Idiopathic recurrent pancreatitis: long-term results after ERCP, endoscopic sphincterotomy, or ursodeoxycholic acid treatment

OBJECTIVE: In about 30% of cases, the etiology of acute recurrent pancreatitis remains unexplained, and the term "idiopathic" is currently used to define such disease. We aimed to evaluate the long-term outcome of patients with idiopathic recurrent pancreatitis who underwent endoscopic cholangiopancreatography (ERCP) followed by either endoscopic biliary (and seldom pancreatic) sphincterotomy or ursodeoxycholic acid (UDCA) treatment, in a prospective follow-up study. METHODS: A total of 40 consecutive patients with intact gallbladder entered the study protocol after a 24-month observation period during which at least two episodes of pancreatitis occurred. All patients underwent diagnostic ERCP, followed by biliary or minor papilla sphincterotomy in cases of documented or suspected bile duct microlithiasis and sludge, type 2 sphincter of Oddi dysfunction, or pancreas divisum with dilated dorsal duct. Patients with no definite anatomical or functional abnormalities received long-term treatment with UDCA. After biliary sphincterotomy, patients with further episodes of pancreatitis underwent main pancreatic duct stenting followed by pancreatic sphincterotomy if the stent had proved to be effective. RESULTS: ERCP found an underlying cause of pancreatitis in 70% of cases. Patients were followed-up for a period ranging from 27 to 73 months. Effective therapeutic ERCP or UDCA oral treatment proved that occult bile stone disease and type 2 or 3 sphincter of Oddi dysfunction (biliary or pancreatic segment) had been etiological factors in 35 of the 40 cases (87.5%) After therapeutic ERCP or UDCA, only three patients still continued to have episodes of pancreatitis. CONCLUSIONS: Diagnostic and therapeutic ERCP and UDCA were effective in 92.5% of our cases, over a long follow-up, indicating that the term "idiopathic" was justified only in a few patients with acute recurrent pancreatitis.     

ERCP, biliary crystal analysis, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis

BACKGROUND: This study investigated the role of ERCP, analysis of bile for microcrystals, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis. METHODS: One hundred twenty-six patients met criteria for idiopathic recurrent pancreatitis. Patients with a normal ERCP underwent sphincter of Oddi manometry and analysis of bile. Bile was also collected in patients with papillary stenosis (defined as ductal dilation with delayed drainage of contrast, sphincter basal pressures greater than 40 mm Hg, and positive analysis for cholesterol and/or calcium bilirubinate crystals). RESULTS: ERCP alone identified a cause of idiopathic recurrent pancreatitis in 47 (37%) patients: papillary stenosis in 26 (21%), pancreas divisum in 9 (7%), and choledocholithiasis in 6 (5%). Among patients with a gallbladder, microcrystals were found in 27 (50%) and sphincter dysfunction in 17 (31%). Among patients who have undergone cholecystectomy, sphincter dysfunction was identified in 24 (47%). Minor papilla sphincterotomy was performed in 8 patients (89%) with pancreas divisum. Biliary sphincterotomy was performed in 85 patients and included all patients with choledocholithiasis, choledochocele, microcrystals, papillary stenosis, and sphincter dysfunction except 2 patients with microcrystals who underwent cholecystectomy. Additionally, pancreatic sphincterotomy was performed in 32 (78%) patients with pancreatic sphincter hypertension and in 6 (23%) of 26 patients with papillary stenosis with dilated pancreatic ducts. Thus, among the 126 patients, 93 of the 100 patients with a detected abnormality underwent endoscopic sphincterotomy. Response rates varied from 67% to 100% during follow-up (mean 29.6 months, range 18 to 33 months). CONCLUSION: ERCP techniques including minor papilla cannulation, analysis of bile for microcrystals, and sphincter of Oddi manometry identified a cause of idiopathic recurrent pancreatitis in 79% (endoscopically treatable in 75%) of patients, with or without prior cholecystectomy.     

Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction

BACKGROUND AND AIM: The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared. RESULTS: A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality. CONCLUSION: Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.     

Microlithiasis: an important cause of "idiopathic" acute pancreatitis?

