Pancreatology 14 (2014) 411e414

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Pancreatology
journal homepage: www.elsevier.com/locate/pan

Letter to the Editor

Controversial issues in biliary pancreatitis: When should we perform

MRCP and ERCP?
a b s t r a c t

Keywords: Objectives: The majority of bile duct stones (BDS) that cause acute biliary pancreatitis (ABP) pass
Pancreatitis
spontaneously into the duodenum. If not passed, they worsen the prognosis or cause recurrence.
Choledocholithiasis
Therefore, they must be treated. The purpose of this study was to assess the number and timing of
MRCP
ERCP spontaneous passage of BDS using magnetic resonance cholangiopancreatography (MRCP) and to
EUS determine the effect of this approach on endoscopic retrograde cholangiopancreatography (ERCP).
Acute Methods: Sixty patients diagnosed with ABP were evaluated prospectively. MRCP was performed be-
tween the 1st and 4th days of an acute attack in all the patients. A control MRCP was performed after 7
days in patients with MRCP-identied choledocholithiasis. Patients in whom BDS were visible on im-
aging or who showed no decrease in bilirubin or cholestasis enzymes underwent ERCP.
Results: MRCP revealed choledocholithiasis in 20 (33%) of the 60 patients. In the control MRCP imaging,
choledocholithiasis was detected in 16 of 20 (80% of those who had stone initially) patients. ERCP was
performed in these patients and in 2 patients who did not have BDS on the control MRCP but whose
bilirubin values and cholestatic enzyme levels had not decreased. ERCP veried choledocholithiasis in 16
of the 18 patients. The positive predictive value of MRCP was 93.7% (15/16).
Conclusions: MRCP performed in the second week in ABP patients with a nonworsening prognosis and a
suspicion of choledocholithiasis will give more specic results. This will avoid unnecessary ERCP and the
potential morbidity and mortality that can develop with this invasive procedure.
Copyright 2014, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All
rights reserved.

Introduction were prospectively investigated. In addition to typical clinical char-

Acute biliary pancreatitis (ABP) develops as a result of ampullary
obstruction by stones passing from the gallbladder [1]. Stones in
the bile duct affect the course of pancreatitis and require treatment
[2]. Most cases are self-limiting and improve with conservative
treatment. However, some patients may suffer severe conse-
quences, such as signicant uid loss, metabolic imbalances, hypo-
tension, and sepsis [1].
According to various studies, some bile duct stones (BDS) in
patients diagnosed with ABP pass spontaneously to the duo-
denum during an acute attack [3e5]. However, it is uncertain
when and to what extent this passage happens. The purpose of
this study was rst to investigate the positive predictive value
of MRCP in the diagnosis of choledocholithiasis in ABP and sec-
ond to determine the level of spontaneous passage of BDS during
an acute attack and the effect of this on the therapeutic use of
ERCP.
Methods
In this study, sixty patients diagnosed with ABP and treated be-
tween January 2006 and January 2009 at the general surgery clinic
of Haydarpasa Numune Teaching and Research Hospital in Turkey
acteristics, the diagnosis of ABP was based on serum amylase values
being 3 times higher than normal and stones in the gallbladder
determined by ultrasound. Patients with pancreatitis attributed to
other causes were excluded.
MRCP was performed in all patients between days 1 and 4 of an
acute attack (1.5 T Philips Gyroscon MR). Early cholecystecomy
was performed between days 7 and 18 (mean 10 days) for pa-
tients with mildly edematous ABP with no choledocholithiasis
on MRCP. A control MRCP was performed 7 days after the initial
imaging in the patients with MRCP-identied choledocholithiasis.
ERCP was performed in patients with persistent choledocholithia-
sis on the control MRCP and in patients in whom choledocholithia-
sis was not detected but who showed no decrease in bilirubin or
cholestasis enzymes. Cholecystectomy was performed in patients
with MRCP-identied choledocholithiasis and decreased chole-
static enzyme levels and bilirubin values (days 9e20, mean 15th
day).
The patients' demographic data, laboratory ndings, Ranson's
criteria, course of disease, and MRCP/ERCP ndings were examined.
The relationship between the course of hepatic and cholestatic en-
zymes, serum bilirubin values (direct and total), and choledocholi-
thiasis, along with the effect of the timing of MRCP on the
therapeutic approach, was investigated.

http://dx.doi.org/10.1016/j.pan.2014.08.002
1424-3903/Copyright 2014, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
412 Letter to the Editor / Pancreatology 14 (2014) 411e414

