Treating An Insidious Intruder
are ubiquitous. More than 20 million adults in the U.S. have them, but
only 1 to 4 percent of these patients develop symptoms of gallstone
disease; of these, only 5 percent develop pancreatitis.
has one purpose only: to store bile, which helps digest fats in the
small intestine. But bile can become concentrated and thicken. Eventually,
bile salts can combine with cholesterol to form stones; gallstones are
composed of a combination of crystallized cholesterol deposits or calcium
crystals ionized with bilirubin. These stones can block the flow of
bile from the gallbladder; this is typically manifested as pain in the
upper right quadrant of the abdomen. Gallstone pancreatitis is caused
when a migrating gallstone obstructs the ampulla of Vater. 1
pancreatitis is a clinical syndrome consisting of epigastric abdominal
pain, often radiating to the back; nausea; vomiting (not always present);
and a serum amylase or lipase level greater than three to five times
normal," writes John Baillie, a professor of medicine at Duke University
Medical Center's gastroenterology division.2
amylase and lipase levels are not the only indicators of acute pancreatitis;
C-reactive protein, leukocyte elastase, trypsinogen-activating peptides
and lactate dehydrogenase are also gauges but are rarely tested by clinicians.
A urinary trypsinogen-II assay can be performed at the bedside; the
3-minute dipstick test is "highly sensitive and specific in detecting
acute pancreatitis," but it is not currently licensed for use in
the United States.2
for gallbladder disease besides the "five Fs" (fair, fat,
female, fertile and 40-plus years of age) include a larger-diameter
cystic duct, a larger-diameter common bile duct, high basal sphincter
of Oddi pressure, more pancreatic duct reflux and a common pancreatobiliary
prevalent is it?
pancreatitis is typically seen in patients described by the five Fs.
There are other forms of pancreatitis -- such as alcoholic pancreatitis,
which is generally seen in men aged 30 to 45, who have chronic pancreatitis
with a "superimposed acute flare-up" of the disease, and idiopathic
pancreatitis, which is often related to microlithiasis (caused by gallstones
less than 2 mm which are too small to be visualized with imaging techniques).3
is it caused?
of gallstone pancreatitis is debatable. Reflux of bile into the pancreas
by a common channel may contribute; this is a controversial theory,
but supported by the fact that there have been gallstones recovered
in the feces of 85 to 95 percent of gallstone pancreatitis cases.3
hypothesis proposes reflux secondary to an incompetent sphincter of
Oddi, which allows duodenal contents (such as lysolecithin, enterokinase
or bacterial toxin) to pass into the pancreatic duct. Of note, the sphincter
of Oddi may already be incompetent due to an earlier passage of a gallstone.
"It is reasonable to assume that the pathogenesis is related to
a combination of the above which allows small stones to cause temporary
obstruction and flow of infected bile into the pancreas," writes
John T. Bjork, Chief of the Department of Internal Medicine at St. Luke's
Medical Center in Milwaukee, Wis.
foods have been linked to gallbladder attacks; some physicians believe
that undiagnosed food allergies contribute by causing the bile duct
to swell and by impairing bile flow.4 Food elimination diets
have had some success in reducing symptoms; potentially problematic
foods include eggs, pork, onions, poultry, milk, coffee, oranges, corn,
beans and nuts.5
is potential severity assessed?
the severity of acute pancreatitis, Ranson's signs, APACHE II or modified
Imrie's score have often been used; other indicators are organ failure,
pulmonary disease, renal insufficiency, liver failure or cardiac disease.
"However, no special assessment is necessary for a physician to
realize that a patient who is hypotensive, hypoxic, oliguric, febrile
and confused is seriously ill," notes Baillie.
published in the Archives of Surgery concluded that simple admission
criteria was superior to the scoring systems in predicting severe complications;
specifically, a serum glucose level of 8.3 mmol/L (150 mg/dL) or more
was the best predictor, while a white blood cell count of >=14.5
109/L, an APACHE II score of >=5, a modified Imrie score of >=3,
and a biliary Ranson score of >=3 were all statistically associated
with the development of severe complications.6
tomography (CT) is one choice for imaging the pancreas. CT allows the
identification of pancreatic edema, fluid or cysts, and it allows the
severity of pancreatitis to be graded. Later in the disease, it may
also be of use in recognizing complications.3
states that CT scanning should only be done if the diagnosis is uncertain,
if severe pancreatitis is expected, or if the pancreatitis worsens or
does not resolve. Transabdominal ultrasonography (TUS) can be used to
identify cholelithiasis and dilatation of the extrahepatic biliary tree,
but in detecting bile duct stones, it is 95 percent specific and 60
percent sensitive. TUS seldom visualizes the pancreas in patients with
acute pancreatitis due to air in the distended loops of the small bowel.
If TUS is utilized, the quality of the results relies heavily on the
expertise of the technician, who should scan the entire abdomen in case
abdominal pain has a nonbiliary, nonpancreatic source.
imaging options include ultrasonography and MR cholangiography, which
is noninvasive and does not require contrast. "[MR cholangiography]
is especially useful for common bile duct stones," Bjork adds.
