Acute pancreatitis--ERCP/endoscopic papillotomy (EPT) yes or no?

Until the mid eighties ERCP and EPT were considered to be contraindicated in acute pancreatitis, because of possible aggravation of active pancreatitis or induction of new attacks of pancreatitis. This attitude was revised with the new knowledge obtained from four prospective randomised studies, which compared the effects of endoscopic treatment with conservative management of acute pancreatitis. Although the four studies are not strictly comparable their results indicate that there is no advantage to ERCP +/- EPT over conservative treatment alone in mild biliary pancreatitis. In severe biliary pancreatitis, however, ERCP with EPT reduced the number of purulent cholangitis and incidence of morbidity and in one study mortality was also significantly reduced. There is evidence, that ERCP + EPT may be important in a deteriorating acute mild pancreatitis, in the smouldering type of pancreatitis and in pancreatitis with persistent cholostasis. To avoid recurrent severe pancreatitis in patients unfit for surgery without bile duct stones but with gallbladder stones, EPT is recommended. ERCP and EPT in acute severe biliary pancreatitis during the first trimester of pregnancy have been successfully performed in four patients. Sludge and microlithiasis may be the cause of recurrent "idiopathic" pancreatitis and ERCP + EPT is effective especially in cholecystectomised patients. Furthermore in patients with recurrent pancreatitis due to malformations, such as pancreas divisum, ERP and minor-papillotomy produced similar results to surgical treatment. Acute pancreatitis in patients with pancreatic duct stones or ductal leaks may be treated by ERP and EPT in selected patients. Alcoholic, metabolic and infectious pancreatitis remain within the domain of conservative treatment.