Correspondence
Aggressive hydration the subset of people who develop 3 Warndorf MG, Kurtzman JT, Bartel MJ, et al.
Early fluid resuscitation reduces morbidity
post-ERCP pancreatitis and thereby
and post-ERCP attenuate its course. Development
among patients with acute pancreatitis.
Clin Gastroenterol Hepatol 2011; 9: 705–09.
pancreatitis and validation of predictors of post- 4 Choi JH, Kim HJ, Lee BU, Kim TH, Song IH.
Vigorous periprocedural hydration with
ERCP pancreatitis and markers of lactated Ringer’s solution reduces the risk of
The rigorous multicentre randomised early post-ERCP pancreatitis to help pancreatitis after retrograde
cholangiopancreatography in hospitalized
controlled trial comparing combi to tailor therapy merit evaluation. patients. Clin Gastroenterol Hepatol 2017;
nation therapy with aggressive Additionally, although Sperna Weiland 15: 86–92.
hydration and non-steroidal anti- and colleagues compellingly showed 5 Avila P, Holmes I, Kouanda A, Arain M, Dai SC.
Practice patterns of post-ERCP pancreatitis
inflammatory drugs (NSAIDs) versus that the benefit of an 8 h infusion is prophylaxis techniques in the United States:
NSAIDs alone for prevention of not worth the time and labour that is a survey of advanced endoscopists.
Gastrointest Endosc 2020; 91: 568–73.
pancreatitis occurring after endoscopic required, the role of more rapid and
retrograde cholangiopancreatography bolus fluid administration will likely be
(ERCP) by Christina Sperna Weiland and the subject of future study. Authors’ reply
colleagues represents an important A final crucial question is how to James Buxbaum argues that peri
study in the field of evidence-based measure the incremental benefit procedural hydration could ameliorate
pancreatology. 1 The concept of of new therapies in addition to the disease course of post-endoscopic
aggressive hydration for prophylaxis proven agents. In the initial trials retrograde cholangiopancreatography
of pancreatitis emerged from animal of aggressive hydration to prevent pancreatitis (ERCP) and that the
models correlating diminished post-ERCP pancreatitis, few patients co-administration of non-steroidal
perfusion with pancreatic necrosis received rectal NSAIDs.4 In the interim, anti-inflammatory drugs (NSAIDs)
and observational human cohorts NSAID prophylaxis has evolved into might have obscured the effect.
suggesting that early aggressive the standard of care.5 Sperna Weiland Buxbaum might be right; our dataset
fluid resuscitation improves clinical and colleagues designed their trial to points in that direction and a study
outcomes for acute pancreatitis.2,3 show a 60% reduction of post-ERCP of periprocedural hydration in
Sperna Weiland and colleagues pancreatitis to match the performance patients who did not receive rectal
indicated that hydration does not of NSAIDs versus placebo.1 Never NSAIDs reported similar results.1,2
diminish post-ERCP pancreatitis by a theless, it seems more plausible The question is whether early
clinically significant amount in people that in patients already receiving periprocedural hydration is better at
already receiving NSAID prophylaxis. an agent with strong efficacy, such preventing a severe disease course
Nevertheless, there are several as NSAIDs, the favourable effect than is aggressive hydration once
concepts that merit consideration. of additional therapies could be of post-ERCP pancreatitis is ongoing.
