Clinical Endoscopy

Original Article

Practice Patterns and Use of Endoscopic Retrograde Cholangiopancreatography in the Management of Recurrent Acute Pancreatitis: Jonathan B. Reichstein, Vaishali Patel, Parit Mekaroonkamol, Sunil Dacha, Steven A. Keilin, Qiang Cai, Field F. Willingham; Clin Endosc 2020;53(1):73-81. Published online July 5, 2019; DOI: https://doi.org/10.5946/ce.2019.052

Background
/Aims: There are conflicting opinions regarding the management of recurrent acute pancreatitis (RAP). While some physicians recommend endoscopic retrograde cholangiopancreatography (ERCP) in this setting, others consider it to be contraindicated in patients with RAP. The aim of this study was to assess the practice patterns and clinical features influencing the management of RAP in the US.
Methods
An anonymous 35-question survey instrument was developed and refined through multiple iterations, and its use was approved by our Institutional Review Board. The survey was distributed via email to 408 gastroenterologists to assess the practice patterns in the management of RAP in multiple clinical scenarios.
Results
The survey was completed by 65 participants representing 36 of the top academic/tertiary care centers across the country. Approximately 90.8% of the participants indicated that they might offer or recommend ERCP in the management of RAP. Multinomial logistic regression analysis revealed that ductal dilatation and presence of symptoms were the most predictive variables (p<0.001) for offering ERCP.
Conclusions
A preponderance of the respondents would consider ERCP among patients with RAP presenting to tertiary care centers in the US. Ductal dilatation, presence of symptoms, and pancreas divisum significantly increased the likelihood of a recommendation for ERCP

Citations

Citations to this article as recorded by

Controversies in ERCP: Technical aspects
ChristophF Dietrich, NoorL Bekkali, Sean Burmeister, Yi Dong, SimonM Everett, Michael Hocke, Andre Ignee, Wei On, Srisha Hebbar, Kofi Oppong, Siyu Sun, Christian Jenssen, Barbara Braden
Endoscopic Ultrasound.2022; 11(1): 27. CrossRef
Controversies in ERCP: Indications and preparation
ChristophF Dietrich, NoorL Bekkali, Sean Burmeister, Yi Dong, SimonM Everett, Michael Hocke, Andre Ignee, Wei On, Srisha Hebbar, Kofi Oppong, Siyu Sun, Christian Jenssen, Barbara Braden
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Juan J. Vila, Juan Carrascosa, Ignacio Fernández-Urién, Paul Yeaton, Gonzalo González, Leire Aburruza, José Manuel Zozaya
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A Case of Successful Endoscopic Treatment for Acute Recurrent Pancreatitis Due to Pancreas Divisum with Santorinicele Masquerading as Drug Induced Pancreatitis: Yun Suk Shim, M.D., Tae Hoon Lee, M.D., Jun Ho Choi, M.D., Sang Pil Kim, M.D., Sae Hwan Lee, M.D., Il Kwun Chung, M.D., Sang Heum Park, M.D. and Sun Joo Kim, M.D.; Korean J Gastrointest Endosc 2010;40(2):139-143. Published online February 27, 2010

Abstract PDF: There are various causes of acute pancreatitis, and accurately determining the etiology is pivotal for selecting appropriate management. Other hidden causes, such as congenital anomaly, should be considered in patients with recurrent abdominal pain or unexplained recurrent pancreatitis. A santorinicele is a focal cystic dilatation of the terminal dorsal pancreatic duct, and this is usually associated with pancreas divisum and it is a risk factor for acute pancreatitis due to the accompanying relative stenosis of the minor papilla. We present here the case of a patient who was treated for acute pancreatitis that was presumably was caused by either Rifampin or Brucellosis, and the patient recovered with conservative management. However, we eventually diagnosed pancreas divisum with santorinicele by performing MRCP and ERCP after the pancreatitis had relapsed. We report here on a case of successful endoscopic treatment for pancreas divisum with santorinicele as a cause of recurrent pancreatitis, and this was initially confused with drug or infection related pancreatitis. (Korean J Gastrointest Endosc 2009; 40:139-143)

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Endoscopic Removal of a Severed, Impacted Lithotomy Basket in the Pancreatic Duct in a Patient with Pancreas Divisum -Endoscopic Removal of Severed, Impacted Basket-: Soo Jung Park, M.D., Sung Koo Lee, M.D., Jeung Hye Han, M.D., Kyung Uk Jo, M.D., Sang Soo Lee, M.D., Dong Wan Seo, M.D. and Myung-Hwan Kim, M.D.; Korean J Gastrointest Endosc 2007;34(5):286-290. Published online May 30, 2007

