Recurrent acute pancreatitis: an algorithmic approach to identification and elimination of inciting factors

Risk of Pancreatic Cancer After Acute Pancreatitis: A Retrospective Analysis of the Korean National Sample Cohort

BACKGROUND

Acute pancreatitis may increase the risk of pancreatic cancer, although this association remains unclear. Therefore, we aimed to investigate this association.

METHODS

We retrospectively analyzed the 2002-2019 Korean National Health Insurance Service-National Sample Cohort using 1:3 propensity score matching for sex and age (acute pancreatitis, n = 4,494; matched controls, n = 13,482). We calculated the hazard ratio (HR) for pancreatic cancer risk in patients with acute pancreatitis using Cox proportional hazards regression.

RESULTS

Acute pancreatitis was significantly associated with an increased risk of pancreatic cancer throughout the study period (adjusted HR, 7.56 [95% confidence interval, 5.00-11.41]), which persisted for 2, 2-5, and > 5 years post-diagnosis (19.11 [9.60-38.05], 3.46 [1.35-8.33], and 2.73 [1.21-6.15], respectively). This pancreatitis-related pancreatic cancer risk became insignificant beyond 10 years of follow-up (1.24 [0.24-6.49]). Furthermore, this risk notably increased as the number of recurrent acute pancreatitis episodes increased (1 episode: 5.25 [3.31-8.33], 2 episodes: 11.35 [6.38-20.19], ≥ 3 episodes: 24.58 [13.66-44.26]).

CONCLUSION

Following an acute pancreatitis diagnosis, the risk of pancreatic cancer increases significantly in the initial years, with a rapid increase further accentuated with recurrent acute pancreatitis episodes. Additional study is needed to evaluate whether this increased risk of carcinogenesis is attributed to accumulated inflammation.

Acute recurrent pancreatitis in a child with pancreatic divisum– A case report

Introduction and importance

In children, acute recurrent pancreatitis is attributed to pancreato-biliary anomalies, hereditary pancreatitis and cystic fibrosis. Pancreatic divisum is a common congenital ductal anomaly that leads to recurrence of pancreatitis.

Case presentation

A 13 years old female presented with clinical features of acute recurrent pancreatitis. After ruling out common causes, magnetic resonance cholangiopancreatography was done which showed pancreatic divisum. Her symptoms resolved following duodenum preserving pancreatic head resection.

Discussion

Acute recurrent pancreatitis is attributed to raised intrapancreatic dorsal ductal pressure due to ductal anomalies especially pancreatic divisum (PD). It is the embryological failure in the fusion of the dorsal and ventral ductal system. PD is further classified into a classical subtype where there is complete failure of ductal fusion and an incomplete subtype where there is partial fusion of the ductal system. The diagnosis is commonly done through abdominal imaging with secretin enhanced magnetic resonance cholangiopancreatography being the choice of imaging modality. The initial approach is endoscopic intervention unless patients present with signs of pancreatic fibrosis where a duodenum preserving pancreatic head resection can be carried out.

Conclusion

A keen suspicion should be given towards anatomical or structural variants in absence of common etiologies. Early identification and management of pancreatic divisum prevents the recurrence of pancreatitis.

•

Pancreatic divisum is a ductal anomaly which leads to acute recurrent pancreatitis.

•

In symptomatic cases the diagnosis is established following abdominal imaging.

•

Conservative or surgical management are weighed upon by the severity of pancreatitis.

•

Symptomatic patients may benefit from endoscopic or open surgical interventions.

SPINK1 Mutation in Idiopathic Chronic Pancreatitis: How Pertinent Is It in Coastal Eastern India?

Background and aim Idiopathic chronic pancreatitis (ICP) is said to be present when no identifiable etiology can be identified. Robust evidence suggested that the serine protease inhibitor nucleus Kazol type 1 (SPINK1) N34S mutation was frequently associated with ICP. As there is a paucity of data on genetic studies in ICP cases from the coastal eastern region of India, we performed this study with an aim to evaluate the SPINK1 genetic mutations and other associated clinical correlates in ICP cases. Material and methods Consecutive ICP cases attending the department of gastroenterology, Institute of Medical Sciences (IMS) and SUM Hospital, were enrolled and evaluated for the pertinent clinical history and undergone detailed biochemical and radiological evaluations. Two ml of venous blood in ethylenediaminetetraacetic acid (EDTA) vials were collected from each case and subjected to a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) test for genetic analysis. Result In this study, the mean age of the cases at the time of the first consultation with us and the age of the first clinical presentation were 34.52±6.44 and 28.73±5.52 years, respectively. Males outnumbered females (Male:Female - 2.12:1). Out of the total of 200 cases, 50% had no SPINK1 mutation, whereas 40% and 10% cases had SPINK1 N34S heterozygous and homozygous mutations, respectively. The mean age of clinical presentation, severe abdominal pain, exocrine and endocrine insufficiency, and parenchymal atrophy were significantly more common in mutants as compared to non-mutants (p-value <0.05). Conclusion In our region, 50% of ICP cases had the SPINK1 N34S mutation. The SPINK1 mutants had a relatively more severe variety of pancreatitis as compared to non-mutants.

Etiology of Acute Recurrent Pancreatitis in Vietnamese Children: an Initial Report

Objectives:

The aim of this study was to describe the epidemiological characteristics of acute recurrent pancreatitis (ARP) among children who were admitted at Children’s Hospital 2, Ho Chi Minh City, Vietnam, from May 2014 to May 2019.

Methods:

Authors presented Case series study.

Results:

A total of 33 cases met the criteria for study inclusion. The mean age of first onset 7.3 ± 4.4 years (range, 1.4–15 years), the male to female ratio was 18:15 (1.2:1). The median number of ARP admissions per patient was 3 (range, 2–14), and the median time between ARP-related hospitalization was 168 days (range, 82–240 days). The chief complaint upon hospitalization was abdominal pain, accounting for 96.9% of cases, vomiting in 87.9% of cases, and severe ARP was observed in 24% of cases. All patients underwent magnetic resonance cholangiopancreatography (MRCP), and abdominal computed tomography (CT) scans. Genetic testing was performed in 14 of 33 cases, and 5 cases had at least 1 mutation, whereas 9 were negative. The most common etiology of ARP was biliary tract disease, in 17 cases (51.5%; 11 choledochal cysts, 6 gallstones), abnormalities of the pancreas were observed in 18.2% (abnormalities of pancreatic structures in 3 cases), hypertriglyceridemia and metabolic disease were observed in 6.1% of cases, and genetic mutations were identified in 15.2% of cases.

