In our latest Clinical Therapeutics article, a 74-year-old man is admitted to the hospital with acute gallstone pancreatitis without evidence of coexisting ascending cholangitis or biliary obstruction. Conservative treatment is recommended, with the option of removing the obstructing stone if his condition worsens.
Acute pancreatitis is a common diagnosis worldwide, and more than 240,000 cases are reported annually in the United States alone. Gallstone disease, the most common cause of acute pancreatitis, accounts for approximately 50% of cases in Western countries.
Mortality is approximately 5% among all patients with acute pancreatitis and has been as high as 20 to 30% among those with severe cases, although this rate may be declining. Patients with progressive multisystem organ dysfunction are at highest risk for death, and in one study, mortality among such patients was reported to be higher than 50%. Deaths that occur within the first 2 weeks after the pancreatitis episode are usually due to the systemic inflammatory response syndrome and multisystem organ failure, whereas deaths that occur later are typically attributable to complications of necrotizing pancreatitis.
Most patients with biliary pancreatitis, regardless of the predicted severity, do not benefit from ERCP, with or without sphincterotomy. ERCP is performed within 24 to 48 hours after presentation in patients with acute disease and symptoms or signs of coexisting cholangitis (e.g., fever, jaundice, and septic shock) or persistent biliary obstruction (a conjugated bilirubin level >5 mg per deciliter [86 micromoles per liter]). Intervention with ERCP is also considered in patients who have clinical deterioration (e.g., worsening pain, leukocytosis, and a change in vital signs) and increasing liver-enzyme levels. Finally, if radiologic imaging such as abdominal ultrasonography or computed tomography shows a stone in the common bile duct, ERCP should be performed. The consensus is that in the absence of cholangitis and biliary obstruction, performance of early ERCP (within 24 to 72 hours after admission to the hospital) does not lead to a reduction in mortality or in local or systemic complications. Furthermore, the results are not dependent on the predicted severity of pancreatitis.
Morning Report Questions
Q: What are the contraindications to ERCP in patients with acute biliary pancreatitis?
A: An unstable medical condition that precludes safe moderate sedation is an absolute contraindication to ERCP; relative contraindications have typically included altered postsurgical anatomical features that prevent endoscopic access to the major papilla and clinically significant coagulopathy.
Q: What are the complications of ERCP?
A: Pancreatitis is the most common complication after ERCP, with frequency estimates in the range of 2 to 8% among low-risk patients, such as those with uncomplicated choledocholithiasis. Other complications of ERCP include bleeding (typically after sphincterotomy), ductal or intestinal perforation, infection, and cardiopulmonary events. When sphincterotomy is not performed, bleeding and periampullary perforations should not occur. However, perforations of the pancreatic duct, the bile duct, or both with wire as well as intestinal perforations due to trauma from the scope or another instrument (particularly in patients with anatomical alterations after surgery) can occur without a sphincterotomy.