Gallstone Pancreatitis – Who Really Needs an ERCP?

Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia Correspondence: Dr Michael F Byrne, Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, 100-2647 Willow Street, Vancouver, British Columbia V5Z 3P1. Telephone 604-875-5640, fax 604-875-5373, e-mail michael.byrne@vch.ca Gallstones are the leading cause of acute pancreatitis (AP) in developed countries, accounting for up to 50% of cases. Although advances have been made, there is still a significant mortality associated with AP in the range of 2% to 10%, with rates as high as 25% found in the presence of infected pancreatic necrosis (1,2). However, the majority of patients with acute gallstone (biliary) pancreatitis (ABP) have a mild attack and recover uneventfully. A gallstone etiology is suggested by an early rise in the bilirubin, serum transaminases or both, or by findings of ductal stones or ductal dilation on imaging. The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in the management of gallstone pancreatitis has been a subject of much debate over the past few years. There is a growing consensus among gastroenterologists that ERCP should be reserved principally, if not solely, for patients in whom therapeutic intervention is likely, because the procedure carries a morbidity of 5% to 10% and a mortality of 0.1% to 0.5%. ERCP shares the risks associated with all endoscopic techniques, as well as having complications particular to this procedure. Risks specific to instrumentation of the pancreaticobiliary system include pancreatitis, cholangitis, bleeding and retroduodenal perforation. Several studies in the laparoscopic age have investigated the use of preoperative criteria, such as liver function tests, ultrasound findings and features and severity of pancreatitis and cholangitis to predict the likelihood of common bile duct (CBD) stones. The results vary somewhat among studies but overall have been fairly disappointing (3,4). Use of these and other criteria to ‘drive’ the use of preoperative ERCP results in a high percentage of negative studies. One must always consider that, at the time of initial management of the gallstone pancreatitis patient, there are several options we can consider for detecting and subsequently removing any bile duct stones – preoperative ERCP, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), laparoscopic cholecystectomy with intraoperative cholangiography followed by bile duct exploration (laparoscopic or open), or postoperative ERCP and stone extraction. So, what about the role of early ‘preoperative’ ERCP in ABP? There are four much quoted prospective randomized trials that have evaluated the role of early ERCP in patients with suspected or confirmed ABP (5-8). The United Kingdom and Hong Kong studies (5,6) essentially concluded that patients with severe gallstone pancreatitis benefit from early ERCP and sphincterotomy with a reduction in morbidity and mortality. The study from Germany (7) suggested that early ERCP does not benefit patients with ABP without obstructive jaundice or biliary sepsis. In fact, the early ERCP group in this study had a higher incidence of respiratory failure and more severe complications. Finally, a Polish study (8) concluded that all patients with ABP, irrespective of the severity of disease, would benefit from early ERCP. These are the hard data from which we have to draw a set of recommendations. Most experts in the field conclude from the current body of evidence that early ERCP is most certainly to be encouraged in the setting of one or more of the following: severe ABP, dilation of the CBD on imaging, jaundice, cholangitis or persistently abnormal and rising liver enzymes (9). In addition, one should also perform urgent ERCP when there is clinical deterioration or in patients with initial mild prognostic signs who fail to improve after 48 h. Early ERCP has been shown to reduce the length of hospital stay in patients with severe ABP. However, in the majority of patients with ABP, preoperative ERCP is not indicated (10). Gallstones causing pancreatitis tend to be small and typically pass spontaneously. A useful statistic to highlight is that ERCP will detect CBD stones in less than 20% of patients with ABP 48 h to 72 h after the onset of an attack. In fact, the offending stone has often passed out of the bile duct by the time the patient has actually presented clinically with pancreatitis. So, what if one does not follow these recommendations closely, but rather performs ERCP in any patient with ABP, even those with mild disease or those with no jaundice or cholangitis? Are we potentially doing harm? This nonselective policy is undoubtedly practiced by some endoscopists. For the patient who is not fit to have a cholecystectomy, endoscopic sphincterotomy (ES) performed during ERCP is, as discussed below, an intervention that seems to protect the patient against future attacks. However, because most patients with mild features and resolving liver numbers will settle without intervention, exposing this group to the known risks of ERCP and ES is difficult to support. It really is not clear from the literature whether ERCP in this group of patients significantly increases their morbidity, but I like to heed the advice that the CURRENT ENDOSCOPIC PRACTICES – THE EXPERTS SPEAK

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