Acute Relapsing Pancreatitis - Touch Gastroenterology

Figure 3: Recommended Algorithm for the Diagnostic Management of ARP
diagnostic algorithm of ARP, where no evident
cause is identified after initial evaluation procedures.
ERCP may be indicated for diagnostic purpose in
the few patients who suffer two or more attacks of
acute pancreatitis in whom the aetiology of ARP
cannot be achieved using high-quality S-MRCP
and EUS. The aim of diagnostic ERCP is to
perform ancillary procedures that may improve the
diagnostic accuracy, such as brush cytology or
biopsy in suspected neoplasm, minor papilla
cannulation in suspected PD to clearly demonstrate
a santorinicele (defined as focal cystic dilation of the
termination of the dorsal pancreatic duct at the
minor papilla), 23 sphincter of Oddi manometry in
suspected SOD or collection of bile in suspected
occult biliary stones. 7,24 However, ERCP is
associated with a 3% to 5% complication rate, which
is much higher in patients with a history of
pancreatitis and may rise to 30% in cases with
suspected SOD. 25 Nowadays, sphincter of Oddi
manometry tends to be replaced by the non-invasive
S-MRCP, 26 providing information regarding the
morphology of the pancreatic gland, the dynamics of
the emptying of the main pancreatic duct and the
functional status of the exocrine pancreas through
assessment of the duodenal filling after secretin
administration. Therefore, ERCP has evolved from
a diagnostic procedure to an almost exclusively
therapeutic procedure for the treatment of
Acute Relapsing Pancreatitis
ARP = acute relapsing pancreatitis; Lab = laboratory data; U/S = abdominal ultrasound; CT = computed tomography; S-MRCP = secretin-enhanced magnetic resonance cholangio-pancreatography; EUS = endoscopic
ultrasonography; MRC = magnetic resonance cholangiography; BD = bile duct; ERCP = endoscopic retrograde cholangio-pancreatography; APBU = anomalous pancreaticobiliary union; CP = chronic pancreatitis;
SOD = sphincter of Oddi dysfunction; SOM = sphincter of Oddi manometry; IPMT = intraductal papillary mucinous tumor; FNA = fine needle aspiration; PD = pancreas divisum.
This figure is based on a review of current literature and on the author’s personal experience.
abnormalities found by less invasive imaging
techniques such as S-MRCP and EUS. 27
Management
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After a negative initial evaluation in patients younger
than 40 years of age with only one mild episode of
unexplained acute pancreatitis, expectant approach
and no further testing is an acceptable management
strategy, because the medium-term recurrence rate is
believed to be low and the incidence of malignant
neoplasm is low in patients with no family history of
pancreatic cancer and no use of tobacco. 28,29
However, in patients older than 40 years of age, with
more than one attack of acute pancreatitis or when
the initial attack is severe, a systematic identification
and/or elimination of correctable inciting factors is
required (see Figure 3). 4
Occult biliary stones can be demonstrated using
repeated U/S (for the gallbladder) or EUS (for the
common bile duct) and treated using endoscopic
biliary sphincterotomy (EBS) and laparoscopic
cholecystectomy if the gallbladder is in situ.
Early ERCP and EBS are safe and beneficial,
particularly in severe biliary pancreatitis and when
there is evidence of bile duct obstruction or
cholangitis (see Figure 4). 30
4