Endoscopic Retrograde Cholangiopancreatography in the Management of Acute Biliary Pancreatitis

Acute biliary pancreatitis occurs frequently in the general populations, with a maximum incidence in 40-60 years old people. Modern methods of treatment are beneficial in acute pancreatitis (laparoscopic cholecystectomy, choledochal and papillary desobstruction). Pain is the main clinical symptom, present from the very beginning of this acute disease. We performed a retrospective study (2009-2016) in the First Surgical Clinic, University Emergency Hospital Bucharest. We analyzed 495 ERCP procedures. 327 out of these were performed for common bile duct stones and 79 out of these were indicated in acute pancreatitis due to stone impaction. The majority of patients were women (52 women, 27 men). Imaging diagnostic techniques were applied (abdominal ultrasound, repeated in 18-36 hours; abdominal computed tomography). Ultrasound diagnosed cholecystic stones, moderate common bile duct dilatation (7-1 mm), common bile duct stones, stone in the terminal choledocus or in the papilla (52%), Wirsung duct dilatation (35%). Abdominal CT was performed at presentation (19%) of cases because of unclear diagnosis. It diagnosed 69% of inclavated stones (in the terminal choledocus or in the papilla) and also a duodenal diverticulum in 7 cases (12%), which was of importance in the impaction of the stones. Upper digestive endoscopy was performed in the first 24 hours after presentation. It diagnosed periampular duodenal diverticulum, stains of cytosteatonecrosis on the duodenal mucosa, papillary impacted stones. ERCP was performed in 79 cases with acute pancreatitis, 12 procedures have been performed in the first 24 hours from presentation. The decision of performing ERCP was the imagistic confirmation of impacted stone, very intense pain, increasing cholestasis, cholangitis and evolution to more severe clinical forms. For opening of the ampula of Vater and gaining access to the choledocus we performed: needle-knife precut 30%, precut plus standard sphincterotomy 48%, only standard sphincterotomy 22%. The success rate of impacted stone removal was 94.74%. ERCP is the gold standard in the management of pain due to biliary acute pancreatitis, preventing the development of severe, potential lethal clinical forms.