Direct Endoscopic Necrosectomy: Timing and Technique

Walled-off pancreatic necrosis (WOPN) is one of the local complications of acute pancreatitis (AP). Several interventional techniques have been developed over the last few years. The purpose of this narrative review is to explore such methodologies, with specific focus on endoscopic drainage and direct endoscopic necrosectomy (DEN), through evaluation of their indications and timing for intervention. Findings indicated how, after the introduction of lumen-apposing metal stents (LAMS), DEN is becoming the favorite technique to treat WOPN, especially when large solid debris or infection are present. Additionally, DEN is associated with a lower adverse events rate and hospital stay, and with improved clinical outcome.

Towards an updated view on the clinical management of pancreatic adenocarcinoma: Current and future perspectives

Pancreatic cancer has a dire prognosis and will represent the second leading cause of cancer death in the next 10 years. The multifactorial approach represents one of the main issues in controlling the extension of this neoplasm. In recent years, the characteristics of the tumor microenvironment, metastasis mechanisms and the relationship between immune system and neoplastic cells have been described, which has made it possible to understand the pathophysiology of pancreatic adenocarcinoma. Currently, there is a failure to provide an effective preventive method or early detection, so patients present with an advanced stage at the time of diagnosis. Despite numerous efforts, little progress has been made in clinical outcome and in improving survival in long term. Therefore, in the recent years, diverse diagnostic tests, treatments and possible approaches have been developed in the fields of radiotherapy, chemotherapy and surgery to find a combination of them that improves life expectancy in patients diagnosed with pancreatic cancer. At the moment, numerous clinical trials are being conducted to evaluate preventive diagnostic procedures such as serological markers or perfecting available imaging tests. On the other hand, implementation of immunotherapy is being studied in a neoplasm that has lagged in the application of this procedure since present possible treatments do not substantially improve quality of life. Therefore, the purpose of our study is to summarize the main progresses that have been made in the diagnosis, treatment and screening of this disease, explaining the limitations that have been observed and analyzing future prospects in the management of this illness.

Self-reported olfactory and gustatory dysfunction and psychophysical testing in screening for Covid-19: A systematic review and meta-analysis

Background

A substantial proportion of coronavirus disease‐2019 (COVID‐19) patients demonstrate olfactory and gustatory dysfunction (OGD). Self‐reporting for OGD is widely used as a predictor of COVID‐19. Although psychophysical assessment is currently under investigation in this role, the sensitivity of these screening tests for COVID‐19 remains unclear. In this systematic review we assess the sensitivity of self‐reporting and psychophysical tests for OGD.

Methods

A systematic search was performed on PubMed, EMBASE, and ClinicalTrials.gov from inception until February 16, 2021. Studies of suspected COVID‐19 patients with reported smell or taste alterations were included. Data were pooled for meta‐analysis. Sensitivity, specificity, and diagnostic odds ratio (DOR) were reported in the outcomes.

Results

In the 50 included studies (42,902 patients), self‐reported olfactory dysfunction showed a sensitivity of 43.9% (95% confidence interval [CI], 37.8%‐50.2%), a specificity of 91.8% (95% CI, 89.0%‐93.9%), and a DOR of 8.74 (95% CI, 6.67‐11.46) for predicting COVID‐19 infection. Self‐reported gustatory dysfunction yielded a sensitivity of 44.9% (95% CI, 36.4%‐53.8%), a specificity of 91.5% (95% CI, 87.7%‐94.3%), and a DOR of 8.83 (95% CI, 6.48‐12.01). Olfactory psychophysical tests analysis revealed a sensitivity of 52.8% (95% CI, 25.5%‐78.6%), a specificity of 88.0% (95% CI, 53.7%‐97.9%), and a DOR of 8.18 (95% CI, 3.65‐18.36). One study used an identification test for gustatory sensations assessment.

Conclusion

Although demonstrating high specificity and DOR values, neither self‐reported OGD nor unvalidated and limited psychophysical tests were sufficiently sensitive in screening for COVID‐19. They were not suitable adjuncts in ruling out the disease.

A Study of Prevalence of Occult Hepatitis B Virus Infection, Knowledge and Preventive Practices Against Hepatitis B Virus in Barbers Serving the Armed Forces

OBJECTIVE

Hepatitis B virus (HBV) infection is a major health problem in the world. Barbers deal with frequent abrasions/lacerations due to sharp equipment, making them a high-risk group. Determination of HBsAg positive status excludes most reservoirs of transmission in the population. However, Occult Hepatitis B continues to be a source of transmission. The aim of this study was to study the prevalence of occult HBV infection in barbers serving the armed forces clientele and evaluate their knowledge and preventive practices against HBV transmission.

METHODS

Seventy-nine HBsAg negative barbers were included in this study and interviewed for the status of immunisation and preventive practices. Anti-HBc total and HBV DNA levels were measured along with a complete haemogram, LFT, PT INR, ultrasound abdomen and Fibroscan of the liver.

RESULTS

The prevalence of occult Hepatitis B status was 3.79%. Among barbers who were anti-HBc total positive, 100% were found to have replicative HBV DNA status. All barbers (100%) were unaware of the existence and modes of HBV transmission and were never screened for HBV; 98.73% of barbers followed improper disinfection practices and were never immunised.

CONCLUSION

The prevalence of occult HBV infection in barbers, absence of immunisation, unawareness and improper disinfection practices are significantly at risk for transmission to the unaware clients. It is important to educate barbers, establish a universal disinfection procedure and implement a system of compulsory Hepatitis B vaccination before the commencement of their trade work.

Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type, rate and route

BACKGROUND

Adequate fluid resuscitation is paramount in the management of acute pancreatitis (AP). The aim of this study is to assess benefits and harms of fluid therapy protocols in patients with AP.

METHODS

MEDLINE, Embase, Science Citation Index and clinical trial registries were searched for randomised clinical trials published before May 2020, assessing types of fluids, routes and rates of administration.

RESULTS

A total 15 trials (1073 participants) were included. Age ranged from 38 to 73 years; follow-up period ranged from 0.5 to 6 months. Ringer lactate (RL) showed a reduced number of severe adverse events (SAE) when compared to normal saline (NS) (OR 0.48; 95%CI 0.29-0.81, p = 0.006); additionally, NS showed reduced SAE (RR 0.38; 95%IC 0.27-0.54, p < 0.001) and organ failure (RR 0.30; 95%CI 0.21-0.44, p < 0.001) in comparison with hydroxyethyl starch (HES). High fluid rate fluid infusion showed increased mortality (OR 2.88; 95%CI 1.41-5.88, p = 0.004), increased number of SAE (RR 1.42; 95%CI 1.04-1.93, p = 0.030) and higher incidence of sepsis (RR 2.80; 95%CI 1.51-5.19, p = 0.001) compared to moderate fluid rate infusion.

CONCLUSIONS

In patients with AP, RL should be preferred over NS and HES should not be recommended. Based on low-certainty evidence, moderate-rate fluid infusion should be preferred over high-rate infusion.

