ERCP-Guided Endoscopic Therapy for Recurrent Acute Pancreatitis in Normal Pancreas and Chronic Pancreatitis

Recurrent acute pancreatitis is a clinical entity involving more than one episode of acute pancreatitis. Pancreatitis generally recurs in a subject with a normal anatomical and functional gland; however, either early or advanced chronic disease may be seen at the first episode of pancreatitis or during the follow-up. The etiology of recurrent acute pancreatitis can be identified in the majority of patients but, despite advanced diagnostic techniques, the causes still remain unknown in 10-30%: in these cases the term "idiopathic" is used. The efficacy of ERCP-guided endoscopic therapy in patients with RAP depends on two main factors: whether the acute pancreatitis involves a normal pancreas or is already in a setting of chronic pancreatitis, and whether a cause can be identified and removed. Occult common bile duct stone disease, sphincter of Oddi dysfunction, and pancreas divisum account for the majority of cases of recurrent acute pancreatitis, which can be successfully treated by endoscopic biliary and/or pancreatic sphincterotomy or minor papillary sphincterotomy, or stenting. However, in recent years concerns have been voiced about the efficacy of endo-therapy to treat sphincter of Oddi dysfunction and prevent the progression toward chronic pancreatitis in pancreas divisum. Trans-papillary endo-therapy has also proved effective for recurrent acute pancreatitis in patients with early or advanced chronic pancreatitis, and depending on pancreatic ductal obstruction or fluid collection; however, here again, despite symptom improvements, data on the impact of endo-therapy on the course of chronic pancreatitis remain uncertain.