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ERCP IN ACUTE PANCREATITIS
Durgesh Borkar*, Anand Nande**
*Clinical Fellow in Surgery, Shrikhande Clinic. **Consultant Surgeon and Endoscopist, Bombay Hospital.
INTRODUCTION
Acute pancreatitis continues to intrigue clinicians, as a significant minority of patients will eventually succumb to the ravages of extensive pancreatic necrosis and multi-organ failure.
The emerging role of therapeutic endoscopy has met with considerable enthusiasm. Gall-stones remain the leading cause of acute pancreatitis (approx 34-54% of the 4.8-24.2 cases per 1,00,000 per year).
Despite modern intensive care, approximately 10% of patients die during hospitalization (according to a 1994 US Govt. Report).
The success rate in experienced hands exceeds 90% for effective removal of the offending stones and establishing biliary clearance. These results have been reproduced time and again and have been consolidated by randomized controlled trials (RCTs).
ENDOSCOPIC INTERVENTION
The management of biliary pancreatitis is multi-disciplinary in nature, and is largely dependant on the local expertise available.
Endoscopic treatment is definitely being increasingly integrated into the treatment of severe biliary pancreatitis.
ERCP and endoscopic sphincterotomy was initially based on sporadic reports with the apprehension of ERCP induced pancreatitis and worsening of symptoms. However, as experience gathered and randomized trials were published, these concerns were laid back, with substantiated benefits of therapeutic ERCP becoming increasingly evident and aggressive efforts of endoscopists manifesting as better success rates.
Though 4 large series have been reported since 1988, the Leicester study and the HongKong group study are really worth mentioning.
RANDOMIZED CONTROLLED TRIAL FROM UK (Neoptolemos et al)
The Leicester group from England randomized 121 patients with suspected acute biliary pancreatitis to receive either conventional conservative treatment, or to undergo urgent ERCP within 72 hours after admission.
Patients with CBD calculi underwent endoscopic sphincterotomy and stone removal. The severity of pancreatitis was stratified according to Glasgow criteria. The results were clear : ERCP was successful in 94% of mild and 80% of severe attacks, while choledocholithiasis was found in 25% and 63% of patients predicted to have mild and severe attacks respectively.
All CBD calculi could be extracted without complications.
The salient features were:
A) ERCP could be safely performed in an expert centre.
B) ERCP reduces morbidity (61% in conventional versus 24% in ERCP group) and mortality (18% in conventional versus 4% in ERCP group).
C)ERCP reduces the hospital stay (17 days in Conventional group versus 9.5 days in ERCP group).RANDOMIZED CONTROLLED TRIAL FROM HONG KONG : (Fan et al)
This group had a large number of patients with gall-stones (due to increased prevalence in population). They randomized 195 patients with acute pancreatitis to early ERCP (within 24 hrs) versus conventional treatment.
i. Severity of the attack was based on:
ii. Blood urea > 45 mg/dl and
iii. Blood sugar > 198 mg/dl on admission
The results were comparable to those from UK in patients with bile duct stones.
The morbidity was decreased from 54% in the conventional group to 15% in the ERCP group and mortality dropped from 18% in the conventional group to 3% in the ERCP group.
The trials from Hong Kong and UK did not reveal any benefit in "mild pancreatitis" in patients treated by ERCP or by conventional means, however the benefits were obvious and distinct in "severe pancreatitis".
Results of Trials
Designing a perfect randomized trial is extremely difficult in a situation of acute pancreatitis. The results deduced above were also challenged based on ethnic, environmental as well as local technical expertise differences reported.
It is not surprising that drawing "take-home messages" based on the above results is difficult. However, until a formal meta-analysis has been performed, recommendations for the preferred methodology of treatment should be guided by qualitative assessment of these trials.
ARGUMENTS PRO EARLY ERCP
a) In cholangitis and impacted ampullary stones, ERCP is the "saviour".
b) Endoscopic sphincterotomy definitely helps in prevention of re-obstruction at the papilla.
c) An adequate decompression of the dilated CBD and pancreatic duct is achieved.
d) Accurate road-mapping of the free biliary passage becomes evident.
ARGUMENTS CONTRA - EARLY ERCPVery few arguments stand in this favour now, as most of the technical procedure related complications have drastically fallen.
However, a cautious approach should prevail, as the risks of perforation, bleeding and iatrogenic pancreatitis are linking just beyond the corner.
PRACTICAL TIPS
The crux of the matter lies in establishing a diagnosis of biliary pancreatitis and timing an "early ERCP". This would assure a favourable outcome in "severe pancreatitis".
The criteria for judging severity should be applied scrupulously. Also; co-existent cholangitis, jaundice, dilated CBD or clinical deterioration in patients with mild signs should be monitored.
Local, available expertise also plays a role in determining results.
Endoscopic sphincterotomy protects against recurrence of gall-stone pancreatitis in patients with local and/or systemic complications, in patients with a dilated bile duct without demonstrable stones and in patients with multiple, small gall stones, if cholecystectomy is not possible or planned early.
FUTURISTIC APPROACH
It has been firmly asserted that ‘Diagnostic ERCP’ is a fading modality due to associated significant morbidity and mortality.
Hence, less invasive methods are gradually developing to allow selection of patients with choledocholithiasis without exposing "innocent" bile ducts to the risks of ERCP. Refined results are expected with rapid progress in detecting choledocholithiasis "non-invasively" in the field of radiology (MR cholangiopancreatography) and in endoscopy (endoscopic ultrasound).
Though results are improving as technology progresses, certain logistic and technical barriers still exist which need to be tackled, before these investigations are available as a routine protocol.
Slowly and steadily as we gain wisdom, prudential ‘therapeutic ERCP’ would be directed towards removing offending stones and establishing biliary drainage, thus benefitting many patients. This would be an essential armamentarium for clinicians in their conquest of pancreatitis.
REFERENCES
1.Balthazar E, Robinson D, Megibow A, Ranson J. Acute Pancreatitis : Value of CT in establishing prognosis. Radiology 1990; 174 : 331-6.
2.Neoptolemos J, Carr-Locke D, London N, et al. Controlled trial of Urgent ERCP and Endoscopic Sphincterotomy versus Conservative treatment for acute pancreatitis due to gall-stones. Lancet 1988; 2 : 979-83.
3.Ranson J. Etiologic and prognostic factors in human acute pancreatitis : a review. American J Gastroenterology 1982; 77 : 633-8.
4.David L Carr-Locke. Therapeutic Endoscopy at the end of this millennium. ERCP and Gall stone Pancreatitis. 65-74.
5.MW Buchler, W Uhl, H Friess, P Malfertheiner (Eds.) Acute Pancreatitis : Novel Concepts in Biology and Therapy.
6.Roy Soetikno, David Carr-Locke. Endoscopic Management of Acute Gall-Stone Pancreatitis. Gastro-intestinal Endoscopy Clinics of North America (Jan).
7.Richard Kozarek, John Sekijima. Acute Pancreatitis : Gastrointestinal Disease - An Endoscopic approach.
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