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“Endoscopic Ultrasound First Policy” in Acute Pancreatitis of Presumed Biliary Origin

(A) Focused radial endoscopic ultrasound (EUS) at the level of the papilla, illustrating a formal double duct sign with the pancreatic duct (PD) measuring 5 mm and the common bile duct (CBD) measuring 10 mm with stone material in the distal (arrow) and papillary CBD segments (asterisk). (B) Duodenoscopic visualization of the papilla during endoscopic retrograde cholangiography (ERC) confirming papillary stone impaction underlying acute biliary pancreatitis.

A 61-year-old patient without significant alcohol history presented with epigastric pain of 2 days’ duration, most recently aggravating and radiating into the back. Laboratory analysis indicated acute pancreatitis (ie, serum lipase 1839 U/L; procalcitonin 11.1 ng/mL) as well as moderately elevated liver function tests (ie, bilirubin 1.6 mg/dL). Abdominal ultrasound demonstrated gallbladder stones with normal intrahepatic bile ducts, but the common bile duct could not be properly visualized. Therefore, the patient underwent urgent radial endoscopic ultrasound (EUS) indicating mild edematous pancreatitis in parts of the body and head as well as a formal double-duct sign (Figure A) with stone material visible in the distal and papillary common bile duct segments. Next, an uncomplicated endoscopic retrograde cholangiography (ERC) confirmed papillary stone impaction (Figure B). An endoscopic papillotomy with subsequent stone extraction was performed. The patient took a favorable clinical course, and laparoscopic cholecystectomy was scheduled during the same hospital stay.


Acute pancreatitis of presumed biliary origin is commonplace in clinical practice, and a decades-long clinical and scientific tradition revolves around the indication or timing of invasive endoscopic retrograde cholangiopancreatography (ERCP) intervention with equivocal findings in large-scale clinical trials. In current clinical practice, prompt endoscopic ultrasound–based stratification (“EUS first policy”) for high-quality endoscopic retrograde cholangiography is considered to represent the most rational clinical approach, albeit in need of rigorous scientific evaluation.

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-Vincent Zimmer

This article originally appeared in the July 2019 issue of The American Journal of Medicine.

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