The Role of Lumen-Apposing Metal Stents in Transmural Endoscopic Drainage of Postinflammatory Pancreatic and Peripancreatic Fluid Collections

Rapid development of advanced gastrointestinal endoscopic techniques contributed to the appearance of new biomedical materials including polymers, which are used for the production of different types of endoprostheses. Endotherapy (ET) of postinflammatory pancreatic and peripancreatic fluid collections (PPFCs) with the use of lumen-apposing metal stent (LAMS) is an effective method of treatment. This paper describes the high efficacy of ET and its potential complications, which are mostly related to the design of the LAMS used. The high efficacy of LAMS in the transmural drainage of PPFCs is associated with lower safety of treatment. Complications of ET presented in the manuscript are mainly related to endoprosthesis' construction. This paper presents possible directions of development in the field of transmural LAMSs, which in the future may contribute to the invention of an innovative type of LAMS based on new biomedical technologies. Possibly, subsequent novel endoprosthesis projects, based on the above results, will be able to meet the current needs and requirements associated with endoscopic transmural drainage procedures in cases of postinflammatory PPFCs. The ultimate goal is to improve safety of minimally invasive techniques for treatment of the local consequences of pancreatitis.

The D614G Virus Mutation Enhances Anosmia in COVID-19 Patients: Evidence from a Systematic Review and Meta-analysis of Studies from South Asia

The prevalence of chemosensory dysfunction in patients with COVID-19 varies greatly between populations. It is unclear whether such differences are due to factors at the level of the human host, or at the level of the coronavirus, or both. At the host level, the entry proteins which allow virus binding and entry have variants with distinct properties, and the frequency of such variants differs between ethnicities. At the level of the virus, the D614G mutation enhances virus entry to the host cell. Since the two virus strains (D614 and G614) coexisted in the first six months of the pandemic in most populations, it has been difficult to distinguish between contributions of the virus and contributions of the host for anosmia. To answer this question, we conducted a systematic review and meta-analysis of studies in South Asian populations when either the D614 or the G614 virus was dominant. We show that populations infected predominantly with the G614 virus had a much higher prevalence of anosmia (pooled prevalence of 31.8%) compared with the same ethnic populations infected mostly with the D614 virus strain (pooled anosmia prevalence of 5.3%). We conclude that the D614G mutation is a major contributing factor that increases the prevalence of anosmia in COVID-19, and that this enhanced effect on olfaction constitutes a previously unrecognized phenotype of the D614G mutation. The new virus strains that have additional mutations on the background of the D614G mutation can be expected to cause a similarly increased prevalence of chemosensory dysfunctions.

Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis

OBJECTIVES

Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency.

METHODS

This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected.

RESULTS

Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications.

CONCLUSIONS

CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.

Novel variant in glycophorin c gene protects against ribavirin-induced anemia during chronic hepatitis C treatment

BACKGROUND

The current use of ribavirin in difficult-to-cure chronic hepatitis C patients (HCV) and patients with severe respiratory infections is constrained by the issue of ribavirin-induced hemolytic anemia that affects 30% of treated patients, requiring dosage modification or discontinuation. Though some genetic variants have been identified predicting this adverse effect, known clinical and genetic factors do not entirely explain the risk of ribavirin-induced anemia.

METHODS

We assessed the associations of previously identified variants in inosine triphosphatase (ITPA), solute carrier 28A2 (SLC28A2) and vitamin D receptor (VDR) genes with ribavirin-induced anemia defined as hemoglobin decline of ≥30 g/L on treatment, followed by a staged discovery (n = 114), replication (n = 74), and combined (n = 188) genome-wide association study to uncover potential new predictive variants.

RESULTS

We identified a novel association in the gene coding glycophorin C (rs6741425; OR:0.12, 95%CI:0.04-0.34, P = 2.94 × 10^-6) that predicts protection against ribavirin-induced anemia. We also replicated the associations of ITPA and VDR genetic variants with the development of ribavirin-induced anemia (rs1127354; OR:0.13, 95%CI:0.04-0.41, P = 8.66 ×10^-5; and rs1544410; OR:1.65, 95%CI:1.01-2.70, P = 0.0437).

CONCLUSIONS

GYPC variation affecting erythrocyte membrane strength is important in predicting risk for developing ribavirin-induced anemia. ITPA and VDR genetic variants are also important predictors of this adverse reaction.

Concomitant familial hypocalciuric hypercalcemia and single parathyroid adenoma: a case report

Background

Primary hyperparathyroidism (PHPT) is a common endocrine disorder and the most frequent benign cause of hypercalcemia. PHPT is characterized by autonomous hypersecretion of parathyroid hormone (PTH), regardless of serum calcium levels. Familial hypocalciuric hypercalcemia (FHH) is a rare, benign syndrome only affecting the regulation of calcium metabolism. FHH is an autosomal-dominant genetic disease with high penetrance, caused by an inactivating variant in the CASR gene encoding the calcium-sensing receptor (CaSR). We present a unique case of concomitant PHPT and FHH without clinically actionable variants in MEN1.

Case presentation

A 47-year-old Caucasian man with severe hypercalcemia, genetic FHH, and initially normal parathyroid scintigraphy was referred for endocrine evaluation due to nonspecific symptoms. Biochemical evaluation showed elevated serum ionized calcium and PTH. The calcium–creatinine clearance ratio was low. All other biochemical measures were normal, including kidney function. Genetic evaluation was redone and confirmed FHH. A new parathyroid scintigraphy showed a significant single adenoma corresponding to the lower left gland. The patient underwent parathyroidectomy, and a parathyroid adenoma was removed. A reduced level of hypercalcemia persisted due to FHH.

Conclusions

The correct diagnosis of the underlying cause of hypercalcemia is important to ensure the right treatment. Patients with FHH should avoid operative treatment, and PHPT should be differentiated from MEN1 to determine whether surgery should include parathyroidectomy with removal of one adenoma or 3.5 hyperplastic parathyroid glands.

Safety of long-term use of four common conventional disease modifying anti-rheumatic drugs in rheumatoid arthritis

Conventional disease-modifying antirheumatic drugs (DMARDs) have been used in the management of rheumatoid arthritis for a long time. Whereas methotrexate (MTX) is the anchor drug, leflunomide, hydroxychloroquine and sulfasalazine are used along with MTX either in combination or sequentially. Together these four drugs are the most commonly used DMARDs. They are also used in combination with biological DMARDs (bDMARDs) to enhance their efficacy and MTX in particular to reduce antibodies against anti-tumour necrosis factor. Despite their widespread use, concerns regarding their safety especially when used long-term hinder their optimum use in clinical medicine. In this narrative review we have critically appraised the available literature regarding the safety of these four DMARDs when used long-term.

