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Acute biliary pancreatitis (ABP) is a clinical condition that can rapidly evolve into a life-threatening one. Endoscopic retrograde cholangiopancreatography (ERCP) has been considered the standard treatment of ABP for many years, though it entails the risk of morbidity and mortality. Endoscopic ultrasonography (EUS) can reliably diagnose choledocholithiasis avoiding unnecessary ERCP in patients with no stones in the biliary tract.We undertook a systematic review of the randomized controlled trials and clinical trials comparing EUS and ERCP to evaluate procedure performance, complication rates, clinical course of pancreatitis, and hospital stay according to the treatment given.A computerized bibliographic search was performed from 1994 to April 2010. Two reviewers assessed the methodological quality of eligible trials and independently extracted data from the included trials.Seven studies enrolled 545 patients with acute pancreatitis of suspected biliary origin. Only one was a randomized controlled trial. EUS had a lower failure rate than ERCP in all the studies included, avoiding ERCP in 71.2% of cases. No complications were related to EUS, whereas sphincterotomy was associated with bleeding in up to 22% of patients. The procedures did not influence the clinical course of pancreatitis.A strategy based on EUS before ERCP in patients with ABP may be an effective alternative to diagnostic ERCP.