Conclusion:

ARP is not a rare disease, and ARP patients may be admitted to the hospital many times. The chief complaints resulting in hospitalization were abdominal pain and vomiting. The most common causes were biliary tract diseases (bile duct cysts in 33.3% and gallstones in 18.2% of cases), with abnormalities of the pancreatic structure identified in 9.1% of cases, and genetic mutations detected in 15.2% of patients.

Radiomic features of the pancreas on CT imaging accurately differentiate functional abdominal pain, recurrent acute pancreatitis, and chronic pancreatitis

PURPOSE

Patients with recurrent abdominal pain and pancreatic enzyme elevations may be diagnosed clinically with recurrent acute pancreatitis (RAP) even with normal imaging or no imaging at all. Since neither abdominal pain nor enzyme elevations are specific for acute pancreatitis (AP), and patients with RAP often have a normal appearing pancreas on CT after resolution of an AP episode, RAP diagnosis can be challenging. This study aims to determine if quantitative radiomic features of the pancreas on CT can differentiate patients with functional abdominal pain, RAP, and chronic pancreatitis (CP).

METHOD

Contrast enhanced CT abdominal images of adult patients evaluated in a pancreatitis clinic from 2010 to 2018 with the diagnosis of RAP, functional abdominal pain, or CP were retrospectively reviewed. The pancreas was outlined by drawing region of interest (ROI) on images. 54 radiomic features were extracted from each ROI and were compared between the patient groups. A one-vs-one Isomap and Support Vector Machine (IsoSVM) classifier was also trained and tested to classify patients into one of the three diagnostic groups based on their radiomic features.

RESULTS

Among the study's 56 patients, 20 (35.7 %) had RAP, 19 (33.9 %) had functional abdominal pain, and 17 (30.4 %) had CP. On univariate analysis, 11 radiomic features (10 GLCM features and one NGTDM feature) were significantly different between the patient groups. The IsoSVM classifier for prediction of patient diagnosis had an overall accuracy of 82.1 %.

CONCLUSIONS

Certain radiomic features on CT imaging can differentiate patients with functional abdominal pain, RAP, and CP.

Endoscopic Ultrasound for Routine Assessment in Idiopathic Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is one of the most common general acute surgical presentations. Current recommendations are that idiopathic acute pancreatitis (IAP) should account for no more than 20% of AP cases. Some studies suggest gallbladder microlithiasis is the aetiology in up to 75% of IAP patients. Endoscopic ultrasound (EUS) has been reported to be effective in the detection of microlithiasis and choledocholithiasis as well as pancreatic parenchymal, ductal and ampullary disorders. The aims of this study were to evaluate the usefulness of EUS in establishing aetiology in IAP patients and to assess if there is a role for EUS in the selection criteria for laparoscopic cholecystectomy to treat a potential biliary cause in IAP patients.

METHODS

A systematic review following PRISMA guideline was performed to gather data on patients with IAP undergoing EUS for further investigation. Three databases (MEDLINE, PubMed, and EMBASE) were searched to 28 July 2018.

RESULTS

Our systematic review included 28 studies, comprising 1850 patients with an initial diagnosis of IAP prior to having EUS. Diagnosis of a potential aetiology or associated pancreatic pathology was established in 1095 (62%, p < 0.001) of cases. A biliary aetiology (microlithiasis or choledocholithiasis) was found in 37%. Chronic pancreatitis and associated pancreatic findings (dilated pancreatic duct, pancreatic duct stricture or stone) were found in 21%. Pancreatic neoplasms were found in 6%. Of the patients who had identifiable biliary pathology on EUS that proceeded to cholecystectomy, 2% had a recurrence of AP during a mean follow-up period of 20.5 months.

CONCLUSIONS

There is a likely role for the routine use of EUS in the assessment of patients with IAP. The routine use of EUS may decrease the proportion of cases with a diagnosis of IAP. EUS may provide better selection criteria for laparoscopic cholecystectomy in patients with an initial diagnosis of IAP.

Recurrent Acute Pancreatitis: International State-of-the-Science Conference With Recommendations

Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.

Differences between the outcome of recurrent acute pancreatitis and acute pancreatitis

Background and aim

Overall, a handful of studies are available on the outcomes of recurrent acute pancreatitis (RAP), in comparison to the first episode of acute pancreatitis (AP). We aimed to provide a more complete and updated picture of RAP and how it is different from the initial episode of AP.

Methods

Consecutive patients admitted with an episode of AP over 8 years were divided into two groups on the basis of prior episodes: AP and RAP. Primary outcome measures were for surgical necrosectomy and mortality.

Results

Of the 724 patients (age 39.22 ± 13.25 years, 68% male) with an episode of pancreatitis, 632 (87.3%) had presented with a first episode (AP) and 92 (12.7%) with at least one prior episode (RAP). The incidence of severe pancreatitis was significantly less in RAP patients (10.9%) in comparison to AP patients (48.6%). The requirement of surgical intervention and mortality were less in patients with RAP (1.1 and 2.2%, respectively) compared to patients with AP (9.3 and 18%, respectively). The mean number of episodes per RAP patients was 2.97 ± 1.66 (range 2–10), and 64.1% had only two episodes. Regarding the etiology of RAP patients, biliary etiology (32.6%) and alcohol (30.4%) were the two most frequent factors, and no etiology could be identified in 19.6%.

Conclusion

Patients with RAP had milder disease course and lesser mortality when compared to the initial episode of AP. Appropriate evaluation and dealing with etiological factors at the initial episode of AP can prevent a majority of RAP.

