Cause and effect relationship of malnutrition with idiopathic chronic pancreatitis: prospective case-control study

BACKGROUND AND AIM

Patients with chronic pancreatitis are often malnourished. The role of malnutrition in the pathogenesis of chronic pancreatitis is unclear. The aim of the present article was to study prospectively the cause and effect relationship of malnutrition with idiopathic chronic pancreatitis in a case-control study.

METHODS

Consecutive patients with chronic pancreatitis underwent anthropometry, nutritional and dietary assessments. For dietary assessment, food frequency questionnaire and 24-hour dietary recall methods were used. Primary outcome measure was cause and effect relationship of malnutrition with idiopathic chronic pancreatitis.

RESULTS

Of 201 patients with chronic pancreatitis, 120 had idiopathic chronic pancreatitis (mean age 29.60 years, 74 males) who formed the study group. None of the patients consumed cassava. The nutritional status and dietary intake of the patients before the onset of chronic pancreatitis were comparable with those of controls with 20.6% of patients and 22.5% of controls being malnourished (body mass index [BMI] < 18.5). After the onset of chronic pancreatitis, 56.5% of patients lost weight and significantly more patients became malnourished compared with controls (45.8% vs 22.5%; P < 0.001). The causes of weight loss were diabetes, higher calories from proteins, and pseudocyst.

CONCLUSION

Malnutrition was not a cause of idiopathic chronic pancreatitis and weight loss occurred as an effect of chronic pancreatitis. Cassava was not found to be a cause of idiopathic chronic pancreatitis.

Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment

BACKGROUND & AIMS

Patients with carcinoma of the gallbladder (GBC) and obstructive jaundice are usually not amenable to curative resection. Effective palliation by biliary decompression is the goal of treatment. Endoscopic stenting (ES) and percutaneous transhepatic biliary drainage (PTBD) can provide biliary decompression. We compared unilateral PTBD and ES in patients with a hilar block caused by GBC and assessed their quality of life (QOL).

METHODS

Consecutive patients with GBC not suitable for curative resection with Bismuth type 2 or 3 block were randomized to either PTBD or ES with a 10F plastic stent. Technical success, successful drainage, early cholangitis, complications, procedure-related mortality, 30-day mortality, survival, and QOL before and 1 and 3 months after stenting were compared between the 2 groups. All patients were followed up until death.

RESULTS

Fifty-four patients were randomized to PTBD or ES (27 each). Successful drainage was better in the PTBD group (89% vs 41%; P < .001). Early cholangitis was significantly higher in the ES group (48% vs 11%; P = .002). Procedure-related (4% vs 8%) and 30-day mortality (4% vs 8%) and median survival were similar (60 days in both; P = .71). Although the World Health Organization-Quality of Life 1- and 3-month physical and psychological scores were better after PTBD, the difference was not significant. The European Organization for Research and Treatment of Cancer (EORTC)-Quality of Life Questionnaire 30 global health status at 3 months was significantly better after PTBD (75 vs 30.5, P = .02). The EORTC symptom scores improved in both groups, but only fatigue was significantly better after PTBD.

CONCLUSIONS

PTBD provides better biliary drainage and has lower complication rates in patients with GBC and hilar block.

Dietary counseling versus dietary supplements for malnutrition in chronic pancreatitis: a randomized controlled trial

BACKGROUND & AIMS

Up to 50% of patients with chronic pancreatitis (CP) are malnourished. There are limited data on the role of dietary intervention in improving the nutritional status of such patients. The aim was to compare the efficacy of medium chain triglyceride (MCT)-enriched commercial dietary supplements with dietary counseling for homemade food in the management of malnutrition in patients with CP.

METHODS

In a randomized controlled trial, consecutive undernourished patients with CP (body mass index [BMI] <18.5 kg/m(2)) at a tertiary care hospital were randomized to receive either dietary counseling for regular homemade food or commercial MCT-enriched dietary supplements for a period of 3 months to compensate for the dietary calorie deficit. All patients received standard management for CP including pancreatic enzyme supplements. Primary outcome measure was improvement in BMI.