"Endoscopic ultrasound is more accurate than transabdominal ultrasound
but is an invasive endoscopic procedure which requires sedation."
can gallstone pancreatitis be treated?
of ERCP in patients with gallstone pancreatitis is controversial. The
literature indicates that in patients without biliary obstruction, ERCP
does not benefit them and may even produce complications that make the
disease worse. Overall, Baillie says, experts recommend urgent ERCP
for biliary compression only for patients with progressive biliary obstruction
(who have progressive jaundice with or without cholangitis).
not necessary to perform preoperative ERCP in all patients undergoing
laparoscopic cholecystectomy; the surgeon should, alternatively, perform
intraoperative cholangiography, with ERCP incorporated if bile duct
stones are found. However, patients with a suspected or known surgical
reconstruction of the gut should undergo preoperative ERCP, which may
help the surgeon plan her approach.
ERCP should also be performed in patients with persistent or progressive
biliary obstruction (regardless of choledocholithiasis); surgery should
then follow the bile duct clearing to prevent any additional migration
of stones from the gallbladder.2 "Because ERCP and sphincterotomy
combined are associated with much higher morbidity and mortality than
is laparoscopic cholecystectomy -- partly owing to the large number
(more than 500,000) of cholecystectomy procedures performed annually
in the U.S. alone -- endoscopists performing ERCP prior to laparoscopic
cholecystectomy must consider the medicolegal consequences in the event
of a severe complication (usually severe pancreatitis) related to the
procedure," writes Baillie.
if gallstones are confirmed but are not symptomatic, removal of the
gallbladder is not recommended. Diabetic patients are an exception to
the "wait and see" theory; they may be better candidates for
surgical removal of the gallbladder because they can lack "clear-cut
pain signals" and therefore may not recognize a gallbladder attack.5
endoscopic retrograde cholangiopancreatography (ERCP) does increase
morbidity in severe pancreatitis patients and is contraindicated "unless
expertise is available for therapeutic options," Bjork says. "The
therapeutic ERCP with endoscopic sphincterotomy and drainage of the
bile duct with extraction of gallstones is of primary importance in
the therapy of cholangitis. Even though pancreatitis may occur with
endoscopic sphincterotomy, the procedure does not exacerbate the pancreatitis
or have a higher incidence of perforation or hemorrhage in patients
with gallstone pancreatitis. If drainage is not possible by therapeutic
ERCP or the patient is unable to be sedated, percutaneous transhepatic
cholangiography is a possible consideration, especially with dilated
standard for treatment is laparoscopic cholecystectomy, according to
many physicians.4 Richard A. Kozarek, a physician at Virginia
Mason Medical Center in Seattle, expresses concern over potential overuse
of ERCP and recommends laparoscopic cholecystectomy and mandatory intraoperative
cholangiography for patients who have mild gallstone pancreatitis. In
his response to a study published in the American Journal of Gastroenterology,
Kozarek writes that ERCP and other actions that have traditionally been
to treat pancreatitis should be reserved only for patients with severe
forms of the malady, not utilized in those with milder forms.7
both procedures (ERCP and laparoscopic cholecystectomy) are safe and
effective when they are clinically indicated, says Bjork; ERCP, when
performed selectively (not routinely) before laparoscopic cholecystectomy
is cost-effective. Endoscopic sphincterotomy can shorten the hospital
stay and allow laparoscopic cholecystectomy earlier.
management of gallstone pancreatitis is variable. Laparoscopic cholecystectomy
is considered the procedure of choice to prevent recurrent pancreatitis
and to evaluate the bile duct," reports Bjork. "An early therapeutic
ERCP may prevent recurrence of pancreatitis or prevent the complications
of cholangitis and necrotizing pancreatitis. Routine preoperative ERCP
is not indicated since gallstone pancreatitis usually responds to conservative
therapy and subsequent laparoscopic cholecystectomy."
pancreatitis usually responds to conservative medical therapy, but it
is important to identify those patients who require urgent endoscopic
therapy in order to shorten the course of the disease and prevent pancreatic
complications. The majority of patients require laparoscopic cholecystectomy
to prevent a recurrence of the pancreatitis," he concludes.
products are used for patients?
with predicted severe acute pancreatitis should be given prophylactic
antibiotic therapy; imipenem is the preferred antibiotic. This is the
only medication shown to reduce morbidity and mortality in cases of
remedies have value as preventive medicine. Extra doses of vitamin C
may help the body to digest dietary fat and thus lower the risk of gallstones.4
One study published in the Archives of Internal Medicine demonstrated
protection from vitamin C against known gallbladder disease and undetected
gallstones. Deficiencies in vitamins C and E have been associated with
gallstone formation in animals. Other supplements may have use in preventing
gallstone formation, such as:
factor combination (which includes choline, methionine, folic acid
and vitamin B12)
and choleretics (such as milk thistle and dandelion)
(insufficient levels have been linked to gallstones)
(which binds to cholesterol in bile and prevents gallstone formation,
and prevents constipation, which also contributes to gallstones)
oil (which stimulates the flow of bile and is a terpene, which may
help dissolve gallstones)
can reduce their risk of gallstones by sticking to a high-fiber, low-fat,
low-sugar diet, by drinking plenty of water and by maintaining a healthy
weight. Exercise, regular bowel movements and a diet that includes fish
rich in omega-3 oil also help.
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