Accepted Article
Etiology, clinical features and management of acute recurrent pancreatitis1 Running title: Acute recurrent pancreatitis Yi Yun DENG,1 Rui WANG,2,3 Hao WU,4 Cheng Wei TANG,4 Xin Zu CHEN5
1
Intensive Care Unit; 2 Nursing Section, Department of Gastroenterology; 3Infusion Nursing IV
Team; 4Department of Gastroenterology; 5Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
Correspondence to: Hao WU, Department of Gastroenterology, West China Hospital, Sichuan
University, Guo Xue Xiang 37, Chengdu, Sichuan Province 610041, China. Tele: 0086 18980601287; Fax: 0086 28 85463766 Email: [email protected]
Conflict of interest: None.
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/1751-2980.12180 1
This article is protected by copyright. All rights reserved.
Accepted Article
Abstract
Objective: To study the etiology and clinical features of acute recurrent pancreatitis (ARP) and to determine optimal management and outcomes. Methods: The ARP cases among acute pancreatitis between January 2008 and December 2012 were retrospectively collected. The etiology, clinical features, treatments and outcomes of the ARP
patients were analyzed. Results: Totally, 8.9% (168/1894) of cases were classified as ARP among all of the pancreatitis patients. The proportions of mild and severe diseases were 86% and 14%, respectively. The common etiological factors were biliary (31%), alcohol (26%), hyperlipidaemia (21%) and pancreaticobiliary malformation (16%). At onset, 46 cases were cryptogenic, and 36 cases were subsequently confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Among the
hyperlipidaemic ARP patients, 72% failed to routinely monitor and control serum lipids; there were 28 cases with fatty liver and 16 with diabetes. ERCP was performed on 88 cases, and 48 patients also required endoscopic sphincterotomy or calculus removal. There were 22 patients who underwent cholangiopancreatic duct stent placement. A pancreatic necrosectomy was performed on 8 severe cases. The overall outcomes indicate that 8.3% of the cases developed into chronic pancreatitis that 33.3% of the cases receiving etiological treatment were recurrence-free. There were
no deaths in is this study.
Conclusions: The etiological factors of ARP are similar to those of first onset acute pancreatitis. The management of ARP should be fully considered through etiological investigation.
Key words: acute recurrent pancreatitis; etiology; treatment; outcome
2
This article is protected by copyright. All rights reserved.
Accepted Article
INTRODUCTION Acute pancreatitis (AP) is clinically common and generally an isolated incident. However, patients with recurrent bouts who have complete or almost complete relief after each onset are defined as acute recurrent pancreatitis (ARP) patients. Once the onset of ARP, the levels of pancreatic enzymes
might usually increase, but the imaging manifestation of chronic pancreatitis. After remission, the symptoms and signs could basically disappear, while the pancreatic enzymes return to normal. Besides, it is normally without dysfunction of pancreatic endocrine or exocrine, as well as absence of permanent histological changes, e.g. calcification and fibrosis.
A certain etiology can be identified in 70-80% of patients after an attack of AP. Currently, there is still no confirmed consensus on etiology of ARP. As known, some ARP patients have similar causes to AP, such as cholelithiasis, hyperlipoidemia and hypercalcinemia, but some are similar to the causes of chronic pancreatitis, such as sphincter of Oddi dysfunction (SOD), ampullary papillary
stenosis, pancreatic duct stricture, choledochal cyst, papillary epithelial tumors and duodenal obstruction. Besides, a small group of patients in whom an etiological association is not obvious is so-called idiopathic recurrent pancreatitis.1
Without sufficient etiological treatment, any factor capable of causing an initial episode of AP may initiate recurrent episodes.2 The morbidity rate of ARP is approximately 10-20% of all AP cases.3,4 The frequent recurrent attacks not only cause suffering but can also lead to chronic pancreatitis with
irreversible pancreas damage, especially in idiopathic cases5. Therefore, it is important to understand the clinical features of ARP and to investigate the etiology and management of the disease. This retrospective study analysed the 5-year clinical data of inpatients in the department of 3
This article is protected by copyright. All rights reserved.
Accepted Article
gastroenterology in our hospital. The objective of this study was to provide references for the etiological and therapeutic management strategy of the disease.
