Early use of ERCP in acute biliary pancreatitis with(out) jaundice: an unjaundiced view.

Acute pancreatitis is a disease with a wide spectrum of etiologies, including casuistic toxins and viruses, congenital malformations and different vascular pathologies. However, with the exception of areas with a high prevalence of alcohol abuse, “biliary” is the most common form of acute pancreatitis in the majority of countries [1, 2, 3]. It is traditionally thought that “biliary” acute pancreatitis form accounts for 4060% of this disease, and such a frequency may, in fact, be even higher as microlithiasis can be responsible for many cases of so-called “idiopathic” acute pancreatitis [4, 5]. Unfortunately, since its inception as a clinical entity in 1889 and despite more than a century of research, the treatment of acute pancreatitis, regardless of its cause, remains mainly supportive [6]. A ray of hope rose in the 1980s with the introduction of endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy in routine clinical practice as it had the potential of being a pathogenetic treatment in patients with the gallstone etiology of acute pancreatitis. Nevertheless, despite two decades of clinical studies, the early use of this endoscopic intervention in patients with acute biliary pancreatitis is still a notoriously controversial issue. Conventional reasons for such a controversy (differences in study populations, peculiarities of study designs, methodological issues of the studies conducted, etc.) are abundantly discussed by the rival authors of primary evidence (clinical trials) and complemented by the secondary evidence (systematic reviews) of their supporters [7, 8, 9, 10, 11, 12, 13]. However, it can be bewildering for an ordinary practitioner to decide who has the better argument. In case of such doubtfulness, the majority of physicians naturally tend to adhere to the position of a more authoritative evidence provider. In this case, a probability of biased interpretation of the data in a clinical study or inaccurate data calculations in a metaanalysis is neglected by default. However, a question remains unanswered: is this probability indeed negligible? Therefore, the present editorial purports to impartially investigate the wealth of evidence-based literature with particular emphasis on primary and secondary evidence which guide the current practice of early management of patients with acute biliary pancreatitis.