1. Recurrent Acute Pancreatitis with Normal LFT, USG & CECT Johny Cyriac PVS Institute of Digestive Diseases Kochi

2. Recurrent Acute Pancreatitis (RAP) RAP remains a diagnostic dilemma History, labs and routine imaging fail to diagnose nearly 30%

3. Michael J. Levy et al. AJG 2001

4. Indian study

5. 35% 12% Microlithiasis and sludge should be excluded in all patients with RAP. Wilcox M etal GIE 2006 55%

6. EUS or ERCP ? EUS as an important less- invasive alternative to ERCP is emerging has emerged

7. Role of EUS Identify etiology in 68-92% Advantage in early diagnosis of chronic pancreatitis Limitation – SOD EUS recommended after the initial episode of pancreatitis (Yusoff etal Gastrointest Endosc 2004)

8. Tandon M et al 2001 Yusoff et al. 2004 45 68

9. EUS in RAP- GB Sludge

10. Chronic Pancreatitis

11. Obstructive pancreatitis

12. EMERGING S-MRCP! Concurrent use of secretin makes MRCP an attractive first line test for ARP to assess for structural underlying etiologies. SOD- Good correlation with SOM Advantages over ERCP Non invasiveness Absence of procedure related complications Absence of contrast injection No radiation exposure Performance in postsurgical patients. Mariani A et al. Gastrointest Endosc 2003 Khalid A et al Dig Dis Sci 2003

13. Pancreas divisum. Unenhanced (A) and secretin-enhanced magnetic resonance cholangiopancreatography (B). The ventral pancreatic duct (arrow in B) and the entire course of the main dorsal pancreatic duct are seen only after secretin administration.

14. S-MRCP An 80-year-old man presented with 3 attacks of acute pancreatitis over 5 yr Divisum with Santorinicele

15. Ascaris-induced pancreatitis in a 45-year-old woman who presented with severe epigastric pain and a moderately elevated serum amylase level. Linear hypointense filling defect within the distal CBD,

16. M Delhaye et al. World J Gastroenterol February 21, 2008

17. ERCP is Reserved When the etiology cannot be identified by S- MRCP  inspection of the papilla  brush cytology  biopsy sampling  bile or pancreatic juice aspiration  SOM ? Therapeutic purposes.

18. Choledochocele. Endoscopic appearance of a markedly enlarged major papilla in a patient presenting with several unexplained episodes of acute pancreatitis.

19. IPMN

20. Annular pancreas. Pancreatogram outlining the pancreatic duct as it encircles the duodenum in a patient with multiple attacks of pancreatitis.

21. Pancreas Divisum  Only about 5% get pancreatitis  Recent studies- relationship between PD and CFTR mutations

23. SOD- Hen or Egg first? A high frequency (30%-65%) of sphincter hypertension in patients with acute idiopathic pancreatitis, and a 50% to 87% in CP Whether this pancreatic duct obstruction causes the initial injury or is the result of prior inflammation is unknown. However, pancreatic sphincter ablation does decrease future attacks of pancreatitis (although studies are primarily retrospective and uncontrolled)

27. Recurrent acute vs chronic pancreatitis Acute to chronic - events in the progression is not clear Two groups – Recurrent acute episodes before expression of CP features – Features CP at the initial episode

28. AP to RAP to CP- Study from Kerala

29. CP: Comparison of Modalities USGCTERCPEUS Specificity75%95%100% Sensitivity58%75%74% * 88% * n=81 * For Mild CP : EUS - 86%, ERCP - 50 % Buscail et al, Pancreas, 1995

30. Genetic studies Gene mutations – SPINK1 – PRSS1 – PRSS2 – CFTR SPINK – 1 (Tropical pancreatitis) CFTR (Cystic fibrosis, P divisum) PRSS1(Hereditary pancreatitis)

31. True idiopathic recurrent acute pancreatitis (TIRAP) C hallenging problem M edical & endoscopic option limited C onsider evolving chronic pancreatitis ?

32. History,Labs US,CT MRCP / S- MRCP Duodenal aspirate for bile and microscopy ERCP EUS ERCP / SO Manometry Genetic testing In children/ductal anomalies

33. Management of True IRAP (TIRAP) Medical: Enzymes : Anti oxidants Endoscopic: ES Surgical: Cholecystectomy : Pancreatectomy

34. THANK YOU

35. Meandering main pancreatic duct