Endoscopic sphincterotomy for acute pancreatitis: arguments against.

ERCP and sphincterotomy (EPT) are well accepted as the procedure of choice for diagnostic and therapeutic purposes of extrahepatic biliary obstructions. In case of obstructive jaundice and biliary sepsis urgent sphincterotomy is the method of choice, also during acute pancreatitis. The question has been debated whether endoscopic sphincterotomy improves the prognosis of acute (e.g. biliary) pancreatitis itself. With regard to biliary problems different causes of pancreatitis should be distinguished: If the cause of pancreatitis is not obstructive like biliary pancreatitis but metabolic or toxic like alcoholic pancreatitis, no sphincterotomy is indicated. With regard to biliary pancreatitis three prospective randomised trials have been published. All agree to an urgent endoscopic treatment of biliary complications like obstructive jaundice or biliary sepsis during acute pancreatitis. Two of these studies did not find any benefit of interventional endoscopy concerning local or systemic complications of pancreatitis but observed a benefit concerning biliary complications. In one study including patients with biliary problems the complication rate but not mortality rate has been diminished by endoscopy in a subgroup of patients. It is concluded that urgency of ERCP in patients with acute pancreatitis depends on biliary symptoms. Sphincterotomy cannot be generally recommended for acute pancreatitis but only for biliary complications.