Naso-jejunal fluid resuscitation in predicted severe acute pancreatitis: Randomized comparative study with intravenous Ringer's lactate

INTRODUCTION

Early management of severe acute pancreatitis (SAP) includes intravenous fluid resuscitation.

AIM

To confirm feasibility of naso-jejunal (NJ) fluid resuscitation using oral hydration solution (ORS) and compare its efficacy with intravenous (IV) fluid resuscitation using Ringer Lactate (RL) in predicted SAP.

PATIENTS AND METHODS

All patients of predicted SAP (presence of SIRS or BISAP > 2) without significant co morbidities were randomized to NJ group (ORS: 20 ml/kg bolus and then 3 mL/kg/h) or IV group (RL infusion at same rate). The groups were compared vis-à-vis persistent organ failure (POF), pancreatic necrosis, and mortality.

RESULTS

Seventy-seven patients were assessed and after exclusion, 49 patients were randomized to either NJ (24 patients) or IV group (25). The demographic and baseline clinical profile of both groups including BISAP score (2.25 ± 0.73 and 2.32 ± 0.56), hematocrit (40.2 ± 6.8 and 38.3 ± 6.6), blood urea nitrogen (16.88 ± 6.69 and 21.44 ± 17.56 mg/dL), and intra-abdominal pressure (14.55 ± 4.8 and 14.76 ± 5.5 cm of water) were similar. NJ resuscitation had to be stopped in two patients because of abdominal discomfort and distension. The change in intra abdominal pressure after 48 h of hydration was comparable in both groups. The occurrence of POF (66.67% and 68%), pancreatic necrosis (69.5% and 76%), intervention (5 each), surgery (1 each), and mortality (16.5% and 8%) were comparable (P > 0.05).

CONCLUSION

In select group of patients with SAP, NJ fluid resuscitation with ORS is feasible and is equally efficacious as IV fluid resuscitation with RL.

Primary squamous cell carcinoma of pancreas mimicking walled-off pancreatic necrosis

Pancreatic carcinoma is a dreaded diagnosis due to its poor prognosis. Squamous cell carcinoma (SCC) of the pancreas is a rare histological variety of pancreatic carcinoma. Its diagnosis is based on ruling out other site of tumor origin. Pancreatic carcinoma can mimic as mass or cystic lesion. We report a case of primary SCC of the pancreas in a 46-year-old male that closely mimicked acute pancreatitis with walled-off pancreatic necrosis.

Endoscopic ultrasound guided interventional procedures

Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.

Clinical significance of presence and extent of extrapancreatic necrosis in acute pancreatitis

BACKGROUND AND AIM

Extrapancreatic necrosis (EPN) alone represents a subgroup of pancreatitis with better outcome than patients with pancreatic parenchymal necrosis (PN). However, data on clinical significance of EPN is limited, and significance of the extent of EPN is not known.

METHODS

Two hundred thirteen patients (136 [63.8%] males; mean age: 39.8 ± 13.2 years) with acute pancreatitis were prospectively enrolled and followed up till recovery or death. Contrast-enhanced computed tomography of each patient was retrospectively evaluated for presence of PN and EPN, pleural effusion and ascites. EPN was termed extensive if it extended to paracolic gutters or pelvis.

RESULTS

Twenty-one (9.9%) patients had interstitial pancreatitis, seven (3.3%) patients had PN alone, 48 (22.5%) patients had EPN alone, and 137 (64.3%) patients had combined PN and EPN. Patients with EPN alone had significantly higher frequency of organ failure than patients with interstitial pancreatitis. Compared with patients with EPN alone, the patients with combined necrosis had significantly higher frequency of pleural effusion (88.2% vs. 75%), ascites (41% vs. 20.8%), and need for intervention (32.6% vs. 14.6%). Patients with extensive EPN (n = 57) had significantly higher frequency of pleural effusion, ascites, and multi-organ failure than those with limited EPN.

CONCLUSION

EPN alone should be considered as a separate category of acute pancreatitis as it has less severe course than PN but has more severe course than interstitial pancreatitis. Patients with extensive EPN in spite of having increased frequency of ascites, pleural effusion, and multi-organ failure had similar outcome as compared to patients with limited EPN.

