Endoscopic Management for Recurrent Pancreatitis: Expert Review

Endoscopy plays an integral role in the evaluation and management of patients with recurrent acute pancreatitis and chronic pancreatitis, according to a new American Gastroenterological Association clinical practice update published in Gastroenterology.

Acute pancreatitis remains the leading cause of inpatient care among gastrointestinal conditions, with about 10%-30% of patients developing recurrent acute pancreatitis, wrote co-first authors Daniel Strand, MD, from the University of Virginia Health System, Charlottesville, and Ryan J. Law, MD, from the Mayo Clinic, Rochester, Minn., and colleagues. About 35% of patients with recurrent acute pancreatitis will progress to chronic pancreatitis. Both conditions are associated with significant morbidity and mortality.

“Interventions aimed to better evaluate, mitigate the progression of, and treat symptoms related to [acute pancreatitis] and [chronic pancreatitis] are critical to improve patients’ quality of life and other long-term outcomes,” the authors of the expert review wrote.

The authors reviewed randomized controlled trials, observational studies, systematic reviews and meta-analyses, and expert consensus in the field to develop eight clinical practice advice statements.

First, when the initial evaluation reveals no clear explanation for acute or recurrent pancreatitis, endoscopic ultrasound is the preferred diagnostic test. The authors noted that, although there isn’t a concretely defined optimal timing for EUS defined, most experts advise a short delay of 2-6 weeks after resolution of acute pancreatitis. MRI with contrast and cholangiopancreatography can be a reasonable complementary or alternative test, based on local expertise and availability.

Second, the role of endoscopic retrograde cholangiopancreatography (ERCP) remains controversial for reducing the frequency of acute pancreatitis episodes in patients with pancreas divisum, the most common congenital pancreatic anomaly, the authors wrote. However, minor papilla endotherapy may be useful, particularly for those with objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct or santorinicele. However, there is no role for ERCP in treating pain alone in patients with pancreas divisum.

Third, ERCP remains even more controversial for reducing the frequency of pancreatitis episodes in patients with unexplained recurrent acute pancreatitis and standard pancreatic ductal anatomy, according to the authors. It should only be considered after a comprehensive discussion of the uncertain benefits and potentially severe procedure-related adverse events. When used, ERCP with biliary sphincterotomy alone may be preferable to dual sphincterotomy.

Fourth, for long-term treatment of patients with painful obstructive chronic pancreatitis, surgical intervention should be considered over endoscopic therapy, the study authors wrote. Pain is the most common symptom and important driver of impaired quality of life in patients with chronic pancreatitis, among whom a subset will be affected by intraductal hypertension from an obstructed pancreatic duct. The authors noted that endoscopic intervention remains a reasonable alternative to surgery for suboptimal operative candidates or patients who want a less-invasive approach, as long as they are clearly informed that the best practice advice primarily favors surgery.

Fifth, when using ERCP for pancreatic duct stones, small main pancreatic duct stones of 5 mm or less can be treated with pancreatography and conventional stone extraction maneuvers. For larger stones, however, extracorporeal shockwave lithotripsy or pancreatoscopy with intraductal lithotripsy can be considered, although the former is not widely available in the United States and the success rates for the latter vary.

Sixth, when using ERCP for pancreatic duct strictures, prolonged stent therapy for 6-12 months is effective for treating symptoms and remodeling main pancreatic duct strictures. The preferred approach is to place and sequentially add multiple plastic stents in parallel, or up-sizing. Emerging evidence suggests that fully covered self-expanding metal stents may be useful in this case, but additional research is needed. For example, one study suggested that patients treated with these self-expanding stents required fewer ERCPs, but their adverse event rate was significantly higher (39% vs. 14%).

Seventh, ERCP with stent insertion is the preferred treatment for benign biliary stricture caused by chronic pancreatitis. Fully covered self-expanding metal stents are favored over placing multiple plastic stents when feasible, given the similar efficacy but significantly lower need for stent exchange procedures during the treatment course.

Eighth, celiac plexus block shouldn’t be routinely performed for the management of pain caused by chronic pancreatitis. Celiac plexus block could be considered in certain patients on a case-by-case basis if they have debilitating pain that hasn’t responded to other therapeutic measures. However, this should only be considered after a discussion about the unclear outcomes and its procedural risks.

“Given the current lack of evidence, additional well-designed prospective comparative studies are needed to support a more unified diagnostic and therapeutic pathway for the treatment of these complex cases,” the authors concluded.

The authors reported no grant support or funding sources for this report. Several authors disclosed financial relationships with companies such as Olympus America, Medtronic, and Microtech.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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