Is Biliary Microlithiasis a Significant Cause of Idiopathic Recurrent Acute Pancreatitis? A Long-term Follow-up Study

doi:10.1016/j.cgh.2006.06.023

Clinical Gastroenterology and Hepatology

Volume 5, Issue 1, January 2007, Pages 75-79

https://doi.org/10.1016/j.cgh.2006.06.023 Get rights and content

Background & Aims: The cause of recurrent acute pancreatitis (RAP) is not known in 10%–30% of patients. The aim of the present study was to determine the cause of idiopathic RAP in a long-term follow-up study. Methods: All consecutive patients with idiopathic RAP underwent detailed evaluations and investigations to find out the cause. The pancreatitis was considered to be idiopathic when no cause could be found after standard investigations that included serum biochemistry, transabdominal ultrasonography, and computerized tomography scan of the abdomen. The detailed work-up included repeat serum biochemistry and transabdominal ultrasonography, an endoscopic retrograde cholangiopancreatography, duodenal bile microscopy to diagnose biliary microlithiasis, and endoscopic ultrasonography. Results: Seventy-five patients were studied from June 1995 to May 2003. Their mean age was 31.9 years and 80% were male. The mean number of attacks of acute pancreatitis was 4.82 (range, 2–10). The cause of RAP was attributed to biliary microlithiasis in only 10 (13%) of 75 patients. Two additional patients developed gallstones during the follow-up period. Thirty-five (47%) patients developed chronic pancreatitis during the follow-up period. Ten of these 35 patients with chronic pancreatitis had biliary microlithiasis; 8 of these 10 patients had undergone cholecystectomy/endoscopic sphincterotomy yet continued to have recurrent pancreatitis and developed chronic pancreatitis. Miscellaneous causes were found in 10 (13%) patients. No cause was found in the remaining 18 (24%) patients. Conclusions: Microlithiasis was not a significant cause of idiopathic RAP in our patients. About one half of the patients with RAP developed chronic pancreatitis during the follow-up period.

Section snippets

Methods

All patients presenting with a history of acute pancreatitis from June 1995 to May 2003 were included in the study. These patients were either attending the pancreas clinic or were admitted to the gastroenterology ward of the All India Institute of Medical Sciences in New Delhi. The diagnosis of acute pancreatitis was made in the presence of suggestive clinical features, increased serum amylase and/or lipase (>2 times the upper limit of normal) levels, and evidence of pancreatitis on

Results

There were a total of 75 patients with IRAP who were included in the present study. The mean age of these patients was 31.9 years (range, 14–67 y); 60 (80%) were male and 15 were female. The mean duration of disease was 30.42 months (standard deviation, 27.52 mo) and the mean number of attacks of pancreatitis was 4.82 (range, 2–10). The attacks of pancreatitis were mild in 60 patients, although one of the attacks was severe in 15 patients. The mean follow-up period was 17.63 months (range,

Discussion

The cause of IRAP is not known in 10%–30% of patients.1, 2 Microlithiasis, SOD, and pancreas divisum are common causes of IRAP.5, 6, 7, 8, 9 The present study has made 2 important observations: (1) microlithiasis was not a common cause of IRAP in our patients, and (2) CP developed in about half (47%) of such patients during follow-up evaluation.

Microlithiasis has been found to cause IRAP in a few studies, with a high prevalence ranging from 50% to 73%.9, 10, 18 On the other hand, other studies

