Chapter 29, Ep 5 of 7: Recurrent Pancreatitis and Duct Decompression

What this episode covers

Episode five holds EUS and ERCP to one standard in the pancreatitis spectrum: they earn their place only when there is structural disease or stone burden to act on, because every procedure carries a real pancreatitis risk weighed against a modest expected benefit. In the recurrent-attack workup, EUS for microlithiasis is the highest-yield study after MRCP, while sphincterotomy for divisum and idiopathic disease is the reflex sham-controlled data have humbled. In the chronic gland you decompress discrete obstructive lesions and read the true predictors of success, disease duration, cessation, and stone burden rather than head calcification. Standing over all of it, a randomized trial favors early surgical drainage for the painful dilated duct.   Topics covered EUS and ERCP earn their place only with structural disease Idiopathic recurrent acute pancreatitis workup EUS for microlithiasis Sphincter of Oddi manometry caution Pancreas divisum and the sham-controlled trial Chronic dilated duct and predictors of success ESWL and pancreatic duct stone fragmentation Dominant stricture stenting and surgery versus endoscopy   Key decisions Work up idiopathic recurrent acute pancreatitis with history, calcium and triglycerides, MRCP, and IgG4 serologies, then EUS as the highest-yield test because it resolves microlithiasis that surface ultrasound misses. Do not reflexively perform ERCP with manometry after a negative workup; biliary sphincterotomy helps only about half the time even with elevated pressures, so reserve it for documented multiple recurrences with full prophylaxis. Do not offer routine minor papilla sphincterotomy for recurrent pancreatitis in pancreas divisum, since a sham-controlled trial showed no benefit and the tiny minor papilla carries higher post-procedure pancreatitis risk. Predict chronic-pancreatitis endotherapy success from short disease duration, smoking and alcohol cessation, limited stone burden, and achievable complete clearance, not from the presence or absence of head calcification. Fragment pancreatic duct stones larger than five millimeters with extracorporeal shock-wave lithotripsy first (about seventy percent clearance), escalating to pancreatoscopy with electrohydraulic or laser lithotripsy and avoiding mechanical baskets that can impact. Manage a dominant pancreatic duct stricture with a single largest-feasible plastic stent (typically ten French) for about twelve uninterrupted months, reserving multiple side-by-side stents for refractory strictures. Favor early surgical drainage with a longitudinal pancreaticojejunostomy over an endoscopy-first strategy in dilated-duct chronic pancreatitis with intractable pain, per the randomized trial.   For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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