Microlithiasis is the underlying cause in a significant proportion of patients with "idiopathic" acute pancreatitis. The mechanism appears to be a relative deficiency of phosphatidylcholine in bile, with fast and extensive cholesterol crystallization as a result. Diagnosis of microlithiasis by microscopic detection of cholesterol crystals in bile is important and should lead to appropriate therapy (cholecystectomy, endoscopic sphincterotomy or ursodeoxycholic acid maintenance therapy).     

Biliary microlithiasis in patients with idiopathic acute pancreatitis and unexplained biliary pain: response to therapy

BACKGROUND AND AIMS: Microlithiasis has been suspected to cause acute pancreatitis and biliary pain. We studied the frequency of microlithiasis and response to treatment in recurrent idiopathic acute pancreatitis (RIAP) and unexplained biliary pain. METHODS: Gallbladder bile was examined microscopically for cholesterol monohydrate crystals (CMC) and calcium bilirubinate granules (CBG) in patients with RAIP (n = 24; mean age 36 years, range 18-56 years; 14 men), unexplained biliary pain (n = 12; mean age 32 years, range 22-55 years; six men), gallstones (n = 22; mean age 40 years, range 30-58 years; 12 men) and patients without clinical or imaging evidence of gallstone disease (n = 12; mean age 32 years, range 14-54 years; six men). The presence of a single CMC or >25 CBG/slide was considered abnormal. RESULTS: Bile microscopy was abnormal in 75% patients with RAIP (18/24; CMC in 10, CBG in six, CMC and CBG in two), 83.3% patients with unexplained biliary pain (10/12; CMC in seven, CBG in one, CMC and CBG in two) and 95.4% patients with gallstones (21/22; CMC in 12, CBG in one, CMC and CBG in eight). None of the controls without gallstone disease had CMC while three patients had low counts of CBG. Twenty-eight patients with RAIP and biliary pain having microlithiasis agreed to be treated with cholecystectomy (n = 2), endoscopic sphincterotomy (n = 21) or ursodeoxycholic acid (UDCA; n = 5). The 23 patients treated with cholecystectomy or sphincterotomy remained asymptomatic during follow up (mean 23 months, range 6-48 months). Four of five patients treated with UDCA remained asymptomatic for a follow-up period of 9, 10, 11 and 18 months, respectively. One patient who had refused cholecystectomy or sphincterotomy continued to experience pain at the same frequency as before during a follow-up period of 12 months. One patient, who was asymptomatic on UDCA for 9 months, agreed to undergo sphincterotomy and remained asymptomatic over a follow-up period of 14 months. CONCLUSIONS: Microlithiasis is a common cause for idiopathic acute pancreatitis and unexplained biliary pain. Lasting relief is obtained in most patients after treatment with UDCA, cholecystectomy or sphincterotomy.     

ERCP在不明原因复发性急性胰腺炎诊治中的作用

目的探讨ERCP在不明原因复发性急性胰腺炎(RAP)诊治中的作用。方法收集15例不明原因RAP患者。其中男5例,女10例,年龄25～65岁,中位年龄38岁,病程1～2年,发病次数2～5次。10例在急性发作期,5例在发作间期行ERCP诊治。结果15例患者经ERCP明确病因者6例(3例胆管微结石,1例胆总管末端小囊肿,1例胰管小结石,1例胰管蛋白栓子),可疑病因者6例(乳头旁憩室2例,十二指肠乳头炎4例),未明确病因者3例。根据ERCP检查结果,9例行乳头括约肌切开术(EST),6例行胰管括约肌切开术。术后随访2年,15例患者均未复发胰腺炎。ERCP和EST术后2例出现一过性高淀粉酶血症,无其他并发症。结论ERCP对不明原因RAP有明确病因和指导治疗的作用。     

