Endoscopy for the treatment of acute gallstone pancreatitis

Acute pancreatitis refers to sudden inflammation of the pancreas associated with severe abdominal pain. The most common cause is transient blockage of the pancreatic or bile duct (or both) by gallstones. Most attacks of acute pancreatitis are mild, and most patients recover uneventfully with medical management. However, a small proportion of patients have a more severe course requiring intensive medical management.

Endoscopic retrograde cholangiopancreatography (ERCP) combines endoscopy and X-ray to treat problems of the bile and pancreatic ducts. With the patient under sedation, an endoscope is passed down the esophagus, through the stomach and into the duodenum where the opening of the bile and pancreatic ducts (ampulla) is located. A catheter is then inserted through the endoscope and through the ampulla into the bile duct. Contrast is injected into the bile duct, and X-rays are taken to look for gallstones or blockage. If gallstones are found, they can be extracted with a basket or a balloon. However, this procedure is not without risks. It may be associated with bleeding, a hole in the bowel wall, infection of the bile duct, or aggravation of pancreatitis.

In general, pancreatitis caused by gallstones can be managed with two treatment strategies. The first strategy involves the early use of conservative medical management such as nothing by mouth, intravenous fluid rehydration, antibiotics, and medications to relieve pain. If there are signs and symptoms suggestive of infection of the bile duct or persistent blockage of the bile duct by a stone, ERCP can be used for stone removal. However, if the patient's condition improves, then ERCP is not required. The second strategy involves the early use of ERCP (within 72 hours of admission) in addition to conservative medical management routinely in all patients. There has been much debate as to which strategy is better, especially in severe episodes of pancreatitis.

This review compared the effect of the two treatment strategies in patients with acute gallstone pancreatitis. Seven studies, with a total of 757 patients, were reviewed and provide the best available evidence. The early ERCP strategy does not reduce death or complications compared to the early conservative management strategy in patients with acute gallstone pancreatitis, regardless of the severity of the attack. However, early ERCP may be beneficial in patients who have infection of the bile duct or bile duct blockage. ERCP-related complications are infrequent.

Authors' conclusions: 

In patients with acute gallstone pancreatitis, there is no evidence that early routine ERCP significantly affects mortality, and local or systemic complications of pancreatitis, regardless of predicted severity. Our results, however, provide support for current recommendations that early ERCP should be considered in patients with co-existing cholangitis or biliary obstruction.

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Background: 

The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis remains controversial. A number of clinical trials and meta-analyses have provided conflicting evidence.

Objectives: 

To systematically review evidence from randomized controlled trials (RCTs) assessing the clinical effectiveness and safety of the early routine ERCP strategy compared to the early conservative management with or without selective use of ERCP strategy, based on all important, clinically relevant and standardized outcomes including mortality, local and systemic complications as defined by the Atlanta Classification (Bradley 1993) and by authors of the primary study, and ERCP-related complications in unselected patients with acute gallstone pancreatitis.

Search strategy: 

We searched the CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and LILACS databases and major conference proceedings up to January 2012, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions.

Selection criteria: 

RCTs comparing the early routine ERCP strategy versus the early conservative management with or without selective use of ERCP strategy in patients with suspected acute gallstone pancreatitis. We included studies in which the population with acute gallstone pancreatitis was a subgroup within a larger group of patients. We only included studies involving only a selected subgroup of patients with acute gallstone pancreatitis (actual severe pancreatitis) in subgroup analyses.

Data collection and analysis: 

Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test and I² statistic. To explore sources of heterogeneity, we conducted a priori subgroup analyses according to predicted severity of pancreatitis, cholangitis, biliary obstruction, time to ERCP in routine ERCP strategy, use of selective ERCP in conservative management strategy, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed versus random-effects), and per-protocol analysis. We performed influence analysis by exclusion of each study.

Main results: 

Five RCTs comprising 644 participants were included in the main analyses. Two additional RCTs, comprising only patients with actual severe acute gallstone pancreatitis, were included only in subgroup analyses. There was statistical heterogeneity among trials for mortality, but not for other outcomes. In unselected patients with acute gallstone pancreatitis, there were no statistically significant differences between the two strategies in mortality (RR 0.74, 95% CI 0.18 to 3.03), local and systemic complications as defined by the Atlanta Classification (RR 0.86, 95% CI 0.52 to 1.43; and RR 0.59, 95% CI 0.31 to 1.11 respectively) and by authors of the primary study (RR 0.80, 95% CI 0.51 to 1.26; and RR 0.76, 95% CI 0.53 to 1.09 respectively). The results were robust to sensitivity and influence analyses except for systemic complications as defined by the Atlanta Classification. There was no evidence to suggest that the results were dependent on predicted severity of pancreatitis. Among trials that included patients with cholangitis, the early routine ERCP strategy significantly reduced mortality (RR 0.20, 95% CI 0.06 to 0.68), local and systemic complications as defined by the Atlanta Classification (RR 0.45, 95% CI 0.20 to 0.99; and RR 0.37, 95% CI 0.18 to 0.78 respectively) and by authors of the primary study (RR 0.50, 95% CI 0.29 to 0.87; and RR 0.41, 95% CI 0.21 to 0.82 respectively). Among trials that included patients with biliary obstruction, the early routine ERCP strategy was associated with a significant reduction in local complications as defined by authors of the primary study (RR 0.54, 95% CI 0.32 to 0.91), and a non-significant trend towards reduction of local and systemic complications as defined by the Atlanta Classification (RR 0.53, 95% CI 0.26 to 1.07; and RR 0.56, 95% CI 0.30 to 1.02 respectively) and systemic complications as defined by authors of the primary study (RR 0.59, 95% CI 0.35 to 1.01). ERCP complications were infrequent.

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