Observation
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World J Gastrointest Surg. Mar 27, 2012; 4(3): 55-61
Published online Mar 27, 2012. doi: 10.4240/wjgs.v4.i3.55
Conservative management of cholestasis with and without fever in acute biliary pancreatitis
José Sebastião Santos, Rafael Kemp, José Celso Ardengh, Jorge Elias Jr
José Sebastião Santos, Rafael Kemp, José Celso Ardengh, Division of Digestive Surgery, Department of Surgery and Anatomy, Faculty of Medicine of Ribeirão Preto, University of São Paulo, CEP 14049-900 São Paulo, Brazil
Jorge Elias Jr, Department of Internal Medicine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, CEP 14049-900 São Paulo, Brazil
Author contributions: All the authors contributed to this paper.
Supported by Fundação Waldemar Barnsley Pessoa
Correspondence to: José Sebastião Santos, PhD, Professor of Digestive Surgery of the Medical School, University of São Paulo, Ribeirão Preto, CEP 14049-900 São Paulo, Brazil. jsdsanto@fmrp.usp.br
Telephone: +55-16-36022508 Fax: +55-16-36330836
Received: January 15, 2011
Revised: December 31, 2011
Accepted: January 10, 2012
Published online: March 27, 2012
Abstract

The presence of cholestasis in both mild and severe forms of acute biliary pancreatitis (ABP) does not justify, of itself, early endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (ES). Clinical support treatment of acute pancreatitis for one to two weeks is usually accompanied by regression of pancreatic edema, of cholestasis and by stone migration to the duodenum in 60%-88% of cases. On the other hand, in cases with both cholestasis and fever, a condition usually characterized as ABP associated with cholangitis, early ES is normally indicated. However, in daily clinical practice, it is practically impossible to guarantee the coexistence of cholangitis and mild or severe acute pancreatitis. Pain, fever and cholestasis, as well as mental confusion and hypotension, may be attributed to inflammatory and necrotic events related to ABP. Under these circumstances, evaluation of the bile duct by endo-ultrasonography (EUS) or magnetic resonance cholangiography (MRC) before performing ERC and ES seems reasonable. Thus, it is necessary to assess the effects of the association between early and opportune access to the treatment of local and systemic inflammatory/infectious effects of ABP with cholestasis and fever, and to characterize the possible scenarios and the subsequent approaches to the common bile duct, directed by less invasive examinations such as MRC or EUS.

Keywords: Biliary pancreatitis; Cholestasis; Endoscopic sphincterotomy; Cholangitis; Mortality; Magnetic resonance cholangiopancreatography; Endoscopic retrograde cholangiography; Endoscopic ultrasonography; Intensive care; Health system regulation