RESULTS

Sixty malnourished patients with CP were randomized to counseling group (n = 29; mean age, 32 +/- 10 years; male, 83%) and supplementation group (n = 31; mean age, 28 +/- 10 years; male, 84%). BMI increased in both the counseling group and supplementation group (17.2 +/- 1.7 vs 18.1 +/- 1.8 kg/m(2), P = .001; 16.7 +/- 1.6 vs 18.2 +/- 1.6 kg/m(2), P = .001). There were similar improvements in triceps skinfold thickness, dietary intake, fecal fat, and pain score during a period of 3 months in both groups. There was, however, no significant difference between the counseling and supplementation groups with regard to any of the outcome measures.

CONCLUSIONS

Dietary counseling for a balanced homemade diet is as good as commercial food supplements in improving malnutrition in patients with CP.

Leptin and its correlation with exocrine and endocrine pancreatic function in idiopathic chronic pancreatitis: implications for pathophysiology

OBJECTIVES

Leptin alters pancreatic exocrine and beta-cell secretion in animal studies. We hypothesized that leptin might be important in the pathogenesis of idiopathic chronic pancreatitis (ICP) and/or the development of diabetes in ICP.

METHODS

Fifty patients with ICP (25 with diabetes, 25 without diabetes) and 25 healthy controls were included in a prospective, case-control study. Fasting plasma leptin concentration was measured by enzyme-linked immunosorbent assay. Exocrine and endocrine pancreatic functions were assessed by fecal chymotrypsin and serum C-peptide, respectively. Anthropometric parameters and body fat mass (FM) were measured.

RESULTS

Patients with ICP (mean age, 30 years; 33 men) had significantly lower body mass index (19.5 +/- 2.6 kg/m2) and FM (10.6 +/- 4.2 kg) as compared with controls (body mass index, 21.7 +/- 4.1 kg/m2; FM, 19.0 +/- 16.6 kg; P < 0.01). Fecal chymotrypsin (median, 5.2 [range, 0.3-42.6] U/kg) and C-peptide (median, 1.7 [range, 0.2-9.5] ng/mL) were significantly lower in patients than in controls (12.9 [range, 2.5-33.0] U/kg and 3.5 [range, 0.3-10.3] ng/mL; P < 0.01). Plasma leptin concentration was slightly lower but statistically insignificant in patients with ICP (median, 4.0 [range, 2.0-62.5] ng/mL) as compared with controls (median, 5.0 [range, 2.0-63.0] ng/mL). Patients with and those without diabetes were also comparable with regard to their leptin concentration, pancreatic functions, and anthropometric parameters.

CONCLUSIONS

Leptin does not seem to have a pathophysiological role in either ICP or the development of diabetes in ICP.

CT enteroclysis in the diagnosis of obscure gastrointestinal bleeding: initial results

AIM

To evaluate the usefulness of computed tomography (CT) enteroclysis in patients with obscure gastrointestinal (GI) bleeding.

MATERIALS AND METHODS

In a prospective study, CT enteroclysis was performed in 21 patients (median age 50 years; range 13-71 years) with obscure GI bleeding in which the source of the bleeding could not be detected despite the patient having undergone both upper GI endoscopic and colonoscopic examinations. The entire abdomen and pelvis was examined in the arterial and venous phases using multisection CT after distending the small intestine with 2l of 0.5% methylcellulose as a neutral enteral contrast medium and the administration of 150ml intravenous contrast medium.

RESULTS

Adequate distension of the small intestine was achieved in 20 of the 21 (95.2%) patients. Potential causes of GI bleeding were identified in 10 of the 21 (47.6%) patients using CT enteroclysis. The cause of the bleeding could be detected nine of 14 (64.3%) patients with overt, obscure GI bleeding. However, for patients with occult, obscure GI bleeding, the cause of the bleeding was identified in only one of the seven (14.3%) patients. The lesions identified by CT enteroclysis included small bowel tumours (n=2), small bowel intussusceptions (n=2), intestinal tuberculosis (n=2), and vascular lesions (n=3). All vascular lesions were seen equally well in both the arterial and venous phases.

