A practical guide to pancreatitis

Gall stones and chronic pancreatitis: the black box in between

The relation between gall stones and chronic pancreatitis is uncertain; there are differing opinions on this issue. Firstly, gall stones are the most common reason for acute pancreatitis, but it cannot cause chronic pancreatitis. Secondly, a connection between gall stones and chronic inflammation of the pancreas might exist. Numerous studies or investigations have shown that changes associated with chronic pancreatitis are common in gallstone patients. Although it seems that gall stones might be a cause of chronic pancreatitis according to these findings, clinical and experimental studies are still needed for confirmation, and further studies are required to determine the mechanisms involved.

Cyclooxygenase-2 gene disruption attenuates the severity of acute pancreatitis and pancreatitis-associated lung injury

BACKGROUND & AIMS

Cyclooxygenase (COX) catalyzes the rate-limiting step in prostaglandin production; the inducible isoform, COX-2, has been implicated in a variety of inflammatory processes. The role of COX in acute pancreatitis and pancreatitis-associated lung injury is not known.

METHODS

Acute pancreatitis was induced in Swiss Webster mice or mice deficient in the COX-2 (Ptgs2) or the COX-1 (Ptgs1) genes. Pancreata and lungs were harvested, and histologic sections of these tissues were scored. COX-2 expression, myeloperoxidase activity (a measurement of neutrophil sequestration), and serum amylase levels were determined.

RESULTS

Acute pancreatitis was associated with induction of COX-2 expression. Treatment with NS-398 (a COX-2 inhibitor) significantly decreased the severity of pancreatitis. Furthermore, Ptgs2-deficient mice showed minimal histologic evidence of pancreatitis, a marked attenuation in the severity of lung injury, and a significant reduction in myeloperoxidase activity. In contrast, Ptgs1-deficient mice had pancreatitis and pulmonary inflammation, which was as severe or, in some instances, more severe than in the wild-type mice.

CONCLUSIONS

Inhibition of COX-2 by either pharmacologic inhibition or selective genetic deletion markedly attenuated the severity of acute pancreatitis. Our findings identify the COX-2 isoform as an important regulator of the severity of acute pancreatitis and pancreatitis-associated lung injury.

Unusual gastrointestinal complications in neurosurgery

Nine neurosurgical patients with unusual gastrointestinal complications are presented. Their diagnostic clinical features, as well as pitfalls in their diagnosis are highlighted. A high index of clinical suspicion of these unusual complications is important as patients' decreased level of consciousness and concomitant steroid therapy often complicates the clinical presentation. Progressive abdominal distension and absent or sluggish bowel sounds were the most consistent clinical features in comatose patients with peritonitis, whereas, high fever and markedly elevated white cell counts were often absent.

Chronic pancreatitis in China: etiology and management

The incidence of chronic pancreatitis in China is unknown. Endoscopic retrograde cholangiopancreatography (ERCP), surgery, and autopsy demonstrated that chronic pancreatitis in China is mainly secondary to cholelithiasis and other diseases of the bile ducts. Stones in the common bile duct, both intra- and extrahepatic, are extremely frequent in China. Such patients may have scores, even hundreds, of stones filling the common bile duct and its radicles. Biliary tract disease constitutes the etiology of chronic pancreatitis in 40-50% of our patients. The prolongation of necrosis, abscess, or pseudocyst after acute pancreatitis may also lead to chronic inflammation of the pancreas, as may a diverticulum at the second part of the duodenum. The pancreatitis observed in China is apt to be of the chronic relapsing type. Pancreatic ductal stones and ascaris lumbricoides may sometimes be associated with chronic inflammation of the pancreas; however, the cause of chronic pancreatitis is obscure in a large segment of the patients. Beside the ordinary clinical manifestation of chronic pancreatitis, such as abdominal pain, fever, jaundice, and steatorrhea, regional (splenic) portal hypertension may be observed. ERCP has been useful in diagnosis, and the major changes found in the pancreatic duct are discussed. Since the symptoms and signs of chronic pancreatitis in China are usually mild or moderate, the patient with intractable pain is uncommon, most being treated with medication. Most surgical procedures utilized to treat chronic pancreatitis are related to the biliary system, such as cholecystectomy with internal or external drainage of the choledochus. Internal drainage of a pancreatic pseudocyst, partial pancreatectomy, and pancreaticojejunostomy are also performed, as indicated, but are less frequent.

