Early ERCP in acute biliary pancreatitis: 20 years of dispute
Biliary is the most common form of acute pancreatitis and is believed to result from transient obstruction of the bile and pancreatic ducts. The severity of the disease is determined by the extent and the intensity of the ensuing local and systemic inflammatory reaction, which depends on multiple factors possibly including the persistence of obstruction. Early ERCP with endoscopic sphincterotomy and disobstruction of the common bile duct has been proposed as a procedure to improve the outcome of acute pancreatitis. Over the last 20 years a number of clinical trials and meta-analyses have addressed the issue of early ERCP in acute pancreatitis producing conflicting results. Inconsistencies in the various clinical trials and meta-analyses should be interpreted within the context of several limitations, namely the difficulties in excluding patients with concurrent cholangitis and the unavailability of a reliable and accurate scoring system to predict the severity of acute pancreatitis early in the course of the disease. Reviewing the clinical trials and meta-analyses we conclude that, at present, strong evidence supports early ERCP in acute biliary pancreatitis only in the presence of cholangitis or persistent obstruction of the common bile duct when the predicted outcome of the disease is severe.