PANCREAS NEWS
Am J Gastroenterol 2000; 95:1702-7
Testoni PA, Caporuscio S, Bagnolo F, Lella F
Department of Biomedical Sciences, University of Milan, IRCCS San Raffaele Hospital, Italy
JOP expert comment (G Uomo: uomogir@libero.it)
The etiology of acute recurrent pancreatitis remains unexplained in about 30% of the cases. In this study, the authors evaluated in a prospective follow-up study, the long-term outcome of 40 patients with idiopathic recurrent pancreatitis and intact gallbladder who underwent endoscopic cholangiopancreatography (ERCP) followed by either endoscopic biliary, and rarely, pancreatic sphincterotomy or ursodeoxycholic acid (UDCA) treatment.
All patients underwent diagnostic ERCP, followed by biliary or minor papilla sphincterotomy in cases of documented or suspected bile duct microlithiasis and sludge, type 2 sphincter of Oddi dysfunction, or pancreas divisum with dilated dorsal duct. Patients with no definite anatomical or functional abnormalities received long-term treatment with UDCA. After biliary sphincterotomy, patients with further episodes of pancreatitis underwent main pancreatic duct stenting followed by pancreatic sphincterotomy if the stent had proven to be effective.
ERCP found an underlying cause of pancreatitis in 70% of the cases. Patients were followed-up for a period ranging from 27 to 73 months. Effective therapeutic ERCP or UDCA oral treatment proved that occult bile stone disease and type 2 or type 3 sphincter of Oddi dysfunction (biliary or pancreatic segment) had been the etiological factors in 35 of the 40 cases (87.5%) After therapeutic ERCP or UDCA, only three patients still continued to have episodes of pancreatitis. In conclusion, diagnostic and therapeutic ERCP and UDCA were effective in 92.5% of our cases, over a long follow-up, indicating that the term "idiopathic" was justified only in a few patients with acute recurrent pancreatitis.
This is an important study, which confirms previous observations that "occult" biliary disease is the main etiological factor of recurrent idiopathic pancreatitis. Further studies are needed to elucidate other possible etiological factors of recurrent pancreatitis such as hereditary diseases and the variants of cystic fibrosis which may play a role in the small number of patients in whom biliary origin has been excluded.
Gastrointest Endosc 2000; 52:153-9
Sahai AV, Mishra G, Penman ID, Williams D, Wallace MB, Hadzijahic N, Pearson A, Vanvelse A, Hoffman BJ, Hawes RH
Division of Gastroenterology and Hepatology/Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
JOP expert comment (R Pezzilli: pezzilli@orsola-malpighi.med.unibo.it)
EUS is an emerging technique used to diagnose pancreatic disease. In this interesting study, one of the few prospective studies utilizing this technique, the authors compared the prevalence of endosonographic pancreatic abnormalities in patients with dyspepsia and in control subjects. In fact, mild chronic pancreatitis is difficult to diagnose and the diagnosis is therefore not sought routinely in patients with dyspepsia.
Patients in whom there was any suspicion of pancreatic disease were analysed separately.
One-hundred-fifty-six patients with dyspepsia were compared with 27 control subjects. The 2 groups were similar except for the fact that the control patients were significantly older and more likely to be men.
The mean number of endosonographic abnormalities was higher in dyspeptic patients than in the control patients and the strongest independent predictors of severe endosonographic abnormalities, defined as 5 or more abnormalities, were the presence of suspected pancreatic disease (odds ratio 7.29; 95% CI: 2.03-26.14) and dyspepsia (odds ratio 7.21: 95% CI: 1.99-26.26). In the dyspepsia group, no clinical variables were significant predictors of severe abnormalities. However, most patients had a nonspecific-type dyspepsia or persistent symptoms after therapeutic trials of acid suppression.
The authors concluded that dyspepsia may be an atypical presentation of pancreatic disease in patients with persistent or nonspecific symptoms and we agree with the view of the authors that endosonography may be useful in screening for pancreatic disease in patients with persistent dyspepsia, especially in those in whom any pancreatic disease may be suspected.
This paper further highlights the fact that clinical assessment of the patient remains the gold standard for patients with pancreatic disease: the new imaging techniques (like the older ones in the past) are ancillary to clinical assessment.