Endoscopic retrograde cholangiopancreatography-induced acute pancreatitis often has a benign outcome

Endoscopic management of acute biliary pancreatitis

Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to severe acute illness with a significant risk of death. Urgent endoscopic treatment of acute pancreatitis is considered when there is causal evidence of biliary pancreatitis. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.

Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review

The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.

New advances in acute pancreatitis

PURPOSE OF REVIEW

We endeavor to review important new advances in acute pancreatitis made in the past year. We focused on clinical aspects of acute pancreatitis, which contained new observations or insights into new or old concepts. For experimental acute pancreatitis we refer readers to a recent comprehensive review.

RECENT FINDINGS

Recently, case fatality rates of acute pancreatitis have stabilized; carbohydrate-deficient transferrin was shown to predict alcoholic acute pancreatitis; idiopathic chronic pancreatitis or occult cholelithiasis have been associated with 'recurrent acute pancreatitis' in most patients; and cystic fibrosis transmembrane conductance regulator genetic mutations were frequently found (10-50%) in patients with recurrent acute pancreatitis. In addition, alcohol was shown to increase the risk of pancreatic necrosis regardless of the cause of acute pancreatitis. Persistent organ failure and multiple organ dysfunction syndrome but not necessarily extent of necrosis were demonstrated to predict increased mortality in acute pancreatitis. Chemoprevention of post-endoscopic retrograde cholangiopancreatography acute pancreatitis remains unproven. Enteral feeding has been strongly recommended in severe acute pancreatitis. Finally, data are lacking for routine, prophylactic antibiotic administration to all patients with pancreatic necrosis.

SUMMARY

We reviewed studies this past year that further characterize the epidemiology, etiology and risk stratification of acute pancreatitis. Evolving areas include chemoprevention of post-endoscopic retrograde cholangiopancreatography acute pancreatitis and enteral feeding and antibiotics in severe acute pancreatitis. We await translation of novel therapies from the bench to bedside.

Endoscopic management of acute pancreatitis

Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to devastating acute illness with a significant risk of death. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.