Pancreatic pleural effusion due to ductal disruption upstream of a tight ductal stricture in patient with chronic calcific pancreatitis: Successful management with pancreatic sphincterotomy and dilatation of ductal stricture by Guide Wire

Endoscopic therapy has evolved as the standard of care for pancreatic pleural effusion and pancreatic ascites. Endoscopic retrograde cholangiopancreatography and bridging the disruption of ductal disruption with stent placement is the treatment of choice. However, it may not be always possible to negotiate tight pancreatic duct (PD) strictures or stricture stone complex, and endoscopic sphincterotomy alone may not be sufficient. We report a 53-year-old male who had chronic calcific pancreatitis with bilateral pancreatic pleural effusion and a tight stricture at head body junction, across which conventional endoscopic accessories could not be negotiated except for the 0.035 inch guidewire, which we kept across the stricture for 48 h for guidewire induced stricture dilation. This led to the complete resolution of symptoms and pancreatic pleural effusion. Combination of endoscopic sphincterotomy and guide wire induced stricture dilation can be used as rescue technique in cases of very tight PD strictures with complications such as pancreatic pleural effusion.

Comparison of CT colonography with conventional colonoscopy in patients with ulcerative colitis

RATIONALE AND OBJECTIVE

Patients with ulcerative colitis require recurrent conventional colonoscopy (CC) to define the extent of the disease. Computed tomography (CT) colonography (CTC) can be used as an alternative technique for studying the colon in these patients. The purpose of the study was to compare the findings of CTC to CC in patients with ulcerative colitis.

MATERIALS AND METHODS

Twenty patients proven to have ulcerative colitis on biopsy and in clinical remission state were enrolled in the study. They underwent CTC and CC within 1 week of each test. The investigators performing CTC and CC were blinded to the findings of each other. The chi-square test, kappa test, sensitivity, and specificity were used to compare the findings on CTC and CC. In addition, patient acceptance for both the procedures was compared.

RESULTS

Sensitivity and specificity on CTC for detecting granular appearance were 81.0% and 73.8%, respectively, and for pseudopolyps were 82.1% and 84.5%, respectively. Good correlation was seen between CTC and CC for detection of granular appearance and pseudopolyps. Loss of haustral folds, wall thickening, pericolonic vascularity, and pericolonic lymph nodes seen on CTC were found to correlate with intraluminal findings seen on CC. Patient acceptance for CTC was better than that for CC.

CONCLUSIONS

CTC can be used for evaluating patients with ulcerative colitis who are in remission.

Comparison of abdominal ultrasound, endoscopic ultrasound and magnetic resonance imaging in detection of necrotic debris in walled-off pancreatic necrosis

Background: Walled-off pancreatic necrosis (WOPN) is an important complication of acute pancreatitis that is diagnosed by imaging modalities such as endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI), which can clearly visualize necrotic debris. The effectiveness of abdominal ultrasound (USG) in detecting solid debris in WOPN is not clear.

Methods: A total of 52 patients (37 males, mean age 38.9 ± 12.6 years) with symptomatic WOPN were prospectively studied using EUS, MRI and USG. These investigations were done at a mean of 11.7 ± 5.5 weeks of onset of acute pancreatitis and within two days.

Results: WOPN was detected by EUS & MRI in all patients, whereas USG could not detect it in 4 (7.6%) patients (3 had predominantly solid WOPN, whereas one had air foci in WOPN). USG, MRI and EUS could detect solid debris in all patients with detectable WOPN. EUS and USG detected <10% debris in 10 (20%) patients, whereas MRI detected <10% debris in 14 (27%) patients. EUS and USG detected 10–40% debris in 33 patients whereas MRI detected 10–40% debris in 30 (58%) patients. More than 40% debris was better characterized on EUS and MRI with both detecting >40% debris in 8 patients (15%) compared to 5 (11%) patients having >40% debris on USG. EUS detected collaterals around WOPN that were not detected on USG or MRI.

Conclusion: USG can characterize the majority of WOPN, with accuracy comparable to that of EUS/MRI. However its limitations are the inability to detect collaterals around WOPN and characterize collections with high solid content or air.

Indian Society of Gastroenterology consensus statements on Crohn's disease in India

In 2012, the Indian Society of Gastroenterology's Task Force on Inflammatory Bowel Diseases undertook an exercise to produce consensus statements on Crohn's disease (CD). This consensus, produced through a modified Delphi process, reflects our current recommendations for the diagnosis and management of CD in India. The consensus statements are intended to serve as a reference point for teaching, clinical practice, and research in India.

A study of radiological scoring system evaluating extrapancreatic inflammation with conventional radiological and clinical scores in predicting outcomes in acute pancreatitis

BACKGROUND

A number of scoring systems are available to predict prognosis in acute pancreatitis (AP). The aim of the study was to compare extra-pancreatic inflammation on computed tomography (CT) (EPIC score) and renal rim sign with clinical scores (BISAP, SIRS) and conventional CT severity index (CTSI) and modified CTSI (MCTSI) in predicting persistent organ failure (POF), intervention and mortality.