Acute biliary pancreatitis: staging and management

BACKGROUND/AIMS: Acute biliary pancreatitis is a clinical entity with a high morbidity rate (15-50%) and mortality rate (20-35%). Early diagnosis has a primary importance for an appropriate treatment (75% of cases of idiopathic acute pancreatitis are of biliary origin). METHODOLOGY: Diagnosis of acute biliary pancreatitis in 78 patients was based on careful clinical and instrumental assessment: ultrasonography (76.9% of cases) and laboratory tests in 23.1% of cases. In our study we used the Ranson and APACHE II scores and 24 of the cases (30.7%) were classified as severe, while 54 (69.2%) were mild. All patients with severe acute biliary pancreatitis underwent emergency endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy (within 24-48 hours) followed by laparoscopic cholecystectomy (10 days). Patients with mild acute biliary pancreatitis underwent laparoscopic cholecystectomy associated with intraoperative cholangiography, within 10 days. RESULTS: In 19 patients with severe acute biliary pancreatitis operative endoscopy was curative. Subsequent laparoscopic cholecystectomy provoked subcutaneous emphysema only in one case but did not show any other serious morbidity. In the remaining 5 cases laparotomy was required because of necrosis, with a mortality rate of 60%. In all cases of mild acute biliary pancreatitis, laparoscopic cholecystectomy was successfully performed with a morbidity rate of 7.3%. Common bile duct stones were revealed with intraoperative cholangiography in 31.4% of the mild cases and in 75% of the severe cases. CONCLUSIONS: In conclusion acute biliary pancreatitis treatment is always surgical; in almost all severe cases it is performed with minimally invasive procedures (endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy with laparoscopic cholecystectomy < or = 10 days) if surgery is carried out within 24-48 hrs, as well in the mild cases (laparoscopic cholecystectomy + intraoperative cholangiography) when surgery is performed within 10 days.     

Microscopic examination of bile directly collected during endoscopic cannulation of the papilla

The usefulness of microscopic examination of pure bile directly collected from the biliary tract during endoscopic retrograde cholangiography and without hormonal simulation was prospectively evaluated in 72 patients. According to clinical, biochemical, ultrasonographic, and radiographic data, the patients were separated into two groups: group 1, patients with proven stones (N = 50), and group 2, patients with suspected microlithiasis presenting symptoms suggestive of cholelithiasis but without evidence of macroscopic stones at echography or cholangiography (N = 22). Cholesterol crystals and/or bilirubinate granules were observed (eg, positive examination) in the bile of 41 of the 50 patients of group 1 (82%). Among patients of group 2, seven (32%) had a positive bile examination: cholecystectomy (N = 2) or endoscopic sphincterotomy (N = 5) disclosed minute stones in all cases. In the 15 patients of group 2 with a negative bile examination, cholecystectomy (N = 3), sphincterotomy (N = 2), and clinical (and/or echographic) 20-month follow-up (N = 9) revealed biliary lithiasis in only one patient, in whom recurrent cholangitis led to disclosure of one bile duct stone. According to these results, microscopic examination of bile samples collected during endoscopic retrograde cholangiography exhibited a sensitivity and a specificity for cholelithiasis recognition of 82.7% and 100%, respectively, with a positive predictive value of 88%. We conclude that the accuracy of this method makes it useful to investigate and manage patients with suspected microlithiasis.     

Biliary pancreatitis.

Gallstone-induced acute pancreatitis is a prevalent condition that is associated with an unacceptably high mortality rate. Early endoscopic intervention, including endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy within 24 to 72 h of hospital admission, can be used to remove stones in the common bile duct (CBD) and establish biliary drainage. Anecdotal evidence of its effectiveness led to formal testing in randomized clinical trials. Although the design and results of the four published studies have varied, the overall conclusion is that early endoscopic therapy reduces morbidity and mortality in patients with acute biliary pancreatitis. Benefits are especially apparent in patients who satisfy generally accepted criteria for severe pancreatitis. The author's practice is to undertake endoscopic retrograde cholangiopancreatography in patients with severe or worsening pancreatitis, or in patients with jaundice, cholangitis or dilation of the CBD. Endoscopic sphincterotomy is performed in patients with CBD stones or in patients with biliary pancreatitis and cholelithiasis who are not candidates for cholecystectomy. The roles of newer diagnostic modalities, including magnetic resonance cholangiopancreatography and endoscopic ultrasonography, are not yet clear.     

Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients

BACKGROUND & AIMS: In patients with stones in their bile ducts and gallbladders, cholecystectomy is generally recommended after endoscopic sphincterotomy and clearance of bile duct stones. However, only approximately 10% of patients with gallbladders left in situ will return with further biliary complications. Expectant management is alternately advocated. In this study, we compared the treatment strategies of laparoscopic cholecystectomy and gallbladders left in situ. METHODS: We randomized patients (>60 years of age) after endoscopic sphincterotomy and clearance of their bile duct stones to receive early laparoscopic cholecystectomy or expectant management. The primary outcome was further biliary complications. Other outcome measures included adverse events after cholecystectomy and late deaths from all causes. RESULTS: One hundred seventy-eight patients entered into the trial (89 in each group); 82 of 89 patients who were randomized to receive laparoscopic cholecystectomy underwent the procedure. Conversion to open surgery was needed in 16 of 82 patients (20%). Postoperative complications occurred in 8 patients (9%). Analysis was by intention to treat. With a median follow-up of approximately 5 years, 6 patients (7%) in the cholecystectomy group returned with further biliary events (cholangitis, n = 5; biliary pain, n = 1). Among those with gallbladders in situ, 21 (24%) returned with further biliary events (cholangitis, n = 13; acute cholecystitis, n = 5; biliary pain, n = 2; and jaundice, n = 1; log rank, P = .001). Late deaths were similar between groups (cholecystectomy, n = 19; gallbladder in situ, n = 11; P = .12). CONCLUSIONS: In the Chinese, cholecystectomy after endoscopic treatment of bile duct stones reduces recurrent biliary events and should be recommended.     

Biliary sphincterotomy reduces the risk of acute gallstone pancreatitis recurrence in non-candidates for cholecystectomy

BackgroundPopulation aging and comorbidity are leading to an increase in patients unfit for cholecystectomy.AimsTo evaluate whether endoscopic biliary sphincterotomy after a first episode of acute gallstone pancreatitis reduces the risk of pancreatitis recurrence and gallstone-related events in non-surgical candidates.MethodsRetrospective study of patients admitted for a first episode of acute gallstone pancreatitis rejected for cholecystectomy between 2013–2018. The role of endoscopic sphincterotomy was evaluated by adjusting for age, severity of pancreatitis, and presence of choledocholithiasis.ResultsWe included 247 patients (mean age 80 ± 12 years; Charlson index: 5; severity of pancreatitis: 72% mild). Sphincterotomy was performed in 23.9%. Recurrence of pancreatitis occurred in 17.4% patients (median follow-up: 426 days). The one-year cumulative incidence of a new episode of pancreatitis was 1.8% (95% confidence interval [CI]: 0.2–12%) and 23% (95% CI: 17–31%) in patients with and without sphincterotomy, respectively (p = 0.006). In multivariate analysis, sphincterotomy showed a protective role for recurrence of pancreatitis (adjusted hazard ratio [HR]: 0.29, 95% CI: 0.08–0.92, p = 0.037) and for any gallstone-related event (HR 0.46, 95% CI: 0.21–0.98, p = 0.043).ConclusionsEndoscopic biliary sphincterotomy reduced the risk of gallstone pancreatitis recurrence and other biliary-related disorders in patients with a first episode of pancreatitis non-candidates for cholecystectomy.     

Do patients with recurrent choledocholithiasis after endoscopic sphincterotomy benefit from regular follow-up?