CONCLUSIONS

The success rate in detection of the cause of bleeding using CT enteroclysis was 47.6% in patients with obscure GI bleeding. The diagnostic yield was higher in patients with overt, obscure GI bleeding than in those with occult obscure GI bleeding.

Elevated level of interleukin-6 predicts organ failure and severe disease in patients with acute pancreatitis

BACKGROUND AND AIM

Cytokines play an important role in the pathogenesis of acute pancreatitis (AP). The aim of the present paper was to study the profile of anti- and proinflammatory cytokines in AP and to determine their predictive value for severity of AP, organ failure and mortality.

METHODS

Consecutive patients with AP were included in the study. Cytokines were measured in those patients who presented within the first 72 h of the onset of AP. Plasma levels of proinflammatory cytokines tumor necrosis factor (TNF)-alpha, interleukin (IL)-Ibeta, IL-6 and anti-inflammatory cytokine IL-10 were measured on days 1, 3, 7 and 14 of AP.

RESULTS

Of 108 patients, 30 presented within 72 h of the onset (mean age 40.27 +/- 13.89 years; 22 males). Of the 30 patients, 13 (43.3%) had severe and 17 (56.7%) had mild pancreatitis. Eleven (36.7%) patients developed organ failure and three died. The level of IL-6 on day 3 was significantly higher in severe pancreatitis than in mild pancreatitis (146.29 +/- 57.53 pg/mL vs 91.42 +/- 71.65 pg/mL; P = 0.04) and was significantly higher in patients who developed organ failure compared with those who did not (161.59 +/- 53.46 pg/mL vs 88.16 +/- 65.50 pg/mL; P = 0.004). At a cut-off value of 122 pg/mL on day 3, IL-6 predicted organ failure and severe pancreatitis with a sensitivity and specificity of 81.8% and 77.7%, respectively. TNF-alpha and IL-10 were detectable only in one-third of patients and were not related to the severity of pancreatitis, while Il-1beta was not detectable.

CONCLUSION

Elevated levels of IL-6 predicted organ failure and severe pancreatitis and suggested its pathophysiological significance in AP.

Is biliary microlithiasis a significant cause of idiopathic recurrent acute pancreatitis? A long-term follow-up study

BACKGROUND & AIMS

The cause of recurrent acute pancreatitis (RAP) is not known in 10%-30% of patients. The aim of the present study was to determine the cause of idiopathic RAP in a long-term follow-up study.

METHODS

All consecutive patients with idiopathic RAP underwent detailed evaluations and investigations to find out the cause. The pancreatitis was considered to be idiopathic when no cause could be found after standard investigations that included serum biochemistry, transabdominal ultrasonography, and computerized tomography scan of the abdomen. The detailed work-up included repeat serum biochemistry and transabdominal ultrasonography, an endoscopic retrograde cholangiopancreatography, duodenal bile microscopy to diagnose biliary microlithiasis, and endoscopic ultrasonography.

RESULTS

Seventy-five patients were studied from June 1995 to May 2003. Their mean age was 31.9 years and 80% were male. The mean number of attacks of acute pancreatitis was 4.82 (range, 2-10). The cause of RAP was attributed to biliary microlithiasis in only 10 (13%) of 75 patients. Two additional patients developed gallstones during the follow-up period. Thirty-five (47%) patients developed chronic pancreatitis during the follow-up period. Ten of these 35 patients with chronic pancreatitis had biliary microlithiasis; 8 of these 10 patients had undergone cholecystectomy/endoscopic sphincterotomy yet continued to have recurrent pancreatitis and developed chronic pancreatitis. Miscellaneous causes were found in 10 (13%) patients. No cause was found in the remaining 18 (24%) patients.

