Acute pancreatitis: The acute attack. Acute recurrent pancreatitis

Due to the well accessibility of the pancreatobilary system, the potential role of EUS and EUS-FNA in an acute attack of a first episode or recurrent idiopathic pancreatitis seems to be an issue. Since EUS is competing with other imaging modalities such as CT, MRCP and ERCP, the following questions have to be raised. (1) Is there a role for EUS as one of the initial imaging modalities? (2) Can EUS replace other diagnostic procedures, especially ERCP? (3) In which period of the acute attack may EUS and EUS-FNA play a role?

The published studies about these issues are quite limited. They mainly focused on the role of EUS in cause finding. A potential issue which has not really been addressed is the role of EUS in the early management of complications of an acute pancreatitis such as pancreatic fluid collections and infection.

The definition of an acute attack especially with regard to the exact time frame has not clearly been defined yet. Clinically the acute attack is present as long as the pancreatic enzymes are elevated. However, from our experience even though the enzymes have returned to normal values, the pancreas parenchyma can be still edematous and fluid collections may be present. EUS may provide information about the status of the parenchymatous stage of inflammation in addition to laboratory findings. This information can be important for further management of patient and predicting the further progress of the attack.

CT has been the gold standard imaging to access the severity of acute pancreatitis using the Balthazar computed tomography index which grades the severity based on pancreatic inflammation and necrosis. There are no published studies comparing EUS and CT in grading the severity of the disease. EUS provides good locoregional visualization, however extension of the necrosis is still best visualized by CT. Therefore EUS cannot replace CT as the index imaging. The situation is supposed to be different with regards to cause finding.

References

• 1 Frossar J L, Sosa-Valencia L, Amouyal G. et al . Usefulness of endoscopic ultrasonography in patients with ”idiopathic” acute pancreatitis.  Am J Med. 2000;  109 96-200
• 2 Tandon M, Topazian M. Endoscopic ultrasound in idiopathic acute pancreatitis.  Am J Gastroenterol. 2001;  96 705-709
• 3 Chen R Y, Hawes R H. Idopathic acute pancreatitis: Is EUS worth doing?.  Am J Gastroenterol. 2002;  97 1244-1246
• 4 Ballinger A B, Barnes E, Alstead E M. et al . Is intervention necessary after a first episode of acute idiopathic pancreatitis?.  Gut. 1996;  38 293-295
• 5 Yusoff I F, Raymond G, Sahai A V. A prospective comparison of the yield of EUS in primary vs. recurrent idiopathic acute pancreatitis.  Gastrointest Endosc. 2004;  60 673-678
• 6 Coyle W J, Pineau B C, Tarnasky P R. et al . Evaluation of unexplained acute and acute recurrent pancreatitis using endoscopic retrograde cholangiopancreatography, sphincter of Oddi manometry and endoscopic ultrasound.  Endoscopy. 2002;  34 617-623
• 7 Prat F, Edery J, Meduri B. et al . Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis.  Gastrointest Endosc. 2001;  54 724-729
• 8 Napoleon B, Dumortier J, Keriven-Souquet O. et al . Do normal findings at biliary endoscopic ultrasonography obviate the need for endoscopic retrograde cholangiography in patients with suspicion of common bile duct stone? A prospective follow-up study of 238 patients.  Endoscopy. 2003;  35 411-415
• 9 Rocca R, De Angelis C, Castellino F. et al . EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.  Gastrointest Endosc. 2006;  63 479-484