Correspondence
The Early Treatment of Acute Biliary Pancreatitis
N Engl J Med 1993; 329:58-59July 1, 1993
- Article
To the Editor:
A problem with the study by Fan et al. (Jan. 28 issue)1 is the authors' inability to distinguish reliably patients presenting with acute pancreatitis and secondary biliary obstruction from those presenting with primary biliary obstruction and sepsis. At least one of the patients randomly assigned to initial conservative treatment had a serum bilirubin concentration of 37.2 mg per deciliter. Patients who present with acute abdominal symptoms, fever, and leukocytosis should probably undergo emergency endoscopic retrograde cholangiopancreatography (ERCP), regardless of their serum amylase concentrations2.
Furthermore, even in patients with unequivocal pancreatitis, potentially life-threatening biliary obstruction cannot always be excluded clinically. Details are not provided in the study about the results of liver-function tests or the presence of biliary dilatation (as determined by ultrasonography or computed tomography) in patients later found to have stones in their biliary ducts. In the absence of such information, we can only suspect that biliary decompression was unnecessarily delayed in the subgroup of patients initially assigned to conservative treatment who subsequently underwent selective ERCP. It is possible that at least three deaths (those of the three patients in this subgroup who underwent laparotomy) might have been avoided.
Patients with stones in the common bile duct are less likely to have biliary sepsis after early and adequate biliary decompression. In our opinion, however, the real question remains unanswered: Should emergency ERCP be performed in patients with biliary pancreatitis who have no overt evidence of acute biliary obstruction or sepsis?
2 ReferencesPankaj J. Pasricha, M.B., B.S.
Anthony N. Kalloo, M.D.
Johns Hopkins Hospital, Baltimore, MD 212051
Fan S-T ,Lai ECS ,Mok FPT ,Lo C-M ,Zheng S-S ,Wong J . Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med 1993;328:228-232
Full Text | Web of Science | Medline2
Ranson JHC. The timing of interventional therapy in gallstone pancreatitis. In: Burns GP, Bank S, eds. Disorders of the pancreas: current issues in diagnosis and management. New York: McGraw-Hill, 1992:115-31.
To the Editor:
In their study of the role of ERCP and endoscopic papillotomy in the early treatment of acute pancreatitis, Fan et al. concluded that emergency ERCP with or without endoscopic papillotomy is “indicated in the management of acute pancreatitis irrespective of the predicted severity and suspected cause.” Their results demonstrate the efficacy of ERCP performed by expert endoscopists in the early phase of acute pancreatitis in a group of patients of whom a majority (65 percent) had biliary pancreatitis. The efficacy of the therapy in the hands of the average endoscopist in other patient groups remains to be determined. In patients with acute inflammation of the papilla, the incidence of serious complications and death after endoscopic sphincterotomy may well exceed the usually quoted figures of 7 percent and 1 percent, respectively.1 Furthermore, injection of contrast medium into the pancreatic duct in patients with nonbiliary pancreatitis may have additional adverse effects.
Even if the efficacy of this procedure is confirmed, cost-benefit analyses are needed. In a common disease such as acute pancreatitis, from which about 80 percent of patients recover without specific intervention, recommending an invasive and costly procedure requires an analysis of cost data. The cost of preventing minor complications may be excessive when using routine ERCP with or without papillotomy as compared with selective ERCP.
1 ReferencesPierre-Alain Clavien, M.D., Ph.D.
University of Toronto, Toronto General Hospital, Toronto, ON M5G 2C4, Canada1
Vaira D ,D'Anna L ,Ainley C , et al. Endoscopic sphincterotomy in 1000 consecutive patients. Lancet 1989;12:431-434
CrossRef
To the Editor:
Only 39 of 97 patients studied by Fan et al. who underwent emergency ERCP had common-duct stones noted at the time of the procedure. This means that 58 patients with acute pancreatitis (60 percent) underwent unnecessary ERCP. An 18 percent complication rate was noted in this group. These results are consistent with those of Cotton, who has reported an incidence of 8 to 10 percent for major complications of ERCP and endoscopic sphincterotomy and a 0.5 to 1.0 percent mortality rate1.
We have a different approach to patients with acute biliary pancreatitis. Laparoscopy with intraoperative cholangiography is performed. A transcystic-duct common-duct exploration is then performed if common-duct stones are present, and laparoscopic cholecystectomy is performed if no stones are discovered. We recently reported on 66 patients who underwent transcystic-duct common-duct exploration2. Five patients had complications: mild pancreatitis, pneumothorax, and wound infection. Half the patients suspected before surgery to have common-duct stones had none on cholangiography. A negative cholangiogram can obviate the need for any manipulation of the sphincter of Oddi. Therefore, we think this approach is preferable.
2 ReferencesBrendan J. Carroll, M.D.
Edward H. Phillips, M.D.
8635 W. 3rd St., Los Angeles, CA 900481
Cotton PB . Endoscopic management of bile duct stones (apples and oranges). Gut 1984;25:587-597
CrossRef | Web of Science | Medline2
Phillips EH ,Carroll BJ ,Pearlstein AR ,Daykhovsky L ,Fallas MJ . Laparoscopic choledochoscopy and extraction of common bile duct stones. World J Surg 1993;17:22-28
CrossRef | Web of Science | Medline
To the Editor:
I could not find any information in the article by Fan et al. concerning the use of antibiotics before ERCP, as is standard practice in many places. Also, did the patients who were initially treated conservatively receive antibiotics from the start, or only if their condition deteriorated? In centers where biliary-stone disease rather than alcoholism is the most common cause of pancreatitis, the use of antibiotics from the beginning of treatment may be a more important intervention than ERCP and papillotomy.
A. Sidney Barritt, III, M.D.
Veterans Affairs Medical Center, Salem, VA 24153Author/Editor Response
Dr. Fan replies:
To the Editor: Dr. Pasricha and Kalloo question our ability to distinguish acute pancreatitis with secondary biliary obstruction from primary biliary obstruction and sepsis. The difference, in my opinion, is immaterial. The presence of hyperamylasemia in all our patients indicated that injury to the pancreas had occurred. Whether biliary obstruction was primary or secondary, it could be treated effectively by early endoscopic papillotomy.
Dr. Clavien and Drs. Carroll and Phillips question the value of emergency ERCP. In the group of patients randomly assigned to emergency ERCP, ultrasonography, liver biochemistry, or both together failed to diagnose or exclude the possibility of persistent common-bile-duct stones at the time of admission. In areas where such stones are a common cause of acute pancreatitis, emergency ERCP is worthwhile. Our conclusions also pertain to areas where gallstones are common and to patients in whom alcoholism has been excluded, as long as an expert endoscopist is available.
In response to Dr. Barritt, intravenous antibiotics were given to all the patients immediately after admission. Antibiotics by themselves are not effective for all patients with acute biliary pancreatitis. In our study, 20 percent of the patients randomly assigned to conservative treatment subsequently had biliary sepsis.
Sheung-Tat Fan, M.S.
University of Hong Kong, Queen Mary Hospital, Hong Kong- Citing Articles (1)
Citing Articles
1
Enns, Baillie. (1999) Review article: the treatment of acute biliary pancreatitis. Alimentary Pharmacology and Therapeutics 13:11, 1379-1389
CrossRef
