Endoscopic retrograde cholangiopancreatography in the diagnosis and management of pancreatic diseases

Value and safety of ERCP and endoscopic treatment for acute biliary pancreatitis

AIM

To evaluate the value and safety of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic treatment in acute biliary pancreatitis.

METHODS

Ninety-one patients with acute biliary pancreatitis including 13 patients with severe acute biliary pancreatitis in the ERCP group underwent ERCP and endoscopic therapy. 15 patients with severe acute biliary pancreatitis were not treated by either surgery, endoscopy or early ERCP in the control group. Etiological factors, therapeutic effects and complications were observed in all the patients of the two groups.

RESULTS

In ERCP group, ERCP showed biliary tract disease in 56 cases, common bile duct stones in 26, cholecyst stone in 17, microcholelith in 4, cholangitis in 9, larger diverticula around the papilla in 3, papillitis in 5, pancreatic diverticulum in 2, and normal in 25. 46 cases of biliary tract disease were treated by endoscopy including papillosphincterotomy, endoscopic nasal biliary drainage and endoscopic dilatation of the accessory papilla. There were no significant differences in the recovery days of serum amylase back to normal between ERCP group (3.4±1.6 d) and control group (4.5±2.8 d), but the mean days of disappearance of abdominal pain (4.4±2.0 d), fever (5.0±3.4 d), abnormal white blood cell count (6.5±5.4 d) and hospitalization (21.9±8.4 d) were significantly shorter in the ERCP group than in the control group (8.4±6.1 d, 16.1±19.0 d, 19.1±19.3 d, 41.3±20.0 d, P<0.05). Complication rate (53.9%) and mortality rate (0%) in ERCP group were lower than those of control group (80.0%, 23.1% P<0.05). 17 cases had early complication (18.7%) in ERCP group. Of them, biliary tract infection occurred in 2 cases (2.2%), retroperitoneal pneumatosis in 1 case (1.1%), bleeding of digestive tract in 1 case (1.1%), deterioriation of pancreatitis in 13 cases. 15 patients were cured by medication treatment. Operations were performed in one patient. One patient died.

CONCLUSION

ERCP and endoscopic therapy are safe and effective for patients with acute pancreatitis.

Recurrent Acute Pancreatitis

Patients with recurrent acute pancreatitis should be treated with the same supportive and symptom-oriented measures as those with acute pancreatitis. The need for specific treatment depends on the cause of the pancreatitis. Patients should discontinue alcohol use, putative causative medications, and exposure to toxins or helminths in endemic areas. Metabolic abnormalities need to be corrected, and appropriate treatment should be initiated for associated infections, autoimmune diseases, vasculitis, and hypercoagulable states. For patients with gallstone pancreatitis, endoscopic retrograde cholangiopancreatography is indicated if biliary obstruction persists or if cholangitis is present. Elective cholecystectomy may be performed in appropriate patients; otherwise, consider biliary sphincterotomy and ursodeoxycholic acid for prevention of recurrent attacks. Transpapillary stenting or sphincterotomy of the minor papilla benefits some patients with pancreas divisum and no other explanation for recurrent pancreatitis. Surgical sphincteroplasty is reserved for those failing endoscopic treatment. Biliary sphincterotomy benefits more than 50% of patients with sphincter of Oddi dysfunction and recurrent acute pancreatitis. Some authors advocate pancreatic sphincter manometry and sphincterotomy for persistent pancreatic segment hypertension in patients who have recurrent pancreatitis after biliary sphincterotomy. In patients with pancreatic duct strictures, transpapillary stent placement serves as a short-term measure; most patients ultimately require surgery.

Acute pancreatitis

The pathophysiologic concept of acute pancreatitis focuses on early events inside acinar cells such as activation of trypsin. Despite significant progress in the understanding of molecular events in experimental pancreatitis, knowledge of these mechanisms has not yet been translated into therapeutic strategies useful in humans. A single morphologic or laboratory marker reliably predicting the individual course of acute pancreatitis still awaits discovery. The clinical outcome of acute pancreatitis is dependent on the presence of necrosis and systemic complications. The extent of the systemic inflammatory response to local pancreatitis seems to be the rate-limiting step. Several mechanisms shed light on the interconnectivity between intra-acinar protease activation and immunoregulatory processes. Deciphering these cell biologic connections has already had an impact on the clinical management of patients and the identification of prognostic markers in human disease. However, further investigations of pancreatic pathophysiology are needed to initiate novel therapeutic strategies.

Recurrent acute pancreatitis: an algorithmic approach to identification and elimination of inciting factors

Recurrent acute pancreatitis represents a challenging clinical problem associated with significant morbidity, impairment in quality of life, and expense. If unchecked, recurrent episodes of acute pancreatitis may lead to chronic pancreatitis. In this work we have combined the opinion of experts in pancreatology and an extensive review of the literature to develop a logical algorithm that facilitates the stepwise identification and elimination of inciting factors using current technology. The approach taken in recurrent acute pancreatitis is clearly dependent on adequate and appropriate evaluation and treatment of the patient with an initial episode of acute pancreatitis. Future advances in the treatment of these patients will almost certainly depend on improved imaging modalities, prospective clinical trials assessing the efficacy of endoscopic and surgical intervention, a better understanding of mutations and pathophysiologic mechanisms responsible for recurrent acute pancreatitis, and the development of novel, effective preventive and therapeutic strategies.