ERCP

Only one study to date has been conducted on the treatment of acute pancreatitis with antioxidants. Clemens et al. (1991) were unable to show any difference in the incidence or severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in a prospective, randomized, double-blind, placebo-controlled trial of allopurinol. However, Salim (1991) performed a similar trial of the effect of allopurinol and DMSO in patients with pain from recurrent pancreatitis, and found significant benefit. On the basis that depletion of antioxidants is important in the pathogenesis of chronic pancreatitis, the administration of a cocktail of antioxidants was assessed for its effect on pain in this disease. Treatment with a combination of organic selenium, d-carotene, vitamins C and E, and methionine was of benefit in the initial pilot study, and in a placebo-controlled trial (San-dilands etal., 1990 Uden et al., 1990). 

Clemens, J.A., Bulkley, G.B., Cameron, J.L., Milligan, F.L., Hutcheon, L., Horn, S.D. and MacGowan, S.W. (1991). Effect of xanthine oxidase inhibition with allopurinol on the incidence and severity of post-ERCP pancreatitis and hyper-amylasaemia in a prospective, randomized, double-blind, placebo-controlled clinical trial of 168 patients. Gastroenterology 100, A270. 

EPA Eicosapentaenoic acid EpDIF Epithelial-derived inhibitory factor also known as epithelium/derived relaxant fector EPO Eosinophil peroxidase EPOR Erythropoietin receptor EPR Effector cell protease EPX Eosinophil protein X ER Endoplasmic reticulum ERCP Endoscopic retrograde cholangiopancreatography E-selectin Endothelial selectin formerly known as endothelial leucocyte adhesion molecule-1 (ELAM-1)... 

O In the Western hemisphere, acute pancreatitis is caused mainly by ethanol use/abuse and gallstones. Other common causes of acute pancreatitis include hypertriglyceridemia, endoscopic retrograde cholangiopancreatography (ERCP), and autodigestion due to early activation of pancreatic enzymes. Numerous medications have also been implicated as causes of acute pancreatitis (Table 20-1). 

FIGURE 20-2. Algorithm for evaluation and treatment of acute pancreatitis. ERCP, endoscopic retrograde cholangiopancreatography. (From Berardi RR, Montgomery PA. Pancreatitis. In DiPiro JT, Talbert RL, Yee GC, et al, (eds.) Pharmacotherapy A Pathophysiologic Approach. 6th ed. New York McGraw-Hill 2005 726, with permission.)... 

Differentiating an episode of acute pancreatitis from chronic pancreatitis maybe difficult because the clinical presentations can be similar. The diagnosis of chronic pancreatitis is made by looking for the effects of chronic pancreatic inflammation and scarring on the pancreas and the patient as a whole. Computed tomography or ERCP will allow visualization of chronic calcified lesions in the pancreas when present.37... 

CRNP Certified Registered Nurse Practitioner ERCP Endoscopic retrograde cholangiopancreatography... 

FIGURE 28-1. Algorithm of guidelines for evaluation and treatment of acute pancreatitis. (ERCP, endoscopic retrograde cholangiopancreatography.)... 

Additionally, ultrasound may show a thickened gallbladder wall or tumor extension into the liver. However, CT scans are more helpful in assessing adenopathy and the spread of disease into the liver, porta hepatis, or adjacent structures. ERCP or transhepatic cholangiography (THC) may be useful in the presence of obstruction to localize primary tumor. 

Abbreviations ARDS, Acute respiratory distress syndrome ERCP, Endoscopic retrograde cholangiopancrea-topography. 

In principle, pancreatic function can be tested by quantifying exocrine secretory output directly by duodenal intubation, juice aspiration, and measurement of enzymes under defined stimulatory conditions, usually by intravenous application of cholecystokinin and/or secretin. ERCP-guided direct cannulation and collection of pure pancreatic juice is, however, not a routine procedure due to its substantial inherent risk of iatrogenic pancreatitis. Pancreatic enzymes can also be quantified indirectly by measuring a representative enzyme in a stool sample. 

CHCP RrtagfB 4f bia duCtx lulldwig Ihnr idns anloAcn Figure 1.8 ERCP illustrating bile tract anatomy. 

Contrast medium is injected into the bile ducts via an endoscopic tube. X-rays are then used to visualise the pancreas and biliary tree. Gallstones can be removed during ERCP and stents can be inserted to widen narrowed bile ducts, which may be the cause of jaundice. 

MRCP visualises the biliary and pancreatic system and is used to identify obstruction. It uses MRI and the inherent contrast properties of bile and pancreatic fluids to produce the image, and therefore does not require the injection of contrast media. It is used as an alternative to ERCP as it is non-invasive and can be used for patients with a history of allergy to iodine. 

ERCP/HIDA results will provide information regarding bile flow and any mechanical problems identified. They may be useful for highlighting the degree of cholestasis. 

Kluender CN, Klein R, Kohler B (2003) Dramatic increase in bilirubin after ERCP - pethidine as a possible cause of drug-induced hepatitis. Zeitschr Gastroenterol 41 1157—1160. 

ERCP - intra- and extrahepatic PSC ANCA positive, other autoantibodies negative Liver biopsy consistent with PSC MRI scan - no evidence of tumour... 

Farrell, R.J., Agarwal, B., Brandwein, S.L., Underhill, J., Chuttani, R., Pleskow, D.K. Intraductal US is a useful adjunct to ERCP for distinguishing mahgnant from benign bihary strictures. Gastrointest. En-... 

Carr-Locke, D.L. Overview of the role of ERCP in the management of diseases of the biliary tract and the pancreas. Gastrointest. Endosc. 2002 56 (Suppl.) 157-160... 

Hintze, R.E., Adler, A., Veltzke, W., Abou-Rebyeh, H., Hammerstingl, R., Vo, T., Felix, R. Clinical significance of magnetic resonance cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1997 29 182-187... 

Kiesslich, R., Holfelder, M., Will, D., Hahn, M., Nafe, B., Genitsariotis, R., Daniello, S., Maeurer, M., Jung, M. Interventional ERCP in patients with cholestasis. Degree of biliary bacterial colonization and antibiotic resistance. Zsch. Gastroenterol. 2001 39 985-992... 

Ponchon, T., Pilleui, F. Diagnostic ERCP (review). Endoscopy 2002 34 29-42... 

Roses, L.L., Alonso, D., Iniguez, R, Mateos, A., Bal, M., Agiiero, X Hepatic fascioliasis of long-term evolution diagnosis by ERCP. Amer. 

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