Comparing the Roles of EUS, ERCP and MRCP in Idiopathic Acute Recurrent Pancreatitis

Acute Gallstone Pancreatitis in Pregnancy: A Multidisciplinary Approach

A common cause of gastrointestinal-related hospitalizations in the United States of America is acute pancreatitis (AP), with an annual incidence of up to 80 cases per 100,000 people. The incidence of AP in pregnancy varies and is approximately 1 in 1000 to 1 in 10,000 births due to the prevalence of obesity and gallstone-related conditions. Deciding on the timing of surgical intervention in acute biliary pancreatitis during pregnancy remains challenging, and there are no consensus recommendations. Gallstone pancreatitis has a high recurrence rate of up to 50% during the first trimester. A 30-year-old G3P2 at 34 weeks of gestation presented to the emergency room (ER) with recurrent intermittent sudden severe epigastric and right upper quadrant abdominal pain radiating to the back. She had no history of alcohol consumption, and lipid studies were normal on presentation. A right upper quadrant ultrasound scan showed cholelithiasis without signs of acute cholecystitis and a common bile duct diameter of 0.5 cm. However, her serum lipase level was 824, compared to normal levels on her previous ER visits. Other significant labs included elevated alkaline phosphatase (ALP) of 125 and mild transaminitis, with alanine transaminase (ALT) and aspartate aminotransferase (AST) levels of 84 and 57, respectively. She was admitted on account of suspected gallstone pancreatitis and was treated supportively with IV fluids and adequate pain control with opioids. A subsequent magnetic resonance cholangiopancreatography (MRCP) revealed no obvious choledocholithiasis. After consultation with the obstetrics, gastroenterology, and general surgery teams, it was decided to defer cholecystectomy until after delivery. The patient was induced at 36 weeks of gestation, and she had an uneventful vaginal delivery. Two weeks later, she had an elective laparoscopic cholecystectomy with no complications.

Utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis

Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP.

The Lived Experience of Inpatients With Acute Recurrent Pancreatitis: A Qualitative Research Study From West China

The incidence of acute pancreatitis (AP) has increased year by year. Approximately 20%-30% of these patients will have further subsequent attacks, described as acute recurrent pancreatitis (ARP). Patients who are repeatedly admitted to hospitals suffer significant psychological problems and mental hardships. In the current study, we aimed to illuminate the lived experience of inpatients with ARP from Chongqing, China. A purposive sample of 13 ARP patients was recruited from the First Affiliated Hospital of Chongqing Medical University. Semistructured and in-depth qualitative interviews were adopted in this phenomenological research. Data were analyzed by Colaizzi's Method of descriptive phenomenology and feedback on early findings from the participants. All interviews were audio-recorded and transcribed with the permission of the participants. Five themes presented in the study: anxiety and fear, lack of related knowledge, inevitability and helplessness, guilt and shame, hope, and perseverance. Overall, the ARP inpatients showed complexed experience, both active and positive. They also performed poor compliance during their hospitalization but wished for professional knowledge. Nurses should pay attention to their psychological changes to take effective interventions for them.

Management of Gallstone-Induced Acute Pancreatitis in Pregnancy: A Tertiary-Center Experience

Objectives:

Gallbladder stones are the most frequently reported etiology of acute pancreatitis in pregnancy and are often diagnosed in the third trimester. This condition is associated with both mother and infant morbidity and mortality, and its treatment remains controversial.

Methods:

Relevant patient data between September 2010 and April 2017 from the Kanuni Sultan Suleyman Training and Research Hospital were analyzed regarding etiology (of gallstone pancreatitis), trimester of pregnancy, diagnostic tools, pancreatitis stage, clinical status, medical treatment, surgical interventions, and pregnancy status.