Abstract PDF: Therapeutic endoscopy in patients with pancreas divisum has continued to evolve with the availability of minor papilla endoscopic sphincterotomy, stenting, or sphinteroplasty. A combination of a sphincterotomy followed by balloon/basket deployment and emergency mechanical lithotripsy had facilitated the removal of impacted or large stones in the pancreatic and biliary ducts. The impaction of the basket with captured stones or rupture of the basket traction-wire during mechanical lithotripsy are rare complications. We report the successful retrieval of a center-severed and impacted lithotomy basket in the duct of Santorini in a 47-year-old patient with pancreas divisum. Endobiliary biopsy forceps were introduced into minor papilla, the basket was drawn and the stone was removed successfully after 2 months. To the best of our knowledge, this is a first report of the removal of a center-severed and impacted lithotomy basket in the pancreatic duct. (Korean J Gastrointest Endosc 2007;34:286⁣290)

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Three Cases of Santorinicele without Pancreas Divisum: Ran Song, M.D., Kwang Ro Joo, M.D., Jae Young Jang, M.D., Ki Duk Nam, M.D., Nam Hoon Kim, M.D., Sang Kil Lee, M.D., Seok Ho Dong, M.D., Hyo Jong Kim, M.D., Byoung-Ho Kim, M.D., Young-Woon Chang, M.D., Joung Il Lee, M.D. and Rin Chang, M.D.; Korean J Gastrointest Endosc 2005;30(6):350-353. Published online June 30, 2005

Abstract PDF: Santorinicele is defined as a focal cystic dilatation of the terminal portion of the dorsal pancreatic duct at the minor papilla. It is unclear whether a santorinicele is congenital or an acquired lesion secondary to relative obstruction and a weakness of the distal dorsal duct wall. Because almost all santorinicele reported to date have been associated with pancreas divisum, it has been assumed that santorinicele is related to the obstruction of pancreatic outflow and resultant pancreatitis that occurs in the pancreas divisum. We describe three cases of santorinicele without pancreatic divisum which were identified incidentally. (Korean J Gastrointest Endosc 2005;30:350⁣354)

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A Case of Acute Pancreatitis Caused by Santorinicele with Incomplete Pancreas Divisum: Dong Won Lee, M.D., Dong Yup Ryu, M.D., Bo Hyun Kim, M.D., Jung Sup Kim, M.D., Young Eun Park, M.D., Seong Hun Lee, M.D., Tae Oh Kim, M.D., Suk Kim, M.D.*, Gwang Ha Kim, M.D., Jeong Heo, M.D., Dae Hwan Kang, M.D., Geun Am Song, M.D. and Mong Cho, M.D.; Korean J Gastrointest Endosc 2005;30(4):230-233. Published online April 30, 2005

Abstract PDF: A focal cystic dilatation of the terminal portion of the dorsal pancreatic duct at the minor papilla, termed "santorinicele", is seen in a small number of patients with pancreas divisum. Santorinicele is believed to result from a combination, either acquired or congenital, of relative obstruction and weakness of the distal ductal wall and has been suggested as a possible cause of relative stenosis of the accessory papilla, a risk factor for pancreatitis. We report a case of santorinicele associated with incomplete pancreas divisum, found in a 68-year-old woman presented with acute pancreatitis with a brief review of the literatures. (Korean J Gastrointest Endosc 2005;30:230⁣234)

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불완전 분할췌와 동반된 췌석을 포함한 Santorinicele 1예: Korean J Gastrointest Endosc 2003;27(5):486-486. Published online November 20, 2003

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부유두 개구부에 감돈된 췌석에 의해 급성 췌장염으로 발현한 분할 췌 1예 ( An Impacted Pancreatic Stone at the Orifice of the Minor Papilla Causing a Bout of Acute Pancreatitis in a Patient with Pancreas Divisum ): Korean J Gastrointest Endosc 2000;21(2):666-670. Published online November 30, 1999

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체외충격파 쇄석술이 유효했던 췌관결석과 췌관협착을 동반한 분할 췌 1예 ( A Case of Pancreas Divisum Associated with a Pancreatic Duct Stone and Stricture for which Extracorporeal Shock Wave Lithotripsy was Effective ): Korean J Gastrointest Endosc 2000;21(1):581-585. Published online November 30, 1999

Abstract PDF: A 40-year-old man was presented with recurrent abdominal pain. An ERCP (Endoscopic RETROGRADE Cho-langiopancreatography) revealed complete pancreas divisum and pancreatic duct stricture with a stone. Initially, endoscopic stone removal through the minor papilla origice was unsuccessful due to an impacted pancreatic stone associated with a dominant stricture at the dorsal pancreatic duct. Extracorporeal shock wave lithotripsy (ESWL) was performed twice and the impacted pancreatic stone was fragmented. After ESWL, endoscopic stone removal became possible and pancreatic stenting was performed for the correction of the dorsal duct stricture. This case in herein reported in which ESWL was successful in treating an impacted dorsal pancreatic duct stone associated with pancreas divisum. (Korean J Gastrointest Endosc 2000;21:581-585)