Surgical management of necrotizing pancreatitis

The most important diagnostic step in the management of patients with severe acute pancreatitis is the discrimination between acute interstitial and necrotizing pancreatitis. Measurement of C-reactive protein, lactic acid dehydrogenase, alpha-1-antitrypsin, and alpha-2-macroglobulin and contrast-enhanced CT are useful in detecting the necrotizing course of acute pancreatitis. C-reactive protein, lactic acid dehydrogenase, and contrast-enhanced CT offer detection rates of 85 per cent to more than 90 per cent for pancreatic necrosis. Surgical decision-making in necrotizing pancreatitis should be based on clinical, morphologic, and bacteriologic data. Patients with focal pancreatic necrosis, in general, respond well to medical treatment and do not need surgery. Extended (50 per cent or more) pancreatic necroses, infected necroses, and intrapancreatic parenchymal necroses plus extrapancreatic fatty tissue necroses are indicators for surgical management. The decision for the timing of operation in patients with proved necrotizing pancreatitis should be based on clinical criteria: the development of an acute surgical abdomen, generalized sepsis, shock, persisting or increasing organ dysfunction, or some combination thereof despite maximum intensive care treatment for at least 3 days. Major pancreatic resection for the treatment of necrotizing pancreatitis appears disadvantageous. Necrosectomy and continuous local lavage allow debridement of devitalized tissue and preservation of vital pancreatic tissue. Postoperative local lavage thus results in an atraumatic evacuation of necrotic tissue, the bacterial material, and biologically active substances. The hospital mortality rate of patients treated with necrosectomy and continuous local lavage (the Ulm protocol) is below 10 per cent. Nevertheless, controlled prospective clinical trials should be performed in order to bring more precision to our clinical decisions in respect to the role of surgery for this disease.

Early postoperative acute abdominal complications

The detection and management of acute postoperative conditions of the abdomen present a challenge to the surgeon. Many of these conditions threaten life because of their association with disorders of oxygenation, circulatory stability, and infection leading to multiple organ failure. This discussion highlights features of rapid diagnosis and focuses on problems relating to the decision to reoperate for diagnosis and therapy.

Necrosectomy and postoperative local lavage in necrotizing pancreatitis

Necrosectomy with postoperative continuous local lavage was performed in a prospective study involving 95 patients with necrotizing pancreatitis. In the same period 567 patients with oedematous-interstitial pancreatitis were treated non-operatively with a hospital mortality rate of 0.7 per cent. In patients with necrotizing pancreatitis the median Ranson criteria score was 4.5 points; operation was required at a median of 7 days after the onset of symptoms because of non-response to conservative treatment. In all, 59 per cent of the patients (56 out of 95) developed extended intrapancreatic parenchymal necrosis, 70 per cent had ascites, and 66 per cent had intra- and extrapancreatic necrosis; 42 per cent of the patients had bacterial infection of the necrotic tissue. For lavage a median of 8 l/24 h of fluid were instilled postoperatively for 25 days (median). The lavage fluid showed high levels of immunoreactive trypsin, phospholipase A2, and endotoxin in the early postoperative period. Hospital mortality rate was 8.4 per cent. Necrosectomy and continuous postoperative lavage can achieve high survival rates in patients with necrotizing pancreatitis. Postoperative local lavage allows the continuous non-operative evacuation of biologically active compounds and devitalized tissue, and avoids damage to remaining vital exocrine and endocrine pancreatic tissue.

Early diagnosis of pancreatic infection by computed tomography-guided aspiration

We performed 92 computed tomography-guided percutaneous needle aspirations of pancreatic inflammatory masses in 60 patients suspected of harboring pancreatic infection. Thirty-six patients (60%) were found by Gram stain and culture to have a total of 41 separate episodes of pancreatic infection. Among 42 aspirates judged to be infected by computed tomography-guided aspiration, all but one were confirmed by surgery or indwelling catheter drainage. Among 50 aspirates judged to be sterile, no subsequent evidence of infection was found. All patients tolerated the procedure well and no complications were noted. As a result of this technique, we observed that pancreatic infection occurs earlier than has been previously appreciated (within 14 days of the onset of pancreatitis in 20 of the 36 patients) and that infection may recur during prolonged bouts of pancreatitis. We conclude that guided aspiration is a safe, accurate method for identifying infection of the pancreas at an early stage.

Gallstone pancreatitis in adolescents

During a 5-year period (1980 to 1985) in the Adolescent Unit at Bronx-Lebanon Hospital Center, 18 patients were admitted with the diagnosis of gallstone disease, four of whom, at the time of their admission, had associated acute pancreatitis. Although gallstone pancreatitis is infrequent in adolescents, it is an important differential diagnosis of upper abdominal pain in youngsters with gallstone disease. The most frequently encountered mechanisms of gallstone pancreatitis in adolescents appear to be impacted stones, congenital pathology in the ampullary area, and passage of small stones through the common bile duct, with temporary obstruction and inflammation followed by disruption of pancreatic ductules and/or acinar cell membrane. Proper management includes cholecystectomy and the mandatory performance of an intraoperative cholangiogram. Sphincterotomy or sphincteroplasty, which are frequently performed in adults with gallstone pancreatitis, should be avoided in adolescents. Even if impacted stones have to be removed at this age, papillotomy suffices. After an acute episode, a properly timed surgical treatment is curative.