METHODS

The demographic, clinical and radiographic data from patients with AP were retrospectively evaluated. The scores were evaluated by calculating receiver operator characteristic (ROC) curves and area under the ROC (AUROC).

RESULTS

Of the 105 patients (65 males; mean age 40.6±12.9 years) included, 8 died, 71 developed POF, and 16 needed intervention. The mean CTSI, MCTSI and EPIC scores were 5.8±3.0, 7.1±2.6 and 4.0±1.9 respectively. The AUROC for SIRS, BISAP, CTSI, MCTSI, Renal Rim Score and EPIC score in predicting POF were 0.65 (95%CI 0.53-0.78), 0.75 (95%CI 0.65-0.86), 0.66 (95%CI 0.54-0.78), 0.70 (95%CI 0.58-0.81), 0.64 (95%CI 0.52-0.76), 0.71 (95%CI 0.60-0.83), for radiological/endoscopic intervention were 0.50 (95%CI 0.35-0.65), 0.64 (95%CI 0.49-0.78), 0.51 (95%CI 0.36-0.66), 0.55 (95%CI 0.41-0.70), 0.51 (95%CI 0.36-0.67), 0.66 (95%CI 0.52-0.81), and for mortality 0.57 (95%CI 0.38-0.75), 0.90 (95%CI 0.83-0.97), 0.67 (95%CI 0.50-0.83), 0.68 (95%CI 0.51-0.85), 0.73 (95%CI 0.57-0.89) and 0.77 (95%CI 0.64-0.90) respectively.

CONCLUSION

The prognostic performance of various clinical and radiological scoring systems in AP is comparable with BISAP having the highest accuracy for predicting POF and mortality.

Bone mineral metabolism and bone mineral density in alcohol related and idiopathic chronic pancreatitis

BACKGROUND

There is limited information on the bone mineral metabolism in patients with chronic pancreatitis (CP).

METHODS

103 patients with CP (all males: mean age 38.6 ± 20.64 yrs) and 40 age matched control males (mean age: 36.7 ± 20.70 yrs) were prospectively studied. Serum levels of 25 (OH) Vitamin D3, alkaline phosphatase (ALP), and parathyroid hormone (PTH) were measured. Bone mineral density (BMD) was measured using adual-energy X-ray absorptiometry (DEXA) scanner.

RESULTS

Seventy two (70%) patients had alcohol related chronic pancreatitis (ACP), 30 (29.1%) patients had idiopathic chronic pancreatitis (ICP) and one patient had post-traumatic chronic pancreatitis. Fifty nine (59.8%) patients had chronic calcific pancreatitis (CCP) and 39 (37.8%) patients were diabetic. Steatorrhea was noted in 21 (20.4%) patients. On comparison with controls, patients with chronic pancreatitis had significantly lower 25 (OH) Vitamin D3 levels (p = 0.01). On evaluation of bone mineral density (BMD) at lumbar spine, 46% patients were osteopenic and 12% patients were osteoporotic. On evaluation of BMD of femur, 30.1% patients were osteoporotic and 39.8% patients were osteopenic. No significant difference was found in the frequency of metabolic osteopathy between alcoholic and idiopathic groups (p = 0.108), calcific and non-calcific groups (p = 0.410), diabetic and non-diabetic groups (p = 0.126). smokers and non-smokers (p = 0.198), and patients with and without history of steatorrhea (p = 0.265) and indifferent severity groups ofupancreatitis (p = 0.910) CONCLUSIONS: Majority of patients with both ACP and ICP had low BMD and similar frequency of bone changes between various groups suggests that systemic inflammation may play an important role in its pathogenesis. Further detailed metabolic studies are necssary to define the pathogenic mechanism of metabolic osteopathy associated with chronic pancreatitis.

Clinical outcomes and prognostic significance of early vs. late computed tomography in acute pancreatitis

BACKGROUND

Guidelines recommend that contrast-enhanced computed tomography (CT) should be carried out 72 hours after onset of an attack of acute pancreatitis (AP). However, the exact time beyond 72 hours at which CT will produce the best diagnostic yield for local complications, or whether doing a CT early in acute pancreatitis has any adverse effect on the course of disease, is not clear.

