Endoscopic Therapy for Recurrent Acute Pancreatitis

Recurrent acute pancreatitis (RAP) is a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of a normal anatomical and functional gland, however, a chronic disease at early stage may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The etiology of RAP can be identified in up to 70% of cases; for the remaining cases the term “idiopathic” is used. Most common causes include bile duct stone disease, sphincter of Oddi dysfunction, anatomical ductal variants interfering with pancreatic juice outflow, genetic mutations, any obstruction of the main pancreatic duct or pancreatico-biliary junction, and alcohol consumption. Patients with RAP have few treatment options available to them to manage their symptoms or prevent progression to chronic pancreatitis. Endoscopic therapy has been found effective in those cases in whom a mechanical obstruction is found. The efficacy of endoscopic therapy in patients with a history of RAP depends on two main factors: whether or not the bouts of acute pancreatitis occur in a normal pancreas or in a setting of chronic pancreatitis, and whether or not a cause can be identified and removed. Because occult bile stone disease and sphincter of Oddi dysfunction account for the majority of cases, cholecystectomy, and eventually endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. However, in the last years concerns the efficacy of endotherapy in sphincter of Oddi dysfunction have been raised. Pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis caused by pancreatic ductal obstruction, independently from the cause of obstruction, in symptomatic pancreas divisum and in some cases of genetic mutations.