Table 1 alkaline phosphatase (ALP), and gamma glutamyl transferase

Patient characteristics and laboratory values at presentation. (GGTP) enzyme levels, total and direct bilirubin values between pa-
Characteristics Na tients with choledocholithiasis and those without at the MRCP
Male/female 36/24
(p < 0.01) (Table 2). With the exception of ALP and GGTP, other lab-
Age (years) 52 2.4 oratory parameters (in patients without choledocholithiasis at
Mean amylase (IU/L) 1514.8 138.8 MRCP) decreased to normal limits on the 5th day, but none of the
Mean AST (IU/L) 251.5 34.7 parameters returned to normal limits in patients with MRCP-
Mean ALT (IU/L) 276.9 30.9
identied choledocholithiasis. Choledocholithiasis persisted in 16
Mean total bilirubin (mg/dL) 2.9 0.3
Mean direct bilirubin (mg/dL) 1.9 0.3 (80%) of the 20 patients with stones detected on the control
Mean Ranson's criteria 1.3 0.2 MRCP. The stones were conrmed with ERCP in 15 of the patients
AST: aspartate aminotransferase, ALT: alanine aminotransferase, ALP: akaline
and removed. The positive predictive value of MRCP (15/16) was
phosphatase. 93.7%. ERCP was performed in another 2 patients who did not
a
Continuous variables are presented as means SD. have choledocholithiasis on the control MRCP but who had suspi-
cious clinical and laboratory ndings (Table 3). Choledocholithiasis
was identied and removed by ERCP in one of these patients.
Statistical analysis Cholestasis enzymes and bilurubin values were within normal
limits in the other 2 patients who did not have choledocholithiasis
Laboratory data are presented as means standard devia- on the control MRCP (Table 3). These patients underwent cholecys-
tion. Demographic data and biochemical parameters in patients tectomy without ERCP. No complications related to choledocholi-
with and without MRCP-identied choledocholithiasis and thiasis were seen during the follow up (months 48e62, mean 55
ERCP were examined with bivariate analysis using Jump 5.1 months). Fig. 1 presents a diagram of the management of all the
software. patients.

Results Discussion

Twenty-four of the 60 patients with ABP were men and 36 were
women (mean age 52). All the patients' demographic data and
biochemical parameters at presentation are shown in Table 1. Chol-
edocholithiasis were determined by MRCP in 20 of the 60 patients
on days 1e4 of hospitalization (33%). There were no signicant dif-
ferences in serum amylase values in sequential measurements
taken at the time of admission to observation in patients with or
without stones detected by MRCP (p > 0.5) (Table 2). There was a
statistically signicant difference at all monitoring times in the
serum alanine aminotransferase, aspartate aminotransferase,
This study showed that up to 15% (3/20) of stones seen during an
acute attack of ABP pass spontaneously after the attack. Based on
these ndings, we think that the decision to perform ERCP in biliary
pancreatitis should be made on MRCP ndings performed on the
7th day at the earliest following an acute attack if clinical and lab-
oratory parameters of the disease have not worsened.
Several mechanisms are implicated in the pathogenesis of ABP.
One of them is the BDS that may cause trauma as they pass the
ampulla of Vater or obstruct the ampulla, thereby increasing pres-
sure in the duct of Wirsung [2]. Obstruct of ampulla results in a rise

Table 2
Laboratory values according to MRCP results at time of presentation and all monitoring times.

Biochemical parameters MRCP result positive (N:20) MRCP result negative (N:40)

First examination 1st day 3rd day 5th day First examination 1st day 3rd day 5th day

Amylase 1484 274 1063 192 387 104 154 35 1527 162 795 117 251 32 126 21
(IU/L)
Total bilurubin (mg/dL) 4.2 0.7* 3.7 0.7* 2.8 0.6* 1.3 0.2* 2.3 0.3 1.8 0.2 1.1 0.1 0.8 0.1
Direct bilurubin (mg/dL) 3.1 0.6* 2.9 0.7* 2.8 0.6* 0.7 0.2* 1.4 0.2 1.0 0.1 0.5 0.1 0.4 0.08
AST (IU/L) 376 103* 228 61* 148 29* 78 15* 199 23 103 11 45 4 35 3
ALT (IU/L) 380 84* 275 44* 218 39* 137 23* 233 24 169 16 103 10 70 8
ALP (IU/L) 309 65* 314 61* 235 37* 166 11 145 8 130 8
GGTP (IU/L) 505 95* 447 82* 321 46* 225 22 183 17 144 14

SD: continuous variables are represented as the mean (Results are presented as means SD. *P < 0.01 compared to the MRCP result is negative).
AST: aspartate aminotransferase, ALT: alanine aminotransferase, ALP: akaline phosphatase, GGTP: gamma glutamyl transferase.

