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. Continue reading
Category Archives: Biliary pancreatitis
The fourth study, recently completed in Poland, has been published in abstract form only. A total of 280 patients with suspected ABP underwent duodenoscopy within 24 h of admission. The 75 patients who were found to have stones impacted at the papilla underwent immediate ES. The remaining patients were randomly assigned to either immediate ERCP or conventional therapy. ERCP and ES were associated with a significant decrease in complications (17% versus 36%) and mortality (2% versus 13%). Moreover, earlier timing of ERCP correlated with decreased morbidity and mortality, and the benefits of early endoscopic therapy applied also to patients with mild pancreatitis. A detailed analysis of this study, however, will require publication as a full-length article. Continue reading
A prospective multicentre German trial enrolled 238 patients with ABP who had no evidence of obstructive jaundice, and assigned them to either ERCP within 72 h of admission or conventional therapy. Of the 126 patients in the interventional group, 121 (96%) successfully underwent ERCP, and 58 proved to have choledocholithiasis. Twenty of the 112 patients in the control group subsequently required ERCP, and 13 of these underwent removal of CBD stones. There were no significant differences in the morbidity or mortality rates between the two groups, but patients who received early ERCP experienced a higher incidence of respiratory failure and more severe complications. Moreover, there was a trend toward increased mortality in the ERCP group, which was contrary to the findings of the other RCTs. Stratification of the patients according to the severity of disease did not affect the findings. Continue reading
A second RCT was undertaken at the University of Hong Kong, where the incidence of choledocholithiasis as a cause of AP is quite high. Because of this fact, the results may not be applicable to other parts of the world. The investigators randomly assigned 195 patients with AP to early ERCP (within 24 h of admission) or conventional treatment. A severe attack was defined as one in which the serum urea concentration exceeded 45 mg/dL (16.2 mmol/L) and the plasma glucose concentration was greater than 198 mg/dL (11.0 mmol/L) on admission. Continue reading
The mortality rate is virtually zero if there is no organ failure, but increases to nearly 20% if at least one of the above criteria is met. Patients with organ failure are more likely to have necrotizing than interstitial pancreatitis. However, waiting for such complications to occur may negate the benefits of early therapy.
Early prognostic indices have been employed during the patient’s initial evaluation. These include the biliary version of Ranson’s criteria that are frequently used in the United States, the modified Imrie’s criteria that are used mainly in Europe, and APACHE-II scores that are widely used in intensive care units. Continue reading
Gallstones are the leading cause of acute pancreatitis (AP) in many Western and Asian countries, accounting for 34% to 54% of the 4.8 to 24.2 cases per 100,000 each year of the disease. Despite advances in intensive care management, the case fatality rate of severe AP is still approximately 10%.
Early endoscopic intervention has been increasingly used in the management of acute biliary pancreatitis (ABP). It allows the removal of the offending stone(s) and the establishment of biliary drainage. Observational data and, more importantly, four randomized controlled trials (RCTs) involving more than 800 patients have supported the use of endoscopic sphincterotomy (ES). In specialized centres, success rates exceed 90%. This article summarizes the results of these studies and describes the optimal approach to the management of ABP. Continue reading