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Conservative Management of Cholestasis with and Without Fever in Acute Biliary Pancreatitis

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Conservative Management of Cholestasis with and Without Fever in Acute Biliary Pancreatitis Online Submissions: http://www.wjgnet.com/1948-9366office World J Gastrointest Surg 2012 March 27; 4(3): 55-61 [email protected] ISSN 1948-9366 (online) doi:10.4240/wjgs.v4.i3.55 © 2012 Baishideng. All rights reserved. OBSERVATION Conservative management of cholestasis with and without fever in acute biliary pancreatitis José Sebastião Santos, Rafael Kemp, José Celso Ardengh, Jorge Elias Jr José Sebastião Santos, Rafael Kemp, José Celso Ardengh, access to the treatment of local and systemic inflamma- Division of Digestive Surgery, Department of Surgery and Anat- tory/infectious effects of ABP with cholestasis and fever, omy, Faculty of Medicine of Ribeirão Preto, University of São and to characterize the possible scenarios and the sub- Paulo, CEP 14049-900 São Paulo, Brazil sequent approaches to the common bile duct, directed Jorge Elias Jr, Department of Internal Medicine, Faculty of Med- by less invasive examinations such as MRC or EUS. icine of Ribeirão Preto, University of São Paulo, CEP 14049-900 São Paulo, Brazil © 2012 Baishideng. All rights reserved. Author contributions: All the authors contributed to this paper. Supported by Fundação Waldemar Barnsley Pessoa Correspondence to: José Sebastião Santos, PhD, Professor Key words: Biliary pancreatitis; Cholestasis; Endoscopic of Digestive Surgery of the Medical School, University of São sphincterotomy; Cholangitis; Mortality; Magnetic reso- Paulo, Ribeirão Preto, CEP 14049-900 São Paulo, nance cholangiopancreatography; Endoscopic retro- Brazil. [email protected] grade cholangiography; Endoscopic ultrasonography; Telephone: +55-16-36022508 Fax: +55-16-36330836 Intensive care; Health system regulation Received: January 15, 2011 Revised: December 31, 2011 Accepted: January 10, 2012 Peer reviewer: Calogero Iacono, MD, Professor, Department of Published online: March 27, 2012 Surgery, University Hospital “GB Rossi”, Verona 37134, Italy Santos JS, Kemp R, Ardengh JC, Elias Jr J. Conservative man- agement of cholestasis with and without fever in acute bili- Abstract ary pancreatitis. World J Gastrointest Surg 2012; 4(3): 55-61 The presence of cholestasis in both mild and severe Available from: URL: http://www.wjgnet.com/1948-9366/full/ forms of acute biliary pancreatitis (ABP) does not jus- v4/i3/55.htm DOI: http://dx.doi.org/10.4240/wjgs.v4.i3.55 tify, of itself, early endoscopic retrograde cholangiogra- phy (ERC) or endoscopic sphincterotomy (ES). Clinical support treatment of acute pancreatitis for one to two weeks is usually accompanied by regression of pan- INTRODUCTION creatic edema, of cholestasis and by stone migration to the duodenum in 60%-88% of cases. On the other The association between acute pancreatitis (AP) and the hand, in cases with both cholestasis and fever, a condi- migration of gallbladder stones and sludge to the com- tion usually characterized as ABP associated with chol- mon bile duct and the intestinal lumen, the possibility that impaction of these stones in the ampulla of Vater angitis, early ES is normally indicated. However, in daily [1-4] clinical practice, it is practically impossible to guarantee will worsen the pancreatic injuries and the detection of an impacted stone at autopsy in about half the cases of the coexistence of cholangitis and mild or severe acute [5] pancreatitis. Pain, fever and cholestasis, as well as acute biliary pancreatitis (ABP) have contributed to the mental confusion and hypotension, may be attributed adoption of early endoscopic retrograde cholangiography to inflammatory and necrotic events related to ABP. (ERC) and endoscopic sphincterotomy (ES) in ABP. The Under these circumstances, evaluation of the bile duct incorporation of diagnostic and therapeutic endoscopy by endo-ultrasonography (EUS) or magnetic resonance into clinical practice, technology diffusion due to market cholangiography (MRC) before performing ERC and ES forces and the influence of studies published in the last seems reasonable. Thus, it is necessary to assess the decades of the 20th century[6-8] have also been determi- effects of the association between early and opportune nant factors in the adhesion to early ERC and ES in ABP. WJGS|www.wjgnet.com 55 March 27, 2012|Volume 4|Issue 3| Santos JS et al . Cholestasis in biliary pancreatitis However, on the basis of the results of recent studies ing equivalent results in terms of morbidity and mortality and meta-analyses[9-13], as well as critical analyses[14,15], it compared to early ERC and ES, also contributes to a re- has been concluded that the systematic adoption of early duction of the incidence of choledocholithiasis and con- ERC followed by ES for ABP has exposed many patients sequently of the need for early ERC and ES, thus avoid- to invasive diagnosis and unnecessary surgery. The most ing the possible complications of these procedures. Pain, recent meta-analysis based on three prospective and ran- dilation of the bile duct at