Utility of ultrasound in acute pancreatitis

A new sight to acute pancreatitis through paracolic gutter exudation, a multicenter retrospective study

Objectives

Paracolic gutter exudation (PGE) may influence the severity of acute pancreatitis, but no study has explored it extensively. The objective of this study was to evaluate PGE for assessing the severity of disease.

Methods

We performed a retrospective analysis of 488 patients from three tertiary hospitals in Guangxi, China. General clinical information, severity, and clinical courses were recorded. The PGE score were classified as follows: 0 for no exudation, 1 for unilateral exudation, and 2 for bilateral exudation. We used ROC curves to assess the predictive value of the PGE score, and logistic regression analysis to determine risk factors associated with death, ICU admission, and the occurrence of MODS.

Results

This study included 352 patients with moderately severe acute pancreatitis (MSAP) and 136 patients with severe acute pancreatitis (SAP). Patients who had PGE experienced higher total hospitalization costs, longer hospital stays, a higher incidence of SAP, higher mortality rates, higher ICU admission rates, a higher incidence of MODS, and higher incidence of infections than those without (P < 0.05). Diagnostic efficacy in predicting severity in patients with MSAP and SAP increased after BISAP, MCTSI, modified Marshall, and SOFA scores combined with PGE score respectively. The PGE score of >1 is an independent risk factor for ICU admission and MODS occurrence. (P < 0.05).

Conclusion

The PGE provides reliable and objective information for assessing severity and clinical course of patients with MSAP and SAP.

Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications

This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.

The role of bacteria in gallstone formation

Gallstones are a prevalent biliary system disorder that is particularly common in women. They can lead to various complications, such as biliary colic, infection, cholecystitis, and even gallbladder cancer. However, the etiology of gallstones remains incompletely understood. The significant role of bacteria in gallstone formation has been demonstrated in recent studies. Certain bacteria not only influence bile composition and the gallbladder environment but also actively participate in stone formation by producing enzymes such as β-glucuronidase and mucus. Therefore, this review aimed to analyze the mechanisms involving the types and quantities of bacteria involved in gallstone formation, providing valuable references for understanding the etiology and clinical treatment of gallstones.

Fatty infiltration of the pancreas: a systematic concept analysis

Fatty infiltration of the pancreas (FIP) has been recognized for nearly a century, yet many aspects of this condition remain unclear. Regular literature reviews on the diagnosis, consequences, and management of FIP are crucial. This review article highlights the various disorders for which FIP has been established as a risk factor, including type 2 diabetes mellitus (T2DM), pancreatitis, pancreatic fistula (PF), metabolic syndrome (MS), polycystic ovary syndrome (PCOS), and pancreatic duct adenocarcinoma (PDAC), as well as the new investigation tools. Given the interdisciplinary nature of FIP research, a broad range of healthcare specialists are involved. This review article covers key aspects of FIP, including nomenclature and definition of pancreatic fat infiltration, history and epidemiology, etiology and pathophysiology, clinical presentation and diagnosis, clinical consequences, and treatment. This review is presented in a detailed narrative format for accessibility to clinicians and medical students.

Endoscopic necrosectomy of infected WON in acute necrotising pancreatitis - Development of an effective therapeutic algorithm based on a single-center consecutive patient cohort

OBJECTIVE

Development of an effective therapeutic algorithm for interventional (minimally invasive) approach to infected walled-off necrosis (WON) in patients with necrotising pancreatitis reflecting real-word data.

MATERIAL/METHODS

All consecutive patients who underwent endoscopic necrosectomy for necrotising pancreatitis through a defined study period were enclosed in this retrospective observational case study. The therapeutic approach was analysed for clinical success rate, complication spectrum and rate as well as mortality and compared with data from the literature. Finally, a therapeutic algorithm was derived.

