)B;(" d9  4+ y  <o_? @ jbZ___PPT9<4@@  4.7 percentB (" d  ")  <t_?  H@8___PPT9@ e6332(" d  o  <x_?p  XPH___PPT9*"@ Endoscopic sphincterotomy4(" d * R  <_?0 p XPH___PPT9*"@ ~Monocenter study4(" d W  <_? 0 XPH___PPT9*"@ Rabenstein et al 19994(" d \  <_?@  XPH___PPT9*"@ Pancreatic opacification4(" d N  <_?@j XPH___PPT9*"@ z Age under 704 (" d   Q  <\5_?@jXPH___PPT9*"@ }Small bile duct4(" d   <_? @ jbZ___PPT9<4@@  1.6 percent*P (" d   "*  <V? H@8___PPT9@ f18272(" d  R  <hV?p XPH___PPT9*"@ ~Therapeutic ERCP4(" d S  <hV?0p XPH___PPT9*"@ Multicenter study4(" d V  <nV?0 XPH___PPT9*"@ Loperfido et al 19984(" d j  <rV?@XPH___PPT9*"@ (Number of pancreatic contrast injections4)(" d( (]  <wV?@LXPH___PPT9*"@ Difficulty of cannulation4(" d Y  <t{V?@LXPH___PPT9*"@ Precut sphincterotomy4(" d M   <V?@XPH___PPT9*"@ y Younger age4 (" d   n ! <V?@.XPH___PPT9*"@ *Suspected dysfunction of sphincter of Oddi4+(" d* *y " <V? .@jbZ___PPT9<4@@  5.4 percentB (" d  "* # <V?. H@8___PPT9@ f23472(" d   $ <V?p.XPH___PPT9*"@ !Endoscopic biliary sphincterotomy4"(" d! < S % <XV?0.pXPH___PPT9*"@ Multicenter study4(" d U & <V?.0XPH___PPT9*"@ Freeman et al 19964(" d Z ' <V?@.XPH___PPT9*"@ Independent risk factors4(" d y ( <xV? @.XPH___PPT9*"@ !Post- procedure pancreatitis rate4"(" d! ,T ) < V? .XPH___PPT9*"@ Number of patients4(" d U * <#V?p.XPH___PPT9*"@ Object of the study4(" d G + <(V?0p.XPH___PPT9*"@ sStudy4(" d H , <-V?0.XPH___PPT9*"@ tAuthor4(" d ZB - s *1 ?ZB . s *1 ?00TB / c $g  ?0ZB 0 s *1 ?0ZB 1 s *1 ?..TB 2 c $g  ?000TB 3 c $g  ?pp0TB 4 c $g  ?0TB 5 c $g  ?  0TB 6 c $g  ?@@0ZB 7 s *1 ?ZB 8 s *1 ?@ZB 9 s *1 ?@ZB : s *1 ?@LLZB ; s *1 ?@ZB < s *1 ?  ZB = s *1 ?@jjZB > s *1 ?@  ZB ? s *1 ?  ZB @ s *1 ?@  ZB A s *1 ?@  ZB B s *1 ?@] ] ZB C s *1 ?@  ZB D s *1 ?@{{H  0޽h ? 3380___PPT10.Y W WV ``V(    <9V7^VN___PPT90(@@ dRisk factors for post-ERCP pancreatitis identified by multivariate analysis in prospective studies Zd0 0 bccc,Lg#  # #":. zp{poooooz  <L:V?jbZ___PPT9<4@@ 91 or more injections of contrast into the pancreatic ductD:(!" d 7 "7_  < <='?  XPH___PPT9*"@ Pancreatic brush cytology6(!" d [ ? <DB'? XPH___PPT9*"@ Difficult cannulation6(!" d ] @ <E'?oXPH___PPT9*"@ Prior ERCP pancreatitis6(!" d \ A <J'?oXPH___PPT9*"@ Recurrent pancreatitis6(!" d { B <O'? : jbZ___PPT9<4@@  7.2 percentD (!" d  ", C <S'?@ : H@8___PPT9@ h12234(!" d  c D <XW'?@: XPH___PPT9*"@ Diagnostic and therapeutic ERCP6 (!" d T E <['?`: XPH___PPT9*"@ Monocenter study6(!" d Z F <_'?`: XPH___PPT9*"@ Vandervoort et al 20026(!" d ZB G s *1 ?`ZB H s *1 ?]]TB I c $g  ?]ZB J s *1 ?]ZB K s *1 ?: : TB L c $g  ?``]TB M c $g  ?]TB N c $g  ?@@]TB O c $g  ?  ]ZB P s *1 ?ooTB Q c $g  ?]ZB R s *1 ?ZB S s *1 ?  ZB T s *1 ?  ZB U s *1 ?  ZB V s *1 ?! ! ZB W s *1 ?  ZB X s *1 ?X X ZB Y s *1 ?  ZB Z s *1 ???ZB [ s *1 ?ZB \ s *1 ?`ZB ] s *1 ?@ZB ^ s *1 ?@ ZB _ s *1 ? ZB ` s *1 ?H  0޽h ? 3380___PPT10.Y % %%0&&$(    <s%J^VN___PPT90(@@ FIncidence and grading of post-endoscopic sphincterotomy pancreatitis ZF0 0 DcccR   z   # #"&     +  <s%?  H@8___PPT9@ g0.64(!" d )  <x%?v  H@8___PPT9@ e44(!" d +  <D{%? v H@8___PPT9@ g0.44(!" d )  <}%? H@8___PPT9@ e94(!" d Y  <(?  