METHODS

The medical records of 214 consecutive patients with AP were analysed retrospectively and these patients were divided into two groups: the early CT group (CT done at 4-5 days after the onset of pain) and the late CT group (CT done in days 6-14 following onset of pain). The two groups were compared for differences in clinical outcomes and prognostic information obtained from CT, such as detection of pancreatic necrosis and local complications, and CT severity index.

RESULTS

Of 214 patients [143 (66.8%) males; mean age 39.87 ± 13.52 years], 21 patients were excluded as they did not undergo CT or CT was done more than 14 days after onset of an attack of AP. The early CT group included 114 patients, whilst the late CT group had 79. The mean CT severity index was higher in the late CT group (6.65 ± 2.27 vs. 5.52 ± 2.7; P = 0.005). The incidence of persistent organ failure in the early group was no different from that of the late group (38.6% vs. 49.4%; P = 0.143). Local complications were detected more often in the late CT group (84.8% vs. 68.4%; P = 0.011). There was no difference between the two groups in the need for percutaneous drainage, surgery, or mortality (all P > 0.05).

CONCLUSIONS

Although performing early CT does not adversely affect the outcome in AP, CT carried out more than 5 days after the onset of symptoms may detect more local complications.

Pancreatic encephalopathy: an unusual cause of asterixis

CONTEXT

Pancreatic encephalopathy is the occurrence of neuropsychiatric abnormalities in setting of acute pancreatitis which is not otherwise explained by presence of electrolyte abnormities, or organic lesions. The pathogenesis of pancreatic encephalopathy is incompletely understood. The clinical presentation is variable.

CASE REPORT

A 60 year old male, a diabetic for 5 years, was admitted with three days of abdominal pain associated with vomiting and complicated by altered sensorium for one day. He developed asterixis during the course of his hospital stay. Other workup was non-contributory and patient improved with supportive management.

CONCLUSION

Asterixis has not hitherto been reported in pancreatic encephalopathy.

Arterial pH, bicarbonate levels and base deficit at presentation as markers of predicting mortality in acute pancreatitis: a single-centre prospective study

Background. Arterial blood gas (ABG) parameters such as pH form part of multi-parameter scoring systems for predicting severe acute pancreatitis; however, literature on detailed evaluation of ABG alone in this context is scarce.

Methods. Patients with acute pancreatitis presenting to our unit between January 2012 and November 2013 were prospectively studied. ABG analysis was done at admission and development of organ failure, any need for intervention, and mortality were noted. The association between various parameters of ABG analysis and the development of organ failure or local complications, need for interventions (endoscopic/radiological/surgical) and mortality were analysed.

Results. Two hundred and five patients (mean age: 39.33 ± 13.85 years; 61.0% males) were prospectively studied. The aetiology of acute pancreatitis was alcohol in 93 patients (45.4%) and gall stone disease in 73 (35.6%). Organ failure developed in 71.2% patients and 83.9% had local complications. In 18% of patients, endoscopic/radiological/surgical interventions were needed and 14.6% died. The patients (n = 35) with metabolic acidosis (pH <7.35) suffered higher frequency of organ failure, need for interventions and mortality. Patients with low arterial bicarbonate levels, as well as higher base deficit, also displayed higher frequency of organ failure, need for interventions and mortality. The receiver operating characteristic (ROC) curves for pH <7.35, bicarbonate <22 meq/L and base deficit of >−4 meq/L for prediction of mortality were 0.771 (95% CI: 0.664–0.878), 0.707 (95% CI: 0.622–0.791) and 0.780 (95% CI: 0.693–0.867), respectively.

Conclusion. Arterial pH, bicarbonate levels, and base deficit at presentation are useful early markers for predicting adverse outcome in acute pancreatitis.

A modification of rendezvous technique for endoscopically treating transected common bile duct following cholecystectomy

Endoscopic therapy is the standard of care for management of most benign biliary strictures. However, endoscopic therapy can fail in very tight strictures. We report a case of a 52-year-old lady who had complete bile duct transection with stricture after laparoscopic cholecystectomy. In initial attempt, at endoscopic retrograde cholangiopancreatography (ERCP), guidewire could not be negotiated endoscopically across the narrowing as there was complete cut off of the bile duct and so a percutaneous transhepatic biliary drainage (PTBD) was done and subsequently internalized into the duodenum. We cannulated the internalized end of PTBD catheter with the standard ERCP cannula with guidewire and advanced it across the biliary stricture. PTBD catheter was withdrawn externally, and the guidewire was left in the left ductal system. We report this innovation as this may be helpful in managing patients with ERCP after an initial PTBD has been successfully internalized into the duodenum.