RESULTS

From 2004 to 2019, 126 patients with necrotising pancreatitis (median of APACHE II score, 10.5 points) were treated. In 92.9 % of cases (n=117), an infected WON with microbial pathogen detection was found. After a median of 18 days from symptom onset, first intervention was performed (53.2 % as percutaneous drainage with programmed rinsing, 29.4 % as EUS-guided internal drainage). From 2004 to 2010, double pigtail stents were used. Later, lumen-apposing metal stent (LAMS) such as AXIOS^TM stent (Boston Scientific, Ratingen, Germany) was preferred. The combined percutaneous and internal drainage was performed in approximately 50 % of subjects.Endoscopic transluminal necrosectomy was performed in 123 patients (97.6 %) at a median of 33 days from symptom onset. Endoscopic percutaneous necrosectomy was conducted in 11.1 % of the individuals. A median number of two endoscopic necrosectomy sessions per patient was necessary for the therapy. The clinical success rate (discharge without surgical intervention) was 82.5 %. The complication rate (bleeding and perforation) and the need for surgery were both 9.5 %. The overall mortality was 8.7 %.

CONCLUSION

Therapy of necrotising pancreatitis with infected WON consists of early calculated antibiotic therapy with adequate drainage. Combined external and internal drainages with programmed rinsing seem to improve prognosis, as well as minimise I) : the need for forced necrosectomies (mainly via a transluminal access site) and II) : complication rate as well as, thus, improve outcome.

Using machine learning models to predict acute pancreatitis in children with pancreaticobiliary maljunction

PURPOSE

To develop a model to identify risk factors and predictors of acute pancreatitis in children with pancreaticobiliary maljunction (PBM).

METHODS

We screened consecutive PBM patients treated at two centers between January, 2015 and July, 2021. For machine learning, the cohort was divided randomly at a 6:4 ratio to a training dataset and a validation dataset. Three parallel models were developed using logistic regression (LR), a support vector machine (SVM), and extreme gradient boosting (XGBoost), respectively. Model performance was judged primarily based on the area under the receiver operating curves (AUC).

RESULTS

A total of 99 patients were included in the analysis, 17 of whom suffered acute pancreatitis and 82 did not. The XGBoost (AUC = 0.814) and SVM (AUC = 0.813) models produced similar performance in the validation dataset; both outperformed the LR model (AUC = 0.805). Based on the SHapley Additive exPlanation values, the most important variable in both the XGBoost and SVM models were age, protein plugs, and white blood cell count.

CONCLUSIONS

Machine learning models, especially XGBoost and SVM, could be used to predict acute pancreatitis in children with PBM. The most important contributing factor to the models were age, protein plugs, and white blood cell count.

The Utility of Abdominal Ultrasound Following Negative Computed Tomography in Diagnosing Acute Pancreatitis

Aim

Acute pancreatitis is a diagnosis established by fulfillment of at least two out of three clinical features, including epigastric pain, elevated lipase, and/or radiographic evidence of acute pancreatitis. Computed tomography of the abdomen and pelvis (CTAP) is the gold standard imaging modality for evaluating acute pancreatitis. Although abdominal ultrasound (AUS) is increasingly utilized given the widespread availability and high sensitivity and specificity for detecting gallstone-related complications, including gallstone pancreatitis, the leading cause of acute pancreatitis in the US. However, recent literature has concluded that performing AUS following a negative CTAP rarely led to changes in management and imparted an increased length of service (LOS) in the ED. Our study investigated whether a similar relationship was observed when managing acute pancreatitis in the inpatient setting. We aimed to quantify how performing AUS influenced inpatient LOS for patients admitted for acute pancreatitis without radiographic evidence of acute pancreatitis on CTAP. We also aimed to quantify how AUS influenced the likelihood of subsequent intervention via endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy, including the relative impact of certain demographic or clinical features.

Methods

A retrospective analysis was performed using a cohort of 6069 patient encounters extracted via the HCA Healthcare enterprise data warehouse (EDW) database. Inclusion criteria were all adult patients with an index admission for acute pancreatitis between January 1 and December 31, 2019, who underwent CTAP during admission. Patients younger than 18 years, with prior cholecystectomy, or without documentation of demographic or clinical data of interest were excluded. The primary outcome was to quantify how performing AUS within 48 hours impacted LOS for patients admitted for acute pancreatitis following negative CTAP. Secondary outcomes examined whether AUS changed management (i.e., per likelihood of subsequent ERCP or cholecystectomy). This included determining the influence of various demographic or clinical characteristics on the likelihood of intervention via ERCP or cholecystectomy. Linear regression was used to determine the effect of performing AUS on the duration of LOS. Logistic regression was used for covariate analysis based on demographic (BMI, sex, race, age) and clinical data (comorbid conditions, abnormal labs, and vital signs).