BACKGROUND: As many as 24% of patients who undergo endoscopic sphincterotomy for the removal of bile duct stones have recurrent biliary complications develop for which there is no effective method of prevention. The aim of this study was to determine whether patients who undergo routine clinical follow-up after endoscopic sphincterotomy for bile duct stones have a different outcome than those who do not. METHODS: All patients who had endoscopic sphincterotomy for bile duct stones were scheduled for follow-up visits, liver function tests, and transabdominal US every 3 to 6 months. ERCP was performed whenever symptoms recurred, or abnormal liver function or US was noted. The patients themselves decided whether to adhere to the follow-up schedule; this was not a randomized trial. RESULTS: Seven hundred sixty-seven patients underwent endoscopic sphincterotomy for bile duct stones from October 1990 to July 1999. Seventy-seven (10%) were found to have recurrent bile duct stones. Three patients who had undergone Billroth II gastrectomy were excluded. Among the remaining 74 patients (52 men, 22 women; mean age 65 years), 42 (57%) had a juxtapapillary diverticulum and 21 (28%) an intact gallbladder. The mean time to recurrence of bile duct stones was 19.7 months (range 5-72 months). Sixty-four patients (87%) had recurrent bile duct stones within 3 years. Fifty-one (69%) were followed regularly (Group A) and 23 (31%) were not (Group B). At the time of stone recurrence, 20 patients in Group A (39%) and 1 in Group B (4%) were asymptomatic (p = 0.002). Liver function tests were normal in 17 patients (13 Group A, 4 Group B). Endoscopic treatment for recurrent bile duct stones was successful in 46 patients (90%) in Group A and 16 (70%) in Group B (p = 0.04); surgical treatment was successful in all 5 patients in Group A and 4 of the 7 patients in Group B. Two patients in Group B were treated by nasobiliary drainage and biliary endoprosthesis insertion caused by extremely large stones and poor condition; both died (acute pancreatitis and sepsis). CONCLUSION: Regular follow-up after endoscopic sphincterotomy detects recurrent bile duct stones early and thus avoids complications of bile duct stones.     

Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis.

BACKGROUND: Endoscopic sphincterotomy can benefit patients with suspected biliary pancreatitis, although there are procedure-related complications. EUS can be used to select patients for endoscopic sphincterotomy. The results of this strategy were assessed. METHODS: Information on patients referred for EUS were recorded in a database. One hundred twenty-three patients with suspected biliary pancreatitis (57 men, 66 women; median age 55 years) were included and followed. All underwent EUS followed by endoscopic sphincterotomy during the same procedure if choledocholithiasis was identified. Outcomes were studied in relation to the initial severity of biliary pancreatitis (Ranson and Balthazar scores), presence of stones, and time span between onset of biliary pancreatitis and EUS plus endoscopic sphincterotomy. RESULTS: Thirty-five patients (28%) had a Ranson score greater than 3 on admission and 38 (31%) were Balthazar D-E. The median time from admission to EUS was 3 days. EUS imaging of the bile duct was complete in all but 3 patients. Thirty-three patients (27%) had choledocholithiasis on EUS and underwent endoscopic sphincterotomy. Stones were more frequent in patients with jaundice (p < 0.005) and when EUS was performed less than 3 days after admission (p < 0.05). One hundred patients (81%) recovered without complication. Two patients (1.6%) died, 1 had recurrent BP develop, 6 (5%) had further biliary symptoms, and 16 (13%) had complications of pancreatitis develop (9 pseudocysts). There were 3 mild endoscopic sphincterotomy-related complications (complication rate 6.5%). CONCLUSIONS: In this series in which endoscopic sphincterotomy was performed selectively depending on the endosonographic presence or absence of ductal stones early in the course of the pancreatitis, and not according to its predicted severity, mortality and complications of endoscopic sphincterotomy were low and unrelated to the predicted severity of biliary pancreatitis or the presence of choledocholithiasis. Controlled trials are needed to confirm the superiority of this strategy compared with ERCP alone for the management of biliary pancreatitis.     

Late biliary complications after endoscopic sphincterotomy for common bile duct stones in patients older than 65 years of age with gallbladder in situ

The aim of this retrospective study was to evaluate the nature and the frequency of biliary complications after endoscopic retrograde cholangiography for common bile duct stones in elderly patients with gallbladder in situ. METHODS: Between 1991 and 1993, 169 consecutive patients with gallbladder in situ, older than 65 years (79 +/- 8) had an endoscopic retrograde cholangiography with sphincterotomy for choledocholithiasis. Information on the early (<1 month) and late biliary complications, treatment and mortality were obtained by mail or phone calls from patients and general practitioners. Long-term data were obtained for 139 patients (82%). Mean follow-up was 56.5 months (80 months for patients still alive at the end of the study). RESULTS: Early complications occurred in 13 patients (10.8%). Seven patients had acute cholecystitis, present before the procedure in all cases; all were treated by surgery. Other early complications included cholangitis (n =7), mild acute pancreatitis (n =3), bleeding (n =1), perforation (n =1), biliary colic (n =1), pneumopathy (n =1) and bradycardia (n =1), all treated medically. Forty patients underwent early cholecystectomy, and 5 died during the first month without biliary disease. Late complications were thus assessed in 94 patients and occurred in 13 (14%), i.e around 2% per year. Complications were acute cholangitis (n=4), biliary pain (n =4), cholecystitis (n =2), abdominal pain (n =2) and jaundice due to sphincterotomy stenosis (n =1). Five patients had cholecystectomy, 1 a radiological drainage and 7 were treated medically. No death due to a biliary complication was observed. The presence of gallstones, the absence of gallbladder opacification at cholangiography were not prognostic factors for the recurrence of biliary symptoms. 65 patients (50%) died without biliary disease during the follow-up (actuarial death rate 10.5% per year). CONCLUSION: Late biliary complications after endoscopic retrograde cholangiography for choledocholithiasis in patients with gallbladder in situ are rare (2% per year). Prophylactic cholecystectomy after sphincterotomy does not seem warranted in elderly patients, because of rare recurrent biliary symptoms, low mortality rate, and limited life expectancy.     

