If the initial work-up following an attack of pancreatitis is negative and successive attacks occur, or if the first episode of pancreatitis is moderate to severe or occurs after the age of 40 years of age, a more extensive evaluation will reveal a diagnosis in around two-thirds of this group of patients.2
Advanced laboratory analysis may include genetic testing in patients younger than 40 years of age, tumour markers (carbohydrate antigen (CA) 19–9) in patients older than 40 years of age with a positive family history or with tobacco use, and serological markers of autoimmune pancreatitis if imaging studies are compatible with this diagnosis.
As an additional diagnostic procedure, endoscopic ultrasonography (EUS) is able to postulate a cause for pancreatitis in approximately one-third of the patients with ARP for whom conventional evaluation, including transabdominal U/S and pancreatic CT with contrast injection, is negative.diagnostic algorithm of ARP, where no evident cause is identified after initial evaluation procedures.
ERCP may be indicated for diagnostic purpose in the few patients who suffer two or more attacks of acute pancreatitis in whom the aetiology of ARP cannot be achieved using high-quality S-MRCP and EUS. The aim of diagnostic ERCP is to perform ancillary procedures that may improve the diagnostic accuracy, such as brush cytology or biopsy in suspected neoplasm, minor papilla cannulation in suspected PD to clearly demonstrate a santorinicele (defined as focal cystic dilation of the termination of the dorsal pancreatic duct at the minor papilla),23 sphincter of Oddi manometry in suspected SOD or collection of bile in suspected occult biliary stones.7,24 However, ERCP is associated with a 3% to 5% complication rate, which is much higher in patients with a history of pancreatitis and may rise to 30% in cases with suspected SOD.25 Nowadays, sphincter of Oddi manometry tends to be replaced by the non-invasive S-MRCP,26 providing information regarding the morphology of the pancreatic gland, the dynamics of the emptying of the main pancreatic duct and the functional status of the exocrine pancreas through assessment of the duodenal filling after secretin administration. Therefore, ERCP has evolved from a diagnostic procedure to an almost exclusively therapeutic procedure for the treatment of abnormalities found by less invasive imaging techniques such as S-MRCP and EUS.27
Myriam Delhaye is an Associate
Clinical Director in the
Medicosurgical Department of
Gastroenterology (headed by
Professor Jacques Devière) at the
Erasme University Hospital.
Together with the team directed by
Professor Michel Cremer, she was
involved in the controversy
surrounding the clinical significance
of pancreas divisum and she
pioneered the use of extracorporeal
shock wave lithotripsy of bile duct
and pancreatic stones in 1987.
Dr Delhaye’s main research interests
are inflammatory pancreatic
diseases, pancreatic cystic neoplasms
and endoscopic therapeutic
procedures for biliopancreatic
diseases. She completed a five-year
academic residency in internal
medicine with a two-year fellowship
in gastroenterology at Erasme
University Hospital. She obtained
her MD from the Free University of
Brussels in 1979.
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