Authors (including presenting author) :
CW Chow (1), SY Cheung (2,3), HK Wong (1), Rita Leung (2), NK Wong (3), LS Lee (1), Yvonne Lai (1), Jeffrey WC Lai (1), CY Shum (1), CK Wong (1), KY Chan (1), WY Chui (1), Steven WC Tsang (1)
Affiliation :
(1) Medicine, Tseung Kwan O Hospital (TKOH)
(2) Combined Endoscopy Unit, TKOH
(3) Day Medical Centre, TKOH
Introduction :
Endoscopic-retrograde-cholangiopancreatography (ERCP) is a common endoscopic procedure. Post-ERCP pancreatitis (PEP) is a common and serious adverse event. Incidence of PEP varies from 3.5%-9.7% and reported PEP mortality is 0.1-0.7%. PEP also results in patient dissatisfaction, longer hospital length-of-stay and higher medical cost. Peri-ERCP intravenous fluid (IVF) and per-rectal (PR) diclofenac can reduce the rate and severity of PEP. We aim to enhance the adherence of both prophylactic treatments in ERCP cases performed by Department of Medicine, Tseung Kwan O Hospital (TKOH).
Objectives :
Facilitate utilization of prophylactic treatments to reduce incidence and severity of PEP
Methodology :
In May 2019, we created a chop reminding endoscopists to prescribe peri-procedural Hartmann's solution and PR diclofenac if not contraindicated. If patients were not on IVF, IVF was initiated immediately after ERCP. In June 2021, to further enhance quality and safety, IVF was pre-prescribed at the time of ERCP booking in specialist outpatient clinic. IVF was given to all patients upon Day Medical Centre admission 4-6 hours before ERCP.
Result & Outcome :
From May 2019 to October 2020, 303 ERCP procedures were performed, with 161 (53%) male patients. The median age was 76 years (range 18-97). PEP occurred in 11/303 (3.6%) of the cases. In contrast to a TKOH ERCP audit in 2011, PEP occurred in 29/331 patients (8.8%), a reduction from 8.8% to 3.6% (p=0.008, Chi Square test).
Among the 11 PEP cases, all were mild in severity using the revised Atlanta classification. No mortality was reported. PR diclofenac was prescribed in 146/303 (48%) and IVF was given in 296/303 (98%) of cases. Among patients on IVF, 247/296 (83%) of the cases were given Hartmann's solution. Only one patient developed congestive heart failure two days after ERCP, which was managed successfully with diuretics.
In conclusion, a simple chop reminder and prompt prescription of PR diclofenac and IVF had led to a significant reduction in PEP. Furthermore, all PEPs were classified as mild in severity and no mortality occurred.
