Pancreatitis and the biliary tree: the continuing problem

Acute Pancreatitis: Work-up and Management

Acute pancreatitis is still a common clinical entity that causes significant morbidity and mortality. The most common etiological associations include chronic al coholism, biliary tract disease, iatrogenic (e.g., endo scopic retrograde cholangiopancreatography-induced), hypertriglyceridemia, and idiopathic varieties. New radiological techniques such as dynamic pancreatog raphy appear to be useful in diagnosing and determin ing the extent of necrotizing pancreatitis. Biochem ical variables such as the C-reactive protein and the trypsinogen-activated peptide seem promising in de tecting severe disease within the first few days of hospi talization. Computed tomographic-guided percutane ous aspiration of phlegmonous pancreatitis may be helpful in differentiating infected from noninfected masses. Although current studies have not identified any pharmacological agent as efficacious in improving sur vival, emergency sphincterotomy and removal of im pacted gallstones in severe gallstone pancreatitis may be beneficial in this regard. Prolonged (i.e., 7 day) perito neal dialysis may reduce the severity of pancreatic sep sis. Surgical drainage of infected fluid collections such as abscesses is a well-accepted adjunct to medical therapy. Surgical necrosectomy for necrotizing pancreatitis, however, which is advocated in some aggressive surgi cal units, is not yet commonplace and its role needs to be determined in controlled studies.

Gall stones and chronic pancreatitis: the black box in between

The relation between gall stones and chronic pancreatitis is uncertain; there are differing opinions on this issue. Firstly, gall stones are the most common reason for acute pancreatitis, but it cannot cause chronic pancreatitis. Secondly, a connection between gall stones and chronic inflammation of the pancreas might exist. Numerous studies or investigations have shown that changes associated with chronic pancreatitis are common in gallstone patients. Although it seems that gall stones might be a cause of chronic pancreatitis according to these findings, clinical and experimental studies are still needed for confirmation, and further studies are required to determine the mechanisms involved.

Biliary pancreatitis: a review. Emphasizing appropriate endoscopic intervention

Gallstones are a common cause of acute pancreatitis. This article reviews acute biliary pancreatitis and includes natural history, noting the serious nature of some cases; pathogenesis, identifying transient obstruction as the primary pathogenetic event; diagnosis, including biochemical parameters and imaging; assessment of severity, underlining the importance of early prognostic signs, organ failure, and local complications; and management. Management is reviewed in detail, giving a historical perspective to the role of surgery, highlighting the role of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy and paying particular attention to the four prospective randomized clinical trials in suggesting which patients are most likely to benefit from early endoscopic evaluation and therapy. Also discussed are additional clinical situations related to biliary pancreatitis in which endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy play a role. Finally, a suggested endoscopic approach to acute biliary pancreatitis is presented along with an algorithm incorporating severity stratification, principles of endoscopic intervention, and concepts of sterile and infected pancreatic necrosis.

Endoscopic management of pancreatic disease

Since its introduction in 1968, ERCP has developed from being a purely diagnostic method, mostly used in the investigation of unexplained upper abdominal pain, to an invaluable tool for the management of patients with pancreatic disorders. In cases with severe gallstone pancreatitis, the biliary obstruction is disclosed and relieved by ERCP and ES. In patients with severe acute pancreatitis of other aetiologies, as well as in post-traumatic pancreatitis, ERCP is indispensable for revealing complications (e.g. pancreatic duct rupture) and/or for planning the treatment strategy. Furthermore, in cases of pancreatitis not related to alcohol or gallstones, it often demonstrates causes which may be treatable, and it is also useful for evaluation of the gland after massive pancreatic necrosis. Moreover, ERCP is helpful in establishing the diagnosis of chronic pancreatitis and its complications as well as in demonstrating morphological grounds for therapeutic intervention. Although the indications, limitations, and practicability of the different techniques of therapeutic ERCP in various pancreatic diseases still remain to be defined, the method appears to offer an alternative to surgery, particularly in cases in which operative treatment is technically difficult and the results are less favourable. Frequency and severity of complications associated with both diagnostic and therapeutic ERCP seem to be, at least in the hands of experts, reasonably low.

Gallstone pancreatitis

Gallstone pancreatitis is caused by transient obstruction of the ampulla of Vater by a migrating gallstone. Intraglandular activation of pancreatic enzymes occurs (by an unclear mechanism), and their entry into the circulation causes most of the local and systemic events of pancreatitis. The diagnosis is based on history and physical examination, an elevation of serum amylase above 1000 IU/L, and ultrasound and CT scans. Endoscopic retrograde cholangiopancreatography can be used in less certain cases to confirm the presence of common bile duct stones. Because of the absence of an agent that can abort progression of the disease, therapy should consist of adequate resuscitation, nutritional support, and careful monitoring to detect early complications. In patients with mild pancreatitis, surgery usually can be performed within 48 or 72 hours of admission or as soon as symptoms and amylase levels return to normal. For patients with severe disease, endoscopic sphincterotomy is emerging as the therapeutic modality of choice. Elective treatment of the associated biliary disease should be performed during the same hospitalization after the acute phase of the disease has subsided.

Gallstone pancreatitis: a proposed management strategy

It has been usual practice to manage gallstone pancreatitis conservatively over the acute phase and to perform an elective cholecystectomy after an interval of 2-3 months. Because of the risks of recurrent pancreatitis, and in an effort to reduce the high morbidity and mortality associated with severe pancreatitis, there has been a trend towards early surgical intervention and, more recently, endoscopic sphincterotomy. From the Greenlane Hospital experience during 1979-1987, and from a review of recent literature, a strategy is proposed for the management of acute gallstone pancreatitis.

Treatment of chronic alcoholic pancreatitis by pancreatic resection

Forty-one patients with chronic pancreatitis caused by alcoholism were selected for resective surgery on the basis of clinical criteria and findings on pancreatography. Five patients had Whipple resections, 32 had 80 percent resections, and 7 had total pancreatectomies (3 previously had subtotal pancreatectomies). One perioperative and three late deaths accounted for the overall mortality of 10 percent. Complete freedom from pain on long-term follow-up was achieved in all of the patients who had total pancreatectomy, in half of the patients who had 80 percent resection, and in only one of five patients who had Whipple resection. Diabetes occurred in only one patient after Whipple resection, in nearly half of the patients after 80 percent pancreatectomy, in a gradually accelerating manner, up to 5 years, and in all patients after total resection, where it was frequently complicated by recurrent alcoholism. Jaundice was a rare complication of disease progression in the overall treatment group; none of these patients presented with cholestasis preoperatively. Recurrent alcoholism was reported in 32 percent of the patients and contributed to two deaths.