Mechanisms of Post-Pancreatitis Diabetes Mellitus and Cystic Fibrosis-Related Diabetes: A Review of Preclinical Studies

Anatomical proximity and functional correlations between the exocrine and endocrine pancreas warrant reciprocal effects between the two parts. Inflammatory diseases of the exocrine pancreas, such as acute or chronic pancreatitis, or the presence of cystic fibrosis disrupt endocrine function, resulting in diabetes of the exocrine pancreas. Although novel mechanisms are being increasingly identified, the intra- and intercellular pathways regulating exocrine-endocrine interactions are still not fully understood, making the development of new and more effective therapies difficult. Therefore, this review sought to accumulate current knowledge regarding the pathogenesis of diabetes in acute and chronic pancreatitis, as well as cystic fibrosis.

Reducing the risk of developing walled-off necrosis in patients with acute necrotic collection using recombinant human soluble thrombomodulin

BACKGROUND/PURPOSE

The purpose of the present study was to investigate the possibility of reducing clinical impacts of acute necrotic collection (ANC) on patients with acute pancreatitis (AP) using recombinant human soluble thrombomodulin (rTM).

METHODS

In this retrospective multicenter study, 233 consecutive AP patients with ANC and acute peripancreatic fluid collection (APFC) from 2012 to 2016 were enrolled. To assess clinical impacts of ANC, severity on admission (JPN score, JPN CT grade, and Modified CT severity index), development of walled-off necrosis (WON), imaging costs for follow-up, and mortality were recorded. Finally, we investigated whether rTM could reduce the clinical impacts, adjusting the severity using propensity analysis with Inverse probability of treatment weighting.

RESULTS

Patients with ANC developed WON with higher ratio than APFC (58/98 [59.2%] vs 20/135 [14.8%], OR = 8.3, P < .01]. Severity on admission and imaging costs for follow-up in ANC patients were significantly higher than those in APFC (P < .01). However, regarding mortality, there was no significant difference between patients with ANC and APFC (P = .41). Adjusting severity, it was revealed that rTM administration significantly reduced the risk of ANC developed WON (OR = 0.23, P = .01).

CONCLUSIONS

While ANC had a higher clinical impact than that of APFC, we found that early administration of rTM may reduce the impact.

COVID-19 and Parkinson's disease: Defects in neurogenesis as the potential cause of olfactory system impairments and anosmia

Anosmia, a neuropathogenic condition of loss of smell, has been recognized as a key pathogenic hallmark of the current pandemic SARS-CoV-2 infection responsible for COVID-19. While the anosmia resulting from olfactory bulb (OB) pathology is the prominent clinical characteristic of Parkinson's disease (PD), SARS-CoV-2 infection has been predicted as a potential risk factor for developing Parkinsonism-related symptoms in a significant portion of COVID-19 patients and survivors. SARS-CoV-2 infection appears to alter the dopamine system and induce the loss of dopaminergic neurons that have been known to be the cause of PD. However, the underlying biological basis of anosmia and the potential link between COVID-19 and PD remains obscure. Ample experimental studies in rodents suggest that the occurrence of neural stem cell (NSC) mediated neurogenesis in the olfactory epithelium (OE) and OB is important for olfaction. Though the occurrence of neurogenesis in the human forebrain has been a subject of debate, considerable experimental evidence strongly supports the incidence of neurogenesis in the human OB in adulthood. To note, various viral infections and neuropathogenic conditions including PD with olfactory dysfunctions have been characterized by impaired neurogenesis in OB and OE. Therefore, this article describes and examines the recent reports on SARS-CoV-2 mediated OB dysfunctions and defects in the dopaminergic system responsible for PD. Further, the article emphasizes that COVID-19 and PD associated anosmia could result from the regenerative failure in the replenishment of the dopaminergic neurons in OB and olfactory sensory neurons in OE.

Impairments in odour detection and hedonic ratings of unpleasant smells in asymptomatic university students as SARS-Cov-2 emerged locally

Sudden olfactory loss in the absence of concurrent nasal congestion is now a well-recognized symptom of COVID-19. We examined olfaction using standardized objective tests of odour detection, identification and hedonics collected from asymptomatic university students before and as SARS-CoV-2 emerged locally. Olfactory performance of students who were tested when the virus is known to be endemic (n = 22) was compared to students tested in the month prior to viral circulation (n = 25), a normative sample assessed during the previous 4 years (n = 272) and those tested in prior years during the same time period. Analyses showed significantly reduced odour detection for the virus exposed cohort compared to students tested before (t = 2.60; P = .01; d = 0.77; CI 0.17, 1.36) and to the normative sample (D = 0.38; P = .005). Odour identification scores were similar, but the exposed cohort rated odours as less unpleasant (P < .001, CLES = 0.77). Hyposmia increased 4.4-fold for students tested 2 weeks before school closure (N = 22) and increased 13.6-fold for students tested in the final week (N = 11). While the unavailability of COVID-19 testing is a limitation, this naturalistic study demonstrates week-by-week increase in hyposmia in asymptomatic students as a virus was circulating on campus, consistent with increasing airborne viral loads. The specific hedonic deficit in unpleasantness appraisal suggests a deficit in the TAAR olfactory receptor class, which conveys the social salience of odours. Assessment of odour detection and hedonic ratings may aid in early detection of SARS-CoV-2 exposure in asymptomatic and pre-symptomatic persons.

C-reactive protein predicts the development of walled-off necrosis in patients with severe acute pancreatitis

BACKGROUND AND AIM

Walled-off necrosis (WON) is reported to occur in 1-9% of patients with acute pancreatitis. However, the factors associated with the onset of this condition have not been elucidated. This study aimed to investigate the potential predictive factors for WON in patients diagnosed with severe acute pancreatitis at our hospital.

METHODS

This study included 26 patients with severe acute pancreatitis identified among the 211 patients with acute pancreatitis admitted to our hospital between January 2014 and December 2018. Patients with and without WON (WON and non-WON groups, respectively) were compared to identify potential factors involved in the onset of this condition.

RESULTS

The 26 patients had a median age of 67 years, and 65% were male. WON occurred in 15 patients (57.7%). In a univariate analysis, the WON and non-WON groups differed significantly in terms of maximum C-reactive protein (CRP) levels (median) (322.7 mg/L vs 163.8 mg/L [P = 0.001]). In a multivariate analysis, a significant association was identified between the maximum CRP level and the onset of WON (odds ratio: 1.20, 95% confidence interval: 1.05-1.37). The CRP level peaked within 3 days in 88%.

CONCLUSION

The maximum CRP level was identified as a predictive factor for the onset of WON, and a high proportion of patients with WON exhibited elevated CRP levels within 3 days after diagnosis. This work suggests the clinical importance of continuous monitoring at an early stage after diagnosis to identify the maximum CRP level.

Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence. In the early phase, most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment. However, in some cases, they will develop into pancreatic pseudocyst (PPC) or walled-off necrosis (WON). When causing symptoms or coinfection, both PPC and WON may require invasive intervention. Compared to PPC, which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents, the treatment of WON is more complicated and challenging, particularly in the presence of infected necrosis. In the past few decades, with the development of minimally invasive interventional technology especially the progression of endoscopic techniques, the standard treatments of those severe complications have undergone tremendous changes. Currently, based on the robust evidence from randomized controlled trials, the step-up minimally invasive approaches have become the standard treatments for WON. However, the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected. In this review article, we will mainly discuss the indications of PPC and WON, the timing for intervention, and minimally invasive treatment, especially endoscopic treatment. We also introduced our preliminary experience in endoscopic gastric fenestration, which may be a promising innovative method for the treatment of WON.

Order Set Use and Education Association With Pediatric Acute Pancreatitis Outcomes

BACKGROUND

The management of acute pancreatitis (AP) in children was historically derived from adult practice recommendations. Pediatric-specific recommendations for treatment of AP were recently developed by North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, but their impact on clinical outcomes has yet to be evaluated. We developed an AP order set on the basis of these recommendations to assess impact on clinical outcomes.

METHODS

Patients admitted to a single center with 3 children's hospitals in 2017 and 2018 for isolated AP were included in a retrospective review. Patient demographic data, order set use, treatment variables (eg, fluid type, rate, type and timing of diet initiation, and narcotic use), and outcome variables (eg, length of stay [LOS], PICU admission, and 30-day readmission) were collected. Mixed-effects modeling was used to estimate the impact of order set use on clinical outcomes.

RESULTS

There were 159 pancreatitis encounters and 137 unique patients who met inclusion criteria. In 2018, when using the log transform of LOS in a linear mixed-effects model for clustering by hospital, there was a 10% decrease in mean LOS, but this failed to reach statistical significance (P = .30). Among the 107 encounters who received at least 1 dose of narcotic, there were significantly fewer doses prescribed after implementation of the order set: mean (SD) of5.22 (2.86) vs 3.59 (2.47) (P < .001). Thirty-day readmission (P = .25) and PICU admission rates (P = .31) were not different between years.

CONCLUSIONS

The implementation of a pancreatitis order set is associated with a significant decrease in narcotic use in pediatric patients with AP without increasing readmission rates or PICU admissions.

Comparison of clinical characteristics and outcomes between alcohol-induced and gallstone-induced acute pancreatitis: An Australian retrospective observational study

OBJECTIVES

To compare the characteristics and outcomes of patients presenting to hospital with alcohol-induced and gallstone-induced acute pancreatitis.

METHODS

Retrospective study of all patients with alcohol-induced or gallstone-induced pancreatitis during the period 1 June 2012 to 31 May 2016. The primary outcome measure was hospital mortality. Secondary outcome measures included hospital length of stay, requirements for intensive care unit admission, intensive care unit mortality, mechanical ventilation, renal replacement therapy, requirement of inotropes and total parenteral nutrition.

RESULTS

A total of 642 consecutive patients (49% alcohol; 51% gallstone) were included. No statistically significant differences were found between alcohol-induced and gallstone-induced acute pancreatitis with respect to hospital mortality, requirement for intensive care unit admission, intensive care unit mortality and requirement for mechanical ventilation, renal replacement therapy, inotropes or total parenteral nutrition. There was significant difference in hospital length of stay (3.07 versus 4.84; p < 0.0001). On multivariable regression analysis, Bedside Index of Severity in Acute Pancreatitis score (estimate: 0.393; standard error: 0.058; p < 0.0001) and admission haematocrit (estimate: 0.025; standard error: 0.008; p = 0.002) were found to be independently associated with prolonged hospital length of stay.

CONCLUSION

Hospital mortality did not differ between patients with alcohol-induced and gallstone-induced acute pancreatitis. The duration of hospital stay was longer with gallstone-induced pancreatitis. Bedside Index of Severity in Acute Pancreatitis score and admission haematocrit were independently associated with hospital length of stay.

Novel Approaches in the Management of Type 2 Diabetes and Associated Vascular Complications

Diabetes mellitus (DM) is growing in pandemic proportion and affects the affluent and developing nations equally. India has the dubious distinction of being known as the diabetes capital of the world. Epidemiological studies have shown that DM is under diagnosed and inadequately treated in our country. Insulin resistance and β-cell dysfunction are the two key pathophysiological determinants of the DM. The disease has metamorphosed during the last couple of decades with a significant change in the clinical presentation. Simultaneously, the therapeutic options for the management of DM have also increased in the last decade. This article highlights the research conducted by us over the last decade in the areas of pathogenesis, management, and complications of DM.

Pancreatic Disorders of Pregnancy

The pancreas is an organ with both exocrine and endocrine functions that has a vital role in both digestion as well as glucose metabolism. Although pancreatic dysfunction and disorders are rare in pregnancy, they are becoming increasingly more common. Recognition of these disorders and understanding how they can affect pregnancy is imperative to allow for proper management. We provide an overview of the most common pancreatic disorders that are seen in pregnancy.

Endoscopic cystogastrostomy: Still a viable option in children with symptomatic pancreatic fluid collection

BACKGROUND/OBJECTIVES

Endoscopic transmural drainage is the preferred method of drainage of pancreatic fluid collections (PFCs) in adults; however, there is scant literature in children. We analyzed our experience of 33 endoscopic cystogastrostomies done in 29 children to find its efficacy and safety.

METHODS

We retrospectively analyzed the prospectively collected database of 31 consecutive children (<18 years) who underwent endoscopic cystogastrostomy from June 2013 to December 2017. The procedure was done using the standard technique with an adult duodenoscope. Data related to clinical details, technical success, complications and follow-up were collected.

RESULTS

The median age was 14 (3-17) years (22 males). Indications were early satiety in 28 (90%), vomiting in 15 (48%), and duodenal obstruction and infected pseudocyst in 2 children each. Etiology includes acute pancreatitis 22, post-traumatic 4 and chronic pancreatitis 5. The procedure was successful in 29 of 31 (93.5%) children with no mortality. Adverse events happened in four cases (12.9%); two infections, another with bleeding and another with pneumoperitonium, both of which resolved spontaneously. Incidents (minor bleeding) were noted in 6 (19%). Stents were removed in 26 (90%) after 12 (7-20) weeks and got spontaneously migrated out in 3 (10%) cases. Over a median follow-up of 26 (5-48) months, 26 (90%) had no recurrence of pseudocyst and 3 (10%) had recurrence of a small, asymptomatic pseudocyst.

CONCLUSIONS

Endoscopic cystogastrostomy is a safe and effective method of draining bulging PFCs in children. The procedure carries acceptable morbidity with minimal recurrence. In younger children it may be the preferred method of drainage of PFCs.

