Although uncommon, surgeons and physicians are sometimes confronted with patients who presents with recurrent episodes of acute pancreatitis. When two or more episodes of acute pancreatitis occur without an identifiable cause, it is referred to as Recurrent Acute Pancreatitis (RAP). In such patients, selecting the most appropriate management strategy continue to pose a challenge due to multiple aetiological factors, associated conditions, microanatomical and pathological processes and complex immunological mechanisms of this condition.
The identifiable causes of RAP such as bile duct stones, biliary sludge or crystals, Sphincter of Oddi Dysfunction (SOD), pancreatic duct obstructions due to benign and malignant neoplasms, genetic mutations, Pancreatic Divisum (PD), metabolic disorders, alcohol consumption and smoking may be identified in some patients. There are several other rare conditions which may be associated with RAP. However, in about 30%, no cause/s can be identified. Diagnosis is further complicated by the fact that, although the gland may appear morphologically normal following the initial episode of Acute Pancreatitis (AP), in some patients, evidence of Chronic Pancreatitis (CP) may manifest later. Furthermore, there is an ongoing debate as to whether, recurrent bouts of pancreatitis following the first; the Sentinel Acute Pancreatitis episode in patients who are 'immunologically' predisposed may lead to Chronic Pancreatitis. In such patients who subsequently develop acute episodes, i.e., Acute on Chronic Pancreatitis will further complicate recognition of aetiological factors of RAP.
The recognition of possible causes, associated factors, and understanding of pathological progressions are therefore important in the management of such patients. Detailed clinical assessment and clinical reasoning, standard haematological and biochemical workup and basic and advanced imaging studies will help identify patients who can be selected for specific invasive and medical therapy to prevent acute episodes.
This brief review is a clinical update to guide clinicians, the best way forward in the management of RAP.