Impact of endoscopic ultrasonography on the management of idiopathic pancreatitis

Abstract

Abstract Background Conventional ultrasonography may fail to detect small stones responsible for acute pancreatitis, leading to a false diagnosis of idiopathic pancreatitis and exposing 33–66 per cent of these patients to the risk of a recurrent attack from untreated gallstone disease. The aim of this study was to assess whether identification of a potential aetiology in patients with ‘idiopathic’ pancreatitis, using endoscopic ultrasonography (EUS), had any effect on outcome. Methods EUS was performed following a diagnosis of idiopathic pancreatitis, using the GF UM-20 echoendoscope (Olympus). The presence of gallstones or other pathology was determined and any appropriate treatment was provided. The frequency of attacks of pancreatitis before and after treatment of the presumed cause was calculated. Results Of 20 patients with idiopathic pancreatitis, evidence of gallstone disease (e.g. stones, microlithiasis) was seen in 12 patients leading to endoscopic sphincterotomy and/or cholecystectomy in nine. Pancreatic disease was seen in three patients, of whom one underwent pancreatic duct stenting. One patient underwent cholecystectomy for recurrent pain, despite a normal EUS result, with a diagnosis of acalculous cholecystitis. No pathology was seen in a further four patients. The frequency of attacks of pancreatitis was 1·1 per patient-year before treatment versus 0 per patient-year after treatment (P < 0·0001). The overall morbidity rate from investigation and treatment was 0·05 per cent. This resulted from one episode of post-ERCP pancreatitis following endoscopic sphincterotomy, which resolved rapidly with conservative treatment. Conclusion EUS is able to detect pancreatic and biliary abnormalities that are not visible with conventional ultrasonography and can guide appropriate treatment. EUS should be performed before a diagnosis of idiopathic pancreatitis is made, to reduce the risk of recurrent pancreatitis from unrecognized gallstones or other pathology.