Binge ethanol exposure causes endoplasmic reticulum stress, oxidative stress and tissue injury in the pancreas

Alcohol abuse is associated with both acute and chronic pancreatitis. Repeated episodes of acute pancreatitis or pancreatic injury may result in chronic pancreatitis. We investigated ethanol-induced pancreatic injury using a mouse model of binge ethanol exposure. Male C57BL/6 mice were exposed to ethanol intragastrically (5 g/kg, 25% ethanol w/v) daily for 10 days. Binge ethanol exposure caused pathological changes in pancreas demonstrated by tissue edema, acinar atrophy and moderate fibrosis. Ethanol caused both apoptotic and necrotic cell death which was demonstrated by the increase in active caspase-3, caspase-8, cleaved PARP, cleaved CK-18 and the secretion of high mobility group protein B1 (HMGB1). Ethanol altered the function of the pancreas which was indicated by altered levels of alpha-amylase, glucose and insulin. Ethanol exposure stimulated cell proliferation in the acini, suggesting an acinar regeneration. Ethanol caused pancreatic inflammation which was indicated by the induction of TNF-alpha, IL-1beta, IL-6, MCP-1 and CCR2, and the increase of CD68 positive macrophages in the pancreas. Ethanol-induced endoplasmic reticulum stress was demonstrated by a significant increase in ATF6, CHOP, and the phosphorylation of PERK and eiF-2alpha. In addition, ethanol increased protein oxidation, lipid peroxidation and the expression of iNOS, indicating oxidative stress. Therefore, this paradigm of binge ethanol exposure caused a spectrum of tissue injury and cellular stress to the pancreas, offering a good model to study alcoholic pancreatitis.

Alcohol, smoking and benign hepato-biliary disease

Gallstone disease and pancreatitis are the most frequent benign hepato-biliary causes of hospital admissions. Gallstone disease is prevalent, but symptomatic disease develops only in about one out of five carriers. Alcohol intake seems to protect gallstone formation in cohort studies possibly through effects on bile cholesterol metabolism, the enterohepatic circulation, and gallbladder function. The impact of smoking on gallstone formation seems minor. Both alcohol intake and smoking do not alter the clinical course of gallstone disease carriers. Cholecystectomy is the preferred treatment for symptomatic gallstone disease. Studies about the impact of alcohol and smoking on the post-cholecystectomy state are few and future studies should be performed. Pancreatitis is associated with both excessive alcohol intake and smoking in observational studies. Interpretation of associations with pancreatitis is hampered by an incomplete understanding of underlying mechanisms and by the co-existence of excessive alcohol intake and smoking. Smoking cessation and alcohol abstinence is recommended in the treatment of pancreatitis, but higher-level evidence is needed.

Validation of Demographics, Etiology, and Risk Factors for Chronic Pancreatitis in the USA: A Report of the North American Pancreas Study (NAPS) Group

BACKGROUND/OBJECTIVES

Our aim was to validate recent epidemiologic trends and describe the distribution of TIGAR-O risk factors in chronic pancreatitis (CP) patients.

METHODS

The NAPS-2 Continuation and Validation (NAPS2-CV) study prospectively enrolled 521 CP patients from 13 US centers from 2008 to 2012. CP was defined by definitive changes in imaging, endoscopy, or histology. Data were analyzed after stratification by demographic factors, physician-defined etiology, participating center, and TIGAR-O risk factors.

RESULTS

Demographics and physician-defined etiology in the NAPS2-CV study were similar to the original NAPS2 study. Mean age was 53 years (IQR 43, 62) with 55% males and 87% white. Overall, alcohol was the single most common etiology (46%) followed by idiopathic etiology (24%). Alcohol etiology was significantly more common in males, middle-aged (35-65 years), and non-whites. Females and elderly (≥65 years) were more likely to have idiopathic etiology, while younger patients (<35 years) to have genetic etiology. Variability in etiology was noted by participating centers (e.g., alcohol etiology ranged from 27 to 67% among centers enrolling ≥25 patients). Smoking was the most commonly identified (59%) risk factor followed by alcohol (53%), idiopathic (30%), obstructive (19%), and hyperlipidemia (13%). The presence of multiple TIGAR-O risk factors was common, with 1, 2, ≥3 risk factors observed in 27.6, 47.6, and 23.6% of the cohort, respectively.

CONCLUSION

Our data validate the current epidemiologic trends in CP. Alcohol remains the most common physician-defined etiology, while smoking was the most commonly identified TIGAR-O risk factor. Identification of multiple risk factors suggests CP to be a complex disease.

Is acute recurrent pancreatitis in children a precursor of chronic pancreatitis? A long-term follow-up study of 93 cases

BACKGROUND/AIMS

In view of paucity of literature we analyzed our experience of acute recurrent pancreatitis (ARP) to study clinical profile and long-term outcome.

METHODS

Over 13 years, 93 consecutive children (≤18 years) diagnosed to have ARP were included in this study. Magnetic resonance cholangiopancreatography was done at baseline and on follow-up. Common mutations for serine-protease-inhibitor (SPINK1 N34S), protease inhibitor (PRSS1 R122S) and cystic fibrosis transmembrane conductance regulator (CFTR deltaF508, 5T) were studied in 22 idiopathic cases.

RESULTS

The median age of the children with ARP was 13 (10-14.5) years, 53 were males. Etiology included biliary in 14 (15%), pancreas divisum in 6 (7%), others in 3 (3.5%) and idiopathic in the remaining 70 (75%). SPINK1 mutation was found in 10/22 (45%) cases. Over a median follow-up of 25.5 (8.25-48) months, 37 (42%) of 88 (5 lost to follow-up) developed chronic pancreatitis (CP). On multivariate analysis idiopathic etiology (p<0.03), presence of SPINK1 mutation (p=0.01), longer follow-up (p<0.001) were associated with progression to CP.

CONCLUSIONS

Biliopancreatic structural/obstructive causes should always be looked for. It seems ARP is a precursor of CP and progression is associated with idiopathic etiology and presence of genetic mutations. Hence, patients with ARP should be kept on regular follow-up to detect CP.

Acute Pancreatitis Etiology Investigation: A Workup Algorithm Proposal

BACKGROUND

Acute pancreatitis represents a significant number of hospital admissions. Most of the patients are admitted in an acute setting. Early identification of its etiology is an essential step toward the rational approach, both for its implications in the immediate therapy and the prevention of recurrence. Although often obvious, the etiological workup of acute pancreatitis can be challenging.

