Pancreatitis remains the most common and potentially fatal complication following ERCP. Various pharmacological agents have been used in an attempt to prevent post-ERCP
pancreatitis, but most randomized controlled trials have failed to demonstrate their efficacy.
Antiproteases, which have been clinically used to manage
acute pancreatitis, would theoretically reduce pancreatic injury after ERCP because activation of
proteolytic enzymes is considered to play an important role in the pathogenesis of post-ERCP
pancreatitis.
Gabexate and
ulinastatin have recently been evaluated regarding their efficacy in preventing post-ERCP
pancreatitis. Long-term (12 hours) infusion of
gabexate significantly decreased the incidence of post-ERCP
pancreatitis; however, no prophylactic effect was observed for short-term infusion (2.5 and 6.5 hours). These results may be due to the short-life of
gabexate (55 seconds). Since long-term infusion requires additional hospitalization, the use of
gabexate in all patients at average risk of developing post-ERCP
pancreatitis is an expensive strategy.
Ulinastatin has a half-life of 35 minutes and can be given as a bolus infusion. Short-term (10 minutes) administration of
ulinastatin showed a significant reduction in the incidence of post-ERCP
pancreatitis in one randomized controlled trial.
Ulinastatin is superior to
gabexate in terms of cost because it does not require additional hospitalization. At present, there is no other randomized, placebo-controlled trial on
ulinastatin under way. Large scale randomized controlled trials revealed that both the long-term infusion of
gabexate and the short-term administration of
ulinastatin may reduce pancreatic injury, but these studies involve patients at average risk of developing post-ERCP
pancreatitis. Additional research is needed to confirm the preventive efficacy of these
antiproteases in patients at a high risk of developing post-ERCP
pancreatitis.