Hepatocrinology

Hepatocrinology is defined as a bidirectional, complex relationship between hepatic physiology and endocrine function, hepatic disease and endocrine dysfunction, hepatotropic drugs and endocrine function, and endocrine drugs and hepatic health. The scope of hepatocrinology includes conditions of varied etiology (metabolic, infectious, autoimmune, and invasive) that we term as hepato-endocrine syndromes. This perspective shares the definition, concept, and scope of hepatocrinology and shares insight related to this aspect of medicine. It is hoped that this communication will encourage further attention and research in this critical field.

Prevalence of Anti-HBc Antibodies among HBsAg Negative Individuals and Its Association with Occult Hepatitis B

Introduction  Hepatitis B virus (HBV) infection is an endemic in many Asian countries, and among the major routes of transmission, transfusion is the one that should be prevented. Occult HBV infection (OBI) is defined as the presence of HBV DNA in the absence of detectable HBsAg, with or without anti-HBV antibodies. The aim of this study was to detect the prevalence of anti-HBc total antibodies among the HB surface antigen (HBsAg) negative individuals by way of enzyme-linked immunosorbent assay (ELISA), and detect the presence of HBV DNA among the anti-HBc seropositives by polymerase chain reaction (PCR). Anti-HBs among the HBV DNA positives were also found out by enzyme-linked fluorescent assay (ELFA). Materials and Methods  A total of 910 serum samples was subjected to initial screening for HBsAg by MERILISA HBsAg ELISA kits. The anti-HB core (HBc) total antibody titer was evaluated using MONOLISA ELISA (Biorad) kits. If found negative, the samples were discarded. If found positive, the samples underwent HBV DNA testing by nested PCR. Antibody to hepatitis B surface antigen (anti-HBs) was calculated among the DNA positives by ELFA. Results  A total of 133 samples were positive for anti-HBC total antibody, resulting in an overall prevalence of 14.6%. Overall prevalence of HBV DNA among the anti-HBc seropositives was 2.2%. Conclusion  Among the three HBV DNA positive patients, two belonged to the preoperative screening group, which is an alarming situation. Screening of blood for HBsAg has reduced the incidence of posttransfusion hepatitis, but HBV still remains the major source of transfusion transmitted infection in India.

[Emphysematous pyelonephritis and cystitis: An exceptional complication in a kidney transplant recipient]

Emphysematous pyelonephritis is a rare and severe infectious complication characterized by the presence of gas in the renal parenchyma, excretory cavities and surrounded tissues. It is due to the development of non-anaerobic gasifier bacteria. We report a new rare case of emphysematous pyelonephritis in a kidney transplant recipient, particular by its occurrence in a non-functional graft and its exceptional association with emphysematous cystitis.

The role of imaging in acute pancreatitis

Acute pancreatitis is one of the most commonly encountered etiologies in the emergency setting, with a broad spectrum of findings that varies in severity from mild interstitial pancreas to severe forms with significant local and systemic complications that are associated with a substantial degree of morbidity and mortality. In this article the radiological aspect of the terminology and classification of acute pancreatitis are reviewed. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed. The authors present a practical image-rich guide, applying the revised Atlanta classification system, with the goal of facilitating radiologists to write a correct report, and reinforcing the radiologist’s role as a key member of a multidisciplinary team in treating patients with acute pancreatitis. Computed tomography is the most performed imaging test for acute pancreatitis. Nevertheless, MRI is useful in many specific situations, due to its superiority soft tissue contrast resolution and better assessment of biliary and pancreatic duct, for example in the ductal disconnection. The purpose if this article is to review recent advances in imaging acquisition and analytic techniques in the evaluation of AP.

Sarcopenia in Children With End-Stage Liver Disease on the Transplant Waiting List

Sarcopenia predicts morbidity and mortality in adults with end-stage liver disease (ESLD) and is determined by total psoas muscle area (tPMA) measurement from computed tomography (CT) imaging. Recently developed pediatric age- and sex-specific tPMA growth curves provide the opportunity to ascertain prevalence and impact of sarcopenia in children awaiting liver transplantation (LT). This retrospective single-center study evaluated sarcopenia in children between 1 and 16 years with ESLD and a clinically indicated abdominal CT less than 3 months before first isolated LT. Sarcopenia was defined as tPMA z score less than -2 measured at the intervertebral L4-5 level. Patient demographic, biochemical, and outcome data were recorded. tPMA was compared with other measures of nutritional status using univariate and multivariate logistic analyses. Outcome measures included 1-year morbidity events and mortality after LT. CT images from 25 (64% female) children with median age of 5.50 (interquartile range [IQR], 3.75-11.33) years were reviewed. Ten children (40%) had a tPMA z score less than -2. Sarcopenia was associated with lower z scores for weight (odds ratio [OR], 0.38; P = 0.02), height (OR, 0.32; P = 0.03), and nutritional support before LT (OR, 12.93; P = 0.01). Sarcopenic children had a longer duration of pediatric intensive care unit (PICU) stay (3.50 [IQR, 3.00-6.00] versus 2.00 [IQR, 2.00-3.50] days; P = 0.03). Sarcopenia was prevalent in 40% of children with ESLD awaiting LT, and lower tPMA z score was associated with deficient anthropometrics and need for nutritional support before LT. Post-LT PICU duration was increased in children with sarcopenia, reflecting adverse outcomes associated with muscle loss. Further studies are needed to elucidate the underlying mechanisms of sarcopenia in children with ESLD.

Is methotrexate hepatotoxicity associated with cumulative dose? A systematic review and meta-analysis

BACKGROUND/OBJECTIVE

Methotrexate (MTX) is widely used in various medical specialties. However, hepatotoxicity is an ongoing concern and this is thought to be directly associated with cumulative dose. We sought to synthesise the published literature to evaluate the association between methotrexate hepatotoxicity and cumulative dose.

METHODS

A systematic review of Medline (PubMed) EMBASE, CINAHL and The Cochrane Library was performed. Full texts of articles were examined, and excluded articles were recorded with reasons for exclusion. A meta-analysis of correlation coefficients was performed using Fisher's z-transformation and a random effects model. Cochran's Q-test and the I² statistic were calculated to assess heterogeneity.

RESULTS

A total of 35 studies met inclusion criteria. Measures of hepatotoxicity were highly varied and included liver biopsy, elastography, FibroTest, biochemical tests and scoring systems (Fib-4, APRI, AST:ALT). Some studies analysed for the association with MTX cumulative dose using more than one modality. Overall, 38 analyses found no significant association between MTX cumulative dose and hepatoxicity vs eight that identified a significant association. The pooled correlation coefficient from five studies which utilised elastography was 0.18 (95% CI, -0.09 to 0.42), with significant heterogeneity between studies (P < 0.0001), I²  = 92%).

CONCLUSIONS

Our synthesis of a large volume of studies in this review found no significant association between MTX cumulative dose and hepatotoxicity, both in terms of vote counting and with regard to the meta-analysis of correlation coefficients from studies that utilised elastography. This challenges the long-held belief that liver injury is a direct result of drug accumulation.