CONCLUSION

There are several studies emphasizing the multiple etiologies underlying acute pancreatitis but lacking structured diagnostic workups to allow a rational and organized study. The main goal of this work is to develop an algorithm proposal, which aims to serve as a guide for the investigation of the etiology of acute pancreatitis based on a review of already published literature, adjusted to the reality of our hospital and the available resources.

Endoscopic sphincterotomy (ES) may not alter the natural history of idiopathic recurrent acute pancreatitis (IRAP)

BACKGROUND

The role of endoscopic sphincterotomy (ES) in idiopathic recurrent acute pancreatitis (IRAP) is unclear. We hypothesized that ES will alter the natural history of IRAP.

METHODS

We retrospectively studied the course of 50 IRAP patients from the NAPS2 study from UPMC based on whether they underwent ES or were managed medically. Data included age at first AP, rate of attacks, and history of severe AP. Primary outcomes were any subsequent AP and rate of attacks; secondary outcome was chronic pancreatitis (CP) diagnosis during follow-up. Similar data was abstracted for alcoholic RAP.

RESULTS

When compared with medically managed IRAP patients (n = 24, 48%), those who underwent ES (n = 26, 52%) had similar rate of attacks/year (median 1.54 vs. 1.41, p = 0.63), but significantly more attacks (median 3 vs. 2, p = 0.04) at baseline. During follow-up (median 7 years), rate of attacks/year decreased significantly, and were similar in both groups (median 0.16 vs. 0, p = ns). Predictors for rate of attacks during follow-up were sex (ratio 0.54 in females, p = 0.045) and rate of attacks at baseline (ratio for doubling 1.2, p = 0.025), but not ES. Alcoholic RAP patients had lower rate of attacks at baseline, but higher risk of subsequent AP (80 vs. 46%, p = 0.021) and rate of attacks/year (median 0.25 vs. 0, p = 0.016) during follow-up. Progression to CP occurred in IRAP and ES, medically managed IRAP, and alcoholic RAP in 27%, 8% and 27% respectively (p = ns).

CONCLUSIONS

ES, chosen in patients with higher burden of attacks, does not seem to impact the natural history of IRAP.

Development and Validation of a Prediction Model for Admission After Endoscopic Retrograde Cholangiopancreatography

BACKGROUND & AIMS

In outpatients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with anesthesia, rates of and risk factors for admission are unclear. We aimed to develop a model that would allow physicians to predict hospitalization of patients during postanesthesia recovery.

METHODS

We conducted a retrospective study of data from ERCPs performed on outpatients from May 2012 through October 2013 at the Indiana University School of Medicine. Medical records were abstracted for preanesthesia, intra-anesthesia, and early (within the first hour) postanesthesia characteristics potentially associated with admission. Significant factors associated with admission were incorporated into a logistic regression model to identify subgroups with low, moderate, or high probabilities for admission. The population was divided into training (first 12 months) and validation (last 6 months) sets to develop and test the model.

RESULTS

We identified 3424 ERCPs during the study period; 10.7% of patients were admitted to the hospital, and 3.7% developed post-ERCP pancreatitis. Postanesthesia recovery times were significantly longer for patients requiring admission (362.6 ± 213.0 minutes vs 218.4 ± 71.8 minutes for patients not admitted; P < .0001). A higher proportion of admitted patients had high-risk indications. Admitted patients also had more severe comorbidities, higher baseline levels of pain, longer procedure times, performance of sphincter of Oddi manometry, higher pain during the first hour after anesthesia, and greater use of opiates or anxiolytics. A multivariate regression model identified patients who were admitted with a high level of accuracy in the training set (area under the curve, 0.83) and fair accuracy in the validation set (area under the curve, 0.78). On the basis of this model, nearly 50% of patients could be classified as low risk for admission.

CONCLUSION

By using factors that can be assessed through the first hour after ERCP, we developed a model that accurately predicts which patients are likely to be admitted to the hospital. Rates of admission after outpatient ERCP are low, so a policy of prolonged observation might be unnecessary.

Acute recurrent pancreatitis: Etiopathogenesis, diagnosis and treatment

Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term “idiopathic” is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches.

Role of endoscopic ultrasonography in patients with first episode of idiopathic acute pancreatitis

BACKGROUND/AIMS

Acute pancreatitis (AP) evades an etiological diagnosis in up to 10 % to 30 % of patients. This group, ie. idiopathic acute pancreatitis (IAP) is prone to a high recurrence (up to 70 %). Endoscopic ultrasound (EUS) is promising, but there is limited data on elucidating the cause of IAP, from India. This observational study was designed to study the role of EUS after the first episode of IAP.

METHODS

All patients diagnosed to have first episode of IAP were included in the study and taken up for EUS examination after 6 weeks. Patients with conditions known to predispose or precipitate AP, like alcohol binge, drugs, metabolic or autoimmune conditions, or even a positive family history, were excluded from the study.

RESULT

A total of 51 patients were included. EUS positivity was found in 29 (56.9 %) patients. It included common bile duct (CBD) calculus in 5 (9.8 %), CBD sludge in 4 (7.8 %), gallbladder calculus in 2 (3.9 %), gallbladder sludge in 2 (3.9 %), and chronic pancreatitis (CP) in 16 (31.4 %) patients. Fourteen patients had a normal study and eight patients had indeterminate CP.

CONCLUSIONS

EUS is safe and has a reasonable diagnostic yield in patients with first episode of IAP. CP and biliary lithiasis are the most frequent positive findings on EUS. EUS should be included in the diagnostic protocol after the first episode of IAP, rather than waiting for recurrent episodes.

Defining a therapeutic program for recurrent acute pancreatitis patients with unknown etiology

AIM

To define a therapeutic program for mild-moderate acute pancreatitis (AP), often recurrent, which at the end of the diagnostic process remains of undefined etiology.

MATERIAL AND METHODS

In the period 2011-2012, we observed 64 cases of AP: 52 mild-moderate, 12 severe; biliary 39, biliary in alcoholic chronic pancreatitis 5, unexplained recurrent 20. The clinical and instrumental evaluation of the 20 cases of unexplained AP showed 6 patients with biliary sludge, 4 microlithiasis, 4 sphincter of Oddi dysfunction, and 6 cases that remained undefined.

