Evaluation of Unexplained Acute and Acute Recurrent Pancreatitis Using Endoscopic Retrograde Cholangiopancreatography, Sphincter of Oddi Manometry and Endoscopic Ultrasound

W. J. Coyle; B. C. Pineau; P. R. Tarnasky; W. L. Knapple; L. Aabakken; B. J. Hoffman; J. T. Cunningham; R. H. Hawes; P. B. Cotton

doi:10.1055/s-2002-33245

Endoscopy 2002; 34(8): 617-623
DOI: 10.1055/s-2002-33245

Original Article

Evaluation of Unexplained Acute and Acute Recurrent Pancreatitis Using Endoscopic Retrograde Cholangiopancreatography, Sphincter of Oddi Manometry and Endoscopic Ultrasound

W. J. Coyle¹ , B. C. Pineau¹ , P. R. Tarnasky¹ , W. L. Knapple¹ , L. Aabakken¹ , B. J. Hoffman¹ , J. T. Cunningham¹ , R. H. Hawes¹ , P. B. Cotton¹

¹Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA

The opinions expressed herein are solely those of the authors and do not reflect those of the United States Navy, the Department of Defense, or the United States Government.

Abstract

Background and Study Aims: Unexplained pancreatitis represents a diagnostic challenge. The aim of this study was to determine the diagnostic utility of endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry (SOM), bile analysis, and endoscopic ultrasound (EUS) in evaluating such patients.
Patients and Methods: Of 162 patients referred for evaluation of pancreatitis, 72 with a known cause were excluded. The remainder (n=90) was classified as having prior acute (n=24) or recurrent acute pancreatitis (n=66). Bile sampling and SOM were performed at the time of ERCP. EUS was used to assess for tumors and for chronic pancreatitis. Clinical outcomes were evaluated by questionnaire.
Results: ERCP was successful in 88/89 patients (99 %). Manometry was successful in 63/67 patients (94 %), and 56 patients underwent EUS. Findings were categorized into five distinct etiologies: sphincter of Oddi dysfunction (SOD) (n=28; 31 %), pancreas divisum (n=18; 20 %), biliary (n=18; 20 %), idiopathic (n=18; 20 %) and tumor-related (n=8; 9 %). Features of moderate or severe chronic pancreatitis by EUS and ERCP criteria were found in 18 patients (21 %); an additional nine patients had chronic pancreatitis by EUS criteria alone. EUS identified all the tumors. The condition was improved in 96 % of all patients undergoing endoscopic therapy.
Conclusion: An etiology was identified in the majority of patients with unexplained pancreatitis. SOD represented the most common finding. Moderate to severe chronic pancreatitis was found in over one-fifth of these patients. Bile analysis, SOM, and EUS are useful tools in the evaluation of unexplained acute pancreatitis.