Early on-demand drainage or standard management for acute pancreatitis patients with acute necrotic collections and persistent organ failure: A pilot randomized controlled trial

BACKGROUND/PURPOSE

The current standard care for acute pancreatitis with acute necrotic collections (ANC) is to postpone invasive intervention for 4 weeks when indicated. However, in patients with persistent organ failure (POF), this delayed approach may prolong organ failure. In this study, we aimed to assess the feasibility and safety of earlier drainage for acute pancreatitis patients with ANC and POF.

METHODS

A single-center, randomized controlled trial was conducted. Eligible patients were randomly assigned to either the early on-demand (EOD) group or the standard management (SM) group. Within 21 days of randomization, early drainage was triggered by unremitted or worsening organ failure in the EOD group. The primary endpoint was a composite of major complications/death during 90-days follow-up.

RESULTS

Thirty patients were randomized. Within 21 days of randomization, eight of the 15 patients (53%) in the EOD group underwent percutaneous drainage compared to four of the 15 patients (27%) in the SM group (P = 0.26). The primary outcome occurred in three of the 15 (20%) patients in the EOD group and seven of the 15(46.7%) in the controls (P = 0.25, relative risk 0.43, 95%CI 0.14 to 1.35).

CONCLUSIONS

Although the EOD approach did not result in significant differences between groups, the primary outcome assessed in this trial demonstrated the potential for clinical benefits favoring early drainage.

An Underdiagnosed Hypothyroidism and Its Clinical Significance in Patients with Advanced Hepatocellular Carcinoma

BACKGROUND

Many systemic therapies for advanced hepatocellular carcinoma (HCC) may cause hypothyroidism; however, in these patients, hypothyroidism prevalence before therapy and its prognostic impact remain unclear.

MATERIALS AND METHODS

We previously established a prospective cohort of patients who received sorafenib as first-line therapy for advanced HCC. No patients had been clinically diagnosed with hypothyroidism before or during sorafenib treatment. We retrospectively determined the levels of thyrotropin and free thyroxine before initiation of systemic therapy. Hypothyroidism was defined as thyrotropin level higher than the upper limit of the normal range. Among patients with hypothyroidism, free thyroxine level less than the lower normal range was defined as overt hypothyroidism, and free thyroxine level within the normal range was defined as subclinical hypothyroidism.

RESULTS

In total, 79 patients were enrolled; of them, 16 (20%) had hypothyroidism (overt hypothyroidism, 10; subclinical hypothyroidism, 6). Patients with hypothyroidism, compared with those without hypothyroidism, were more likely to be older than 65 years (56% vs. 29%, p = .037), have a serum α-fetoprotein level of >400 ng/mL (81% vs. 52%, p = .037), and have a significantly poorer overall survival (OS; median, 5.5 vs. 11.6 months, p = .043). After adjusting for other potential prognostic factors, hypothyroidism remained an independent predictor for poorer OS (hazard ratio, 2.53, p = .018). Patients with overt hypothyroidism and subclinical hypothyroidism exhibited similarly poor OS (p = .768).

CONCLUSION

Underdiagnosis of hypothyroidism in patients with advanced HCC was common. Hypothyroidism, whether overt or subclinical, is associated with poor prognosis of advanced HCC.

IMPLICATIONS FOR PRACTICE

The results of this study showed the underdiagnosis of hypothyroidism in patients with advanced hepatocellular carcinoma (HCC) and its influence on prognosis. These findings implied the importance of thyroid function check before initiation of systemic therapy for patients with advanced HCC.

Prevalence of liver fibrosis by Fibroscan in patients on long-term methotrexate therapy for rheumatoid arthritis

INTRODUCTION

Data on the long-term use of methotrexate (MTX) causing liver fibrosis in patients with rheumatoid arthritis (RA) is sparse. Liver biopsy is the gold standard to assess fibrosis but is an invasive procedure. Transient elastography (TE) by Fibroscan is a noninvasive validated tool to detect and quantify liver fibrosis. The present study aimed to assess the prevalence of liver fibrosis by Fibroscan in patients with RA on long-term MTX therapy and its correlation with cumulative dose of MTX.

METHODS

This cross-sectional study included adult patients (≥ 18 years age) of RA who had been on MTX for ≥ 3 years. The patients' records were reviewed, and the cumulative dose of MTX was calculated. Liver fibrosis was assessed by TE method, and the cutoff value of 7.1 kPa (kilopascal) was considered abnormal (liver fibrosis). Spearman's rank test was used to assess the correlation between the cumulative dose of MTX and Fibroscan score.

RESULTS

Seventy-five patients were enrolled of which 69 were females (92%). The mean age was 47.2 ± 11.3 years. The mean body mass index and waist circumference were 24.8 ± 3.9 kg/m² and 91.6 ± 9.9 cm, respectively. The median duration and cumulative dose of MTX were 336 weeks (interquartile range,144-912 weeks) and 6300 mg (interquartile range, 2400-22,000 mg), respectively. The mean liver stiffness was 5.22 ± 2.03 kPa. Twelve patients (16%) had Fibroscan score ≥ 7.1 kPa, of which 3 patients had severe liver stiffness (9.5 to 12.5 kPa) and one patient had liver stiffness in the range of cirrhosis (> 12.5 kPa). Fibroscan scores significantly correlated with cumulative dose of MTX (r= 0.30, p = 0.008).

CONCLUSIONS

Long-term MTX therapy in RA was associated with increased liver stiffness on Fibroscan. Key Points • Fibroscan is a useful tool for monitoring MTX-induced liver fibrosis. • Liver fibrosis as evidenced by increased liver stiffness on Fibroscan is prevalent among patients on long-term MTX therapy for RA.

Acute biliary pancreatitis has better outcomes but increased resource utilization compared to acute alcohol-induced pancreatitis: insights from a nationwide study

Background

The differences in outcomes between acute biliary pancreatitis (ABP) and acute alcohol-induced pancreatitis (AAP) have not been well studied. We sought to examine the differences between ABP and AAP as regards to in-hospital outcomes and resource utilization, using a large nationwide database.

Methods

We queried the National Inpatient Sample databases 2016 and 2017 using the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) coding system to identify the patients with a primary diagnosis of AAP and ABP. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were hospital length of stay (LOS), hospitalization charge/cost, shock, acute kidney injury (AKI), intensive care unit (ICU) admission, and home discharge. Analysis was performed with STATA software.

Results

There was no significant difference in mortality between patients with AAP and ABP (0.42% vs. 0.82%, adjusted odds ratio [aOR] 0.95, 95% confidence interval [CI] 0.69-1.31; P=0.79). Patients with ABP had a significantly longer LOS (+0.48 days, P<0.001). Patients with ABP had significantly higher adjusted mean hospitalization charges ($+19,958, P<0.001) and costs ($+4,848, P<0.001). Patients with ABP had a significantly lower likelihood of shock (aOR 0.75, 95%CI 0.59-0.95; P=0.02), AKI (aOR 0.76, 95%CI 0.71-0.82; P<0.001) or ICU admission (aOR 0.74, 95%CI 0.62-0.88; P=0.001). They were more likely to be discharged home (aOR 1.26, 95%CI 1.18-1.34; P<0.001).