One issue is whether post-ERCP smaller but still crucial magnitude. The window of opportunity for
pancreatitis represents a continuous Incremental improvement is the attenuating the disease course is
clinical process of degrees ranging strategy underlying combination thought to be up to 72 h after the
from subclinical to severe disease therapy to control HIV, malignancy, start of abdominal pain.3 Buxbaum
or whether it is a discrete event. and cardiovascular disease. rightly considers a targeted approach
As measured by use of the revised I declare no competing interests. and suggests providing fluid
Atlanta criteria there was a trend resuscitation in people who are in the
towards fewer patients with
James Buxbaum early stages of post-ERCP pancreatitis
jbuxbaum@[Link]
moderate and severe pancreatitis rather than the uniform preventive
Division of Gastrointestinal and Liver Diseases,
in the aggressive hydration group strategy used in our trial. Although
Department of Medicine, Keck School of Medicine,
than in the control group (p=0·089) University of Southern California, Los Angeles, this concept requires examination in
in the trial. 1 Thus, whether the CA 90033–1370, USA a rigorous trial, biomarkers to guide
therapy in combination with NSAIDs 1 Sperna Weiland CJ, Smeets X, Kievit W, et al. the early prediction of post-ERCP
has zero efficacy or a possible Aggressive fluid hydration plus non-steroidal pancreatitis are scarce. Additionally,
anti-inflammatory drugs versus non-
incremental role to prevent the most steroidal anti-inflammatory drugs alone an ongoing debate exists on the ideal
serious consequences of post-ERCP for post-endoscopic retrograde hydration schedule in patients with
cholangiopancreatography pancreatitis
pancreatitis is unclear. (FLUYT): a multicentre, open-label, acute pancreatitis.4
A related concept is whether randomised, controlled trial. To date, no study of periprocedural
Lancet Gastroenterol Hepatol 2021; 6: 350–58.
periprocedural aggressive resuscitation 2 Kinnala PJ, Kuttila KT, Gronroos JM, Havia TV,
hydration has been powered to detect
might not prevent post-ERCP Nevalainen TJ, Niinikoski JH. Splanchnic and a difference in severity of post-ERCP
pancreatitis development but pancreatic tissue perfusion in experimental pancreatitis. To attain an adequately
acute pancreatitis. Scand J Gastroenterol 2002;
might provide early treatment for 37: 845–49. powered cohort, it is desirable to do a
686 [Link]/gastrohep Vol 6 September 2021
Correspondence
trial in patients who are at the highest Stringent criteria for inflammation, defined as a Nancy index
risk for post-ERCP pancreatitis. of 2 or more, at baseline. It would be
However, a universally used risk
withdrawal of biologics valuable to know the baseline Nancy
stratification system for post-ERCP in ulcerative colitis scores of patients who relapsed, which
pancreatitis does not exist, especially might suggest that deeper histological
for risk stratification before the start We read with great interest the Article remission would be a better target.
of ERCP. Considerable variability by Taku Kobayashi and colleagues, 1 An MES of 1 has been shown to
exists among studies in stratifying which evaluated the effects of correlate poorly with histological
patients as high, moderate, or low discontinuing infliximab in patients activity, with half of patients
risk for post-ERCP pancreatitis, which with ulcerative colitis in remission. with an MES of 1 having features
can be explained by the absence of The pragmatic design of this of acute inflammation (crypt
a clear definition in international randomised trial allowed physicians abscesses, neutrophils, erosions)
guidelines.5 Risk factors addressed to reintroduce treatment without on histopathology. 4 Perhaps it is
in the guidelines are mostly based endoscopic assessment. A nocebo- time to abandon an MES of 1 as a
on old studies, and evidence exists like effect from discontinuation therapeutic goal. A more stringent
suggesting that risk factors identified of treatment could contribute to target of an MES of 0 or an Ulcerative
before the era of rectal NSAIDs as symptoms, leading to additional Colitis Endoscopic Index of Severity
standard of care are not applicable in treatment. It would be informative (UCEIS) score of 1 or less could be used
modern populations. to know the various reasons why before cessation of biologics, as these
We declare no competing interests. patients failed to remain in remission scores have stronger correlation with
at 48 weeks, and the proportion of histological remission, thus predicting
*Christina J Sperna Weiland, relapsed patients who had endoscopic sustained remission.5
Xavier J N M Smeets, Devica S Umans,
assessment. We suggest that a combination
Joost P H Drenth, Erwin J M van Geenen,
The 54·3% rate of remission at week of parameters—persistent clinical or
on behalf of the Dutch Pancreatitis
Study Group 48 in the group who discontinued endoscopic remission for 36 months
[Link]@[Link] infliximab is low compared with rates or longer, faecal calprotectin of
from previous retrospective studies, 125 µg/g or less, Nancy index of 1 or
Department of Gastroenterology and Hepatology,
Radboudumc, Nijmegen 6525 GA, Netherlands which range from 64·7% to 83·5%.2 less, an MES of 0 or UCEIS of 1 or less—
(CJSW, JPHD, EJMvG); Department of We wonder if the remission rates would strongly predict a favourable
Gastroenterology and Hepatology, Jeroen Bosch in Kobayashi and colleagues’ trial course after biologics cessation.