PATIENTS AND METHODS Patients
This study retrospectively analyzed the clinical data of patients who admitted to the Department of Gastroenterology, West China Hospital (Chengdu, Sichuan Province, China) between January 2008 and December 2012 with the first diagnosis of AP. The etiology, clinical features, laboratory
findings, therapeutic approaches and outcomes were investigated.
Diagnostic criteria The diagnosis of AP met the classification system for acute pancreatitis according to the summary of the International Symposium on Acute Pancreatitis at the Atlantic International Conference in 1992.6 A diagnosis of ARP was given to patients who met the diagnostic criteria of AP and developed the clinical syndromes and signs of AP more than one time with complete release of
symptoms and normal amylase in serum and urine during each episode. Additionally, to be diagnosed as recurrent acute pancreatitis, the patients had to have no histological changes (calcification or fibrillation) or internal and external secretion dysfunction.7 The exclusion criteria included imaging features of chronic pancreatitis, such as pancreatic duct stones, calcification of the pancreas accompanied with internal or external secretion dysfunction, and pancreatic cancer.
Etiology
The definitions of various etiological causes were as follows: (i) Biliary—jaundice in clinical 4
This article is protected by copyright. All rights reserved.
Accepted Article
finding, elevated bilirubin, imaging features of dilated intrahepatic and extrahepatic duct (≥1 cm in diameter) or calculus found in the biliary system; (ii) Hyperlipidemia—concentration of serum triglyceride (TG) ≥11.30 mmol/L or between 5.65 and 11.30 mmol/L with chylaemia8; (iii)
Alcohol—alcohol was considered as the cause of pancreatitis due to heavy consumption, which was defined as more than 80 g per day for more than 5 years, and laboratory markers included elevated serum glutamyl transferase and mean red blood cell corpuscular volume. Other aetiologies were
excluded by history, laboratory tests and imaging9; (iv) Pancreaticobiliary malformation confirmed by magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP); (v) Idiopathic—cases of pancreatitis wherein a diagnosis could
not be made through a thorough history, physical examination, laboratory studies, and non-invasive imaging modalities such as abdominal ultrasonography/computerised tomography (CT)10.
Endoscopic management The indication of ERCP included (i) confirmed or suspected biliary pancreatitis, namely with
obviously raised level of bilirubin, alanine aminotransferase (ALT) or alkaline phosphatase (ALP) at admission, and imaging indicating bilipancreatic duct dilatation, obstruction and cholelith, as
well as exclusion of other causes of ARP; and (ii) idiopathic acute recurrent pancreatitis (IARP), namely whose causes of ARP are unable to be made clear through common examinations at present
or previous hospitalization11. The patterns of ERCP intervention concerned endoscopic
sphincter-papillotomy (EST), mechanical basket lithotripsy and papillary balloon dilation lithotomy. The placement of endoscopic nasobiliary drainage (ENBD) or stent was according to the operators’ realtime decision.
5
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Accepted Article
Statistical analysis SPSS 10.0 statistical software (SPSS Inc., Chicago, IL, USA) was used to analyze the data. For the continuous variables with normal distribution, the one-way ANOVA test was used. Both the continuous variables without normal distribution and the ranked variables were compared using the Mann-Whitney U test. The categorical variables were compared by using the Pearson’s Chi-square
test (or Likelihood ratio). Two-sided P values less than 0.05 were considered statistically significant.
6
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Accepted Article
RESULTS General information
A total of 168 patients met the diagnostic criteria of ARP in a 5-year period among 1894 patients
with AP (Table 1) and the recurrence rate was 8.9%. There were 114 male and 54 female ARP patients and the mean age at first onset was 41.4 ± 13.8 years (range 15-75 years). Average number of recurrences was 4.9 ± 3.7. Average length of hospital stay was 11.3 ± 8.6 days. Average time from the first onset to analysis was 49.7 ± 45.2 months.
Clinical characteristics The clinical features were similar between ARP and non-ARP groups, which included abdominal pain and distension, nausea and vomiting, fever, elevation of serum amylase and lipase, imaging tests showing a swollen pancreas, exudation or necrosis. Among the 168 cases, 144 (85.7%) had mild ARP and 24 (14.3%) developed severe ARP. There were 14 cases with pseudocyst formation, among these, 8 were treated with incision and drainage, and pseudocysts were absorbed without surgery in 6 patients. No deaths occurred during the study period (Table 1). There were 112 cases that no longer suffered from relapse after etiological management. The pancreatitis symptoms
re-emerged in 42 cases, and the other 14 cases progressed into chronic pancreatitis (8 with pancreaticobiliary malformation, 4 were alcohol-related, and 2 idiopathic).
