Review ArticleRole of endoscopic evaluation in idiopathic pancreatitis: a systematic review
Section snippets
Methods
Our systematic review was conducted according to previously proposed criteria.22 We searched PubMed (1966–January 1, 2006; English language) using the search terms “idiopathic pancreatitis, unexplained pancreatitis, and recurrent pancreatitis.” We also searched using the term “genetic testing in idiopathic pancreatitis.” We retrieved potentially relevant articles and reviewed their reference list to identify studies that our search strategy may have missed. We also searched our personal
Defining idiopathic pancreatitis
There are no agreed-on criteria for what constitutes an appropriate evaluation before an attack is labeled as being idiopathic. Generally, an attack is considered idiopathic after history, physical examination, laboratory studies, and US and CT imaging reveal no cause. Intuitively, the prevalence of idiopathic pancreatitis will necessarily depend on the epidemiologic setting, the criteria used to define specific causes, and the extent of the diagnostic evaluation. Nevertheless, for unclear
Role of microlithiasis
Although gallstones have been recognized as a cause of acute pancreatitis for about a century, only recently have biliary sludge and microlithiasis been linked to acute biliary pancreatitis.27, 28, 29, 30 Microlithiasis is often referred to as small stones less than 3 mm in diameter.27, 28, 30, 31 Biliary sludge is defined as a suspension of crystals (usually cholesterol monohydrate), mucin, glycoproteins, cellular debris, and proteinaceous material within bile.16 Sludge may be visualized by
ERCP
As noted above, current practice has traditionally been to more aggressively evaluate patients after multiple attacks rather than after the first idiopathic attack, presumably because of the inherent complications of ERCP.23, 24 However, to our knowledge, there have been only 2 studies, only one of which was prospective, whose primary focus was evaluating such a cohort, and in only one was follow-up reported. In the earliest study, Ballinger et al52 retrospectively identified 31 patients with
ERCP
Studies performed early on after the birth of ERCP suggested a potential role for pancreatography in patients with idiopathic pancreatitis,56 and a number of centers worldwide have now reported their experience with ERCP in RIP10, 53, 54, 55, 59, 60, 61, 62, 63, 64 (Table 2). Many of the initial studies are flawed by the inclusion of patients with only a single attack11, 54 or inclusion of those with gallbladder stones55 and outdated by the technologic infancy of US and CT and by failure of
Recommendations for evaluation
The majority of patients with acute pancreatitis will have a diagnosis established with use of routine investigations. Recent studies with EUS used after conventional evaluation underscore that the true prevalence of idiopathic pancreatitis depends on the extensiveness of the evaluation. Long-term follow-up has not been commonly performed in most studies and, thus, the true importance of some causes, on the basis of the recurrence of pancreatitis, remains less well defined.
On the basis of the
Areas for future investigation
The data presented above clearly demonstrate the importance of biliary sludge in the genesis of idiopathic pancreatitis. Although duodenal sampling for crystal analysis and EUS have shown promise, additional studies are warranted to determine whether initial EUS and, if results are negative, microscopic examination of bile for crystals is the appropriate diagnostic strategy. Additional studies are also warranted to better determine the ideal method for microscopic examination of bile for
References (92)
- et al.
Epidemiology of pancreatic diseases in Lüneburg County
Pancreatology
(2002) - et al.
Prospective multicentre survey on acute pancreatitis in Italy (ProInf-AISP): results on 1005 patients
Dig Liver Dis
(2004) - et al.
Trends in incidence of acute pancreatitis in a Swedish population is there really an increase?
Clin Gastroenterol Hepatol
(2004) Idiopathic acute pancreatitis: role of ERCP in diagnosis and therapy: clinical update
Am Soc Gastrointest Endosc
(2004)- et al.
Occult microlithiasis in “idiopathic” acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy
Gastroenterology
(1991) - et al.
Idiopathic acute recurrent pancreatitis
Am J Gastroenterol
(2001) - et al.
Recurrent acute pancreatitis: an algorithmic approach to identification and elimination of inciting factors
Gastroenterology
(2001) - et al.
“Idiopathic” pancreatitis
Gastroenterology
(2005) Adverse outcomes of ERCP
Gastrointest Endosc
(2002)- et al.
Gallstone pancreatitis and the effect of cholecystectomy: a population-based cohort study
Mayo Clin Proc
(1988)
The frequency of bile duct crystals in patients with presumed biliary pancreatitis
Gastrointest Endosc
Usefulness of endoscopic ultrasonography in patients with “idiopathic” acute pancreatitis
Am J Med
A prospective comparison of the yield of EUS in primary vs recurrent idiopathic acute pancreatitis
Gastrointest Endosc
Endoscopic ultrasound in idiopathic acute pancreatitis
Am J Gastroenterol
EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis
Gastrointest Endosc
Idiopathic recurrent pancreatitis: long-term results after ERCP, endoscopic sphincterotomy, or ursodeoxycholic acid treatment
Am J Gastroenterol
ERCP, biliary crystal analysis, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis
Gastrointest Endosc
Frequency of abnormal pancreatic and biliary sphincter manometry compared with clinical suspicion of sphincter of Oddi dysfunction
Gastrointest Endosc
Idiopathic recurrent pancreatitis: long-term results after ERCP, endoscopic sphincterotomy, or ursodeoxycholic acid treatment
Am J Gastroenterol
EUS in common bile duct stones
Gastrointest Endosc
Pancreatitis associated with pancreatic carcinoma, preoperative diagnosis: role of CT imaging in detection and evaluation
Pancreatology
An update on recurrent acute pancreatitis: data from five European countries
Am J Gastroenterol
The hunt for microlithiasis in idiopathic acute recurrent pancreatitis: should we abandon the search or intensify our efforts?
