Severe gallstone pancreatitis(GSP)refractory to maximum conservative therapy has wide clinical variations,and its pathophysiology remains controversial.This Editorial aimed to investigate the pathophysiology of severe...Severe gallstone pancreatitis(GSP)refractory to maximum conservative therapy has wide clinical variations,and its pathophysiology remains controversial.This Editorial aimed to investigate the pathophysiology of severe disease based on Opie’s theories of obstruction,the common channel,and duodenal reflux and describe its types.Severe GSP might be a hybrid disease with pathology polarized between acute cholangitis with mild pancreatitis(biliary type)and necrotizing pancreatitis uncomplicated with biliary tract disease(pancreatic type),in which hepatobiliary and pancreatic lesion severity is inversely related to the presence or absence of impacted ampullary stones.Severe GSP is caused by stones that are persistently impacted at the ampulla with biliopancreatic obstruction(biliary type),and probably,stones that are either temporarily lodged at the duodenal orifice or passed into the duodenum,thereby permitting reflux of bile or possible duodenal contents into the pancreas(pancreas type).When the status of the stones and the presence or absence of impacted ampullary stones with biliopancreatic obstruction are determined,the clinical course and outcome can be predicted.Gallstones represent the main cause of acute pancreatitis globally,and clinicians are expected to encounter GSP more often.Awareness of the etiology and pathogenesis of severe disease is mandatory.展开更多
Opie’s“pancreatic duct obstruction”and“common channel”theories are generally accepted as explanations of the mechanisms involved in gallstone acute pancreatitis(AP).Common channel elucidates the mechanism of necr...Opie’s“pancreatic duct obstruction”and“common channel”theories are generally accepted as explanations of the mechanisms involved in gallstone acute pancreatitis(AP).Common channel elucidates the mechanism of necrotizing pancreatitis due to gallstones.For pancreatic duct obstruction,the clinical picture of most patients with ampullary stone impaction accompanied by biliopancreatic obstruction is dominated by life-threatening acute cholangitis rather than by AP,which clouds the understanding of the severity of gallstone AP.According to the revised Atlanta classification,it is difficult to consider these clinical features as indications of severe pancreatitis.Hence,the term“gallstone cholangiopancreatitis”is suggested to define severe disease complicated by acute cholangitis due to persistent ampullary stone impaction.It incorporates the terms“cholangitis”and“gallstone pancreatitis.”“Cholangitis”refers to acute cholangitis due to cholangiovenous reflux through the foci of extensive hepatocyte necrosis reflexed by marked elevation in transaminase levels caused by persistent ampullary obstruction.“Gallstone pancreatitis”refers to elevated pancreatic enzyme levels consequent to pancreatic duct obstruction.This pancreatic lesion is characterized by minimal or mild inflammation.Gallstone cholangiopancreatitis may be valuable in clinical practice for specifying gallstone AP that needs urgent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy.展开更多
文摘Severe gallstone pancreatitis(GSP)refractory to maximum conservative therapy has wide clinical variations,and its pathophysiology remains controversial.This Editorial aimed to investigate the pathophysiology of severe disease based on Opie’s theories of obstruction,the common channel,and duodenal reflux and describe its types.Severe GSP might be a hybrid disease with pathology polarized between acute cholangitis with mild pancreatitis(biliary type)and necrotizing pancreatitis uncomplicated with biliary tract disease(pancreatic type),in which hepatobiliary and pancreatic lesion severity is inversely related to the presence or absence of impacted ampullary stones.Severe GSP is caused by stones that are persistently impacted at the ampulla with biliopancreatic obstruction(biliary type),and probably,stones that are either temporarily lodged at the duodenal orifice or passed into the duodenum,thereby permitting reflux of bile or possible duodenal contents into the pancreas(pancreas type).When the status of the stones and the presence or absence of impacted ampullary stones with biliopancreatic obstruction are determined,the clinical course and outcome can be predicted.Gallstones represent the main cause of acute pancreatitis globally,and clinicians are expected to encounter GSP more often.Awareness of the etiology and pathogenesis of severe disease is mandatory.
文摘Opie’s“pancreatic duct obstruction”and“common channel”theories are generally accepted as explanations of the mechanisms involved in gallstone acute pancreatitis(AP).Common channel elucidates the mechanism of necrotizing pancreatitis due to gallstones.For pancreatic duct obstruction,the clinical picture of most patients with ampullary stone impaction accompanied by biliopancreatic obstruction is dominated by life-threatening acute cholangitis rather than by AP,which clouds the understanding of the severity of gallstone AP.According to the revised Atlanta classification,it is difficult to consider these clinical features as indications of severe pancreatitis.Hence,the term“gallstone cholangiopancreatitis”is suggested to define severe disease complicated by acute cholangitis due to persistent ampullary stone impaction.It incorporates the terms“cholangitis”and“gallstone pancreatitis.”“Cholangitis”refers to acute cholangitis due to cholangiovenous reflux through the foci of extensive hepatocyte necrosis reflexed by marked elevation in transaminase levels caused by persistent ampullary obstruction.“Gallstone pancreatitis”refers to elevated pancreatic enzyme levels consequent to pancreatic duct obstruction.This pancreatic lesion is characterized by minimal or mild inflammation.Gallstone cholangiopancreatitis may be valuable in clinical practice for specifying gallstone AP that needs urgent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy.
