Hyperbilirubinemia in inflammatory pancreatic disease: natural history and management

Of 868 patients admitted with pancreatitis between 1971 and 1976, coexisting hyperbilirubinemia was noted in 125 (14%). The patient population was primarily composed of alcoholics (84%) with chronic pancreatic disease (75% Marsielles Class H or higher) which was of moderate severity (77% fewer than three prognostic signs). The hyperbilirubinemia in these 125 patients was due to extrahepatic obstruction in 22%, hepatocelluar disease in 31%, and was idiopathic in 47%. Transient hyperbilirubinemia (< 10 days duration) occurred most commonly in the idiopathic group. Transitory periductular pancreatic edema may account for the elevated bilirubin in some of these cases. Liver biopsy should be done whenever hyperbilirubinemia persists longer than ten days in patients with pancreatitis. If hepatocellular disease is not found, transhepatic or endoscopic retrograde cholangiography are indicated. If common bile duct obstruction is demonstrated, a brief trial of medical therapy is in order. Persistent conservative treatment, however, exposes the patient to the risk of cholangitis and biliary cirrhosis. In 13 of the 125 cases (10%), persistent extrahepatic obstruction proved to be due to compression of the common bile duct by inflammatory pancreatic tissue. In these circumstances, choledochoduodenostomy is recommended as the procedure of choice. In patients requiring biliary decompression, concommitant procedures upon the pancreas are occasionally indicated.