RESULTS

Among 20 patients with recurrent, unexplained AP at initial etiological assessment, we performed 10 video laparo cholecystectomies (VLCs), 2 open cholecystectomies and 4 endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomies (ERCP/ES) in patients who had undergone previous cholecystectomy; 4 patients refused surgery. Among these 20 patients, 6 had AP that remained unexplained after second-level imaging investigations. For these patients, 4 VLCs and 2 ERCP/ES were performed. Follow-up after six months was negative for further recurrence.

CONCLUSION

The recurrence of unexplained acute pancreatitis could be treated with empirical cholecystectomy and/or ERCP/ES in cases of previous cholecystectomy.

Endoscopic therapy for acute recurrent pancreatitis

Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.

Update on pathogenesis and clinical management of acute pancreatitis

Acute pancreatitis (AP), defined as the acute nonbacterial inflammatory condition of the pancreas, is derived from the early activation of digestive enzymes found inside the acinar cells, with variable compromise of the gland itself, nearby tissues and other organs. So, it is an event that begins with pancreatic injury, elicits an acute inflammatory response, encompasses a variety of complications and generally resolves over time. Different conditions are known to induce this disorder, although the innermost mechanisms and how they act to develop the disease are still unknown. We summarize some well established aspects. A phase sequence has been proposed: etiology factors generate other conditions inside acinar cells that favor the AP development with some systemic events; genetic factors could be involved as susceptibility and modifying elements. AP is a disease with extremely different clinical expressions. Most patients suffer a mild and limited disease, but about one fifth of cases develop multi organ failure, accompanied by high mortality. This great variability in presentation, clinical course and complications has given rise to the confusion related to AP related terminology. However, consensus meetings have provided uniform definitions, including the severity of the illness. The clinical management is mainly based on the disease´s severity and must be directed to correct the underlying predisposing factors and control the inflammatory process itself. The first step is to determine if it is mild or severe. We review the principal aspects to be considered in this treatment, as reflected in several clinical practice guidelines. For the last 25 years, there has been a global increase in incidence of AP, along with many advances in diagnosis and treatment. However, progress in knowledge of its pathogenesis is scarce.

Chronic pancreatitis and exocrine insufficiency

The evaluation, management, and follow-up of patients with chronic pancreatitis (CP) can be simple, but it can also be complex, so having a good referral network of subspecialists experienced in this field is essential. Identifying the cause of CP requires a systematic review of the many potential causes when the cause is not obvious. The identification of patients with autoimmune CP is particularly important because treatment with steroids may be effective. Alterations in pain or other symptoms in patients with CP should not be attributed to worsening disease before evaluations for complications including malignancy are done.

Recurrent and relapsing pancreatitis

Recurrent acute pancreatitis is a common clinical problem. Most cases of pancreatitis are identified by a careful history and physical examination. Despite advanced evaluation, the cause is not apparent in about 10% of cases. The etiology of recurrent acute pancreatitis appears to be multifactorial, with genetic and environmental influences playing a significant role. The strength of evidence for certain etiologies is highly variable, and natural history data are limited. Controversy exists regarding the most appropriate diagnostic and therapeutic approach. Recurrent acute pancreatitis often represents a continuum with chronic pancreatitis.

Prospective comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the etiological diagnosis of "idiopathic" acute pancreatitis

OBJECTIVES

The objectives of the study were to compare endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in the etiological diagnosis of patients initially diagnosed with idiopathic acute pancreatitis and to determine the clinical and analytical factors related to the end result of these techniques.

METHODS

Forty-nine patients, initially diagnosed with idiopathic acute pancreatitis, were evaluated prospectively with EUS and MRCP. Diagnoses were compared between the 2 procedures. The clinical-evolutionary characteristics of these patients with regard to the results obtained with these techniques were compared.

RESULTS

In twenty-eight patients (57%), EUS and/or MRCP diagnosed at least 1 possible cause of acute pancreatitis. The diagnostic yield of EUS was higher than that of MRCP (51% vs 20%; P = 0.001). Cholelithiasis and biliary sludge (24%) were the most frequent EUS diagnoses, and pancreas divisum (8%) was the most frequent MRCP diagnosis. Only in 3 cases (6%) did MRCP identify additional features in patients etiologically undiagnosed using EUS. The EUS yield was lower in patients who had a previous cholecystectomy (11% vs 60%; P = 0.008).

CONCLUSIONS

Endoscopic ultrasonography and MRCP are useful techniques in the etiological diagnosis of acute pancreatitis of nonestablished cause. Endoscopic ultrasonography should be preferred for establishing a possible biliary etiology in patients who have not had a cholecystectomy.

Recurrent acute pancreatitis: clinical profile and an approach to diagnosis

BACKGROUND AND AIMS

Though recurrent acute pancreatitis is often seen in clinical practice, there are few comprehensive articles on this entity. The aim of this study therefore was to assess the etiological and clinical profile as well as diagnostic yield of non-invasive and invasive tests in this group of patients.

METHODS

All patients with recurrent acute pancreatitis seen from 2002 to 2007 were included in the study, retrospectively. Clinical information, investigation, and treatment data were collected for all patients by a standardized review of medical charts. Diagnostic tests were grouped into level one (non-invasive) and level two (invasive) tests and their yield was assessed. Comparison was made between the group with known etiology and idiopathic group to look for significant differences.

RESULTS

A total of 188 patients with recurrent acute pancreatitis were seen during the study period. Common etiological factors were biliary disease (37%), pancreas divisum (8.5%) and alcohol (6.4%). Multiple etiologies were seen in 7% of cases, and no cause was found in 32.4%. The diagnostic yield of level-one investigation (non-invasive) was 29.3%. Level-two tests (invasive) identified presumptive etiologies in 38.3% of cases. Complications developed in 12.2% and there was no mortality. Clinical features and complications were similar in the idiopathic group and those with known etiology.