Biliary sludge: When should it not be ignored

Opinion statement Biliary sludge is usually seen on transabdominal sonography as low-level echoes that layer in the dependent portion of the gallbladder without acoustic shadowing. Synonyms for biliary sludge include microlithiasis, biliary sand or sediment, pseudolithiasis, and microcrystalline disease. In most patients, biliary sludge is composed of calcium bilirubinate and cholesterol monohydrate crystals. A variety of predisposing factors are associated with biliary sludge formation. In most of these patients, removal of the risk factor can lead to resolution of sludge. In asymptomatic patients, biliary sludge can be managed expectantly. In patients who develop biliary-type pain, cholecystitis, cholangitis, or pancreatitis, the treatment of choice is cholecystectomy for those who can tolerate surgery. In patients who are not operative candidates, endoscopic sphincterotomy can prevent further episodes of cholangitis and pancreatitis, whereas medical therapy with ursodeoxycholic acid can prevent sludge formation and recurrent acute pancreatitis.     

Early treatment of biliary lithiasis in biliary pancreatitis

Since 1982, 38 consecutive patients with biliary pancreatitis were treated prospectively in order to prevent recurrent migration of gallstones. Removal of the stones was achieved by "early surgery" i. e. within the first week after admission or by endoscopic sphincterotomy in patients with severe pancreatitis. Gallstones were visualized by ultrasonography in 31 patients (82 p. 100). Microlithiasis was present in 14 (37 p. 100) and was missed at ultrasonography in 7 patients. According to Ranson's prognostic signs, only 4 patients had 4 or more signs. These 4 patients and 2 additional patients aged more than 85 underwent urgent retrograde cholangiography and endoscopic sphincterotomy. No complications could be attributed to this technique. Among the 4 patients with severe pancreatitis, 3 developed an abscess which required delayed surgery without further complications. The 32 other patients underwent a biliary operation within the first week after admission. Common bile duct calculi were present in 14 patients being discovered by cholangioscopy in 6. One patient died after operation and one was reoperated on for a pseudocyst on day 40. No recurrent attack of pancreatitis was observed in either group. Our study suggests that slightly delayed biliary operation with cholangioscopy during the same hospitalization can be performed safety in patients with mild pancreatitis. In patients with severe attack and/or poor general condition, endoscopic sphincterotomy is a safe technique and deserves wider consideration in the management of severe acute pancreatitis for which delayed drainage of pancreatic necrosis may occasionally be required.     

44-j?hrige Patientin mit unklarer Leberwerterh?hung und famili?r geh?uftem Gallensteinleiden

"Low phospholipid associated cholelithiasis" (LPAC) syndrome is an important differential diagnosis in younger patients with biliary symptoms after cholecystectomy and concomitant elevated serum liver tests. Typical symptoms include recurrence of biliary colics after cholecystectomy, echogenic material in the intrahepatic bile ducts, intrahepatic cholestasis of pregnancy or cholestasis under hormonal contraception and a family history of gallstone disease. Patients with LPAC syndrome can be successfully treated with ursodeoxycholic acid.     

Acute idiopathic pancreatitis: does it really exist or is it a myth?

