Background: The timing and need for ERCP in the setting of gallstone pancreatitis without acute cholangitis has been debated widely. Guidelines recommend urgent ERCP for patients with gallstone pancreatitis with concurrent cholangitis, severe cholestasis, or a visualized stone in the duct, but it is unclear if ERCP benefits those with gallstone pancreatitis without those clear indicators.
Dr. Tara Reddy
Study design: Prospective randomized controlled superiority trial.
Setting: 26 hospitals in the Netherlands.
Synopsis: Of patients with severe gallstone pancreatitis without cholangitis, 232 were randomized 1:1 to undergo urgent ERCP with biliary sphincterotomy (less than 24 hours after presentation) or conservative therapy (analgesia, intravenous fluids, with selective ERCP for cholangitis or persistent cholestasis). The primary endpoint was a composite score of mortality or major complications within 6 months of randomization. There was no difference in the primary endpoint, which occurred in 38% of the urgent-ERCP group and 44% of the conservative-therapy group (P = .37). In a subgroup of patients with cholestasis suggestive of biliary obstruction, the primary endpoint occurred in 32% of the urgent-ERCP group and 42% in the conservative group (P = .18). Similar rates of adverse events were observed between both groups. Limitations included difficulty in diagnosis of cholangitis, moderate positive predictive value of scoring tools to isolate those with severe pancreatitis, and lack of endoscopic ultrasound to determine the presence of ductal stones or sludge.
Bottom line: Conservative management was equal to ERCP with sphincterotomy in patients with severe gallstone pancreatitis without cholangitis, and ERCP may be best reserved for patients with persistent cholestasis or later-developed cholangitis.
Citation: Schepers NJ et al. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): A multicentre randomised controlled trial. Lancet. 2020;396:167-76. doi: 10.1016/S0140-6736(20)30539-0.
Dr. Reddy is a hospitalist at Northwestern Memorial Hospital and instructor of medicine, Feinberg School of Medicine, both in Chicago.