XPH___PPT9*"@ Severe pancreatitis6(!" d+   <m? H@8___PPT9@ g4.14(!" d *   <?v H@8___PPT9@ f264(!" d +   <%? v H@8___PPT9@ g5.04(!" d +   <%? H@8___PPT9@ g1184(!" d v   < %? XPH___PPT9*"@ Mild-moderate pancreatitis6(!" d.)  < ?H@8___PPT9@ e4(!" d +  <%?vH@8___PPT9@ g6334(!" d )  <%? vH@8___PPT9@ e4(!" d ,  <%? H@8___PPT9@ h23474(!" d V  <%?XPH___PPT9*"@ Number of patients6(!" dK  < %?XPH___PPT9*"@ wPercent6(!" dY  <%?vXPH___PPT9*"@ Number D(!" dK  <%? vXPH___PPT9*"@ wPercent6(!" dJ  <%? XPH___PPT9*"@ vNumber6(!" dZ  <Ԫ%?vXPH___PPT9*"@ Rabenstein et al, 19986(!" dW  <8%?vXPH___PPT9*"@ Freeman et al, 19966(!" d)  <%?H@8___PPT9@ e4(!" d ZB  s *1 ?ZB  s *1 ?  TB  c $g  ? ZB  s *1 ? ZB  s *1 ?ZB  s *1 ?TB   c $g  ? TB ! c $g  ?vv TB " c $g  ?  TB # c $g  ? ZB $ s *1 ?ZB % s *1 ?   & <p%  PH@___PPT9"@ 3Data from Freeman, et al, Endoscopy 1998; 30:A184. H40 1c c c,,H  0޽h ? 3380___PPT10.X`:  $(  r  S tPp`   r  S 0 p  H  0޽h ? f3f3   $(  r  S dP   r  S    H  0޽h ? f3f3  @$(  r  S 0)P  ) r  S )  ) H  0޽h ? f3f3> ==AA=(    <V`^VN___PPT90(@@ )gPharmaceutical agents evaluated for the prevention of post-ERCP amylase elevation and/or pancreatitis Zg0 0 ecccD:W9 @ # #"rf@~  < Q_?90jbZ___PPT9<4@@ 5-fluorouracilD(!" d  " O  <0_?09XPH___PPT9*"@ { Metabolites6 (!" d   U  <_?90XPH___PPT9*"@ Sodium selenite6(!" d k  <V?9XPH___PPT9*"@ N-acetyl cysteine6(!" d ,g  <V?9 XPH___PPT9*"@  Beta-carotene6(!" d  ,g   < V? 90XPH___PPT9*"@  Anti-oxidants6(!" d  ,P   <V?9  XPH___PPT9*"@ | Diclofenac6 (!" d   R   <V?9`  XPH___PPT9*"@ ~Interleukin-106(!" d S   <|V?9 ` XPH___PPT9*"@ Corticosteroids6(!" d Q   <DV?9@  XPH___PPT9*"@ } Allopurinol6 (!" d   r  <V?@ 9 XPH___PPT9*"@ Anti-inflammatory agents6(!" d ,O  <pV?9 @ XPH___PPT9*"@ { Antibiotics6 (!" d   X  <8V? 9@ XPH___PPT9*"@ Antimicrobial agents6(!" d Q  <V?9  XPH___PPT9*"@ } Ulinastatin6 (!" d   L  <V?9  XPH___PPT9*"@ xHeparins6 (!" d Y  <V?9  XPH___PPT9*"@ C1-esterase inhibitor6(!" d j  <,V?9p XPH___PPT9*"@ Gabaexate mesilate6(!" d * O  <V?9pXPH___PPT9*"@ { Aprotinin6 (!" d   e  <LV?9 XPH___PPT9*"@ !Inhibition of protease activation6"(!" d! !O  <V?9PXPH___PPT9*"@ { Lidocaine6 (!" d   S  <lV?9PXPH___PPT9*"@ Botulinum toxin6(!" d k  <V?90XPH___PPT9*"@ Glyceryltrinitrate6(!" d * P  <V?90XPH___PPT9*"@ | Nifedipine6 (!" d   _  <V?9XPH___PPT9*"@ Reduction of sphincter tone6(!" d N  < V?9XPH___PPT9*"@ zSecretin6 (!" d   <U?9XPH___PPT9*"@ CStimulation of pancreatic secretion and reduction of sphincter tone6D(!" dC CP  <DU?9XPH___PPT9*"@ | Calcitonin6 (!" d   N  <U?9XPH___PPT9*"@ zGlucagon6 (!" d P   <U?9`XPH___PPT9*"@ | Octreotide6 (!" d   R ! <ȷU?9`XPH___PPT9*"@ ~ Somatostatin6 (!" d   f " <PU?9XPH___PPT9*"@ "Inhibition of pancreatic secretion6#(!" d" "J # <U?9@XPH___PPT9*"@ vAgents6(!" d b $ <U?@9XPH___PPT9*"@ Postulated mechanism of action6(!" d ZB % s *1 ?ZB & s *1 ?9@9ZB ' s *1 ?ZB ( s *1 ?9``ZB ) s *1 ?9ZB * s *1 ?9ZB + s *1 ?ZB , s *1 ?ZB - s *1 ?900ZB . s *1 ?9ZB / s *1 ?9PPZB 0 s *1 ?  ZB 1 s *1 ?9ppZB 2 s *1 ?9  ZB 3 s *1 ?9  ZB 4 s *1 ?9  ZB 5 s *1 ?@ @ ZB 6 s *1 ?  ZB 7 s *1 ?9  ZB 8 s *1 ?9` ` ZB 9 s *1 ?9  ZB : s *1 ?00ZB ; s *1 ?9ZB < s *1 ?9`B = 01 ?@@`B > 01 ?@`B ? 01 ?@`B @ 01 ? A BrUwPH@___PPT9"@ #Courtesy of Silvano Loperfido, MD. 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