Results:

We included 68 patients recorded with acute pancreatitis due to biliary gallstones. Pancreatitis symptoms developed in most (n=38) (55.8%) patients during the third trimester. Of 24 patients who had their first episode of pancreatitis in the first trimester of pregnancy, 12 (50%) were readmitted due to recurrence. Seven (11.3%) patients whose Ranson scale score was 3 underwent computed tomography evaluation. The number of patients with acute cholecystitis with pancreatitis was 5 (7.3%), whereas the number of patients with choledocholithiasis was 4 (5.8%). Sphincterotomy with endoscopic retrograde cholangiopancreatography was performed in 2 (2.9%) patients. Laparoscopic cholecystectomy was performed in 9 (13.2%) patients during pregnancy. No fetal and maternal morbidity and mortality was found in all periods.

Conclusion:

Developments in supportive care, wide-spread use of imaging methods, and a multidisciplinary approach with better antenatal care of pregnant patients with acute pancreatitis can help prevent fetal and maternal morbidity and mortality in such cases. Early laparoscopic cholecystectomy should be considered especially in pregnant patients with acute pancreatitis due to gallstones in the first trimester.

Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Idiopathic acute pancreatitis (IAP) poses a diagnostic challenge for gastroenterologists, because confirmation of the disease etiology has important implications for the selection of the best possible treatment and the prevention of possible recurrence or the development of chronic pancreatitis (CP). ERCP, EUS, and MRCP typically are used to diagnose IAP when conventional radiologic methods fail. However, their exact role in the diagnosis of IAP has not yet been determined.

METHODS

We searched the PubMed, EMBASE, OVID, Cochrane Library (including CENTRAL), China National Knowledge Infrastructure (CNKI), and Wanfang databases from inception to April 2017. Studies involving the use of EUS and/or MRCP for the etiologic diagnosis of IAP were included. A meta-analysis was performed by using Review Manager Version 5.2 for comparative studies and R software 3.3.3 to determine diagnostic yield of the studies.

RESULTS

Among the 34 studies that met the inclusion criteria (n = 2338), 7 studies used a combination of EUS and MRCP and totaled 249 patients. The results comparing EUS with MRCP showed a diagnostic yield of 153 of the 239 patients (64%) in the EUS group, which was higher than the yield of 82 of 238 patients (34%) in the MRCP group (P < .001) in the 7 studies, and the diagnostic yield was 60% in the EUS group, 24% in the MRCP group, and 43% in the MRCP after secretin stimulation (S-MRCP) group. In our subgroup analysis of CP and biliary disease, EUS was superior to MRCP (P < .001), but when comparing the efficacy of the modalities in the diagnosis of pancreatic divisum, S-MRCP was obviously superior to MRCP and EUS (12% vs 2% vs 2%).

CONCLUSION

EUS and MRCP should both be used in the diagnostic work-up of IAP as complementary techniques. EUS had a higher diagnostic accuracy than MRCP (64% vs 34%) in the etiologic diagnosis of IAP and should be preferred for establishing a possible biliary disease and CP diagnosis, whereas S-MRCP was superior to EUS and MRCP in diagnosing a possible anatomic alteration in the biliopancreatic duct system, such as pancreatic divisum.

Role of endoscopic ultrasound in idiopathic pancreatitis

Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. The initial evaluation fails to detect the cause of RAP in 10%-30% of patients, whose condition is classified as idiopathic RAP (IRAP). Idiopathic acute pancreatitis (IAP) is a diagnostic challenge for gastroenterologists. In view of associated morbidity and mortality, it is important to determine the aetiology of pancreatitis to provide early treatment and prevent recurrence. Endoscopic ultrasound (EUS) is an investigation of choice for imaging of pancreas and biliary tract. In view of high diagnostic accuracy and safety of EUS, a EUS based management strategy appears to be a reasonable approach for evaluation of patients with a single/recurrent idiopathic pancreatitis. The most common diagnoses by EUS in IAP is biliary tract disease. The present review aims to discuss the role of EUS in the clinical management and diagnosis of patients with IAP. It elaborates the diagnostic approach to IAP in relation to EUS and other different modalities. Controversial issues in IAP like when to perform EUS, whether to perform after first episode or recurrent episodes, comparison among different investigations and the latest evidence significance are detailed.