Table 3
Laboratory values at time of rst MRCP and control MRCP of the patients who have not choledocholithiasis on the control MRCP.

Amylase (IU/L) Total bilurubin (mg/dL) Direct bilurubin (mg/dL) AST (IU/L) ALT (IU/L) ALP (IU/L) GGTP (IU/L)

First Control First Control First Control First Control First MRCP Control First Control First Control
MRCP MRCP MRCP MRCP MRCP MRCP MRCP MRCP MRCP MRCP MRCP MRCP MRCP

Patient 1 78 68 3.8 2.8 1.8 1.2 236 196 125 102 556 386 516 396
ERCP()
Patient 2 1276 112 2.4 2.2 2.0 1.4 196 138 156 112 286 198 256 164
ERCP()
Patient 3 78 46 2.9 1.2 2.1 0.8 236 86 152 62 564 102 440 98
Patient 4 1873 52 3.3 1.1 2.9 0.7 234 68 196 44 259 112 238 86

ERCP (): identied choledocholithiasis, ERCP (): non identied choledocholithiasis, AST: aspartate aminotransferase, ALT: alanine aminotransferase, ALP: akaline phospha-
tase, GGTP: gamma glutamyl transferase.
 Letter to the Editor / Pancreatology 14 (2014) 411e414
Fig. 1. The management of all the patients. (* bilirubin values and cholestatic enzyme levels had not decreased).
in cholestatic enzymes and serum direct bilirubin in ABP [6,7]. Ele-
vations in cholestatic enzymes in biliary pancreatitis frequently
decrease in the early period of an acute attack. The course of chole-
static enzyme levels is thought to be associated with the BDS pass-
ing spontaneously into the duodenum due to a decrease in edema
[8]. In our study, cholestatic enzyme levels and bilirubin values
decreased in the patients with no stones on the initial MRCP.
Although they also decreased in the patients with choledocholi-
thiasis, the levels did not return to normal limits in the latter.
ERCP is an invasive procedure used in both the diagnosis and
treatment of choledocholithiasis; it has high diagnostic sensitivity
[9,10]. MRCP and endoscopic ultrasonography are currently used
for diagnostic purposes, and ERCP is generally reserved for thera-
peutic ones, thereby avoiding the potential morbidity and mortality
associated with ERCP. The place and timing of ERCP in ABP is
controversial. One study reported that emergency ERCP performed
in the rst 72 h of an acute attack in patients with a diagnosis of ABP
did not reduce mortality and increased morbidity [11]. Therefore,
noninvasive MRCP and EUS are used to investigate BDS during
ABP. Studies including patients with ABP showed that the sensi-
tivity and specicity of MRCP was 95e97% and 82e89%,
respectively [8,12].
Our aim was to determine the level of spontaneous passage of
stones with MRCP. Therefore, ERCP was applied only in patients
with stones identied on MRCP, and the sensitivity and specicity
and negative predictive value of MRCP were not evaluated. Only
its positive predictive value was calculated. In the control MRCP
performed after 7 days, choledocholithiasis was not detected in
20% (4/20) of MRCP-identied choledocholithiasis patients who
had an acute attack after admission (days 1e4). 2 patient was
recieved ERCP after negative control MRCP due to elevated chole-
static lab results, MRCP was false negative one of them. This means
control MRCP failed to detect choledocholithiasis in only one of
these 4 patients. We suggest that repeat MRCP save 10% unneces-
sary ERCP.
In conclusion, performing MRCP following an acute attack in pa-
tients with ABP and suspected choledocholithiasis will obviate
413
unnecessary ERCP and optimize the use of ERCP. Wider prospective
studies are needed to determine the ideal timing of MRCP after an
acute attack.
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Faruk Cavdar*
Department of General Surgery, Yalova State Hospital, Yalova, Turkey
Murat Yildar
Department of General Surgery, Balkesir University Faculty of
Medicine, Balkesir, Turkey
414 Letter to the Editor / Pancreatology 14 (2014) 411e414

lu
Grkan Telliog
Department of General Surgery, Gaziosmanpasa Private Hospital,
Istanbul, Turkey
_ E-mail addresses: drcavdarf@hotmail.com, drcavdarf@gmail.com
Melih Kara, Metin Tilki, Mesut Izzet Titiz
Department of General Surgery, Haydarpasa Training and Research
Hospital, Istanbul, Turkey
*
Corresponding author. Yalova State Hospital, Department of
General Surgery, Izmit way 3 kilometers, Yalova 77100, Turkey.
Tel.: 90 505 7273881; fax: 90 226 8115230.
(F. Cavdar).
Available online 23 August 2014