Full Text

References

1 Steinberg W, Tenner S. Acute pancreatitis. N Engl J Med. 1994; 330 1198-1210
2 Thomson S R, Hendry W S, McFarlane G A, Davidson A I. Epidemiology and outcome of acute pancreatitis. Br J Surg. 1987; 74 398-401
3 Venu R P, Geenen J E, Hogan W. et al . Idiopathic recurrent pancreatitis. An approach to diagnosis and treatment. Dig Dis Sci. 1989; 34 56-60
4 Soergel K H. Acute pancreatitis. In: Sleisenger MH, Fordtran JS, editors Gastrointestinal disease. 5th edn. Philadelphia; WB Saunders 1993: 1628-1651
5 Feller E R. Endoscopic retrograde cholangiography in the diagnosis of unexplained pancreatitis. Arch Intern Med. 1984; 144 1797-1799
6 Sherman S, Jamidar P, Reber H. Idiopathic acute pancreatitis (IAP): endoscopic approach to diagnosis and therapy [abstract]. Am J Gastroenterol. 1993; 88 1541
7 Ros E, Navarro S, Bru C. et al . Occult microlithiasis in ”idiopathic“ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology. 1991; 101 1701-1709
8 Lee S P, Nicholls J F, Park H Z. Biliary sludge as a cause of acute pancreatitis. N Engl J Med. 1992; 326 589-593
9 Legorreta A P, Silber J H, Costantino G N. et al . Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA. 1993; 270 1429-1432
10 Escarce J J, Chen W, Schwartz J S. Falling cholecystectomy thresholds since the introduction of laparoscopic cholecystectomy. JAMA. 1995; 273 1581-1585
11 Lam C M, Murray F E, Cuschieri A. Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy in Scotland. Gut. 1996; 38 282-284
12 Hawes R H, Zaidi S. Endoscopic ultrasonography of the pancreas. Gastrointest Endosc Clin N Am. 1995; 5 61-80
13 Dancygier H. Endoscopic ultrasound in chronic pancreatitis. Gastrointest Endosc Clin N Am. 1995; 5 795-804
14 Rösch T, Classen M. Normal anatomy on endosonographic examination. In: Elder D, editor Gastroenterologic Endosonography. Stuttgart; Thieme 1992: 13-35
15 Lees W R. Endosonographic ultrasonography of chronic pancreatitis and pancreatic pseudocysts. Scand J Gastroenterol. 1986; 21 (Suppl. 123) 123-129
16 Natterman C, Goldschmidt A JW, Dancygier H. Endosonography in chronic pancreatitis - a comparison between endoscopic retrograde pancreatography and endoscopic ultrasonography. Endoscopy. 1993; 25 565-570
17 Wiersema M J, Hawes R H, Lehman G A. et al . Prospective evaluation of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in patients with chronic abdominal pain of suspected pancreatic origin. Endoscopy. 1993; 25 555-564
18 Axon A TR, Classen M, Cotton P B. et al . Pancreatography in chronic pancreatitis: international definitions. Gut. 1984; 25 1107-1112
19 Cotton P B, Lehman G, Vennes J. et al . Endoscopic sphincterotomy, complications and their management: an attempt at consensus. Gastrointest Endosc. 1991; 37 383-393
20 Cotton P B. Outcomes of endoscopy procedures: struggling towards definition. Gastrointest Endosc. 1994; 40 514-518
21 Toskes P P. Approach to the patient with acute relapsing pancreatitis. Gastrointest Dis Today. 1994; 3 8-15
22 Bank S, Wise L, Gersten M. Risk factors in acute pancreatitis. Am J Gastroenterol. 1983; 78 637-640
23 Cotton P B, Beales J SM. Endoscopic pancreatography in management of relapsing acute pancreatitis. Br Med J. 1974; 1 608-611
24 Katon R M, Bilbao M K, Eldemiller L R, Benson J A. Endoscopic retrograde cholangiopancreatography in the diagnosis and management of non-alcoholic pancreatitis. Surg Gynecol Obstet. 1978; 147 333-338
25 Hamilton I, Bradley P, Lintott D J. et al . Endoscopic retrograde cholangiopancreatography in the investigations and management of patients after acute pancreatitis. Br J Surg. 1982; 69 504-506
26 Cotton P B. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut. 1980; 21 105-114
27 Rosch W, Koch H, Schaffner O, Demling L. The clinical significance of the pancreas divisum. Gastrointest Endosc. 1976; 22 206-207
28 Cooperman M, Ferrara J J, Carey L C. et al . Idiopathic acute pancreatitis: the value of endoscopic retrograde cholangiopancreatography. Surgery. 1981; 90 666-670
29 Nash J A, Geenen J E, Hogan W J. et al . The role of sphincter of Oddi manometry (SOM) and biliary microscopy in evaluating idiopathic recurrent pancreatitis (IRP) [abstract]. Gastroenterology. 1996; 110 31
30 Dancygier H, Classen M. Endosonographic diagnosis of benign pancreatic and biliary lesions. Scand J Gastroenterol. 1986; 21 (Suppl. 123) 119-122
