• How Should We Treat Recurrent Acute Pancreatitis?

How Should We Treat Recurrent Acute Pancreatitis?

Recurrent acute pancreatitis with a clear cause can be treated with endoscopy, explain Liam Zakko and Timothy B. Gardner in a “Here and Now: Clinical Practice” article in the October issue of Clinical Gastroenterology and Hepatology.

(A) Anatomy of pancreas divisum. (B) Stent placement into the minor papilla. (C) Balloon dilation of the minor papilla. (D) Minor papilla sphincterotomy. ERCP, endoscopic retrograde cholangiography and pancreatography.

Acute pancreatitis affects 40 to 50 of every 100,000 Americans per year and is the most common cause of hospital admission for a gastrointestinal disease in the United States. Although acute pancreatitis is thought of as single event, as many as 22% of patients have at least 1 recurrence. Recurrent acute pancreatitis (RAP) is defined as 2 or more episodes of acute pancreatitis with complete resolution of symptoms between episodes in patients with no evidence of chronic pancreatitis. It is important to prevent pancreatitis recurrence because continued recurrence can lead to chronic pancreatitis or even pancreatic cancer.

Zakko and Gardner review causes of RAP that are can be treated by endoscopyGallstone disease causes up to 30% of all cases of RAP. The authors discuss when to perform immediate endoscopic retrograde cholangiography and pancreatography (ERCP) vs evaluation with pre-operative magnetic resonance cholangiography and pancreatography, endoscopic ultrasound (EUS), or intraoperative cholangiogram.

Acute pancreatitis can also be caused by obstructive cysts, tumors, or pancreatic divisum, which can all be evaluated and treated endoscopically. In patients with pancreatic divisum and no other identifiable cause for RAP, endoscopic interventions are designed to reduce minor papilla tone, leading to increased dorsal duct drainage and decreased pressure (see Figure).

Papillary stenosis and sphincter of Oddi dysfunction, which occur after cholecystectomy when the ampulla of Vater becomes strictured, lead to dilation of the pancreatic and/or biliary ducts, pain, and enzyme abnormalities. These can be treated with ERCP and endoscopic sphincterotomy. A trial that evaluated the effects of endoscopic sphincterotomy in patients with RAP reported that among patients with sphincter of Oddi dysfunction, a combination of biliary and pancreatic sphincterotomy, vs only biliary sphincterotomy, have similar effects in preventing pancreatitis recurrence.

Ten to twenty percent of cases of RAP have no identifiable cause; these patients should be evaluated with EUS, write Zakko and Gardner.

The authors conclude that patients with a clear cause of RAP should be treated with endoscopic interventions. However, when the suspected cause of RAP is pancreatic divisum or sphincter of Oddi dysfunction, the authors recommend referring patients to centers where large numbers of endoscopies are performed, and possibly entering patients into clinical trials.

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