Şurlin Valeriu, Săftoiu Adrian, Dumitrescu Daniela
Valeriu Surlin, 1 Clinic of Surgery, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Dolj, Romania.
World J Gastroenterol. 2014 Nov 28;20(44):16544-9. doi: 10.3748/wjg.v20.i44.16544.
Gallstones represent the most frequent aetiology of acute pancreatitis in many statistics all over the world, estimated between 40%-60%. Accurate diagnosis of acute biliary pancreatitis (ABP) is of outmost importance because clearance of lithiasis [gallbladder and common bile duct (CBD)] rules out recurrences. Confirmation of biliary lithiasis is done by imaging. The sensitivity of the ultrasonography (US) in the detection of gallstones is over 95% in uncomplicated cases, but in ABP, sensitivity for gallstone detection is lower, being less than 80% due to the ileus and bowel distension. Sensitivity of transabdominal ultrasonography (TUS) for choledocolithiasis varies between 50%-80%, but the specificity is high, reaching 95%. Diameter of the bile duct may be orientative for diagnosis. Endoscopic ultrasonography (EUS) seems to be a more effective tool to diagnose ABP rather than endoscopic retrograde cholangiopancreatography (ERCP), which should be performed only for therapeutic purposes. As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography (MRCP) or EUS, especially for small stones and small diameter of CBD, the later techniques are nowadays preferred for the evaluation of ABP patients. ERCP has the highest accuracy for the diagnosis of choledocholithiasis and is used as a reference standard in many studies, especially after sphincterotomy and balloon extraction of CBD stones. Laparoscopic ultrasonography is a useful tool for the intraoperative diagnosis of choledocholithiasis. Routine exploration of the CBD in cases of patients scheduled for cholecystectomy after an attack of ABP was not proven useful. A significant rate of the so-called idiopathic pancreatitis is actually caused by microlithiasis and/or biliary sludge. In conclusion, the general algorithm for CBD stone detection starts with anamnesis, serum biochemistry and then TUS, followed by EUS or MRCP. In the end, bile duct microscopic analysis may be performed by bile harvested during ERCP in case of recurrent attacks of ABP and these should be followed by laparoscopic cholecystectomy.
在全球许多统计数据中，胆结石是急性胰腺炎最常见的病因，估计占40%-60%。准确诊断急性胆源性胰腺炎（ABP）至关重要，因为清除结石（胆囊和胆总管结石）可避免复发。通过影像学检查来确认胆石症。在非复杂病例中，超声检查（US）检测胆结石的敏感性超过95%，但在ABP中，由于肠梗阻和肠扩张，胆结石检测的敏感性较低，低于80%。经腹超声检查（TUS）对胆总管结石的敏感性在50%-80%之间，但特异性较高，可达95%。胆管直径对诊断有一定指导意义。内镜超声检查（EUS）似乎是诊断ABP比内镜逆行胰胆管造影（ERCP）更有效的工具，ERCP仅应出于治疗目的进行。与最先进的磁共振胰胆管造影（MRCP）或EUS相比，计算机断层扫描的敏感性和特异性较低，特别是对于小结石和小直径的胆总管，因此现在更倾向于使用后两种技术来评估ABP患者。ERCP对胆总管结石的诊断准确性最高，在许多研究中被用作参考标准，特别是在括约肌切开术和胆总管结石球囊取出术后。腹腔镜超声检查是术中诊断胆总管结石的有用工具。在ABP发作后计划进行胆囊切除术的患者中，常规探查胆总管未被证明是有用的。相当一部分所谓的特发性胰腺炎实际上是由微结石和/或胆泥引起的。总之，胆总管结石检测的一般算法首先是问诊、血清生化检查，然后是TUS，接着是EUS或MRCP。最后，对于ABP反复发作的病例，可通过ERCP采集的胆汁进行胆管显微镜分析，之后应进行腹腔镜胆囊切除术。
