The Effect of Epinephrine Sprayed on the Papilla on Prevention of Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP); a Double-Blind Randomized Control Trial

  • samaneh kakhki Mail
  • Tahereh Sarboozi Hoseinabadi
  • Abbas Esmaeilzadeh
  • Omid Shadkam
Pancreatitis, Epinephrine, ERCP


Acute pancreatitis is the most common and serious complication of Endoscopic Retrograde Cholangiopancreatography (ERCP). The use of effective medicines with low side effects should be considered in the process of RCP due to acute pancreatitis prevention. Therefore, we investigate the effects of epinephrine sprayed on the papilla in this study. This randomized clinical trial was performed on 343 patients referred to the ERCP Department of Imam Reza Hospital and Apadana Clinic, Mashhad, Iran. About 10 ml of diluted epinephrine (case group) or normal saline (control group) were sprayed on the papilla before diagnostic ERCP. Afterward, the two groups were assessed in terms of post-ERCP pancreatitis. The data were analyzed using Statistical Package for the Social Sciences (SPSS) software, version 20. The level of significance was considered to be 0.05. The overall results of this study indicated that post-ERCP pancreatitis occurred in 4.95% of the patients. Mild pancreatitis was diagnosed in five patients of the case group and three patients of the control group, respectively. Moderate pancreatitis was diagnosed in three patients of the case group and three patients of the control group. Only one patient in the case group and two patients in the control group were shown to have severe pancreatitis. Moreover, there was no significant difference between the incidence of pancreatitis between the two groups (P>0.05). With regard to the findings of this study, it appears that the topical application of epinephrine is not effective in preventing post-ERCP pancreatitis.


1. Freeman ML. Complications of endoscopic retrograde cholangiopancreatography: avoidance and management. Gastrointestinal endoscopy clinics of North America. 2012;22(3):567-86.
2. Kemppainen E, Hedström J, Puolakkainen P, Halttunen J, Sainio V, Haapiainen R, et al. Increased serum trypsinogen 2 and trypsin 2-α1antitrypsin complex values identify endoscopic retrograde cholangiopancreatography-induced pancreatitis with high accuracy. Gut. 1997;41(5):690-5.
3. Zheng M, Bai J, Yuan B, Lin F, You J, Lu M, et al. Meta-analysis of prophylactic corticosteroid use in post-ERCP pancreatitis. BMC Gastroenterology. 2008;8(1):6.
4. Schwartz JJ, Lew RJ, Ahmad NA, Shah JN, Ginsberg GG, Kochman ML, et al. The effect of lidocaine sprayed on the major duodenal papilla on the frequency of post-ERCP pancreatitis. Gastrointestinal endoscopy. 2004;59(2):179-84.
5. Wehrmann T, Schmitt T, Stergiou N, Caspary W, Seifert H. Topical application of nitrates onto the papilla of Vater: manometric and clinical results. Endoscopy. 2001;33(04):323-8.
6. Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointestinal endoscopy. 2004;59(7):845-64.
7. Igawa M, Miyaoka M, Saitoh T. Influence of topical epinephrine application on a microcirculatory disturbance in subjects with ulcerative colitis evaluated by laser Doppler flowmetry and transmission electron microscopy. Digestive Endoscopy. 2000;12(2):126-30.
8. Panteghini M, Pagani F, Alebardi O, Lancini G, Cestari R. Time course of changes in pancreatic enzymes, isoenzymes and, isoforms in serum after endoscopic retrograde cholangiopancreatography. Clinical chemistry. 1991;37(9):1602-5.
9. Matsushita M, Takakuwa H, Shimeno N, Uchida K, Nishio A, Okazaki K. Epinephrine sprayed on the papilla for prevention of post-ERCP pancreatitis. Journal of Gastroenterology. 2009;44(1):71-5.
10. Ohashi A, Tamada K, Tomiyama T, Wada S, Higashizawa T, Gotoh Y, et al. Epinephrine irrigation for the prevention of pancreatic damage after endoscopic balloon sphincteroplasty. Journal of gastroenterology and hepatology. 2001;16(5):568-71.
11. Edlund H. Pancreatic organogenesis--developmental mechanisms and implications for therapy. Nature Reviews Genetics. 2002;3(7):524.
12. Nakaji K, Suzumura S, Nakae Y, Kojima K, Kumamoto M, Kozu T. Effects in the control of edema of the papilla of Vater by epinephrine saline irrigation after endoscopic retrograde cholangiopancreatography in an endoscopy center in Japan, 2003 to 2007: exploratory retrospective analysis to evaluate the characteristics of eligible patients with a focus on serum amylase levels. Internal Medicine. 2009;48(12):945-52.
13. Akshintala V, Hutfless S, Colantuoni E, Kim K, Khashab M, Li T, et al. Systematic review with network meta‐analysis: pharmacological prophylaxis against post‐ERCP pancreatitis. Alimentary pharmacology & therapeutics. 2013;38(11-12):1325-37.
14. Dumonceau J-M, Andriulli A, Devière J, Mariani A, Rigaux J, Baron T, et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pancreatitis. Endoscopy. 2010;42(06):503-15.
15. Xu LH, Qian JB, Gu LG, Qiu JW, Ge ZM, Lu F, et al. Prevention of post‐endoscopic retrograde cholangiopancreatography pancreatitis by epinephrine sprayed on the papilla. Journal of gastroenterology and hepatology. 2011;26(7):1139-44.
16. Kubiliun NM, Adams MA, Akshintala VS, Conte ML, Cote GA, Cotton PB, et al. Evaluation of pharmacologic prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a systematic review. Clinical Gastroenterology and Hepatology. 2015;13(7):1231-9.
17. Freeman M. Complications of Endoscopic Retrograde Cholangiopancreatography. Avoidance and Management2012. 567-86 p.
18. Freeman ML, DiSario JA, Nelson DB, Fennerty MB, Lee JG, Bjorkman DJ, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointestinal endoscopy. 2001;54(4):425-34.
19. Pezzilli R, Romboli E, Campana D, Corinaldesi R. Mechanisms involved in the onset of post-ERCP pancreatitis. Jop. 2002;3(6):162-8.
20. Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointestinal endoscopy. 2005;62(3):367-70.
21. Kawaguchi Y, Ogawa M, Omata F, Ito H, Shimosegawa T, Mine T. Randomized controlled trial of pancreatic stenting to prevent pancreatitis after endoscopic retrograde cholangiopancreatography. World journal of gastroenterology: WJG. 2012;18(14):1635.
How to Cite
kakhki samaneh, ALIPOUR A, Sarboozi Hoseinabadi T, Esmaeilzadeh A, Shadkam O. The Effect of Epinephrine Sprayed on the Papilla on Prevention of Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP); a Double-Blind Randomized Control Trial. Acta Med Iran. 58(9):456-460.