Rectal Indomethacin plus Lactated Ringer’s for Prophylaxis of Post-ERCP Pancreatitis in Children

Background and study aims: Pediatric data on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prophylaxis remains limited. This study evaluated the effectiveness and safety of combined rectal indomethacin and lactated Ringer’s (LR) as prophylaxis for PEP in children undergoing ERCP.

Patients and methods: We retrospectively reviewed all pediatric ERCPs performed at a single tertiary center (2012– 2025). The study group consisted of procedures performed after 2021, when a standardized prophylaxis protocol (100 mg rectal indomethacin before ERCP plus LR at 2.5 L·m-2, started 2 hours before and continued 6 hours after) was implemented. Procedures performed before 2021 served as the control group. Primary and secondary endpoints were the development of PEP and cholangitis, respectively. Analyses considered American Society for Gastrointestinal Endoscopy (ASGE) procedural complexity, stent placement/type, and naive papilla status.

Results: Seventy-five children underwent 95 ERCPs (prophylaxis group: 23 patients/38 procedures; control group: 55 patients/65 procedures). Baseline demographic and procedural characteristics were similar between the prophylaxis and control groups. Post-ERCP pancreatitis developed in 13.2% of procedures in the prophylaxis group and 13.8% in the control group (RD −0.7%; 95% CI −18.5 to 19.9; p = 1.000). Cholangitis developed in 5.3% of procedures in the prophylaxis group and 7.7% in the control group (RD −2.4%; 95% CI −15.3 to 14.0; p = 1.000). Adjustment for stent type did not meaningfully alter the associations between prophylaxis and outcomes. All PEP cases were mild to moderate. No treatment-related adverse events—including indomethacin-associated gastrointestinal or renal complications, or fluid-overload events—were observed in either group.

Conclusions: Combined rectal indomethacin plus LR was feasible and well tolerated in pediatric ERCP but did not significantly reduce PEP or cholangitis. These findings highlight the need for larger, multicenter pediatric trials to define optimal prophylaxis.

Keywords: preventive therapy, hydration protocol, nonsteroidal antiinflammatory drug.