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Idiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence.
Patients diagnosed with IAP from 2015–21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines.
A total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence.
Complete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.
Disparities in uptake of cholecystectomy for idiopathic pancreatitis: A nationwide retrospective cohort study
2022, Surgery (United States)
The majority of cases of idiopathic acute pancreatitis (IAP) are thought to result from occult biliary disease. A growing body of evidence suggests that cholecystectomy for IAP reduces the risk of recurrence by up to two thirds. This study examined nationwide uptake and disparities in adoption of cholecystectomy for IAP.
The National Inpatient Sample was queried to identify admissions for IAP between October 2015 and December 2018. Patients who underwent cholecystectomy before discharge and those that did not were compared using Wald χ² tests for categorical variables and Student’s t test for continuous variables. Patient- and hospital-level predictors of cholecystectomy were identified using weighted multivariable logistic regression.
Of 62,305 estimated admissions for IAP, only 665 (1.1%) underwent cholecystectomy before discharge. Female sex, initiation of total parenteral nutrition (TPN), insurance status, and hospital type were associated with cholecystectomy on univariable analysis. On multivariable analysis, Hispanic patients (odds ration [OR] 1.60, 95% confidence interval [CI] 1.01–2.56), patients on TPN (OR 2.70, 95% CI 1.17–6.24), and those with private insurance (OR 2.18, 95% CI 1.48–3.21 versus Medicare/Medicaid) were more likely to receive operations. Small hospitals and hospitals in rural areas were least likely to perform empiric cholecystectomies.
Despite increasing evidence supporting cholecystectomy after IAP, the practice remains rare in the United States. Educational efforts and active implementation efforts are needed to promote adoption. Particular attention should be focused on small, rural centers and those that disproportionately care for uninsured patients and patients with public insurance.
Pancreatitis in Children
2019, Gastroenterology
Acute, acute recurrent, and chronic forms of pancreatitis have been increasingly diagnosed in children in the past 2 decades. Risk factors in the pediatric group are broad and appear to be strikingly different compared with the adult cohort. However, the disease burden and impact on quality of life are surprisingly similar in children and adults. This review summarizes the definitions, epidemiology, risk factors, diagnosis, and management of pediatric pancreatitis, identifies features that are unique to the childhood-onset disease, identifies gaps, and proposes recommendations for future opportunities.
The role of linear endosonography for the diagnosis of acute pancreatitis when other methods failed
2019, Clinics and Research in Hepatology and Gastroenterology
Citation Excerpt :
Biliary stones and sludge were detected in 28.6% of cases, and chronic pancreatitis was found in 25.7% of the patients, of whom 3 (8.6%) were of autoimmune etiology confirmed by EUS-FNA. In regard to stone disease, microlithiasis will not be detected by trans-abdominal ultrasound and will be the cause of unexplained pancreatitis in 13% to 75% of patients with gallbladder in situ [5,6,10–15]. A review of 15 studies by Rösch et al. [16] estimated the prevalence of stones detected by EUS to be 39.9%, with an overall sensitivity of 93% and a specificity of 89%.
Acute pancreatitis has no obvious cause after clinical, laboratory and radiologic investigation in 10%–30% of patients, and the diagnosis of idiopathic pancreatitis is given. This study investigated the role of linear EUS for identification of possible causes for acute pancreatitis when other investigative methods failed.
Between June 2012 and March 2017, 35 patients [25 women; mean age: 51.9 + 17.8 years] with idiopathic acute pancreatitis underwent linear EUS for investigation. All of these cases were contacted for a follow-up telephone interview to compare the EUS findings with the final diagnosis and outcome.
Pancreaticobiliary abnormalities were identified in 19 of 35 (54.3%) patients. Ten (28.6%) patients had microlithiasis or biliary sludge. Microlithiasis and choledocholithiasis were identified in 8 (22.8%) and a single (2.8%) patient, respectively. Two patients presented gallbladder biliary sludge, one of them with microlithiasis. Chronic pancreatitis was found on EUS in 6 (17.1%) patients, and pseudotumoral masses confirmed by EUS-FNA as autoimmune pancreatitis were detected in other 3 (8.6%) cases. Linear EUS was normal in 13 (37.1%) patients, and demonstrated findings of recent acute pancreatitis but no other etiological factor in 3 (8.6%) cases. After a mean follow-up of 33.3 months, no case with a normal EUS evaluation presented a new episode of pancreatitis, 1 of 9 cases with microlithiasis presented an episode of recurrent pancreatitis due to choledocolithiasis after cholecystectomy, and 3 of 9 cases with chronic pancreatitis presented recurrent episodes, including the 2 cases of autoimmune pancreatitis.
Linear EUS provides diagnostic information in approximately a half of patients with idiopathic acute pancreatitis. Exclusion of pancreaticobiliary abnormalities on EUS has an important prognostic value for absence of new episodes of acute pancreatitis.
Similarities and differences between biliary sludge and microlithiasis: Their clinical and pathophysiological significances
2018, Liver Research
Citation Excerpt :
Notably, the benefits of these therapies have been demonstrated by a significant decrease in recurrent episodes of pancreatitis after therapy (<10%) versus a recurrence rate of approximately 66%–75% in untreated patients.62,170,174-176 Laparoscopic cholecystectomy offers the most definitive therapy and is generally considered the treatment of choice (Fig. 4).122,177-179 Laparoscopic cholecystectomy is indicated in good operative candidates of almost any age because the risks of future gallbladder-related symptoms and complications outweigh the operative risks.90
The terms biliary sludge and cholesterol microlithiasis (hereafter referred to as microlithiasis) were originated from different diagnostic techniques and may represent different stages of cholesterol gallstone disease. Although the pathogenesis of biliary sludge and microlithiasis may be similar, microlithiasis could be preceded by biliary sludge, followed by persistent precipitation and aggregation of solid cholesterol crystals, and eventually, gallstone formation. Many clinical conditions are clearly associated with the formation of biliary sludge and microlithiasis, including total parenteral nutrition, rapid weight loss, pregnancy, organ transplantation, administration of certain medications, and a variety of acute and chronic illnesses. Numerous studies have demonstrated complete resolution of biliary sludge in approximately 40% of patients, a cyclic pattern of disappearing and reappearing in about 40%, and progression to gallstones in nearly 20%. Although only a minority of patients with ultrasonographic demonstration of biliary sludge develop gallstones, it is still a matter of controversy whether microlithiasis could eventually evolve to cholesterol gallstones. Biliary sludge and microlithiasis are asymptomatic in the vast majority of patients; however, they can cause biliary colic, acute cholecystitis, and acute pancreatitis. Biliary sludge and microlithiasis are most often diagnosed ultrasonographically and bile microscopy is considered the gold standard for their diagnosis. Specific measures to prevent the development of biliary sludge are not practical or cost-effective in the general population. Laparoscopic cholecystectomy offers the most definitive therapy on biliary sludge. Endoscopic sphincterotomy or surgical intervention is effective for microlithiasis-induced pancreatitis. Ursodeoxycholic acid can effectively prevent the recurrence of solid cholesterol crystals and significantly reduce the risk of recurrent pancreatitis.

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Original articleIs Biliary Microlithiasis a Significant Cause of Idiopathic Recurrent Acute Pancreatitis? A Long-term Follow-up Study

Section snippets

Methods

Results

Discussion

Am J Gastroenterol

Gastroenterology

Gastroenterol Clin North Am

Gastrointest Endosc

Am J Gastroenterol

J Lipid Res

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Acute pancreatitis

N Engl J Med

Causes of acute and recurrent pancreatitisClinical considerations and clues to diagnosis

Gastroenterol Clin North Am

Etiology and pathogenesis of acute pancreatitis: current concepts

J Clin Gastroenterol

Guidelines for the management of acute pancreatitis

J Gastroenterol Hepatol

Idiopathic recurrent acute pancreatitis

MedGenMed

Original article
Is Biliary Microlithiasis a Significant Cause of Idiopathic Recurrent Acute Pancreatitis? A Long-term Follow-up Study