Conclusion

Although there was no difference in all-cause mortality, patients with ABP had better hospitalization outcomes but greater resource utilization.

Biliary type-II sphincter of Oddi dysfunction with a pancreatic duct dilation: a case report and review of the literature

Background

The double-duct sign is defined as dilation of both the common bile duct and pancreatic duct, which usually indicates pancreatic malignancy. However, benign causes have also been reported to cause a double-duct sign.

Case presentation

We present the case of a 59-year-old Caucasian female patient admitted to the Gastroenterology Department with intermittent right epigastric abdominal pain and an intact gallbladder. A double-duct sign was seen on endoscopic ultrasound. The suspicion of pancreatic malignancy was excluded through follow-up investigations. Biliary type II sphincter of Oddi dysfunction was diagnosed with an association of the double-duct sign. Sphincterotomy was performed to reduce pain, and there was no recurrence of symptoms during follow-up.

Conclusions

This is the third reported case in the literature of the double-duct sign associated with sphincter of Oddi dysfunction. This case emphasizes that the double-duct sign is not always caused by a local malignancy. The literature review of the reported cases has been summarized to help in the diagnosis of future similar cases.

The Role of Endoscopic Transpapillary Stenting of the Main Pancreatic Duct during the Endoscopic Treatment of Pancreatic Fluid Collections

Endotherapy is a recognized, widely available, and minimally invasive treatment method for pancreatic fluid collections (PFCs) formed in the course of acute pancreatitis (AP). The use of endoscopic techniques in the treatment of main pancreatic duct (MPD) disruption due to AP remains unclear. In this article, a comprehensive review of current literature referencing our observations was performed to identify publications on the role of MPD stenting in patients undergoing endoscopic drainage of PFCs resulting from AP. In this paper, we attempt to clarify this most controversial aspect of endotherapy for PFCs based on existing knowledge and our own experience regarding the endoscopic treatment of AP sequelae. Endoscopic retrograde pancreatography should be performed in all patients undergoing endoscopic drainage of walled-off pancreatic necrosis to assess the integrity of the main pancreatic duct and to implement endotherapy if pancreatic duct disruption is detected. Passive transpapillary drainage is an effective method for treating MPD disruption in the course of necrotizing AP and is one of the key components of endoscopic therapy for local pancreatic necrosis. Conversely, in patients with pancreatic pseudocysts, passive transpapillary drainage reduces the effectiveness of endoscopic treatment and should not be used even in cases of MPD disruption during transmural drainage of pancreatic pseudocysts. In conclusion, the use of transpapillary drainage should depend on the type of the PFC. This conclusion is of great clinical importance, as it can help improve the results of pancreatic endotherapy for fluid collections resulting from AP.

Does the Implementation of a Clinical Care Pathway Have an Impact on Early Intravenous Fluid Therapy of Acute Pancreatitis?: A Pilot Quality Improvement Study

OBJECTIVES

Early intravenous fluid (IVF) resuscitation is crucial in the management of acute pancreatitis; variation in IVF prescription practice had been demonstrated. This pilot study aims to assess whether the implementation of an Acute Pancreatitis Care Pathway (APCP) produces a change toward a more adequate IVF regimen in the first 24 hours.

METHODS

Patients with confirmed diagnosis of acute pancreatitis, from July 2015 to February 2016 (group 1) and from September 2017 to March 2018 (group 2), were considered. The APCP was developed between March 2016 and August 2017. Median IVF rate, volume, and type infused in the first 24 hours, were compared between groups. Nonparametric data were analyzed with the Mann-Whitney U test, differences in frequencies with the McNemar test; significance was set at P < 0.05.

RESULTS

Seventy-two patients were included, 36 in each group. In the first 24 hours, the median IVF rate was 177 mL/h vs 225 mL/h (P = 0.004); Ringer lactate infusion was 30% vs 77.8% (P = 0.0003). The median total IVF volume did not differ between groups.

CONCLUSIONS

The implementation of the APCP has the potential to lead to a successful change in early IVF resuscitation practice.

Role of ceramides in the pathogenesis of diabetes mellitus and its complications

Diabetes mellitus (DM) is a systemic metabolic disease that affects 463 million adults worldwide and is a leading cause of cardiovascular disease, blindness, nephropathy, peripheral neuropathy, and lower-limb amputation. Lipids have long been recognized as contributors to the pathogenesis and pathophysiology of DM and its complications, but recent discoveries have highlighted ceramides, a class of bioactive sphingolipids with cell signaling and second messenger capabilities, as particularly important contributors to insulin resistance and the underlying mechanisms of DM complications. Besides their association with insulin resistance and pathophysiology of type 2 diabetes, evidence is emerging that certain species of ceramides are mediators of cellular mechanisms involved in the initiation and progression of microvascular and macrovascular complications of DM. Advances in our understanding of these associations provide unique opportunities for exploring ceramide species as potential novel therapeutic targets and biomarkers. This review discusses the links between ceramides and the pathogenesis of DM and diabetic complications and identifies opportunities for novel discoveries and applications.

Magnetic resonance severity index assessed by T1-weighted imaging for acute pancreatitis: correlation with clinical outcomes and grading of the revised Atlanta classification-a narrative review

Acute pancreatitis (AP) is a common disease that may involve pancreas and peripancreatic tissues with a prevalence of up to 50 per 100,000 individuals for year. The Atlanta classification was assessed for the first time in 1992 and modified in 2012 in order to describe morphological features of AP and its complications. AP can be morphologically distinguished in two main types: interstitial edematous pancreatitis (IEP) and necrotizing pancreatitis (NEP). This classification is very important because the presence of necrosis is directly linked to local or systemic complications, hospital stays and death. Magnetic resonance (MR) is very useful to characterize morphological features in AP and its abdominal complications. Particularly we would like to underline the diagnostic, staging and prognostic role of T1-weighted images with fat suppression that could be significant to assess many features of the AP inflammatory process and its complications (detection of the pancreatic contour, pancreatic necrosis, presence of haemorrhage). Signs of inflammatory and edema are instead observed by T1-weighted images. MR cholangiopancreatography (MRCP) is necessary to study the main pancreatic duct and the extrahepatic biliary tract and contrast-enhancement magnetic resonance imaging (MRI) allows to assess the extent of necrosis and vascular injuries.

Imaging acute pancreatitis

OBJECTIVES

Acute pancreatitis is common; the clinical course of this potentially severe condition varies widely. This paper aims to review the role of different imaging techniques in the management of acute pancreatitis, describe the main imaging findings for this entity, and explain the terms and criteria used to classify them.