Results

Patients with acute pancreatitis who underwent AUS within 48 hours had a reduced LOS of 1.099 days. Patients who underwent AUS were 1.126 times more likely to undergo subsequent ERCP than those who received CTAP alone. Patients who received AUS following CTAP were also 2.711 times more likely to undergo subsequent cholecystectomy. Increasing age and BMI were correlated with an increased likelihood of ERCP and cholecystectomy. Males were less likely to undergo cholecystectomy (OR = 0.753) and ERCP (OR = 0.815) compared to females.

Conclusion

Performing AUS within 48 hours following negative CTAP in this cohort of patients admitted for acute pancreatitis was associated with a decreased LOS. Furthermore, patients who underwent AUS were more likely to undergo ERCP and even more likely to undergo cholecystectomy. The likelihood of ERCP and cholecystectomy increased proportionally to both age and BMI. Females were more likely than males to undergo subsequent ERCP or cholecystectomy.

Magnetic Resonance Imaging of Acute Abdominal Pain in the Pregnant Patient

Evaluation of a pregnant patient presenting with acute abdominal pain can be challenging to accurately diagnose for a variety of reasons, and particularly late in pregnancy. Noncontrast MR remains a safe and accurate diagnostic imaging modality for the pregnant patient presenting with acute abdominal pain, following often an initially inconclusive ultrasound examination, and can be used in most settings to avoid the ionizing radiation exposure of a computed tomography scan. Pathologic processes discussed in this article include some of the more common gastrointestinal, hepatobiliary, genitourinary, and gynecologic causes of abdominal pain occurring in pregnancy, as well as traumatic injuries.

Use of POCUS in Chest Pain and Dyspnea in Emergency Department: What Role Could It Have?

Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.

Acute pancreatitis in children: a review with clinical perspectives to enhance imaging interpretation

Pediatric acute pancreatitis has distinct etiologic, clinical and prognostic characteristics in contrast to the adult form of the disease. This review offers a comprehensive imaging update that emphasizes the importance of recognizing specific findings that are relevant from the clinical standpoint. Knowledge of these features facilitates communication among multidisciplinary team members and ultimately could lead to the improved care of pediatric acute pancreatitis patients.

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.

[Imaging diagnostics in acute pancreatitis]

Abdominal imaging is an important component of the diagnostics of acute pancreatitis. In addition to the clinical features and the laboratory constellation, it serves to establish the diagnosis or the exclusion of other diseases and also the identification and assessment of the course of local complications and vascular changes that can arise during the course of acute pancreatitis. Due to the numerous imaging examination methods that are available, their combination options and the different examination times, there are diverse application options that have to be taken into account, such as the severity and duration of the disease, concomitant diseases and complications of acute pancreatitis. A rational use of imaging is an important prerequisite for high quality and at the same time cost-effective patient care. This review summarizes the current importance of imaging in acute pancreatitis, with particular reference to the updated S3 guidelines on acute pancreatitis.

Current State of Imaging of Pediatric Pancreatitis: AJR Expert Panel Narrative Review

Pancreatitis is as common in children as it is in adults, though causes and accepted imaging strategies differ in children. In this narrative review we discuss the epidemiology of childhood pancreatitis and key imaging features for pediatric acute, acute recurrent, and chronic pancreatitis. We rely heavily on our collective experience in discussing advantages and disadvantages of different imaging modalities; practical tips for optimization of ultrasound, CT, and MRI with MRCP in children; and image interpretation pearls. Challenges and considerations unique to imaging pediatric pancreatitis are discussed, including timing of imaging, role of secretin-enhanced MRCP, utility of urgent MRI, severity prediction, autoimmune pancreatitis, and best methods for serial imaging. We suggest a methodical approach to pancreatic MRI interpretation in children and have included a sample structured report, and we provide consensus statements according to our experience imaging children with pancreatitis.