[Endoscopic treatment in acute biliary pancreatitis].
Overall mortality in acute pancreatitis is over 10%, but exceeds 40% in acute forms. In France, it has been estimated that 40 to 60% of the acute forms are of biliary origin, usually by obstruction of the pancreatic duct. Endoscopic sphincterotomy can liberate the main bile duct and separate the bile ducts from the pancreatic ducts in a minimally invasive procedure. Nevertheless, the decision to use an endoscopic treatment rather than conservative medical treatment raises several questions. Can the endoscopic technique alleviate the obstacle causing pancreatitis? Can it improve the prognosis of acute biliary pancreatitis? Which patients can best benefit from the procedure? Based on a review of the current literature, it can be concluded that endoscopic treatment improves prognosis in patients with severe pancreatitis at admission. Retrograde opacification should reasonably be associated with sphincterotomy in order to avoid leaving small stones. Endoscopy should be performed within a short delay, preferably within 24 hours following admission, by an experienced operator. Inversely, patients with less severe disease, less than 4 of Ranson's modified criteria, could benefit more from conservative management. In all cases, the diagnosis of acute biliary pancreatitis should be made on the basis of evidence of gall bladder lithiasis or sludge and/or elevated transaminase or bilirubin levels and in the absence of severe alcoholic intoxication. Obviously, in the clinical practice, these criteria may be difficult to establish, especially at admission. If the delay should exceed 72 hours, the clinical course must be taken into consideration. It is probably preferable to propose an endoscopic treatment when the situation worsens and conservative therapy if the clinical situation tends to improve.