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World J Gastroenterol. Nov 28, 2014; 20(44): 16544-16549
Published online Nov 28, 2014. doi: 10.3748/wjg.v20.i44.16544
Imaging tests for accurate diagnosis of acute biliary pancreatitis
Valeriu Surlin, Adrian Săftoiu, Daniela Dumitrescu
Valeriu Surlin, 1st Clinic of Surgery, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Dolj, Romania
Adrian Săftoiu, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Dolj, Romania
Daniela Dumitrescu, Department of Radiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Dolj, Romania
Author contributions: Surlin V, Săftoiu A and Dumitrescu D contributed equally to the conception and design of the review, aquisition, analysis and interpretation of data; Surlin V and Dumitrescu D wrote and drafted the manuscript; Săftoiu A revised it critically and gave final approval of the version to be published.
Correspondence to: Adrian Săftoiu, MD, PhD, MSc, FASGE, Professor of Diagnostic and Therapeutic Techniques in Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, 200349 Craiova, Romania. adrian.saftoiu@umfcv.ro
Telephone: +40-251-310287 Fax: +40-251-310287
Received: February 26, 2014
Revised: April 29, 2014
Accepted: May 25, 2014
Published online: November 28, 2014
Processing time: 279 Days and 5.9 Hours
Abstract

Gallstones represent the most frequent aetiology of acute pancreatitis in many statistics all over the world, estimated between 40%-60%. Accurate diagnosis of acute biliary pancreatitis (ABP) is of outmost importance because clearance of lithiasis [gallbladder and common bile duct (CBD)] rules out recurrences. Confirmation of biliary lithiasis is done by imaging. The sensitivity of the ultrasonography (US) in the detection of gallstones is over 95% in uncomplicated cases, but in ABP, sensitivity for gallstone detection is lower, being less than 80% due to the ileus and bowel distension. Sensitivity of transabdominal ultrasonography (TUS) for choledocolithiasis varies between 50%-80%, but the specificity is high, reaching 95%. Diameter of the bile duct may be orientative for diagnosis. Endoscopic ultrasonography (EUS) seems to be a more effective tool to diagnose ABP rather than endoscopic retrograde cholangiopancreatography (ERCP), which should be performed only for therapeutic purposes. As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography (MRCP) or EUS, especially for small stones and small diameter of CBD, the later techniques are nowadays preferred for the evaluation of ABP patients. ERCP has the highest accuracy for the diagnosis of choledocholithiasis and is used as a reference standard in many studies, especially after sphincterotomy and balloon extraction of CBD stones. Laparoscopic ultrasonography is a useful tool for the intraoperative diagnosis of choledocholithiasis. Routine exploration of the CBD in cases of patients scheduled for cholecystectomy after an attack of ABP was not proven useful. A significant rate of the so-called idiopathic pancreatitis is actually caused by microlithiasis and/or biliary sludge. In conclusion, the general algorithm for CBD stone detection starts with anamnesis, serum biochemistry and then TUS, followed by EUS or MRCP. In the end, bile duct microscopic analysis may be performed by bile harvested during ERCP in case of recurrent attacks of ABP and these should be followed by laparoscopic cholecystectomy.

Keywords: Biliary; Pancreatitis; Lithiasis; Endoscopic ultrasonography; Magnetic resonance cholangiopancreatography; Endoscopic retrograde cholangiopancreatography

Core tip: Gallstones represent the most frequent aetiology of acute pancreatitis estimated between 40%-60%. Clearance of lithiasis (gallbladder and common bile duct, CBD rules out recurrences. Confirmation of biliary lithiasis is done by imaging. Endoscopic ultrasonography (EUS) seems to be a more effective tool to diagnose acute biliary pancreatitis rather than endoscopic retrograde cholangiopancreatography, which should be performed only for therapeutic purposes. As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography or EUS, especially for small stones and small diameter of CBD, the later techniques are preferred nowadays.