CONCLUSIONS

Microlithiasis was not a significant cause of idiopathic RAP in our patients. About one half of the patients with RAP developed chronic pancreatitis during the follow-up period.

Endoscopic retrograde cholangiopancreatography-induced acute pancreatitis often has a benign outcome

BACKGROUND

Acute pancreatitis (AP) is the commonest complication of endoscopic retrograde cholangiopancreatography (ERCP). Data regarding the clinical course and outcome of post-ERCP pancreatitis are sparse, although the available data suggest it to be a severe disease.

OBJECTIVE

To examine the clinical course, disease severity, and outcome of patients with post-ERCP-AP.

METHODS

All consecutive patients with post-ERCP-AP were included. They were managed according to a standard protocol. Outcome measures were severity of pancreatitis, infectious complications, need for surgery and mortality. The clinical course and outcome of patients with post-ERCP-AP were also compared with those of patients with gallstone pancreatitis (GS-AP).

RESULTS

Of the 1497 de novo ERCP procedures, 57 (3.8%) patients developed AP. Their mean age was 40.2 years (13.1), 16 were males of them, 54 (95%) patients had mild pancreatitis. Only 2 patients developed organ failure. Fifty-four (95%) patients recovered with conservative management. One of the 57 patients died. As compared with patients with GS-AP (n=174), APACHE II scores at admission [3.3 (3.1) vs. 5.8 (4.8); P=0.011], occurrence of pancreatic necrosis (17.5% vs. 39.1%; P=0.020), organ failure (3.5% vs. 19.0%; P=0.015), infectious complications (8.7% vs. 24.7%; P=0.040), and mortality (1.8% vs. 13.2%; P=0.044) were significantly less among patients with post-ERCP-AP.

CONCLUSION

Unlike previous belief, we found that post-ERCP AP was a mild disease with a favorable outcome in most cases.

Patients with gallstones develop gallbladder cancer at an earlier age

Significant proportions of Indian patients with gallbladder cancer are young. Multiple risk factors for gallbladder cancer are recognized among Indian patients. The effect of these risk factors on the age of development of gallbladder cancer is not known. We conducted a study to determine the influence of risk factors on the age at diagnosis of patients with gallbladder cancer and to assess the interactions between these risk factors. Patients with gallbladder cancer from two tertiary care institutions during the period 1994-2001 were prospectively studied. An ultrasound examination was done to look for the presence of gallstones. The influence of gender, gallstones, socio-economic status, smoking, residence in rural areas and in the Gangetic belt on the age at presentation was analysed using univariate analysis, logistic and linear regression analyses. The mean age of the 121 patients studied was 55+/-11.7 (SD) years. There were 51 (42%) patients aged less than 50 years. The younger patients (age < or =50 years) were more likely to have gallstones (88 versus 66%; P=0.008) and to have come from a lower socio-economic background (88 versus 71%; P=0.02) in comparison with older patients. However, there was no effect of the other risk factors. The independent determinants for younger age of patients with gallbladder cancer on logistic regression analysis were gallstones [odds ratio (OR) 4, 95% confidence interval (CI) 1.5-11; P=0.006] and lower socio-economic status (OR 3.1, 95% CI 1.1-8.6; P=0.03). On linear regression analysis, age at presentation was lowered by 5.6 years if there were associated gallstones. The mean age of patients with these two risk factors was significantly lower than that of those with one risk factor or no risk factor (52+/-12 years versus 57+/-11 years versus 61+/-9 years; P=0.007). In conclusion, the presence of gallstones and lower socio-economic status were both independently associated with a younger age at diagnosis of gallbladder cancer and their effect was additive.

Gallbladder cancer in India: a dismal picture

BACKGROUND

Gallbladder cancer (GBC) is one of the most common gastrointestinal malignancies. The data regarding GBC are, however, limited.

METHODS

Records of 634 patients with GBC over a 10-year period were examined with regard to the clinical presentation, investigative findings, treatment, operative findings and outcome.