31 Sakai K, Nasu T, Tanabe Y. et al . Evaluation of endoscopic ultrasonography for the diagnosis of choledocholithiasis. Gastroenterology. 1991; 100 A338
32 Frederic N, Deltentre M, d’Hondt M. et al . Comparative study of ultrasound and ERCP in the diagnosis of hepatic, biliary, and pancreatic disease. A prospective study based on a continuous series of 424 patients. Eur J Radiol. 1983; 3 208-211
33 Tio T L, Tytgat G NJ, Cikot R JLM. et al . Ampullopancreatic carcinoma: preoperative TNM classification with endosonography. Radiology. 1990; 175 455-461
34 Barkun A N, Jones S. Bowie J, et al. The assessment of ampullary tumors by endoscopic ultrasonography [abstract]. Gastrointest Endosc. 1990; 36 207
35 Buscail L, Escourrou J, Moreau J. et al . Endoscopic ultrasonography in chronic pancreatitis: a comparative prospective study with conventional ultrasonography, computed tomagraphy, and ERCP. Pancreas. 1995; 10 251-257
36 Catalano M F, Geenen J E, Schmalz M, Johnson G K. Comparison of endoscopic ultrasound (EUS) with ERCP and secretin test (ST) or pure pancreatic juice (PPJ) as diagnostic modalities in suspected chronic pancreatitis (CP). Gastrointest Endosc. 1994; 40 A186
37 Amouyal G, Amouyal P, Lévy P. et al . Value of endoscopic ultrasonography in the diagnosis of idiopathic acute pancreatitis [abstract]. Gastroenterol. 1994; 106 A283
38 Barkun A N, Jones S, Putnam W S. et al . Endoscopic treatment of patients with pancreas divisum and pancreatitis. Gastrointest Endosc. 1990; 36 A206-A207
39 Lehman G A, Sherman S, Nisi R, Hawes R H. Pancreas divisum: results of minor papilla sphincterotomy. Gastrointest Endosc. 1993; 39 1-8
40 Lans J I, Geenen J E, Johanson J F, Hogan W J. Endoscopic therapy in patients with pancreas divisum and acute pancreatitis: a prospective, randomized, controlled clinical trial. Gastrointest Endosc. 1992; 38 430-434
41 Goldberg P B, Long W B, Oleaga J A, Mackie J A. Choledochocele as a cause of recurrent pancreatitis. Gastroenterol. 1980; 78 1041-1045
42 Heikkinen E S, Salminen P M. Congenital choledochal cyst opening into the intraduodenal part of the common bile duct and complicated by cystolithiasis and acute pancreatitis. Acta Chir Scand. 1984; 150 183-185
43 Taylor R G, Auldist A W. Choledochal cyst presenting as acute pancreatitis. Aust NZ J Surg. 1985; 55 611-612
44 Greene F L, Brown J J, Rubinstein P, Anderson M C. Choledochocele and recurrent pancreatitis. Am J Surg. 1985; 149 306-309
45 Ballinger A B, Barnes E, Alstead E M, Fairclough P D. Is intervention necessary after a first episode of acute idiopathic pancreatitis?. Gut. 1996; 38 293-295
46 Gregor J C, Ponich T P, Detsky A S. Should ERCP be routine after an episode of ”idiopathic“ pancreatitis? A cost-utility analysis. Gastrointest Endosc. 1996; 44 118-123
47 Tio T L, Cheng J, Wijers O B. et al . Endosonographic TNM staging of extrahepatic bile duct cancer: comparison with pathologic staging. Gastroenterol. 1991; 100 1351-1361
48 Grimm H, Maydeo A, Soehendra N. Endoluminal ultrasound for the diagnosis and staging of pancreatic cancer. Baillière’s Clin Gastroenterol. 1990; 4 869-887
49 Palazzo L, Roseau G, Gayet B. et al . Endosonographic ultrasonography in the diagnosis and staging of pancreatic adenocarcinoma. Endoscopy. 1993; 25 143-150
50 Rösch T, Braig C, Gain T. et al . Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography. Gastroenterol. 1992; 102 188-199
51 Tio T L, Tytgat G N, Cikot R J. et al . Ampullopancreatic carcinoma: preoperative classification with endosonography. Radiology. 1990; 175 455-461
52 Vilmann P, Hancke S, Henriksen F W, Jacobsen G K. Endosonographically guided fine needle aspiration of malignant lesions of the upper gastrointestinal tract. Endoscopy. 1993; 25 523-527
53 Wiersema M J, Kochman M L, Cramer H M. et al . Endosonography-guided real time fine-needle aspiration biospy. Gastrointest Endosc. 1994; 40 700-707
54 Frossard J L, Sosa-Valencia L, Amouyal G. et al . Usefulness of endoscopic ultrasonography in patients with “idiopathic” acute pancreatitis. Am J Med. 2000; 109 196-200
55 Tarnasky P R, Hawes R H. Endoscopic diagnosis and therapy of unexplained (idiopathic) acute pancreatitis. Gastrointest Endosc Clin N Am. 1998; 8 13-37

W. J. Coyle, M.D.

Division of Gastroenterology · Naval Medical Center

San Diego · CA 92134-3301 · USA

Fax: + 1-619-532-9620

Email: waltcoyle@aol.com