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분할 췌와 동반된 췌담관 합류 이상 1예 ( A Case of an Anomalous Union of the Pancreatobiliary Duct Associated with Pancreas Divisum ): Korean J Gastrointest Endosc 2000;20(2):141-144. Published online November 30, 1999

Abstract PDF: An anomalous union of the pancreatobiliary ductal system is defined as the junction between the common bile duct and the pancreatic duct outside the duodenal wall and beyond the influence of the sphincter of Oddi. This anomaly may relate to some pancreatobiliary lesions such as choledochal cysts, biliary tract carcinomas, or pancreatitis. Pancreas divisum is the most common congenital variant of the pancreatic ductal anatomy, and when it occurs, the ductal system of the dorsal and ventral pancreatic bud, fail to fuse during the second month of gestation. There have only been four cases of the coexistence of an anomalous union of the pancreatobiliary duct and pancreas divisum, reported until now. The case of a 29 year old man with epigastric pain and fever was recently experienced. An ERCP revealed an anomalous union of the pancreatobiliary duct, complete pancreas divisum and common bile duct stone. The case is herein reported. (Korean J Gastrointest Endosc 2000;20:141 144)

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원저 : 담도 췌장 ; 분할 췌의 임상적 의의 ( Original Articles : Biliary Tract & Pancreas ; The Clinical Significance of Pancreas Divisum ): Korean J Gastrointest Endosc 1997;17(5):624-631. Published online November 30, 1996

Abstract PDF: Background
/Aims: Pancreas divisum is a congenital anomaly caused by failure of fusion of the ventral and dorsal pancreatic anlagen during the sixth and seventh week of gestation. With widespread use of endoscopic retrograde cholangiopancreatography(ERCP), pancreas divisum is being detected with increasing frequency. Pancreas divisum is the most common congenital pancreatic anatomic variant, occuring in approximately 4.7 - 14% of necropsy series and has been demonstrated 1.3-6.7% of patients undergoing ERCP, The condition is seen least frequently in Asian(1-2%). It has been postulated that this anomaly may be a cause of obstructive pancreatic pain and pancreatitis on the basis of impaired drainage through the minor papilla. But there is a controversy as to whether pancreas divisum is associated with an increased incidence of pancreatitis. This study is performed to evaluate the clinical presentation and significance of pancreas divisum. Methods: 27 cases of pancreas divisum detected among 1,718 ERCP examinations performed from June, 1993 to December, 1996 at our institution were critically analyzed. Results: Overall incidence of pancreas divisum was 1.6%. Among them, 13 cases(48.1%) were classified as complete type, 14 cases(51.9%) were classified as incomplete type. There was a significantly high incidence of pancreatitis, 22.2% in pancreas divisum compared with 5.6% in fused pancreas. Pancreas divisum was misdiagnosed as pancreatic head mass on radiological imaging study in 4 cases(25%). Conclusions: Pancreas divisum may be predispose to development of pancreatitis, and that its presence may lead to misinterpretation of ultrasonographic and CT scan findings.(Korean J Gastrointest Endosc 17: 624-631, 1997)

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증례 : 담도 췌장 ; 부유두내 스텐트 삽입으로 호전된 재발성 췌장염을 동반한 분할 췌 1예 ( Case Reports : Biliary Tract & Pancreas ; Endoscopic Stenting with Minor PapilIa Sphincterotomy in a Patient with Pancreas Divisum and Recurrent Pancreatitis ): Korean J Gastrointest Endosc 1997;17(3):443-447. Published online November 30, 1996

Abstract PDF: A 50-year-old woman presented with recurrent pancreatitis and pancreas divisum. Minor papilla sphincterotomy and endoscopic stent placement were done for the drainage of dorsal pancreatic duct. After stenting of the minor papilla, abdominal pain has disappeared and pancreatitis has not developed during 9 month follow-up. (Korean J Gastrointest Endosc 17: 443-447, 1997)

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증례 : 담도 췌장 ; 담관 낭종과 췌관결석이 동반된 분할 췌 ( pancreas divisum ) 1예 ( Case Reports : Biliary Tract & Pancreas ; Pancreas Divisum , Choledochal Cyst and Pancreatic Stones in a 50-year-old Man ): Korean J Gastrointest Endosc 1995;15(4):811-817. Published online November 30, 1994

Abstract PDF: A 50-year-old man presented with acute pancreatitis. Abdominal CT showed cystic dilatation of common bile duct and diffuse dilatation of pancreatic duct. ERCP showed pancreas divisum, choledochal cyst and pancreatic duct stones. Minor papilla sphincterotomy and insertion of nasopancreatic tube were performed for drainage of dorsal pancreatic duct. And then, he underwent Whipples operation for excision of choledochal cyst and decompresion of dorsal pancreatic duct. (Kor J Gastrointest Endosc 15: 811-816, 1995)

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