RESULTS

The mean age of patients was 51 +/- 11 years and men : women ratio was 0.36:1.00. Pain, jaundice and hepatomegaly were seen in 81.0%, 76.0% and 61.5% patients, respectively. On imaging, a mass replacing the gallbladder was seen in 73% patients. Gallstones were present in 54% patients. Surgery was carried out in 291 (46%) patients and endoscopic treatment in 72 (19%) patients but no intervention was carried out in the remaining patients because of disseminated disease. Among the patients who were operated on, 2.0% had stage I GBC, 3.4% stage II, 17.5% stage III, 47.0% stage IVa and 29.8% stage IVb. Radical resection was possible in 133 (46%) patients. The 30-day mortality was 10% with most (90%) deaths in patients with stage IV disease. The median survival after simple cholecystectomy and radical surgery was 33.5 and 12.0 months, respectively. However, among those who underwent debulking, palliative bypass or exploratory laparotomy alone, the survival ranged between 1 and 3 months. Logistic regression analysis showed that only radical resection improved the long-term survival (P < 0.05).

CONCLUSIONS

The majority of patients with GBC in India have advanced unresectable disease. Detection of GBC at an early stage is incidental and rare but is associated with long-term survival. Radical surgery, when feasible, is the only option for achieving long-term survival.

Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis

BACKGROUND & AIMS

Organ failure is the usual cause of death in acute necrotizing pancreatitis. Our objective was to study whether the extent and infection of pancreatic necrosis correlate with organ failure and mortality.

METHODS

All consecutive patients with acute pancreatitis were prospectively studied. They underwent a detailed clinical and investigative evaluation. Pancreatic necrosis, diagnosed on a computed tomography scan, was graded as <30%, 30%-50%, and >50% necrosis and characterized as either sterile or infected. Logistic regression analysis was done to find out the association of the extent and infection of pancreatic necrosis with organ failure and mortality.

RESULTS

Of 276 patients (mean age, 41.25 years; 172 men), 104 had pancreatic necrosis: 30 had <30% necrosis, 37 had 30%-50% necrosis, and 37 had >50% necrosis; 74 had sterile necrosis, and 30 had infected necrosis. Of them, 37 (35%) patients developed organ failure. Two significant factors were associated with the development of organ failure, the extent of necrosis (<30% necrosis vs 30%-50% necrosis: P = .03; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.15-29.45; <30% necrosis vs >50% necrosis: P = .0004; OR, 18.86; 95% CI, 3.75-94.92) and infected pancreatic necrosis (P = .02; OR, 3.29; 95% CI, 1.17-9.24). The overall mortality was 22%. Infected pancreatic necrosis (P = .006; OR, 4.99; 95% CI, 1.56-16.02) and Acute Physiology, Age, and Chronic Healthy Evaluation II score (P = .004; OR, 1.28; 95% CI, 1.08-1.52) were 2 independent predictors of mortality.

CONCLUSIONS

Extent of necrosis and infected pancreatic necrosis were associated with the development of organ failure in patients with acute necrotizing pancreatitis. Infected pancreatic necrosis was the most significant predictor of mortality.

Survey on chronic pancreatitis in the Asia-Pacific region

BACKGROUND AND AIMS

A survey was conducted of chronic pancreatitis (CP) in different countries in the Asia-Pacific region. The main objective of the survey was to generate a database containing information regarding the prevalence, etiology, clinical presentation, diagnostic work-up, and management of CP in the Asia-Pacific region.

METHODS

Data were collected from seven countries using a structured questionnaire. Expert participants were asked to respond to the questionnaire based on the data of patients with CP studied in their centers.

