AGA Clinical Practice Update on Endoscopy in Recurrent Acute, Chronic Pancreatitis

The American Gastroenterological Association (AGA) released a clinical practice update about the role of endoscopy in recurrent acute and chronic pancreatitis. The expert review, which details 8 best practice advice statements, was published in Gastroenterology.

Up to 30% of patients with pancreatitis will develop recurrent acute pancreatitis, defined as 2 or more acute pancreatitis episodes. Among patients with recurrent acute pancreatitis, approximately 35% will progress to chronic pancreatitis, which is an irreversible fibroinflammatory condition associated with pain.

For up to 27% of patients, the cause of acute pancreatitis remains unclear. Endoscopic ultrasound is the most important diagnostic tool to try to uncover the etiology of acute pancreatitis. The guideline authors recommend that magnetic resonance imaging (MRI) with contrast and cholangiopancreatography may be complementary or alternative diagnostic tools for acute pancreatitis, as MRI may be more sensitive for occult biliary stones and for identifying pancreatic ductal etiologies.

For the subset of patients with pancreas divisum, which is caused by a fusion failure of the dorsal and ventral pancreatic ductal systems during embryogenesis, endoscopic therapy may relieve outflow obstruction by enlarging the minor papilla. Endoscopic therapy may be considered for patients with objective signs of outflow obstruction and should not be used to treat pain alone, the guideline authors noted.

More than half of patients (approximately 60%) with chronic pancreatitis develop pancreatic duct stones. The patients at higher risk for pancreatic duct stones include men and heavy alcohol and tobacco consumers. Extracorporeal shock wave lithotripsy with or without endoscopic retrograde cholangiopancreatography (ERCP) is a highly effective approach for large stone fragmentation. For small stones (£5 mm), the guideline authors recommend pancreatography and conventional stone extraction approaches.

Pancreatic duct strictures are also common in chronic pancreatitis. The guideline authors recommend prolonged stent therapy for remodeling the main pancreatic duct. This can be achieved using ERCP with stent insertion. Fully covered self-expandable metal stents are favored over multiple plastic stents when feasible.

The most common symptom reported by patients with chronic pancreatitis is pain. The guideline authors recommend using surgical intervention over endoscopic therapy for long-term pain relief. For the subset of patients who are not candidates for operation, ERCP can be considered an alternative treatment approach. Patients should be made aware that an operation is a one-time intervention, whereas ERCP often requires serial interventions.

Some patients continue to struggle with pain, despite treatment. The use of celiac plexus block for managing pain remains controversial, and there is limited data supporting its efficacy in the setting of chronic pancreatitis. The guideline authors do not recommend this approach to be routinely used for pain management in chronic pancreatitis. However, celiac plexus block may be considered among patients with debilitating pain who have an unmet need after perusing other treatment options.

“Endoscopy plays an integral role in the evaluation and management of patients with RAP [recurrent acute pancreatitis] and CP [chronic pancreatitis],” the guideline authors wrote. “Controversy remains regarding the benefit of ERCP in the management of unexplained RAP [recurrent acute pancreatitis], whereas endoscopic interventions have been found to be safe and effective for the treatment of various complications arising from CP [chronic pancreatitis]. Management of treatment in these patients is challenging, requiring an individualized and multidisciplinary approach.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.