CONCLUSIONS

Etiological diagnosis was obtained in 67.6% of patients after comprehensive diagnostic work up. Diagnosis in the majority of patients could only be reached after invasive tests (bile crystal analysis, EUS, ERCP). Early diagnosis and etiology-based therapy is the key to optimum patient outcome.

Connections between genetics and clinical data: Role of MCP-1, CFTR, and SPINK-1 in the setting of acute, acute recurrent, and chronic pancreatitis

OBJECTIVES

Acute, acute recurrent, and chronic pancreatitis are inflammatory diseases with multifactorial pathogenic mechanisms. Genetic mutations and polymorphisms have been correlated with pancreatitis. The aim of this study was to investigate the association of cystic fibrosis transmembrane conductance regulator (CFTR) and serine protease inhibitor Kazal type 1 (SPINK-1) gene mutations and monocyte chemoattractant protein 1 (MCP-1) -2518A/G polymorphism with acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis (CP), and to associate genetic backgrounds with clinical phenotype in these three conditions.

METHODS

One hundred eighteen AP, 64 ARP, 142 CP patients, and 88 normal controls were enrolled consecutively. We analyzed MCP-1 serum levels using enzyme-linked immunosorbent assay. Polymorphism -2518 of MCP-1 and SPINK-1 N34S gene mutations were determined by PCR-restriction-fragment length polymorphism. Sequence analysis was performed when necessary. Thirty-three CFTR mutations were analyzed in CP and ARP patients using multiplex DNA testing.

RESULTS

Serum MCP-1 levels were significantly higher in all patients affected by pancreatic inflammatory diseases. Moreover, we found a significant over-representation of the MCP-1G allele in ARP patients. We found a statistically significant association of CFTR gene mutations with ARP, but not with CP. We did not find a statistically significant association of ARP or CP with the N34S SPINK-1 gene mutation. Interestingly, 39 of 64 ARP patients (61%) carried at least one genetic mutation and/or polymorphism. Five of 64 ARP patients had pancreas divisum and four of these five also carried the G allele.

CONCLUSIONS

Analysis of a comprehensive range of potential susceptibility variants is needed to support modeling of the effects of genes and environment in pancreatitis. As such, beyond gene mutations, the context within which those mutations exist must be considered. In pancreatitis the context includes the inflammatory response, clinical features, and exogenous factors.

Investigation of Oddi sphincter structure by optical coherence tomography in patients with biliary-type 1 dysfunction: a pilot in vivo study

BACKGROUND

Type 1 sphincter of Oddi dysfunction is a clinical entity characterised by biliary-type pain, elevated liver biochemical tests, and common bile duct dilation. Sphincter fibrosis is a common finding in this type of dysfunction and may require in some cases a differential diagnosis with a malignant intra-papillary disease. Optical coherence tomography permits high-resolution, real-time imaging of the sphincter of Oddi microstructure by a probe inserted into the common bile duct through an ERCP catheter. No data exist on the evaluation of sphincter of Oddi fibrosis by optical coherence tomography during ERCP in vivo.

OBJECTIVE

To assess the feasibility of optical coherence tomography investigation of the sphincter of Oddi structure and assess its potential for diagnosing type 1 sphincter of Oddi dysfunction.

PATIENTS

Ten consecutive patients, five with biliary-type 1 sphincter of Oddi dysfunction and five with pancreatic head/mid-body adenocarcinoma not involving the papillary region, who underwent both endoscopic ultrasound and therapeutic ERCP, were investigated by optical coherence tomography immediately before biliary sphincterotomy or stenting.

RESULTS

In all sphincter of Oddi dysfunction patients optical coherence tomography recognised a hyper-reflective intermediate, fibro-muscular layer, significantly thicker than in patients with non-pathological sphincter of Oddi (p<0.0001).

CONCLUSIONS

Optical coherence tomography imaging recognised an increased thickness and reflectance of the fibro-muscular layer of the sphincter of Oddi, very likely determined by fibrosis, and was not time-consuming; it can be safely used during ERCP to confirm the diagnosis in difficult cases. Its use in clinical practice has one important limitation since it requires magnification in the post-procedure computer analysis to obtain images useful for diagnosis.

Diagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology

BACKGROUND

Magnetic resonance cholangio-pancreatography (MRCP), endoscopic ultrasonography (EUS), and endoscopic cholangio-pancreatography (ERCP) are the most frequently employed second-step procedures to detect biliary and pancreatic abnormalities in patients with acute recurrent pancreatitis (ARP) of unknown aetiology. MRCP and EUS both give a better view of the bilio-pancreatic ductal system after secretin stimulation (MRCP-S, EUS-S). EUS also serves to identify changes in the pancreatic parenchyma consistent with chronic pancreatitis, at an early stage. However, no studies have compared MRCP-S, EUS-S, and ERCP in the diagnosis of recurrent pancreatitis.

AIM

To prospectively compare the diagnostic yield of MRCP-S, EUS-S, and ERCP in the evaluation of patients with acute recurrent pancreatitis with non-dilated ducts, of unknown aetiology.

METHODS

Forty-four consecutive patients with ARP were prospectively scheduled to undergo MRCP-S, EUS-S and ERCP, in accordance with a standard protocol approved by the institutional review board. Diagnoses such as biliary microlithiasis, congenital variants of the pancreatic ducts, chronic pancreatitis and sphincter of Oddi dysfunction were compared between the three procedures. The diagnosis of chronic pancreatitis was established according to ductal morphology by MRCP-S and ERCP, ductal and parenchymal morphology by EUS-S.

RESULTS

The three procedures combined achieved a diagnosis that could have explained the recurrence of pancreatitis in 28/44 patients (63.6%). EUS-S recognized ductal and/or parenchymal abnormalities with the highest frequency (35/44 patients, 79.5%). Both MRCP-S and EUS-S were superior to ERCP for detecting pancreatic ductal abnormalities. EUS-S showed up pancreatic parenchymal changes in more than half the cases. Both EUS and MRCP secretin kinetics were concordant in identifying two cases with sphincter of Oddi dysfunction.

CONCLUSIONS

The diagnostic yield of EUS-S in recurrent pancreatitis with non-dilated ducts and unknown aetiology was 13.6% and 16.7% higher than MRCP-S and ERCP respectively (although not significant), which both gave substantially similar diagnostic yields. In no case did ERCP alone find a diagnosis missed by the other two procedures. MRCP-S and EUS-S should both be used in the diagnostic work-up of idiopathic recurrent pancreatitis as complementary, first-line, techniques, instead of ERCP.

