Testoni Pier Alberto, Testoni Sabrina
Gastroenterology and Gastrointestinal Endoscopy, La Madonnina Clinic, Vita-Salute San Raffaele University, 20100 Milan, Italy.
Unit of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Policlinico San Donato, Vita-Salute San Raffaele University, 20100 Milan, Italy.
J Clin Med. 2025 Mar 21;14(7):2150. doi: 10.3390/jcm14072150.
This review aims to summarize the role of endoscopic therapy in the management and outcomes of recurrent acute pancreatitis (RAP). RAP is a clinical entity characterized by repeated episodes of acute pancreatitis in the setting of a normal gland or chronic pancreatitis (CP). The aetiology of RAP can be identified in about 70% of cases; for the remaining cases, the term "idiopathic" (IRAP) is used. However, advanced diagnostic techniques may reduce the percentage of IRAP to 10%. Recognized causes of RAP are gallstone disease, including microlithiasis and biliary sludge, sphincter of Oddi dysfunction (SOD), pancreatic ductal abnormalities (either congenital or acquired) interfering with pancreatic juice or bile outflow, genetic mutations, and alcohol consumption. SOD, as a clinical entity, was recently revised in the Rome IV consensus, which only recognized type 1 dysfunction as a true pathological condition, while type 2 SOD was defined as a suspected functional biliary sphincter disorder requiring the documentation of elevated basal sphincter pressure to be considered a true clinical entity and type 3 was abandoned as a diagnosis and considered functional pain. Endoscopic therapy by retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) has been proven effective when a mechanical obstruction is found and can be removed. If an obstruction is not documented, few treatment options are available to prevent the recurrence of pancreatitis and progression toward chronic disease. In gallstone disease, endoscopic biliary sphincterotomy (EBS) is effective when a dilated common bile duct or biliary sludge/microlithiasis is documented. In type 1 SOD, biliary or dual sphincterotomy is generally successful, while in type 2 SOD, endotherapy should be reserved for patients with documented sphincter dysfunction. However, in recent years, doubts have been expressed about the real efficacy of sphincterotomy in this setting. When sphincter dysfunction is not confirmed, endotherapy should be discouraged. In pancreas divisum (PD), minor papilla sphincterotomy is effective when there is a dilated dorsal duct, and the success rate is the highest in RAP patients. In the presence of obstructive conditions of the main pancreatic duct, pancreatic endotherapy is generally successful if RAP depends on intraductal hypertension. However, despite the efficacy of endotherapy, progression toward CP has been shown in some of these patients, mainly in the presence of PD, very likely depending on underlying genetic mutations. In patients with IRAP, the real utility of endotherapy still remains unclear; this is because several unknown factors may play a role in the disease, and data on outcomes are few, frequently contradictory or uncontrolled, and, in general, limited to a short period of time.
本综述旨在总结内镜治疗在复发性急性胰腺炎（RAP）的管理及预后中的作用。RAP是一种临床病症，其特征为在胰腺正常或存在慢性胰腺炎（CP）的情况下反复发生急性胰腺炎。约70%的RAP病例可明确病因；其余病例则称为“特发性”（IRAP）。然而，先进的诊断技术可能会将IRAP的比例降至10%。公认的RAP病因包括胆石症，如微结石症和胆泥，Oddi括约肌功能障碍（SOD），干扰胰液或胆汁流出的胰腺导管异常（先天性或后天性），基因突变以及饮酒。SOD作为一种临床病症，在罗马IV共识中最近有所修订，该共识仅将1型功能障碍视为真正的病理状况，而2型SOD被定义为疑似功能性胆管括约肌疾病，需要记录基础括约肌压力升高才能被视为真正的临床病症，3型则不再作为诊断，被视为功能性疼痛。当发现机械性梗阻并可解除时，经内镜逆行胰胆管造影（ERCP）和内镜超声（EUS）进行的内镜治疗已被证明有效。如果未记录到梗阻，则几乎没有预防胰腺炎复发和疾病进展为慢性疾病的治疗选择。在胆石症中，当记录到胆总管扩张或胆泥/微结石症时，内镜下胆管括约肌切开术（EBS）有效。在1型SOD中，胆管或双括约肌切开术通常成功，而在2型SOD中，内镜治疗应仅用于记录有括约肌功能障碍的患者。然而，近年来，人们对这种情况下括约肌切开术的实际疗效表示怀疑。当未确认括约肌功能障碍时，应不鼓励进行内镜治疗。在胰腺分裂症（PD）中，当背侧导管扩张时，小乳头括约肌切开术有效，且在RAP患者中的成功率最高。在主胰管存在梗阻性病变的情况下，如果RAP取决于导管内高压，胰腺内镜治疗通常会成功。然而，尽管内镜治疗有效，但其中一些患者仍出现了向CP的进展，主要是在存在PD的情况下，很可能取决于潜在的基因突变。在IRAP患者中，内镜治疗的实际效用仍不清楚；这是因为几个未知因素可能在该疾病中起作用，且关于预后的数据很少，经常相互矛盾或无对照，并且一般限于较短时间段。
