Recurrent Acute Pancreatitis with Normal LFT, USG & CECT

1. Recurrent Acute Pancreatitis with Normal LFT, USG & CECT JohnyCyriac PVS Institute of Digestive Diseases Kochi

2. Recurrent Acute Pancreatitis (RAP) • RAP remains a diagnostic dilemma • History , labs and routine imaging fail to diagnose nearly 30%

3. Michael J. Levy et al. AJG 2001

4. Indian study

5. Microlithiasis and sludge should be excluded in all patients with RAP. Wilcox M etal GIE 2006 35% 12% 55%

6. EUS or ERCP ? is emerging has emerged • EUS as an important less-invasive alternative to ERCP

7. Role of EUS • Identify etiology in 68-92% • Advantage in early diagnosis of chronic pancreatitis • Limitation – SOD • EUS recommended after the initial episode of pancreatitis (YusoffetalGastrointestEndosc 2004)

8. Tandon M et al 2001 45 68 Yusoff et al. 2004

9. EUS in RAP- GB Sludge

10. Chronic Pancreatitis

11. Obstructive pancreatitis

12. EMERGING S-MRCP! • Concurrent use of secretin makes MRCP an attractive first line test for ARP to assess for structural underlying etiologies. • SOD- Good correlation with SOM • Advantages over ERCP • Non invasiveness • Absence of procedure related complications • Absence of contrast injection • No radiation exposure • Performance in postsurgical patients. • Mariani A et al.GastrointestEndosc 2003 • Khalid A et alDig DisSci 2003

13. Pancreas divisum. Unenhanced (A) and secretin-enhancedmagnetic resonance cholangiopancreatography (B). The ventral pancreatic duct(arrow in B) and the entire course of the main dorsal pancreatic duct are seen onlyafter secretin administration.

14. S-MRCPAn 80-year-old man presented with 3 attacks of acute pancreatitis over 5 yrDivisum with Santorinicele

15. Ascaris-induced pancreatitis in a 45-year-old woman who presented with severe epigastric pain and a moderately elevated serum amylase level. Linear hypointense filling defect within the distal CBD,

16. M Delhaye et al. World J Gastroenterol February 21, 2008

17. ERCP is Reserved When the etiology cannot be identified by S-MRCP • inspection of the papilla • brush cytology • biopsy sampling • bile or pancreatic juice aspiration • SOM ? • Therapeutic purposes.

18. Choledochocele. Endoscopic appearance of a markedlyenlarged major papilla in a patient presenting with several unexplainedepisodes of acute pancreatitis.

19. IPMN

20. Annular pancreas. Pancreatogram outlining the pancreatic duct as it encircles the duodenum in a patient with multiple attacks of pancreatitis.

21. Pancreas Divisum • Only about 5% get pancreatitis • Recent studies- relationship between PD and CFTR mutations

23. SOD- Hen or Egg first? • A high frequency (30%-65%) of sphincter hypertension in patients with acute idiopathic pancreatitis, and a 50% to 87% in CP • Whether this pancreatic duct obstruction causes the initial injury or is the result of prior inflammation is unknown. • However, pancreatic sphincter ablation does decrease future attacks of pancreatitis (although studies are primarily retrospective and uncontrolled)

27. Recurrent acute vs chronic pancreatitis • Acute to chronic - events in the progression is not clear • Two groups • Recurrent acute episodes before expression of CP features • Features CP at the initial episode

28. AP to RAP to CP- Study from Kerala

29. CP: Comparison of Modalities n=81 *For Mild CP : EUS - 86%, ERCP - 50% Buscail et al, Pancreas, 1995

30. Genetic studies • Gene mutations • SPINK1 • PRSS1 • PRSS2 • CFTR PRSS1(Hereditary pancreatitis) CFTR (Cystic fibrosis, P divisum) SPINK – 1 (Tropical pancreatitis)

31. True idiopathic recurrent acute pancreatitis (TIRAP) • Challenging problem • Medical & endoscopic option limited • Consider evolving chronic pancreatitis ?

32. US ,CT History ,Labs EUS MRCP / S- MRCP In children/ductal anomalies Duodenal aspirate for bile and microscopy ERCP ERCP / SO Manometry Genetic testing

33. Management of True IRAP (TIRAP) • Medical : Enzymes :Anti oxidants • Endoscopic : ES • Surgical : Cholecystectomy :Pancreatectomy

34. THANK YOU

35. Meandering main pancreatic duct