{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 28, Ep 1 of 7: Safe Cannulation and PEP Prophylaxis","html":"","width":"100%","height":180,"duration":641,"description":"Episode one of the ERCP and EUS Procedures chapter starts from the single fact that reorganizes everything: ERCP is a therapy, not a test, so you earn the right to do it only when a non-invasive study cannot answer the question. From there the whole episode is risk management. Wire-guided cannulation replaces the hydraulic contrast push that floods the pancreatic duct, difficult-cannulation maneuvers each solve one anatomic problem, and the prophylaxis stack is held by mechanism because the mechanisms tell you who needs which. The organizing thread: find the duct by guidance, then stack indomethacin, a pancreatic duct stent, and lactated Ringer on the patient whose risk factors say the pancreas will react.\n \nTopics covered\n\nERCP as therapy, not a diagnostic test\nPost-ERCP pancreatitis risk and mechanism\nWire-guided versus contrast-first cannulation\nDifficult-cannulation escalation and EUS rendezvous\nRectal indomethacin prophylaxis\nProphylactic pancreatic duct stent\nAggressive lactated Ringer hydration\nHigh-risk patient profile and protective chronic pancreatitis\n \n \nKey decisions\n\nReserve ERCP for therapeutic intent (stone extraction, stricture stenting, cholangitis decompression, leak repair); if you only need to image the ducts, order MRCP or EUS, which carry no pancreatitis risk.\nUse wire-guided cannulation rather than contrast-first, because threading a soft hydrophilic guidewire avoids the hydraulic acinarization injury that flooding the pancreatic duct with contrast produces.\nGive rectal indomethacin one hundred milligrams before every native-papilla ERCP, timed pre-procedure so the drug is therapeutic at the moment of cannulation.\nIn high-risk patients keep the prophylactic pancreatic duct stent on top of indomethacin, not instead of it, since indomethacin alone was not non-inferior to indomethacin plus a stent.\nRun lactated Ringer at three milliliters per kilogram per hour during the procedure, a twenty milliliter per kilogram bolus immediately after,...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}