Etiology analysis The leading causes of ARP are biliary, alcohol, hyperlipidaemia and pancreaticobiliary anatomic
anomaly (Table 2). There were many cases with unknown cause that were confirmed through 7
This article is protected by copyright. All rights reserved.
Accepted Article
thorough examinations and were classified as idiopathic pancreatitis. In our group of 168 patients, 52 were biliary (31.0%), 44 were alcoholic (26.2%), 36 were hyperlipidaemic (21.4%), 26 were pancreaticobiliary anatomic anomaly (15.4%). Additionally, in 10 cases (6.0%), the etiology remained unexplained. At admission, there were 46 cases with unexplained etiology.
Hyperlipidaemia pancreatitis Within the 1894 patients, 272 cases received an etiological diagnosis of hyperlipidaemia, and 36
hyperlipidaemic patients suffered recurrent attacks (Table 3). Among these 36 cases, 30 patients with ARP had serum TG concentrations ≥11.30 mmol/L, while the remaining 6 patients had serum TG values of 5.65-11.30 mmol/L with chylaemia, and the average level was 38.4 ± 22.9 mmol/L at onset, which dropped to 4.8 ± 3.4 mmol/L after treatment for 3 days. Twelve patients received
continuous renal replacement therapy (CRRT). Serum TG concentrations and tiadenol intake during the release period were not monitored in 26 of the 36 cases. There were 16 cases related to alcohol consumption or high-fat diet. As comorbidities, 14 patients had fatty livers, and 8 patients had diabetes.
ERCP management ERCP was performed in 88 patients within 24 h of meeting the indication of surgery (Table 4). The exact procedure was determined according to particular findings during surgery. There were 48 cases of EST plus ENBD, and 22 cases of biliary or pancreatic duct stent implantation. Among the 26 cases with pancreaticobiliary malformation, 8 were anomalous junction of the pancreaticobiliary duct, 10 showed opening stricture of the biliary or pancreatic duct, 6 were pancreas divisum (PD), and 2 were annular pancreas. The 36 patients with unknown etiology at admission had revised 8
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Accepted Article
diagnoses after ERCP. Twenty-eight patients diagnosed as biliary pancreatitis underwent selective cholecystectomy with the existence of cholecystolithiasis after ERCP. The 6 recurrent cases all
coexisted with hepatolithiasis.
9
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Accepted Article
DISCUSSION Although investigations of AP have been popular recently, studies investigating ARP are relatively rare. Therefore, we performed this retrospective study on patients with AP who suffered from recurrent attacks during the last 5 years. We investigated the etiology, diagnostic and management
strategy of this disease. The rate of recurrence for AP has been reported as 10-31%,3,12-14 which is higher than our result of 8.9% (168/1894). This result may be related to our active etiological assessment and extensive use of ERCP.
There was a similar composition of common causes of ARP and AP, including biliary, alcohol, hyperlipidaemia, and pancreaticobiliary anatomic anomaly. There were also several rare idiopathic cases. However, the ratios of causes of AP and ARP are different; the leading cause of AP is biliary, which accounts for more than 50% of cases in China15; however, the percentage of hyperlipidaemia and pancreaticobiliary malformation in ARP patients is much higher than in AP patients15,16, which is consistent with our study. The frequency and severity of hyperlipidaemia ARP is more severe than biliary cases17. Most of these patients are obese with high BMI and fatty liver, poor supervision or control of blood lipids, and a significant elevation of blood lipids at onset. These characteristics may be related to patient lifestyle, lack of excise and failure to recognise the importance of routine supervision or control of hyperlipidemia.
Patients with biliary ARP often have cholelithiasis, and most are multi-cholecystolithiasis. These patients often have symptoms after consuming a fatty meal or alcohol. Further investigations showed that cases with recurrent episodes did not perform proper treatment after first onset.
According to Hwang’s study18, ERCP mitigates the risk of recurrent pancreatitis and should be 10
This article is protected by copyright. All rights reserved.