CONCLUSIONS

Imaging techniques play a key role in the management of acute pancreatitis, from diagnosis and staging to identifying and treating complications, as well as in determining the underlying causes of the condition. For these reasons, radiologists should know the advantages and limitations of each imaging technique in the evaluation of acute pancreatitis, be familiar with the wide spectrum of imaging findings associated with it, and how to use the specific terminology derived from the Atlanta classification to ensure the standardization and quality of reports.

Clinical efficacy of duodenoscopy combined with laparoscopy in the treatment of patients with severe acute pancreatitis and pancreatic pseudocyst, and the effects on IL-6 and CRP

The study aimed to investigate the clinical efficacy of duodenoscopy combined with laparoscopy in the treatment of patients with severe acute pancreatitis (SAP) and pancreatic pseudocyst (PP), and its effects on serum inflammatory factors. Altogether 94 patients complicated with SAP and PP who were admitted to Weifang People's Hospital (Weifang, China) from September 2015 to December 2018 were included. Based on the different operation methods, 49 patients who underwent traditional laparotomy under laparoscopic surgery were included in group A, and 45 patients who underwent duodenoscopy and laparoscopy under duodenoscope to treat the drainage of nipple and pancreatic pseudocysts were included in group B. The expression levels of related serum indexes and serum stress indexes before and at 48 h after surgery, the postoperative nausea, vomiting and abdominal pain scores, as well as the clinical efficacy, perioperative related indexes, recovery and complications were compared between the two groups. The prognostic factors in both groups were assessed via Logistic univariate and multivariate analyses. C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-β (IL-β), endotoxin and nuclear factor κB (NF-κB) were significantly lower in group B than those in group A (P<0.001). Upregulating cortisol and norepinephrine in group B was lower than that in group A (P<0.001). The total effective rate in group B was higher than that in group A (P<0.05). The perioperative related indexes, recovery, and postoperative complications in group B were better than those in group A (P<0.05). Scores of abdominal pain, nausea and vomiting in group B were markedly lower than those in group A (P<0.001). Multivariate Logistic regression analysis showed that CRP, TNF-α, IL-6, IL-β and surgical methods were independent risk factors for the prognosis of patients with SAP and PP. In conclusion, the combined treatment with duodenoscopy and laparoscopic surgery has little inflammatory and stress reaction, and it is highly safe, worthy to be popularized.

A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management

Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca²⁺) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.

Increase in visceral adipose tissue and subcutaneous adipose tissue thickness in children with acute pancreatitis. A case-control study

AIM

The aim of this study was to investigate the relationship between the development of acute pancreatitis in children and their body mass index (BMI), waist circumference (WC), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) thickness.

METHOD

This was a case-control study carried out in a tertiary hospital between October and November 2019. The diagnosis of acute pancreatitis was based on the presence of at least two of three criteria of the International Study Group of Pediatric Pancreatitis (INSPPIRE) guidelines. AC, VAT, and SAT measurements of patients and controls were performed by using a three-dimensional workstation (Aquarius 3D Workstation, TeraRecon Inc., San Mateo, Calif., USA) through cross sections of the L2 vertebra level after examining previous abdominal computerized tomography (CT) records.

RESULTS

A total of 25 patients diagnosed with acute and acute recurrent pancreatitis who underwent abdominal CT were included in the study and 38 healthy, sex- and age-matched children formed the control group. There were no differences between the patients and healthy children in terms of age, sex and BMI-for-age z-scores. Besides, measurements of WC, SAT, and VAT thickness were found to be higher in the patient group (P=0.007, P=0.021, P=0.016, respectively).

CONCLUSION

In this study, WC, VAT, and SAT were found to be thicker in children with acute pancreatitis compared with healthy children without any difference in BMI. Further studies are needed to clarify whether adipose tissue thickness is an etiological cause or a secondary finding in patients with acute pancreatitis.

Hematochezia secondary to hemosuccus pancreaticus due to a pseudoaneurysm associated with a pancreatic pseudocyst

The patient had a history of recurrent acute necrotizing pancreatitis, chronic pancreatitis and a pancreatic pseudocyst with an associated pseudoaneurysm in the superior mesenteric artery. He presented mesogastric pain, nausea, 187 U/l amylase and 242 U/l lipase. A hemorrhagic appearance inside the pseudocyst and lumen of the common bile duct was seen on ultrasound.

Aggressive Percutaneous Catheter Drainage Protocol for Necrotic Pancreatic Collections

BACKGROUND

Percutaneous catheter drainage (PCD) performed pro-actively for collections in acute pancreatitis (AP) is associated with better outcomes. However, there are only a few studies describing this protocol.

AIM

We aimed to evaluate an aggressive PCD protocol.

METHODS

Consecutive patients with AP who underwent PCD with an aggressive protocol between January 2018 and January 2019 were included. This protocol involved catheter upsizing at a pre-specified interval (every 4-6 days) as well as drainage of all the new collections. The indications and technical details of PCD and clinical outcomes were compared with patients who underwent standard PCD.

RESULTS

Out of the 185 patients with AP evaluated during the study period, 110 (59.4%) underwent PCD, all with the aggressive protocol. The historical cohort of standard PCD comprised of 113 patients. There was no significant difference in the indication of PCD and interval from pain onset to PCD between the two groups. The mean number of catheters was significantly higher in the aggressive PCD group (1.86 ± 0.962 vs. 1.44 ± 0.667, p = 0.002). Additional catheters were inserted in 54.2% of patients in aggressive group vs. 36.2% in the standard group (p = 0.006). Length of hospital stay and intensive care unit (ICU) stay were significantly longer in the standard PCD group (34.3 ± 20.14 vs. 27.45 ± 14.2 days, p < 0.001 and 10.46 ± 12.29 vs. 4.12 ± 8.5, p = 0.009, respectively). There was no significant difference in mortality and surgery between the two groups.

CONCLUSION

Aggressive PCD protocol results in reduced length of hospital stay and ICU stay and can reduce hospitalization costs.

Pathological Mechanisms in Diabetes of the Exocrine Pancreas: What's Known and What's to Know

The clinical significance of diabetes arising in the setting of pancreatic disease (also known as diabetes of the exocrine pancreas, DEP) has drawn more attention in recent years. However, significant improvements still need to be made in the recognition, diagnosis and treatment of the disorder, and in the knowledge of the pathological mechanisms. The clinical course of DEP is different from type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). DEP develops in patients with previous existing exocrine pancreatic disorders which damage both exocrine and endocrine parts of pancreas, and lead to pancreas exocrine insufficiency (PEI) and malnutrition. Therefore, damage in various exocrine and endocrine cell types participating in glucose metabolism regulation likely contribute to the development of DEP. Due to the limited amount of clinical and experimental studies, the pathological mechanism of DEP is poorly defined. In fact, it still not entirely clear whether DEP represents a distinct pathologic entity or is a form of T2DM arising when β cell failure is accelerated by pancreatic disease. In this review, we include findings from related studies in T1DM and T2DM to highlight potential pathological mechanisms involved in initiation and progression of DEP, and to provide directions for future research studies.