Gastrointest Endosc
Role of ERCP in acute pancreatitis
Gastrointest Endosc
Pancreatic FNA in 1000 cases: a comparison of imaging modalities
Gastrointest Endosc
Incidence, aetiology and mortality rate of acute pancreatitis over years in a defined urban population in Sweden
Br J Surg
Incidence and mortality of acute pancreatitis between 1985 and 1995
Scand J Gastroenterol
Hospital admission for acute pancreatitis in an English population 1963-98: database study of incidence and mortality
BMJ
Acute pancreatitis in Bergen, Norway: a study on incidence, etiology and severity
Scand J Surg
Acute pancreatitis: a prospective study of its incidence, aetiology, severity, and mortality in Iceland
Eur J Surg
Incidence, management and recurrence rate of acute pancreatitis
Scand J Gastroenterol
Endoscopic retrograde cholangiopancreatography in the investigation and management of patients after acute pancreatitis
Br J Surg
Detection of gallstones after acute pancreatitis
Gut
Extensive aetiological investigations in acute pancreatitis: results of 1-year prospective study
Eur J Gastroenterol Hepatol
“Idiopathic” acute pancreatitis due to biliary sludge: prevention of relapses by endoscopic biliary sphincterotomy in high-risk patients
Am J Gastroenterol
Biliary sludge as a cause of acute pancreatitis
N Eng J Med
Idiopathic acute pancreatitis
J Clin Gastroenterol
The role of endoscopic retrograde cholangiopancreatography in acute and chronic pancreatitis
J Clin Gastroenterol
Systematic reviews: synthesis of best evidence for clinical decisions
Ann Intern Med
Complications of endoscopic retrograde cholangiography in the post-MRCP era: a tertiary center experience
World J Gastroenterol
ASGE guideline:complications of EUS
Gastrointest Endosc
Prospective evaluation of patient tolerability, satisfaction with patient information, and complications in endoscopic ultrasonography
Endoscopy
Acute pancreatitis related to grossly minute stones in a radiographically normal gallbladder
Am J Dig Dis
Gallstone pancreatitis: exploration of the biliary system in acute and recurrent pancreatitis
Arch Surg
Occult gallbladder microlithiasis causing acute recurrent pancreatitis: a report of three cases
Acta Chir Scand
Physiopathologic role of microlithiasis in gallstone pancreatitis
Surg Gynecol Obstet
Cited by (98)
AGA Clinical Practice Update on the Endoscopic Approach to Recurrent Acute and Chronic Pancreatitis: Expert Review
2022, GastroenterologyCitation Excerpt :Despite routine efforts to identify a cause, which should include a comprehensive personal and family history, physical examination, medications review, laboratory testing (eg, liver biochemistries, triglycerides, and calcium), and noninvasive imaging, the etiology of AP remains unexplained in 16%–27% of all cases.6,7 Endoscopic ultrasound (EUS) has become the most important diagnostic tool for the evaluation of unexplained AP,8,9 uncovering a potential etiology in 29%–88% of patients.10–13 The variable diagnostic yield of EUS can be attributed to several factors, including patient demographic characteristics, the tempo and pattern of RAP, and the a priori likelihood of a biliary etiology on the basis of liver biochemistries and the presence of a gallbladder.11
The role of linear endosonography for the diagnosis of acute pancreatitis when other methods failed
2019, Clinics and Research in Hepatology and GastroenterologyRecurrent Acute Pancreatitis
2019, Clinical Gastrointestinal EndoscopySphincter of Oddi Disorders
2019, Clinical Gastrointestinal EndoscopyComparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis
2018, Gastrointestinal EndoscopyCitation Excerpt :Biliary diseases, including cholelithiasis, choledocholithiasis, microlithiasis, and biliary sludge, are considered to be the leading cause of IAP.5 Microlithiasis, defined as the presence of stones that are <5 mm in diameter, is considered to be a cause of unexplained pancreatitis attacks in up to 75% of patients with a gallbladder in situ.26,53 Kondo et al54 showed that EUS has a better diagnostic yield in detecting common bile duct stones <5 mm in size compared with MRCP.
Endoscopic Ultrasound in Bile Duct, Gallbladder, and Ampullary Lesions
2018, Endosonography, Fourth Edition
Supported in part by grant No. K24-DK-070629 (C. M. W.).
See CME section; p. 1030.