Abstract
Establishing a biliary etiology in acute pancreatitis is clinically important because of the potential need for invasive treatment, such as endoscopic retrograde cholangiopancreatography. The etiology of acute biliary pancreatitis (ABP) is multifactorial and complex. Passage of small gallbladder stones or biliary sludge through the ampulla of Vater seems to be important in the pathogenesis of ABP. Other factors, such as anatomical variations associated with an increased biliopancreatic reflux, bile and pancreatic juice exclusion from the duodenum, and genetic factors might contribute to the development of ABP. A diagnosis of a biliary etiology in acute pancreatitis is supported by both laboratory and imaging investigations. An increased serum level of alanine aminotransferase (>1.0 µkat/l) is associated with a high probability of gallstone pancreatitis (positive predictive value 80–90%). Confirmation of choledocholithiasis is most accurately obtained using endoscopic ultrasonography or magnetic resonance cholangiopancreatography. This Review discusses the pathogenesis of ABP and the clinical techniques used to predict and establish a biliary origin in patients with suspected ABP.
Key Points
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A key feature of the pathogenesis of acute biliary pancreatitis is transient or persistent ampullary obstruction
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Obstruction is associated with pancreatic and biliary ductal anatomy, gallstone-related factors, biliopancreatic reflux and duodenal bile and pancreatic juice exclusion
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The role of genetics in the pathogenesis of acute biliary pancreatitis is not well established
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Elevated levels of alanine aminotransferase (>1.0 µkat/l) in nonobese patients without a medical history of heavy drinking of alcoholic beverages can indicate pancreatitis with a biliary origin
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Magnetic resonance cholangiopancreatography and endoscopic ultrasonography aid diagnosis of acute biliary pancreatitis in patients who are obese, are alcohol dependent, or have normal levels of liver enzymes
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E. J. M. van Geenen researched the data for the article. Both E. J. M. van Geenen and M. J. Bruno provided a substantial contribution to discussion of the content and contributed equally to the writing of this article. E. J. M. van Geenen, D. L. van der Peet, P. Bhagirath, C. J. J. Mulder and M. J. Bruno contributed equally to reviewing or editing the manuscript before submission.
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van Geenen, E., van der Peet, D., Bhagirath, P. et al. Etiology and diagnosis of acute biliary pancreatitis. Nat Rev Gastroenterol Hepatol 7, 495–502 (2010). https://doi.org/10.1038/nrgastro.2010.114
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