In up to 30% of cases of AP, history, physical examination and routine studies do not reveal a clear etiology. Some of these patients have gallstones that are too small to be visualized with conventional imaging techniques. The association of microlithiasis and pancreatitis was reported as long as 50 years ago. Lee et al found evidence of microlithiasis in 74% of 31 patients with an initial diagnosis of idiopathic pancreatitis. The patients who underwent either sphincterotomy or cholecystectomy experienced fewer recurrences of AP during follow-up compared with untreated patients (10% versus 73%). Ros et al reported similar findings.

The results of randomized clinical trials provide some guidance for the management of patients with ABP. In accordance with these findings, the author performs urgent ERCP in patients with suspected or proven biliary origin when the following conditions are met:

•    evidence of severe pancreatitis;

•    coexisting cholangitis;

•    jaundice;

•    dilation of the CBD; and

•    clinical deterioration in patients with initially favourable prognostic signs.

The author uses APACHE II criteria, organ failure and CT findings, if available, to identify patients with severe pancreatitis.

ES almost certainly protects against the recurrence of gallstone-induced pancreatitis. Therefore, the author considers performing this procedure in patients with severe gallstone pancreatitis, a dilated CBD, or gallbladder stones if cholecystectomy is not an option. In the author’s experience, patients with microlithiasis have recurrent episodes of relatively mild AP. When other causes of AP are not apparent, the author routinely collects bile during ERCP and perform a microscopic analysis for crystals. In some cases, the author also undertakes sphincter of Oddi manometry.

Diagnostic ERCP is associated with significant morbidity and mortality rates. The use of other techniques to detect CBD stones, such as magnetic resonance cholangiopancreatography and endoscopic ultrasonography, may more precisely identify patients who require ERCP. In theory, this would reduce the overall risk of complications, but many technical and logistical barriers need to be overcome before these less invasive modalities could be applied in practice. You will love this opportunity to spend less money whenever you need to buy levitra professional online for your symptoms to be under control, so you definitely should check out the pharmacy that will be happy to help you no matter which drug you need and how often.

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