DIAGNOSIS AND TREATMENT OF ACUTE BILIARY PANCREATITIS IN THE ERA OF MINIMALLY INVASIVE SURGERY
Keywords:acute biliary pancreatitis, gallstones, ERSP, MRI cholangiography, endoscopic PST, cholecystectomy
Objectives. Existing studies show that acute biliary pancreatitis accounts for 35-60% of all cases of acute pancreatitis. Current concepts of diagnosis and treatment set out in the literature, are diverse and, in some cases, even contradictory. The aim of the study was to analyze the experience of diagnosis and treatment of patients with acute biliary pancreatitis and associated cholestatic jaundice.
Material and methods. This material represents a prospective clinical study, which included patients treated in the Municipal Clinical Hospital „Saint Archangel Michael", in the period of 2006-2017 years. The results presented include the diagnostic and curative evaluation of 63 cases of acute biliary pancreatitis associated with cholestatic colemia, selected from a total of 191 patients with mechanical jaundice syndrome, present in benign complications of gallstones.
Results and discussions. The analysis showed the prevalence of females – 76.1%. Compared to other complications, acute biliary pancreatitis occurs earlier in gallstones, in 6.4% without a known lithiasis history. The clinical diagnosis presented the features of acute pancreatitis combined with data on cholestatic colemia and variable cholangitis. Instrumental investigations reported: dilated choledochus with diameter >0.8cm in all patients, size of the cephalopancreas >3.5cm, choledocholithiasis (33 cases), absence of choledocholithiasis (30), papillitis with stenosis (16), papillitis without stenosis (15) and parapapillary diverticulum (2). Laboratory data revealed elevated pancreatic enzymes in association with cholestasis and variable hepatic cytolysis. The sequential treatment was used, with the primary solution of pancreatic symptoms and jaundice syndrome, with subsequent cholecystectomy, which was performed in terms adapted to each case. Endoscopic papillotomy was in 4 cases of total absence of biliary flow. In the presence of biliary flow, a complex drug treatment was instituted for 4-5 days, which in 32.1% was estimated with an obvious decrease in pancreatic symptoms and restoration of biliary flow. In these patients, laparoscopic cholecystectomy was performed within 6-7 days of hospitalization. Another 44 patients required biliary decompression with or without litextractions – 42 endoscopic papillotomy, of which 16 „blind” endoscopic papillotomy and 2 suprapapillary duodenotomies in parapapillary diverticulum. In residual choledocholithiasis (n=4) the endoscopic papillotomy was a definitive solution. Out of 39 patients who needed cholecystectomy, in 5 cases of lack of stones in the choledochus, surgery was performed over 24-48 hours after endoscopic papillotomy, and 19 patients underwent cholecystectomy more than 3-4 days after decompression. In 16 cases of maintaining the increased alanineaminotransferase values, cholecystectomy was performed after reduction them in values, over 18-26 days after decompression in repeated hospitalization.
Conclusions. Early hospitalization, etiological diagnosis and reasoned treatment in acute biliary pancreatitis have a major influence in avoiding severe forms of pancreatitis and complications. Diagnosis in the early stages of acute biliary pancreatitis is preferably in the next sequence: ultrasonography, Fibroesophagogastroduodenoscopy, Magnetic resonance imaging cholangiography. Computer Tomography at this stage presents information clearly inferior to Magnetic resonance imaging cholangiography. Endoscopic retrograde cholangiopancreatography has limited indications in this diagnostic stage, being very useful in the curative-interventional stage. Conservative treatment is the basic pillar in the initial management of acute biliary pancreatitis with preserved biliary flow. Absent biliary flow is an absolute indication for biliary decompression, prior to conservative treatment. An opportunity to restore bile flow in small stones and oddian stenoses is „blind” endoscopic papillotomy, in which there is less chance of recurrent pancreatitis. Cholecystectomy has certain indications, not delayed in avoiding the recurrence of acute biliary pancreatitis, but for the selection of time special conditions are necessary: total restoration of internal bile flow and complete regression of both pancreatic and hepatic signs of inflammation.
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