Accepted Article
considered during the initial hospitalisation if a cholecystectomy is not performed. In our study, ARP caused by pancreaticobiliary malformation occurred in more than15% of patients and was
significantly higher than the percentage found in AP (P
Etiology, clinical features and management of acute recurrent pancreatitis1 Running title: Acute recurrent pancreatitis Yi Yun DENG,1 Rui WANG,2,3 Hao WU,4 Cheng Wei TANG,4 Xin Zu CHEN5
1
Intensive Care Unit; 2 Nursing Section, Department of Gastroenterology; 3Infusion Nursing IV
Team; 4Department of Gastroenterology; 5Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
Correspondence to: Hao WU, Department of Gastroenterology, West China Hospital, Sichuan
University, Guo Xue Xiang 37, Chengdu, Sichuan Province 610041, China. Tele: 0086 18980601287; Fax: 0086 28 85463766 Email: [email protected]
Conflict of interest: None.
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/1751-2980.12180 1
This article is protected by copyright. All rights reserved.
Accepted Article
Abstract
Objective: To study the etiology and clinical features of acute recurrent pancreatitis (ARP) and to determine optimal management and outcomes. Methods: The ARP cases among acute pancreatitis between January 2008 and December 2012 were retrospectively collected. The etiology, clinical features, treatments and outcomes of the ARP
patients were analyzed. Results: Totally, 8.9% (168/1894) of cases were classified as ARP among all of the pancreatitis patients. The proportions of mild and severe diseases were 86% and 14%, respectively. The common etiological factors were biliary (31%), alcohol (26%), hyperlipidaemia (21%) and pancreaticobiliary malformation (16%). At onset, 46 cases were cryptogenic, and 36 cases were subsequently confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Among the
hyperlipidaemic ARP patients, 72% failed to routinely monitor and control serum lipids; there were 28 cases with fatty liver and 16 with diabetes. ERCP was performed on 88 cases, and 48 patients also required endoscopic sphincterotomy or calculus removal. There were 22 patients who underwent cholangiopancreatic duct stent placement. A pancreatic necrosectomy was performed on 8 severe cases. The overall outcomes indicate that 8.3% of the cases developed into chronic pancreatitis that 33.3% of the cases receiving etiological treatment were recurrence-free. There were
no deaths in is this study.
Conclusions: The etiological factors of ARP are similar to those of first onset acute pancreatitis. The management of ARP should be fully considered through etiological investigation.
Key words: acute recurrent pancreatitis; etiology; treatment; outcome
2
This article is protected by copyright. All rights reserved.
Accepted Article
INTRODUCTION Acute pancreatitis (AP) is clinically common and generally an isolated incident. However, patients with recurrent bouts who have complete or almost complete relief after each onset are defined as acute recurrent pancreatitis (ARP) patients. Once the onset of ARP, the levels of pancreatic enzymes
might usually increase, but the imaging manifestation of chronic pancreatitis. After remission, the symptoms and signs could basically disappear, while the pancreatic enzymes return to normal. Besides, it is normally without dysfunction of pancreatic endocrine or exocrine, as well as absence of permanent histological changes, e.g. calcification and fibrosis.
A certain etiology can be identified in 70-80% of patients after an attack of AP. Currently, there is still no confirmed consensus on etiology of ARP. As known, some ARP patients have similar causes to AP, such as cholelithiasis, hyperlipoidemia and hypercalcinemia, but some are similar to the causes of chronic pancreatitis, such as sphincter of Oddi dysfunction (SOD), ampullary papillary
stenosis, pancreatic duct stricture, choledochal cyst, papillary epithelial tumors and duodenal obstruction. Besides, a small group of patients in whom an etiological association is not obvious is so-called idiopathic recurrent pancreatitis.1
Without sufficient etiological treatment, any factor capable of causing an initial episode of AP may initiate recurrent episodes.2 The morbidity rate of ARP is approximately 10-20% of all AP cases.3,4 The frequent recurrent attacks not only cause suffering but can also lead to chronic pancreatitis with
irreversible pancreas damage, especially in idiopathic cases5. Therefore, it is important to understand the clinical features of ARP and to investigate the etiology and management of the disease. This retrospective study analysed the 5-year clinical data of inpatients in the department of 3
This article is protected by copyright. All rights reserved.
Accepted Article
gastroenterology in our hospital. The objective of this study was to provide references for the etiological and therapeutic management strategy of the disease.
PATIENTS AND METHODS Patients
This study retrospectively analyzed the clinical data of patients who admitted to the Department of Gastroenterology, West China Hospital (Chengdu, Sichuan Province, China) between January 2008 and December 2012 with the first diagnosis of AP. The etiology, clinical features, laboratory
findings, therapeutic approaches and outcomes were investigated.