admission, jaundice and/or domized studies did not demonstrate any influence of increased bilirubin, alanine aminotransferase, gammaglu- ERC (with or without ES) on the morbidity or mortality tamyltransferase and alkaline phosphatase levels may be rates of patients with mild or severe ABP, without chol- of help in selecting the method with which to image the angitis[13]. The conceptual difficulties for the characteriza- bile duct, although they are not sufficient to determine a tion of ABP associated with cholangitis were reported decision about ES since they may only reflect transitory in these studies, but aspects related to the diagnostic and changes due to stone migration, edema or other pancre- therapeutic approaches to this condition are treated in a atic injuries. consensual manner. Within this context, nuclear magnetic resonance chol- The similar incidence of the severe form of AP in angiography (MRC) and EUS are less invasive methods the different etiologies established in the literature[16,17] that can identify choledocholithiasis with high accuracy supports the thesis that the magnitude of the pancreatic in the presence of persistent and painful cholestasis and insult can be pre-established at the start of the clinical are beginning to be incorporated in evaluation of the manifestations, and the course of the initiated ABP epi- bile duct under ABP by American, European and Asian [9,22-26] sode may not be influenced by ERC or ES[12-18]. Thus, the guidelines . theory that the migration of small gallstones can trigger Finally, the indication of early ERC and ES for ABP the onset of ABP and that their repeated passage, the im- and the related association with cholangitis is well-estab- paction of the ampulla of Vater with larger stones[3,4] or lished. However, it is practically impossible to guarantee the persistence of biliopancreatic obstruction may induce the coexistence of cholangitis and mild or severe pancre- progression to the severe form of ABP[11] is still a matter atitis with cholestasis and fever in daily clinical practice, of speculation. in an effort to institute ERC with early ES in a systematic Based on primary and secondary evidence[15], circum- manner. Fever and cholestasis may be attributed only to stances that delay access to reference services and clinical the inflammatory and necrotic events of ABP and, under practice seem to contribute to the adoption of a more these circumstances, the evaluation of the bile duct by conservative approach to the management of the com- MRC or EUS seems to be reasonable before performing mon bile duct in ABP, as demonstrated by a study per- ERC or ES. formed in the United Kingdom, in which the application Thus, the objective of the present editorial is to ex- of the protocol of the British Society of Gastroenterol- plore data on the effects of the association of early and ogy was found not to be homogeneous. Only 45 of 93 opportune access to treat local and systemic inflamma- (48%) patients with severe ABP, particularly those with tory/infectious effects of ABP with cholestasis (associ- signs of biliary obstruction and cholangitis, were sub- ated or not with fever). The subsequent approach to the jected to ERC and ES, and no increase in complications common bile duct can be guided by less invasive methods or mortality was detected[19]. such as MRC and EUS. The impaction of a gallstone in the common bile duct was recorded in 26% to 72% of ABP patients MANAGEMENT OF BILIARY LITHIASIS IN when surgery was performed in the early phase and was recorded in less than 10% of patients operated upon in ACUTE PANCREATITIS [20,21] an elective manner . Spontaneous disobstruction of The concept that AP in the early phase (approximately the bile duct was demonstrated in 71% to 88% of cases the first two weeks) is an inflammatory disease with or within 48 hours of the onset of ABP, with no changes in without necrosis and hemorrhage and localized clinical [2,3] the course of the disease . The spontaneous relief of (mild form) or systemic manifestations (severe form) is cholestasis and of biliopancreatic obstruction assessed by widely accepted. Clinical support measures aimed at hy- endo-ultrasonography (EUS) followed by ERC in patients droelectric, cardiorespiratory and renal changes plus anal- referred to a reference service with ABP plus cholestasis gesia in the early phase of AP, should be proportional to and/or cholangitis, ranged from 56% to 75%[9,10]. Reduc- the magnitude of the physiological and clinical changes. tion of pain and of hyperbilirubinemia was observed They can be applied in clinical stabilization rooms of in 62% of the patients within 48 hours of the onset of emergency centers, on the clinical or surgical wards and ABP symptoms[11], and 60% of the patients subjected to in the intensive care units, with the participation of dif- conservative treatment did not present choledocholithia- ferent specialists. sis during elective surgery [cholecystectomy and intraop- Invasive procedures for the diagnosis and treatment erative cholangiography (IC)] performed during the same of biliary disease and of eventual residual pancreatic inju- hospitalization[12].
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