RESULTS

The prevalence of CP was found to be very high in southern India (114-200/100 000 population), in contrast to the low reported rate of 4.2/100 000 population in Japan. Alcohol was the most common etiological factor in Australia (95%) and Japan (54%) while idiopathic pancreatitis was the most common type in India (tropical pancreatitis) and China, accounting for approximately 70% of all cases of CP. Pain was the most common clinical feature. Diabetes and steatorrhea were uncommon. With regard to the diagnosis of CP, all the experts believed that a patient could be diagnosed as having CP in the presence of any one or more of the following: ductal changes on endoscopic retrograde cholangiopancreatography, a positive secretin test, pancreatic calcification, and endosonographic abnormalities suggestive of CP. Most experts suggested pancreatic enzymes and analgesics as initial medical therapy for pain relief in CP. Endotherapy was suggested as the therapy of choice if medical therapy failed. Surgery was offered only after the failure of endotherapy. Most experts agreed that research should focus on genetic abnormalities in CP and the role of endotherapy for pain relief.

CONCLUSION

The survey brought out the prevalent types and presentation of CP, common management practices, and also the shortcomings in the existing knowledge of CP in the Asia-Pacific region. These findings might help focus attention on the research priorities for CP in this region.

Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones

BACKGROUND

Mechanical lithotripsy is used to break large bile duct stones. This study investigated the predictors of unsuccessful mechanical lithotripsy.

METHODS

Consecutive patients with bile duct stones underwent endoscopic retrograde cholangiography, sphincterotomy, and basket removal of stones. Mechanical lithotripsy was performed for stones of large size (>15 mm diameter) that precluded extraction intact. Success was defined as complete clearance of the duct. Various predictive factors, including size and number of stones, stone impaction, serum bilirubin, presence of cholangitis, and bile duct diameter were analyzed in relation to the success or failure of lithotripsy.

RESULTS

A total of 669 patients underwent endoscopic retrograde cholangiography for suspected choledocholithiasis, which was found in 401 patients. Of the latter patients, 87 had large stones that required mechanical lithotripsy. Lithotripsy was successful in 69 (79%) patients. Impaction of the stone(s) in the bile duct was the only significant factor that predicted failure of lithotripsy and consequent failure of bile duct clearance. Other factors, including stone size, were not significant.

CONCLUSIONS

Mechanical lithotripsy is successful in about 79% of patients with large bile duct stones. The only significant factor that predicts failure of mechanical lithotripsy is stone impaction in the bile duct.

Tuberculous pseudoaneurysm of gastroduodenal artery

We report a patient with Gastroduodenal artery (GDA) pseudoaneurysm of tuberculous aetiology, who presented with massive hematemesis and who was successfully managed with transarterial steel coil embolization. Pseudoaneurysms are a rare but potentially fatal complication of tuberculosis and hence early recognition and management of this complication is important. To the best of our knowledge this is the first report of a GDA pseudoaneurysm resulting from tuberculosis.

The role of 99mTc mebrofenin hepatobiliary scanning in predicting common bile duct stones in patients with gallstone disease

BACKGROUND

A dilated common bile duct and/or elevated serum alkaline phosphatase, raises a suspicion of bile duct stone(s) in patients with gallstones. Cholangiography, either endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), is the best method for diagnosing bile duct stones. ERCP has the disadvantage of being invasive, and there is a risk of complications; while MRCP is costly and is not widely available.

AIM

The objective of the present study was to evaluate the role of hepatobiliary nuclear scanning in diagnosing bile duct stones.

METHODS

Twenty-five patients with suspected common bile duct (CBD) stones underwent hepatobiliary scintigraphy. The results of scintigraphy were compared with cholangiograms obtained by ERCP in 11 patients and MRCP in 14 patients, considering MRCP/ERCP as the 'gold standard'.

RESULTS

Scintigraphy showed features suggestive of CBD stones in 11 of the 25 patients. The results of ERCP/MRCP confirmed that eight of them had stones. Scintigraphy showed no features of CBD stones in the remaining 14 patients. ERCP/MRCP showed CBD stones in two of these 14 patients. Thus, scintigraphy had a sensitivity of 80% and a specificity of 80%.

CONCLUSION

We conclude that scintigraphy has good sensitivity and specificity in predicting CBD stones in patients with gallstone disease and a dilated CBD.