Recurrent Acute Pancreatitis’Introduction

Pier Alberto Testoni
Division of Gastroenterology and Gastrointestinal Endoscopy, University Vita-Salute San Raffaele
IRCCS, San Raffaele Hospital. Milan, Italy
Recurrent acute pancreatitis still remains a
complex diagnostic and therapeutic challenge
in clinical practice. Recurrent bouts of
pancreatitis mainly occur in a gland which
shows a normal morphology at the time of
diagnosis, so that it is generally believed that
such a clinical entity is characterized by
repeated episodes of pancreatitis occurring in
a normal pancreas. However, in a number of
cases, mild to moderate alterations of the
pancreatic ductal system, suggesting a chronic
process, are seen either at the onset of the
disease or during the follow-up period.
Therefore, the observed pancreatic lesions can
either suggest in these patients the presence of
an underlying chronic process which evolves
over time with recurrent attacks of acute
pancreatitis or can be the consequence of
multiple, single, self-limited acute
inflammatory episodes that induce persistent
lesions within the gland with time. In all
cases, morphological abnormalities are likely
to be the consequence of a persistent or
repeated obstructive mechanism.
It is generally believed that, in about 70% of
cases, a correct aetiological diagnosis is
achieved by means of clinical history,
standard imaging techniques - including
computed tomography (CT) scan, endoscopic
retrograde
cholangio-pancreatography
(ERCP) - and, more recently, magnetic
resonance
cholangio-pancreatography
(MRCP). The latter provides a detailed
morphology of the pancreato-biliary system,
without procedure-related risks and therefore,
when available, it should be utilized instead
of ERCP as an initial diagnostic step.
Another significant improvement in the
knowledge of aetiological factors has been
achieved by the introduction, in clinical
practice, of sphincter of Oddi manometry,
testing for cystic fibrosis transmembrane
conductance regulator- (CFTR-) and cationic
trypsinogen-gene mutations, and the
microscopic search for bile crystals in the
collected bile. Sphincter of Oddi manometry
and the search for bile crystals may improve
the diagnostic yield in patients in whom both
pancreato-biliary junction and duct have a
normal appearance. This reveals the major
role played by sphincter of Oddi dysfunction,
either of the biliary or pancreatic segment,
and by bile sludge or microlithiasis in the
occurrence of “so-called” idiopathic recurrent
pancreatitis.
However,
manometric
investigation of the sphincter of Oddi fails to
document some dysfunction in a
progressively increased percentage of patients
in Type 2 and Type 3 dysfunction,
respectively, when the need for definite
findings is highest. In these conditions, not
only does manometry not provide a definite
diagnosis in a consistent number of patients,
but it is also associated with a relatively high
incidence of post-procedure pancreatitis
which is less acceptable after a diagnostic and
eventually useless procedure than after
therapeutic ERCP. The introduction in
clinical practice of ultrasound- (US-) and the
MRCP-Secretin test could provide indirect

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JOP. J. Pancreas (Online) 2001; 2(6):355-356.
JOP. Journal of the Pancreas – http://www.joplink.net – Vol.2, No.6 – November 2001
356
information about sphincter function avoiding
procedure-related risks. However, at this time,
experience with these procedures is confined
to a few centers and further investigation
involving more patients is required.
Endoscopic bilio-pancreatic manometry using
solid state catheters, as recently proposed by
some investigators, could provide reliable
manometric recordings with a reduced risk of
post-procedure pancreatitis since intraductal
perfusion is avoided. However, the catheters
are fragile, expensive and probably more
difficult to handle in routine practice. Despite
the introduction of these sophisticated
diagnostic procedures, the causes of recurrent
pancreatitis still remain unknown in a number
of patients.
In cases with normo-functional findings
however, the successful results with long-
term ursodeoxycholic (UDCA) oral therapy,
endoscopic biliary and/or pancreatic
sphincterotomy, and cholecystectomy still
confirm that bile microlithiasis or sludge and
sphincter of Oddi dysfunction play a major
role in the occurrence of the so-called
“idiopathic recurrent pancreatitis”. In fact, at
present, we can affirm that, in no more that
10% of cases, cannot the inciting factors be
identified or suspected.
The aim of the present virtual round table has
been to provide a comprehensive overview of
the current knowledge on recurrent acute
pancreatitis. Aetiological factors, diagnostic
and therapeutic procedures, and management
of difficult cases are discussed in depth;
tentative diagnostic and therapeutic flow
charts are proposed on the basis of recent
diagnostic techniques.
Key words
Cholangiopancreatography,
Endoscopic Retrograde; Dissertations,
Academic; Magnetic Resonance Imaging;
Manometry; Oddi's Sphincter; Pancreatitis;
Recurrence
Abbreviations
CFTR: cystic fibrosis
transmembrane conductance regulator; CT:
computerized tomography; ERCP: endoscopic
cholangio-pancreatography; MRCP: magnetic
resonance
cholangio-pancreatography;
UDCA: ursodeoxycholic acid; US: ultrasound
Correspondence
Pier Alberto Testoni
Division of Gastroenterology and
Gastrointestinal Endoscopy
I.R.C.C.S. San Raffaele Hospital
Via Olgettina 60
20132 Milano
Italy
Phone: +39-02-2643.2756
Fax: +39-02-2152.559
E-mail address: testoni.pieralberto@hsr.i

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