Acute biliary pancreatitis (ABP) with and without obstructive signs on ERCP – When is endoscopic sphincterotomy (EST) needed?

It is generally accepted that patients (pts) with ABP and common bile duct (CBD) stones may benefit from early ERCP and EST.

The aim of this study was a prospective analysis of the clinical outcome of ABP pts with and without obstructive signs (CBD stone or dilatation) on the cholangiographic picture after early ERCP and EST.

39 consecutive pts with suspected ABP were referred for early ERCP. Non-alcoholic pts with acute pancreatitis associated with biliary abnormalities on US and concomitant early elevation of obstructive LFTs were selected. In all pts, ERCP was performed within 2 days of the initial disease presentation. 21 pts presented with an obstructive (ERCP+) and 18 with a non-obstructive cholangiogram (ERCP-). Thereafter, they were hospitalized and followed up. 15 ABP pts with similar clinical presentation, but without optimal endoscopic therapy served as controls (7 with EST later than 5 days, 2 with ineffective ERCP, 6 with only MRCP).

On 48 ABP pts with ERCP, we performed 46 EST with complete stone extraction (if needed) without complication. Selective CBD cannulation without pancreatogram was achieved in 33 pts (69%). Comparison of the ERCP+, ERCP- and control groups via disease severity (Ranson scores: 2.1+1.0 vs. 2.1+1.6 vs. 2.1+1.2), average in-hospital stay (8.8+4.8 vs. 9.3+7.7 vs. 19.4+17.7 days), average time to amylase normalization (2.8+0.9 vs. 2.7+1.5 vs. 4.3+2.1 days), and post-pancreatitis complication rate (14% vs. 17% vs. 53%) demonstrated statistically significant differences, which favoured early ERCP and EST, regardless of the actual cholangiographic picture.

In all ABP pts with typical clinical presentation, emergency ERCP and EST is the treatment of choice, which should preferably be performed within 48h of the initial disease presentation.