Neither the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopic retrograde cholangiopancreatography (ERCP) use in choledocholithiasis nor the European Society of Gastrointestinal Endoscopy (ESGE) guidelines for ERCP papillary cannulation and sphincterotomy techniques discuss the use of pharmacologic agents to improve the procedure success rate. The guidelines seem to focus on techniques and the different settings regarding the application of ERCP. [1], [2]
A meta-analysis of randomized controlled trials (RCTs) evaluated the effect of prophylactic glycerin trinitrate (GTN) which found it to be effective for reducing the overall incidence of post-ERCP pancreatitis and hyperamylasemia but did not reduce rates of cannulation. From 12 studies (N=2,649), the risk ratio (RR) for incidence of post-ERCP pancreatitis (PEP) was 0.67 (95% confidence interval [CI] 0.52 to 0.87). However, rates of moderate to severe PEP were not reduced (RR 0.70; 95% CI, 0.42 to 1.15). There was less incidence of hyperamylasemia with GTN treatment (RR 0.69; 95% CI 0.54 to 0.90). The cannulation success rate was not different between GTN and control (RR 1.03; 95% CI 0.99 to 1.06). Intravenous GTN may be associated with greater rates of adverse events, with some studies noting dose reduction or cessation of infusion. [3]
A previous meta-analysis also found that GTN had a lower risk of post-ERCP pancreatitis versus placebo with a reported overall pooled risk (OR) of 0.56 (95% CI 0.40 to 0.79; p=0.001). The analysis consisted of 7 randomized controlled trials (N=1,854). The sublingual form may have been more effective than the transdermal form (p=0.007 versus p=0.05); however, there was no difference between GTN and placebo regarding the overall rate of successful cannulation of bile ducts (RR 0.99; 95% CI 0.93 to 1.06). Hypotension and headache were the most reported adverse events. [4]
A review examined common miscellaneous pharmacologic agents used in interventional radiology which included bowel antiperistalsis agents among other classes (e.g., vasodilators, vasoconstrictors, antiemetics, prothrombotics). Aside from glucagon’s main utility in digital subtraction arteriography for abdominal vascular procedures, glucagon can facilitate other abdominal procedures including biopsies, abscess drainage, esophageal or colonic stenting, and gastrostomy tube placement. Glucagon decreased pyloric opening, trapping the gas in the stomach. This allowed for smooth gastrostomy tube placement for feeding. Since glucagon will hinder the ability of wire or catheter placement beyond the pylorus, its use should be avoided for gastrojejunostomy tube placement. This is as far as the review provided information on glucagon use in gastrostomy tube placement. [5]
Another review described a technique for routine percutaneous radiological gastrostomy catheter placement. Given the variations on the method used for percutaneous gastrostomy placements among radiology departments, only the key features of a routine placement were discussed. During the preparation step where the proposed puncture site is prepped, draped, and anesthetized with lignocaine, the authors noted that some institutions may use 0.5 to 1.0 mg of IV glucagon prior to gastric distension to inhibit gastric motility and emptying. [6]