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ERCP
in pancreatitis
By Kristin Jenkins
Baltimore,
MD—Despite
advances over the past decade in pinpointing the etiology of pancreatitis
using patient history and non-invasive tests (this applies to everyone
with pancreatitis, irrespective of cause) ERCP should not be performed
on its own “just because you think it’s a good idea,”
David L. Carr-Locke, MD, said at the annual meeting of the American
College of Gastroenterology.
Instead, ERCP should be combined with manometry and bile aspiration
followed by therapy, because on its own, ERCP is a risk factor for
pancreatitis, said Dr. Carr-Locke, Director of Endoscopy, Brigham
and Women’s Hospital, Boston, MA.
“We have become very good at defining the cause of pancreatitis
using non-invasive tests such as CT, MRI and ultrasound. Together
with looking at a patient’s drug history, family history and
so on, this usually allows us to make a reasonable diagnosis of
cause in almost 70 per cent of patients.”
In the 30 per cent of patients in whom no obvious cause can be found,
ERCP plus EUS will diagnose another 10 per cent of cases, because
EUS will detect small gallstones missed on other scans. “You
can see changes in the pancreas that you can’t see on ERCP
or MRI,” said Dr. Carr-Locke. “What you’ll probably
find is a subgroup with undiagnosed chronic disease.”
ERCP combined with therapy reduces the risk of pancreatitis post-ERCP,
especially in patients with Sphincter of Oddi dysfunction, said
Dr. Carr-Locke. “You do find other things, including pancreas
divisum, benign tumours of the papilla, and in some parts of the
world, worms.”
ERCP would be used to examine the papilla, the pancreatic duct,
and to assess pressures inside the pancreatic and biliary sphincters.
If the patient still has a gall bladder, you would also aspire bile
at the time of ERCP and look for crystals. “If you’re
not willing to take the bile sample and measure the pressures, then
you probably shouldn’t be doing ERCP in these patients.”
In the patient who has one mild attack and a first run of tests
reveals nothing, the best practice is to wait and see if it recurs.
If it does recur, or the first attack was severe, or there are complications
from the first attack, proceed to ERCP, Dr. Carr-Locke said.
At this stage, “it’s unlikely you will be finding gallstones.
More likely, there are stones in the pancreatic duct— in which
case you remove them—or a stricture, in which case you dilate.
“Basically, we use ERCP to look for obstructive pancreatitis
caused by something other than Sphincter of Oddi dysfunction or
crystals in the bile duct,”said Dr. Carr-Locke. A benign tumor
of the papilla would be treated endoscopically and removed as if
it were a polyp. “Our results and those of others are quite
good using this approach.”
If the finding is pancreas divisum, he said the principle is the
same.“If the minor papilla has become obstructed where the
pancreas drains, then you treat by performing a papillotomy to open
it up.”
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