Prospective Endoscopic Ultrasound-Based Approach to the Evaluation of Idiopathic Pancreatitis: Causes, Response to Therapy, and Long-term Outcome

Abstract

OBJECTIVES:Although idiopathic pancreatitis is common, the natural history is not well studied, and the best diagnostic approach to both single and multiple attacks remains undefi ned. METHODS:We prospectively evaluated patients with idiopathic pancreatitis over a 10-year period, and clinical information for each episode was reviewed. Endoscopic ultrasound (EUS) was performed in all patients. Patients with microlithiasis or bile duct stones were referred for cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP), respectively. For those with a single attack, if EUS was normal or chronic pancreatitis or pancreas divisum was diagnosed, the patient was followed up for recurrence. For those with multiple attacks and a negative EUS, ERCP and sphincter of Oddi manometry with endoscopic therapy as appropriate were recommended. All patients were followed up in the long term to evaluate for recurrent pancreatitis, the primary study end point. RESULTS:Over the study period, 201 patients were identifi ed (80 single attack, 121 multiple attacks; mean age 53 years, range 17-95 years, s.d. 16.3 years; and 53% female). After EUS, 54% of patients with a single attack were categorized as idiopathic, and for multiple attacks sphincter of Oddi dysfunction (SOD) was the most common diagnosis (41%). Long-term follow-up (median 37 months; interquartile range 19-70 months) documented recurrence of pancreatitis in 15 (24%; 95% confi dence interval (CI), 15-38%) patients with a single attack and in 48 (49%; 95% CI, 38-62%) patients with multiple attacks. Despite endoscopic therapy, patients with pancreas divisum and SOD had relapse rates of 50% (95% CI, 35 to 68%) and 55% (95% CI, 31 to 82%), respectively. CONCLUSIONS: Following a single idiopathic attack of pancreatitis and a negative EUS examination, relapse was infrequent. Despite endoscopic therapy, patients with multiple attacks, especially those attributed to pancreas divisum and SOD, had high rates of recurrence. EUS may be a useful, minimally invasive tool for the diagnostic evaluation of idiopathic pancreatitis. The study was listed in Clinicaltrials.gov NCT00609726.

Endoscopic ultrasound as a diagnostic and predictive tool in idiopathic acute pancreatitis

“…Considering relapsing AP, we found an overall recurrence of 27.4%, with the highest proportion in patients with multiple attacks (57.1%) and in patients with a previous cholecystectomy (46.4%). These results are similar to those of previous studies, which found relapsing rates of 11-32% after a first episode when the cause was not identified and treated [26,27], and in which recurrence rates were higher in patients with multiple attacks than in those with a single episode [28]. In this setting, we found a group of patients with a first episode of AP, a high proportion of intact gallbladder and biliary disease, mainly stones.…”

Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis

“…Both EUS and MRCP are useful techniques in the etiologic diagnosis of IAP patients, and intravenous secretin combined with MRCP or EUS not only enhances the pancreatic duct morphology but also provides indirect functional information with which to investigate sphincter of Oddi dysfunction. 19 Overall, many studies showed that EUS has a higher diagnostic yield than MRCP in idiopathic pancreatitis 5,24 because of its high accuracy in recognizing biliary disease, especially in patients who have not had a cholecystectomy. 18 Some studies suggested that EUS should be considered first for idiopathic pancreatitis after failure of conventional radiography.…”

Systematic Review of Most Common Causes of Acute Pancreatitis

“…In cases where PAB remains suspected or in which other causes for BP have been excluded, endoscopic ultrasonography, which has greater sensitivity for the diagnosis of microcapsules (less than 5 mm), may be requested. A study showed that 2/3rd of patients previously diagnosed as idiopathic had biliary etiology confirmed after endoscopic ultrasonography [31,32].…”