Endoscopic Therapy for Recurrent Acute Pancreatitis

Recurrent acute pancreatitis (RAP) is a clinical condition characterized by episodes of acute pancreatitis, occurring on more than one occasion. Pancreatitis generally recurs in a normal anatomical and functional gland. However, chronic disease at an early stage may be found either in the event of the first episode of pancreatitis or during follow-up. The etiology of RAP was identified in up to 70% of cases and the term “idiopathic” is used for the remaining cases. The most common cause include bile duct stone disease, sphincter of Oddi dysfunction, anatomical ductal variants interfering with pancreatic juice outflow, genetic mutations, obstruction of the main pancreatic duct or pancreaticobiliary junction, and alcohol consumption. Patients with RAP have limited treatment options available to manage their symptoms and prevent progression to chronic pancreatitis. Endoscopic therapy is widely used in clinical practice and has been found effective in cases with mechanical obstruction. The efficacy of which in patients with a history of RAP depends on two main actors: the bouts of acute pancreatitis occurrence in normal pancreas or chronic pancreatitis, and whether a cause can be identified and removed. Occult bile stone disease and type I and II sphincters of Oddi dysfunction account for the majority of the cases of RAP. In these patients, when ductal dilation is documented, cholecystectomy, and eventually endoscopic biliary and/or pancreatic sphincterotomy are curative in most of the cases. However, recent concerns about the efficacy of endotherapy in the sphincter of Oddi dysfunction have been raised. Endotherapy should be discouraged when obstructive etiology is not confirmed, thus balancing the risk of complications and the unpredictable benefit of the intervention. Pancreatic endotherapy has been proven effective in the cases of recurrent pancreatitis caused by pancreatic ductal obstruction, independent from the cause of obstruction, in symptomatic pancreas divisum with dilated dorsal duct and in some cases of genetic mutations. However, data from meta-analysis studies report a wide variation in the response rate after minor papilla sphincterotomy. Although endotherapy is currently been used in clinical practice in patients suffering from RAP by endoscopic retrograde cholangiopancreatography (ERCP), its real utility remains unclear. This is because several unknown factors may play a role in the occurrence of the disease, and data on follow-up are limited to a short period. Moreover, the majority of the studies that reported favorable outcomes after endotherapy are uncontrolled or retrospective. Although effective in symptom control, it is still not clear if endoscopic therapy can prevent the development of chronic pancreatitis in the long-term.