Therapeutic effect of pancreas clearing tablets (Qingyi pian) on severe acute pancreatitis

AIM: To explore the therapeutic effect of pancreatic clearance pills (Qingyi pian) on severe acute pancreatitis.

METHODS: From January 1997 to December 2007, 272 cases of severe acute pancreatitis were randomly divided into traditional Chinese medicine group and control group. Their recurrence and nutritional status were recorded.

RESULTS: The 1-year AP recurrence rate after discharge was 46.3% (126/272). The 1-year AP recurrence rate of the Chinese medicine group was significantly lower than that of the control group (39.9% vs 53.0%, P < 0.05). Nutritional damage score at 6 and 12 mo after discharge was significantly lower in Chinese herb group than in the control group (t = 2.23, 2.77, P < 0.05 or 0.01).

CONCLUSION: Use of pancreatic clearance pills within the first 3 months after discharge reduces long-term AP recurrence rate and improves nutritional status for SAP patients.

Cystic fibrosis transmembrane conductance regulator ion channel function testing in recurrent acute pancreatitis

GOALS

To understand the relationship between acute recurrent pancreatitis and cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction.

BACKGROUND

An emerging number of patients present with a nonclassic phenotype of cystic fibrosis (CF) with partial features or single-organ disease only. The association between the phenotype of recurrent pancreatitis CFTR dysfunction is unclear.

METHODS

Patients with idiopathic recurrent pancreatitis were referred for electrophysiologic investigation.

RESULTS

Thirty-three patients (18 males) aged 20+/-12 years with recurrent pancreatitis were studied. Three patients had mild asthma and 1 patient had mild ulcerative colitis. There was no family history of CF. All patients had normal imaging of the pancreatic duct by endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. No patient was pancreatic insufficient. Mean sweat chloride values were 41+/-14 meq/L (range: 18 to 64). Nasal potential difference (NPD) measurement was pathologic in 7 patients. Mean basal potential difference in these 7 patients was -33+/-13 mV and there was an abnormal response to chloride-free and isoproterenol solutions. There was no difference in sweat chloride concentration between the 2 groups. Mutation analysis revealed W1282X/5T, D1152H/5T, and W1282X/- in 3 patients with abnormal NPD and 1 W1282X allele was found in 1 patient with normal NPD.

CONCLUSIONS

In this series, 21% of patients with recurrent pancreatitis have abnormalities of CFTR function. Patients presenting with recurrent, "idiopathic" pancreatitis require CFTR function testing.

MRCP-secretin test-guided management of idiopathic recurrent pancreatitis: long-term outcomes

BACKGROUND

In patients with recurrent pancreatitis of unknown etiology and nondilated ducts, accurate morphofunctional evaluation of the pancreaticobiliary ductal system and sphincter of Oddi function is important in the diagnostic workup. However, ERCP and sphincter of Oddi manometry may be nondiagnostic and postprocedure complications may be frequent.

OBJECTIVE

Our purpose was to assess the diagnostic accuracy of the magnetic resonance cholangiopancreatography with secretin test (MRCP-S) in patients with recurrent acute pancreatitis of unknown etiology. Accuracy was established on the basis of ERCP findings and a minimum of 24 months' clinical follow-up.

DESIGN

Thirty-seven consecutive patients with intact gallbladder and a nondilated pancreaticobiliary ductal system with nonpathologic EUS findings entered a prospective MRCP-S-guided and ERCP-guided diagnostic and therapeutic study protocol.

RESULTS

Patients were followed up for a mean of 31.3 months (range 26-38 months). MRCP-S identified some pancreatic outflow impairment, suggesting morphofunctional dysfunction of either the major or minor papilla, in 12 of 37 patients (32.4%). The addition of ERCP to MRCP-S did not substantially improve the diagnostic yield for the etiology of recurrent pancreatitis, and 13.6% of cases had mild postprocedure pancreatitis. The S-test was abnormal in 12 of 20 cases (60%) in whom some dysfunction of the sphincter of Oddi or minor papilla was assumed on the basis of follow-up findings. The outcome was successful after biliary or pancreatic sphincterotomy in all patients with an abnormal S-test result. Sensitivity, specificity, and positive and negative predictive values of the S-test for the diagnosis of pancreatic outflow impairment at the major or minor papilla were, respectively, 57.1%, 100%, 100%, and 64%. When the test showed an abnormal result, we were unable to distinguish between biliary and pancreatic segment dysfunction of the sphincter of Oddi.

CONCLUSIONS

In idiopathic recurrent pancreatitis with nondilated ducts, the MRCP-S-guided approach gave diagnostic accuracy comparable to ERCP with regard to morphologic lesions, and it can be used as an alternative, avoiding ERCP-related complications in the diagnostic phase. An abnormal S-test result showed an excellent positive predictive value and somewhat disappointing negative predictive value for sphincter of Oddi or minor papilla dysfunction and for clinical success of therapeutic endoscopic approach.

Pancreatic ductal system obstruction and acute recurrent pancreatitis

Acute recurrent pancreatitis is a clinical entity largely associated with pancreatic ductal obstruction. This latter includes congenital variants, of which pancreas divisum is the most frequent but also controversial, chronic pancreatitis, tumors of the pancreaticobiliary junction and sphincter of Oddi dysfunction. This review summarizes current knowledge about diagnostic work-up and therapy of these conditions.

Epidemiology, aetiology and outcome of acute and chronic pancreatitis: An update

Over the past decades several epidemiological studies have been published reporting on incidence trends, hospital admissions, etiological factors and outcome of both acute and chronic pancreatitis. Over time, the incidence of acute pancreatitis has increased in the Western countries. Also, the number of hospital admissions for both acute and chronic pancreatitis have increased. These upward time trends possibly reflect a change in the prevalence of main etiological factors (e.g. gallstones and alcohol consumption) and cofactors such as obesity and genetic susceptibility. Acute and chronic pancreatitis are associated with significant morbidity and mortality and a substantial use of health care resources. Although the case-fatality rate of acute pancreatitis decreased over time, the overall population mortality did not change for both acute and chronic pancreatitis. This chapter will focus on recent developments in the epidemiology, aetiology, natural course and outcome of both acute and chronic pancreatitis.