Hospital, Den Bosch, Netherlands (XJNMS);
Department of Research and Development, could have been improved with There is still a role for infliximab
St Antonius Hospital, Nieuwegein, modifications made to the inclusion withdrawal in well selected patients
Netherlands (DSU) criteria. Patients in clinical remission who have a keen preference to stop
1 Choi J-H, Kim HJ, Lee BU, Kim TH, Song IH. for 6 months or longer were enrolled. treatment with biologics. Shared
Vigorous periprocedural hydration with
lactated Ringer’s solution reduces the risk of Longer remission predicts a favourable decision making, a good patient–
pancreatitis after retrograde disease course; many studies physician relationship, and close
cholangiopancreatography in hospitalized
patients. Clin Gastroenterol Hepatol 2017;
evaluating the relapse rate in ulcerative surveillance after cessation are
15: 86–92. colitis included patients who were essential to keep our patients well.
2 Sperna Weiland CJ, Smeets XJNM, Kievit W, in clinical remission for more than MT reports personal fees from Ferring, Johnson &
et al. Aggressive fluid hydration plus
non-steroidal anti-inflammatory drugs versus 12 months before discontinuation.2 Johnson, Pfizer, and Takeda. WC reports personal
fees from Johnson & Johnson, Pfizer, and Takeda.
non-steroidal anti-inflammatory drugs alone In Crohn’s disease, longer duration of All other authors declare no competing interests.
for post-endoscopic retrograde
cholangiopancreatography pancreatitis
remission before treatment withdrawal
(FLUYT): a multicentre, open-label, is associated with higher likelihood of *Malcolm Tan, Valerie Ng,
randomised, controlled trial. remaining well.3 Clinical remission of Chong Teik Lim, Wei-Qiang Leow,
Lancet Gastroenterol Hepatol 2021; 6: 350–58.
at least 12 months for patients with Webber Chan
3 Sarr MG. Early fluid ‘resuscitation/therapy’ in
acute pancreatitis: which fluid? What rate? ulcerative colitis could be considered [Link].t.k@[Link]
What parameters to gauge effectiveness?
Ann Surg 2013; 257: 189–90.
before treatment withdrawal. Department of Gastroenterology and Hepatology
(MT, CTL, WC), Department of Pharmacy (VN), and
4 Haydock MD, Mittal A, Wilms HR, Phillips A, The use of histological remission as a Department of Anatomical Pathology (W-QL),
Petrov MS, Windsor JA. Fluid therapy in acute predictor of remission after treatment Singapore General Hospital, 169608, Singapore
pancreatitis: anybody’s guess. Ann Surg 2013;
257: 182–88. withdrawal is unknown. Kobayashi 1 Kobayashi T, Motoya S, Nakamura S, et al.
5 Smeets XJNM, Bouhouch N, Buxbaum J, et al. and colleagues’ study included patients Discontinuation of infliximab in patients with
The revised Atlanta criteria more accurately ulcerative colitis in remission (HAYABUSA):
with a Mayo endoscopic subscore a multicentre, open-label, randomised
reflect severity of post-ERCP pancreatitis
compared to the consensus criteria. (MES) of 1 or less, with 13 (19%) of controlled trial. Lancet Gastroenterol Hepatol
2021; 6: 429–37.
United Eur Gastroenterol J 2019; 7: 557–64. 69 patients having histologically active
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