Diagnostic criteria The diagnosis of AP met the classification system for acute pancreatitis according to the summary of the International Symposium on Acute Pancreatitis at the Atlantic International Conference in 1992.6 A diagnosis of ARP was given to patients who met the diagnostic criteria of AP and developed the clinical syndromes and signs of AP more than one time with complete release of
symptoms and normal amylase in serum and urine during each episode. Additionally, to be diagnosed as recurrent acute pancreatitis, the patients had to have no histological changes (calcification or fibrillation) or internal and external secretion dysfunction.7 The exclusion criteria included imaging features of chronic pancreatitis, such as pancreatic duct stones, calcification of the pancreas accompanied with internal or external secretion dysfunction, and pancreatic cancer.
Etiology
The definitions of various etiological causes were as follows: (i) Biliary—jaundice in clinical 4
This article is protected by copyright. All rights reserved.
Accepted Article
finding, elevated bilirubin, imaging features of dilated intrahepatic and extrahepatic duct (≥1 cm in diameter) or calculus found in the biliary system; (ii) Hyperlipidemia—concentration of serum triglyceride (TG) ≥11.30 mmol/L or between 5.65 and 11.30 mmol/L with chylaemia8; (iii)
Alcohol—alcohol was considered as the cause of pancreatitis due to heavy consumption, which was defined as more than 80 g per day for more than 5 years, and laboratory markers included elevated serum glutamyl transferase and mean red blood cell corpuscular volume. Other aetiologies were
excluded by history, laboratory tests and imaging9; (iv) Pancreaticobiliary malformation confirmed by magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP); (v) Idiopathic—cases of pancreatitis wherein a diagnosis could
not be made through a thorough history, physical examination, laboratory studies, and non-invasive imaging modalities such as abdominal ultrasonography/computerised tomography (CT)10.
Endoscopic management The indication of ERCP included (i) confirmed or suspected biliary pancreatitis, namely with
obviously raised level of bilirubin, alanine aminotransferase (ALT) or alkaline phosphatase (ALP) at admission, and imaging indicating bilipancreatic duct dilatation, obstruction and cholelith, as
well as exclusion of other causes of ARP; and (ii) idiopathic acute recurrent pancreatitis (IARP), namely whose causes of ARP are unable to be made clear through common examinations at present
or previous hospitalization11. The patterns of ERCP intervention concerned endoscopic
sphincter-papillotomy (EST), mechanical basket lithotripsy and papillary balloon dilation lithotomy. The placement of endoscopic nasobiliary drainage (ENBD) or stent was according to the operators’ realtime decision.
5
This article is protected by copyright. All rights reserved.
Accepted Article
Statistical analysis SPSS 10.0 statistical software (SPSS Inc., Chicago, IL, USA) was used to analyze the data. For the continuous variables with normal distribution, the one-way ANOVA test was used. Both the continuous variables without normal distribution and the ranked variables were compared using the Mann-Whitney U test. The categorical variables were compared by using the Pearson’s Chi-square
test (or Likelihood ratio). Two-sided P values less than 0.05 were considered statistically significant.
6
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Accepted Article
RESULTS General information
A total of 168 patients met the diagnostic criteria of ARP in a 5-year period among 1894 patients
with AP (Table 1) and the recurrence rate was 8.9%. There were 114 male and 54 female ARP patients and the mean age at first onset was 41.4 ± 13.8 years (range 15-75 years). Average number of recurrences was 4.9 ± 3.7. Average length of hospital stay was 11.3 ± 8.6 days. Average time from the first onset to analysis was 49.7 ± 45.2 months.
Clinical characteristics The clinical features were similar between ARP and non-ARP groups, which included abdominal pain and distension, nausea and vomiting, fever, elevation of serum amylase and lipase, imaging tests showing a swollen pancreas, exudation or necrosis. Among the 168 cases, 144 (85.7%) had mild ARP and 24 (14.3%) developed severe ARP. There were 14 cases with pseudocyst formation, among these, 8 were treated with incision and drainage, and pseudocysts were absorbed without surgery in 6 patients. No deaths occurred during the study period (Table 1). There were 112 cases that no longer suffered from relapse after etiological management. The pancreatitis symptoms
re-emerged in 42 cases, and the other 14 cases progressed into chronic pancreatitis (8 with pancreaticobiliary malformation, 4 were alcohol-related, and 2 idiopathic).
