Rectal indomethacin with topical epinephrine versus indomethacin alone for preventing Post-ERCP pancreatitis - A systematic review and meta-analysis

Pancreatology. 2020 Apr;20(3):356-361. doi: 10.1016/j.pan.2020.02.003. Epub 2020 Feb 19.


Background: Recent studies have compared the utility of rectal indomethacin with topical epinephrine (IE) sprayed on duodenal papilla and rectal indomethacin alone (IS) to prevent post-ERCP pancreatitis (PEP) with conflicting results. We performed a systematic review and meta-analysis to evaluate the benefit of using the combination prophylaxis as oppose to rectal indomethacin alone.

Methods: The following database were searched for our systematic review: PubMed∖Medline, Embase, Cochrane, and Web of Science. We included both randomized controlled trials (RCTs) and cohort studies. Primary outcome was incidence of PEP and secondary outcomes were adverse events and mortality.

Results: A total of 3 studies (all RCTs) with 2244 patients (1132 in IS and 1112 in IE group) were included. The IE group did not demonstrate any significant benefit over IS group in preventing PEP (RR: 1.15, 95% CI 0.62-2.2), mortality (RR: 0.85, 95% CI 0.22-3.24) or overall adverse events (RR: 1.3, 95% CI 0.93-1.7).

Conclusion: The combination of rectal indomethacin and topical epinephrine failed to demonstrate any benefit over indomethacin alone in preventing PEP, decreasing mortality and overall adverse events.

Keywords: ERCP; Epinephrine; Indomethacin; Pancreatitis; Post-ERCP pancreatitis.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Administration, Rectal
  • Anti-Inflammatory Agents, Non-Steroidal / administration & dosage*
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use*
  • Cholangiopancreatography, Endoscopic Retrograde / adverse effects*
  • Epinephrine / administration & dosage*
  • Epinephrine / therapeutic use*
  • Humans
  • Indomethacin / administration & dosage*
  • Indomethacin / therapeutic use*
  • Pancreatitis / drug therapy*
  • Pancreatitis / etiology*
  • Vasoconstrictor Agents / administration & dosage*
  • Vasoconstrictor Agents / therapeutic use*


  • Anti-Inflammatory Agents, Non-Steroidal
  • Vasoconstrictor Agents
  • Indomethacin
  • Epinephrine