pancreas diseases : Occult Biliary Stone Disease or Crystals

Biliary microlithiasis is a significant cause of unexplained acute pancreatitis. In two prospective studies,[5,6] microscopic evaluation of bile was performed in patients convalescing from idiopathic pancreatitis who had no evidence of cholelithiasis. Two thirds of patients had microscopic evidence of cholesterol or calcium bilirubinate crystals; patients with bilirubinate crystals demonstrated sludge on transcutaneous sonography. Importantly patients with microlithiasis had significantly fewer recurrent attacks of pancreatitis when treated with cholecystectomy, endoscopic sphincterotomy, or ursodeoxycholic acid.

Idiopathic Pancreatitis

Gallstone disease and alcohol abuse cause 75% to 80% of all cases of pancreatitis. Including metabolic causes, drug-induced disease, trauma, and viral illness, only approximately 10% of cases of acute pancreatitis remain idiopathic or unexplained.[7] ERCP has an important role in the evaluation of patients with idiopathic disease. Because ERCP is an invasive procedure with well-defined complications, the following question arises: In which patients is ERCP indicated? Most authorities agree that ERCP is indicated:

After two or more mild attacks of acute pancreatitis.

After the first attack of severe acute pancreatitis.

After the first attack of pancreatitis if a patient is more than 45 years of age because the risk for neoplasm increases with age.

Acute, unexplained pancreatitis is the initial presentation in an estimated 3% of patients with pancreatic cancer.[8]

A wide variety of abnormalities may be found on ERCP as causes of pancreatitis and include:

Choledochocoele

Chronic pancreatitis

Intraductal papillary mucinous tumour (IPMT)

Occult stone disease

Pancreas divisum (PD)

Pancreatic cancer

Periampullary tumour

Sphincter of Oddi dysfunction (SOD)

A complete ERCP study in the setting of idiopathic pancreatitis includes:

1.Careful endoscopic examination of the papilla to rule out an ampullary neoplasm or a choledochocoele

2. Complete cholangiography and pancreatography to rule out occult biliary stone disease, chronic pancreatitis, aberrant biliary pancreatic junction, PD and malignant obstruction of the pancreatic duct.

3. Sphincter of Oddi manometry of the biliary and pancreatic sphincters.

In the largest endoscopic series of patients evaluated for idiopathic recurrent acute pancreatitis,[9] 44 of the 116 (38%) patients had an abnormality that could explain the pancreatitis:

72 (62%) No abnormality

17 (14.7%) SOD

11 (9.5%) PD

8 (6.9%) Cholelithiasis

4 (3.4%) Choledochocoele

3 (2.6%) Ampullary tumour

1 (0.8%) Pancreatic duct stricture

by R BAIJAL