Ampullary obstruction monitoring in acute gallstone pancreatitis: A safe, accurate, and reliable method to detect pancreatic ductal obstruction

OBJECTIVE: The aim of this study was to determine the value of ordinary cli nical and laboratory data, including the monitoring of ampullary gallstone obstruction in the early phases of the disease, in the diagnosis of acute g allstone pancreatitis (AGP). METHODS: One hundred and thirty-two patients were studied. The inclusion cr iteria were admission within 48 h from the onset of symptoms, clinical pres entation compatible with AGP, bile-free gastric aspirate, elevation of seru m amylase and bilirubin, and ultrasonographic demonstration of cholelithias is. Monitoring of ampullary obstruction included severity of pain, presence of bile in the gastric aspirate: and serial serum bilirubin determinations . The clinical diagnosis of AGP was confirmed or excluded by surgical explo ration, and that of ampullary obstruction by intraoperative cholangiography (IOC) or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: The overall accuracy of the diagnostic tests for AGP was high: sen sitivity, 0.94; specificity, 0.99; positive predictive value, 0.95; and neg ative predictive value. 0.99. Detection of spontaneous ampullary decompress ion was correct in 100% of the patients, and that of ampullary obstruction, in 61%. The accuracy of this test was sensitivity, 1.0; specificity, 0.92; positive predictive value, 0.61; and negative predictive value, 1.0. CONCLUSIONS: Clinical criteria and ordinary laboratory determinations are s ufficiently accurate to discriminate between patients with AGP and those wi th other acute abdominal pathologies. Careful monitoring of patients' pain, quality of nasogastric aspirate, and serum bilirubin level can accurately identify the few cases with persistent ampullary obstruction. Those patient s can then be selected for intervention to restore the ampullary patency an d prevent progression of acute pancreatitis.