BACKGROUND: Acute pancreatitis is a severe disease with considerable morbidity and mortality. Gallstones and alcohol abuse are the most frequent causes (75% of patients). Other well-known causes are: hyperlipidemia, hypercalcaemia, abdominal surgery and drugs. In 10%-40% of patients however, no cause is identified after initial diagnostic evaluation: acute idiopathic pancreatitis. Identifying a cause in these patients is important, since the recurrence rate is high. METHODS: A systematic review of the current literature was performed to identify possible causes, diagnoses and treatment options of acute idiopathic pancreatitis. Relevant literature was found via Pubmed. RESULTS: The presence of microlithiasis or biliary sludge is an important cause of acute 'idiopathic' pancreatitis (up to 80% of patients). Microlithiasis and sludge can be detected by transabdominal/endoscopic ultrasonography, ERCP or polarizing light microscopy of bile. Cholecystectomy is the treatment of choice, whereas endoscopic sphincterotomy and ursodeoxycholic acid maintenance therapy are effective alternatives. Sphincter of Oddi dysfunction can be identified as the cause of acute 'idiopathic' pancreatitis in up to 30% of patients. Manometry of Oddi's sphincter is the gold standard for its diagnosis. Endoscopic sphincterotomy prevents recurrence in most patients. Anatomic abnormalities such as major papilla stenosis, pancreas divisum, pancreatic duct strictures and tumours may also cause acute 'idiopathic' pancreatitis. Endoscopic sphincterotomy and surgery are effective treatments. Finally, genetic screening may reveal gene mutations as the cause of acute 'idiopathic' pancreatitis. CONCLUSIONS: Acute 'idiopathic' pancreatitis is a severe disease with a high recurrence rate. Extensive diagnostic investigations may lead to a cause in >90% of patients.     

Acute recurrent pancreatitis: Etiopathogenesis,diagnosis and treatment

Acute recurrent pancreatitis(ARP)refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion.Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland,however,an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up.The aetiology of ARP can be identified in the majority of patients.Most common causes include common bile duct stones or sludge and bile crystals;sphincter of oddi dysfunction;anatomical ductal variants interfering with pancreatic juice outflow;obstruction of the main pancreatic duct or pancreatico-biliary junction;genetic mutations;alcohol consumption.However,despite diagnostic technologies,the aetiology of ARP still remains unknown in up to 30%of cases:in these cases the term“idiopathic”is used.Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases,cholecystectomy,and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases.Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80%of patients.Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge.In uncertain cases toxinbotulin injection may help in identifying some sphincter of oddi dysfunction,but this treatment is not widely used.In the last twenty years,pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction,independently from the cause of obstruction,and has been widely used instead of more aggressive approaches.     

Sphincter of Oddi dysfunction and bile duct microlithiasis in acute idiopathic pancreatitis

Although there are numerous causes of acute panc-reatitis, an etiology cannot always be found. Two potential etiologies, microlithiasis and sphincter of Oddi dysfunction, are discussed in this review. Gallbladder microlithiasis, missed on transcutaneous ultrasound, is reported as the cause of idiopathic acute pancreatitis in a wide frequency range of 6%-80%. The best diagnostic technique for gallbladder microlithiasis is endoscopic ultrasound although biliary crystal analysis and empiric cholecystectomy remain as reasonable options. In contrast, in patients who are post-cholecystectomy, bile duct microlithiasis does not appear to have a role in the pathogenesis of acute pancreatitis. Sphincter of Oddi dysfunction is present in 30%-65% of patients with idiopathic acute recurrent pancreatitis in whom other diagnoses have been excluded. It is unclear if this sphincter dysfunction was the original etiology of the first episode of pancreatitis although it appears to have a causative role in recurring episodes since sphincter ablation decreases the frequency of recurrent attacks. Unfortunately, this conclusion is primarily based on small retrospective case series; larger prospective studies of the outcome of pancreatic sphincterotomy for SOD-associated acute pancreatitis are sorely needed. Another problem with this diagnosis and its treatment is the concern over potential procedure related complications from endoscopic retrograde cholangiopancreatography （ERCP）, manometry and pancreatic sphincterotomy. For these reasons, patients should have recurrent acute pancreatitis, not a single episode, and have a careful informed consent before assessment of the sphincter of Oddi is undertaken.