Abstract: Reflection on difficulties in diagnosis and treatment of biliary pancreatitis        GAO Kun, TONG Zhi-hui, LI Wei-qin. Severe Acute Pancreatitis Treatment Center, Jinling Clinical Medical College of Nanjing Medical University, General Hospital of Eastern Theater Command, Nanjing 210002, China
Corresponding author: TONG Zhi-hui, E-mail: njzyantol@hotmail.com
Abstract    Biliary pancreatitis accounts for the majority of acute pancreatitis. Currently, a couple of standard guidelines have been developed for diagnosis and treatment of acute biliary pancreatitis (ABP). However, some issues remain unclear in clinical practice, being tough to handle or easy to ignore by clinicians. Gallstones or sludge on the images and a greater than or equal to 3-fold elevation of alanine aminotransferase have been widely accepted as diagnostic criteria for ABP. If the etiology is unclear, MRI/MRCP, EUS and even diagnostic ERCP should be used as additional diagnostic tests. Common bile duct obstruction or acute cholangitis are the indications of early ERCP. No data to date are available about the usage of preventive pancreatic stenting at the early ERCP in improving the outcome of ABP. Percutaneous transhepatic gallbladder drainage could be an effective alternative for patients who have contraindications for ERCP or when ERCP fails. Immediate antibiotic therapy should be considered when ABP patients complicated with cholangitis or suspected biliary infection. In patients with mild ABP, a cholecystectomy should be performed during the same hospital admission; in patients with severe ABP, cholecystectomy is to be deferred until clinical stability. Patients undergone cholecystectomy are still at risk of AP recurrence. In summary, the optimization of diagnostic criteria, establishment of a developed clinical protocol and improvement of long-term outcome are promising directions for future research on ABP.

Key words: biliary pancreatitis, endoscopic retrograde cholangiopancreatography, cholecystectomy

摘要： 胆源性胰腺炎是急性胰腺炎的第一大病因。尽管当前已经形成了相对规范的诊疗指南，但在临床实践中仍然有一些棘手或容易忽视的问题值得临床医生重视。影像学上发现结石或胆泥的证据以及丙氨酸氨基转移酶升高至正常3倍或以上是目前被广泛接受的诊断标准。当病因不明时，磁共振成像（MRI）或磁共振胰胆管成像（MRCP）、超声内镜甚至诊断性内镜逆行胰胆管造影（ERCP）应该当作为补充性的诊断工具。胆总管梗阻或急性胆管炎是早期ERCP的指征，尚无证据表明早期预防性胰支架置入能否改善急性胆源性胰腺炎（ABP）的预后，对于无条件做ERCP或ERCP失败的病人，经皮经肝胆囊穿刺引流可作为有效的替代方法。胆源性胰腺炎合并胆管炎或疑似胆源性感染的病人，需立即开始抗菌治疗。轻型胆源性胰腺炎病人应在住院期间接受胆囊切除术，重型病人需待临床一般情况稳定后择期手术。即使已行胆囊切除术，仍然存在胰腺炎复发的风险。优化胆源性胰腺炎诊断标准，建立完善的临床干预流程，降低复发率是未来临床研究的方向。

关键词: 胆源性胰腺炎, 内镜逆行性胰胆管造影, 胆囊切除术