Etiology analysis The leading causes of ARP are biliary, alcohol, hyperlipidaemia and pancreaticobiliary anatomic
anomaly (Table 2). There were many cases with unknown cause that were confirmed through 7
This article is protected by copyright. All rights reserved.
Accepted Article
thorough examinations and were classified as idiopathic pancreatitis. In our group of 168 patients, 52 were biliary (31.0%), 44 were alcoholic (26.2%), 36 were hyperlipidaemic (21.4%), 26 were pancreaticobiliary anatomic anomaly (15.4%). Additionally, in 10 cases (6.0%), the etiology remained unexplained. At admission, there were 46 cases with unexplained etiology.
Hyperlipidaemia pancreatitis Within the 1894 patients, 272 cases received an etiological diagnosis of hyperlipidaemia, and 36
hyperlipidaemic patients suffered recurrent attacks (Table 3). Among these 36 cases, 30 patients with ARP had serum TG concentrations ≥11.30 mmol/L, while the remaining 6 patients had serum TG values of 5.65-11.30 mmol/L with chylaemia, and the average level was 38.4 ± 22.9 mmol/L at onset, which dropped to 4.8 ± 3.4 mmol/L after treatment for 3 days. Twelve patients received
continuous renal replacement therapy (CRRT). Serum TG concentrations and tiadenol intake during the release period were not monitored in 26 of the 36 cases. There were 16 cases related to alcohol consumption or high-fat diet. As comorbidities, 14 patients had fatty livers, and 8 patients had diabetes.
ERCP management ERCP was performed in 88 patients within 24 h of meeting the indication of surgery (Table 4). The exact procedure was determined according to particular findings during surgery. There were 48 cases of EST plus ENBD, and 22 cases of biliary or pancreatic duct stent implantation. Among the 26 cases with pancreaticobiliary malformation, 8 were anomalous junction of the pancreaticobiliary duct, 10 showed opening stricture of the biliary or pancreatic duct, 6 were pancreas divisum (PD), and 2 were annular pancreas. The 36 patients with unknown etiology at admission had revised 8
This article is protected by copyright. All rights reserved.
Accepted Article
diagnoses after ERCP. Twenty-eight patients diagnosed as biliary pancreatitis underwent selective cholecystectomy with the existence of cholecystolithiasis after ERCP. The 6 recurrent cases all
coexisted with hepatolithiasis.
9
This article is protected by copyright. All rights reserved.
Accepted Article
DISCUSSION Although investigations of AP have been popular recently, studies investigating ARP are relatively rare. Therefore, we performed this retrospective study on patients with AP who suffered from recurrent attacks during the last 5 years. We investigated the etiology, diagnostic and management
strategy of this disease. The rate of recurrence for AP has been reported as 10-31%,3,12-14 which is higher than our result of 8.9% (168/1894). This result may be related to our active etiological assessment and extensive use of ERCP.
There was a similar composition of common causes of ARP and AP, including biliary, alcohol, hyperlipidaemia, and pancreaticobiliary anatomic anomaly. There were also several rare idiopathic cases. However, the ratios of causes of AP and ARP are different; the leading cause of AP is biliary, which accounts for more than 50% of cases in China15; however, the percentage of hyperlipidaemia and pancreaticobiliary malformation in ARP patients is much higher than in AP patients15,16, which is consistent with our study. The frequency and severity of hyperlipidaemia ARP is more severe than biliary cases17. Most of these patients are obese with high BMI and fatty liver, poor supervision or control of blood lipids, and a significant elevation of blood lipids at onset. These characteristics may be related to patient lifestyle, lack of excise and failure to recognise the importance of routine supervision or control of hyperlipidemia.
Patients with biliary ARP often have cholelithiasis, and most are multi-cholecystolithiasis. These patients often have symptoms after consuming a fatty meal or alcohol. Further investigations showed that cases with recurrent episodes did not perform proper treatment after first onset.
According to Hwang’s study18, ERCP mitigates the risk of recurrent pancreatitis and should be 10
This article is protected by copyright. All rights reserved.
Accepted Article
considered during the initial hospitalisation if a cholecystectomy is not performed. In our study, ARP caused by pancreaticobiliary malformation occurred in more than15% of patients and was
significantly higher than the percentage found in AP (P