Review of idiopathic pancreatitis

Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.

Effect of ethanol on inflammatory responses. Implications for pancreatitis

BACKGROUND/AIMS

Alcohol use alters inflammatory cell responses. While alcohol has direct effects on pancreatic acinar cells, activation of inflammatory cells is a major component of the pathology of alcoholic pancreatitis.

METHODS

The effects of acute or chronic alcohol exposure were evaluated in human monocytes on the production of TNFalpha or IL-10 production, pro-inflammatory gene and nuclear factor-kappaB (NF-kappaB) activation.

RESULTS

Moderate, acute alcohol consumption or equivalent doses of alcohol in vitro had anti-inflammatory effects on monocyte activation via inhibition of pro-inflammatory genes and NF-kappaB activation, inhibition of TNFalpha production and augmentation of the anti-inflammatory cytokine, IL-10. In contrast, acute alcohol treatment augmented NF-kappaB activation and TNFalpha production and inhibited IL-10 levels in the presence of complex stimulation with combined TLR2 and TLR4 ligands. Prolonged alcohol exposure also resulted in an increase in NF-kappaB and TNFalpha production in response to TLR4 stimulation with LPS.

CONCLUSION

These results suggest that alcohol can either attenuate or promote inflammatory responses that are critical in pancreatitis. Our results support the hypothesis that both acute alcohol intake in the presence of complex stimuli (such as necrotic cells) and chronic alcohol exposure result in hyper-responsiveness of monocytes to inflammatory signals and may contribute to increased inflammation in pancreatitis.

Pathobiology of alcoholic pancreatitis

This paper provides a summary of the effects of alcohol abuse on the pathobiologic responses that occur during acute and chronic pancreatitis considering both the human disease and animal/tissue models. The effects are multiple and include ones on cell death leading to necrosis; on inflammation resulting in a sensitized response to pancreatic stress; and fibrosis through effects of ethanol on pancreatic stellate cells and the plasminogen system. Although the effects of alcohol are multiple and complex, it is likely that a combination of a few key effects on these pathobiologic responses drive the increased sensitivity of the pancreas to acute pancreatitis with pancreatic stress and the promotion of chronic pancreatitis with pancreatic injury occurring during acute pancreatitis.

Acute alcohol activates STAT3, AP-1, and Sp-1 transcription factors via the family of Src kinases to promote IL-10 production in human monocytes

Alcohol consumption is associated with an imbalance in pro- and anti-inflammatory cytokines and immunosuppression, partially as a result of enhanced IL-10 production. The mechanisms of IL-10 induction by alcohol remain poorly understood. We identified that increased IL-10 production in human monocytes after acute in vivo alcohol consumption or in vitro alcohol treatment was associated with increased STAT3 activation. Alcohol alone induced and in combination with LPS augmented STAT3 phosphorylation at tyrosine 705 (tyr705) and serine 727 (ser727) residues and increased STAT3 binding to DNA. Upstream, alcohol activated the Src kinases, as indicated by an increase in phosphorylated and a decrease in nonphosphorylated Src proteins. STAT3 activation by Src kinases occurred directly at the tyr705 residue and indirectly at the ser727 residue via JNK MAPKs. Using specific Src (PP2), JNK1/2 (SB600125), or p38 (SB203580) inhibitors, we determined that alcohol treatment alone induced and together with LPS, augmented the DNA-binding capacity of the specificity protein-1 (Sp-1) and AP-1 transcription factors involved in IL-10 production via Src-mediated activation of p38 MAPK and JNK, respectively. Our data suggest that acute alcohol activates Src/STAT3 and Src/MAPK/STAT3, AP-1, and Sp-1 pathways as important mechanisms for IL-10-mediated immunomodulation after acute alcohol use.

Disialotransferrin, determined by capillary electrophoresis, is an accurate biomarker for alcoholic cause of acute pancreatitis

OBJECTIVES

Serum disialotransferrin is a specific marker of heavy alcohol consumption. We tested its accuracy and probability in detecting alcoholic cause of acute pancreatitis (AP).

METHODS

Blood samples from 271 consecutive AP patients, admitted to the Helsinki University Central Hospital emergency unit, were analyzed.

RESULTS

The median (range) disialotransferrin value was significantly higher (P = 0.001) in AP patients with alcoholic (n = 172) 1.6% (0.3%-14.4) than with biliary (n = 60) 0.7% (0.3%-1.3%) or other causes (n = 39) 0.8% (0.3%-4.1%). In receiver operating curve analysis, disialotransferrin, as a single analyte, was significantly (P = 0.001-0.0001) more accurate (area under the curve [AUC], 0.88; 95% confidence interval [CI], 0.84-0.92) in detecting alcoholic AP as compared with glutamyl transferase (AUC, 0.51; 95% CI, 0.45-0.57), aspartate aminotransferase (AUC, 0.57; 95% CI, 0.51-0.63), alanine aminotransferase (AUC, 0.63; 95% CI, 0.57-0.69), erythrocyte mean cell volume (AUC, 0.72; 95% CI, 0.67-0.78), amylase (AUC, 0.74; 95% CI, 0.67-0.78), C-reactive protein (AUC, 0.65; 95% CI, 0.59-0.71), and bilirubin (AUC, 0.55; 95% CI, 0.49-0.62). At a disialotransferrin cutoff of 1.2%, giving an 8% false-positive rate, the positive likelihood ratio was 8.47. Thus, a positive disialotransferrin test result, performed within 24 hours of admission, increased the probability of alcoholic AP from pretest 64% to posttest 94%.

CONCLUSIONS

Disialotransferrin, determined by capillary electrophoresis, is accurate, simple, and a rapid single biomarker of the alcoholic cause of AP.

Analysis of clinical features of acute pancreatitis in Shandong Province, China

AIM

To investigate and obtain a more comprehensive view of the etiology and clinical features of acute pancreatitis in China.

METHOD

The study comprised 1471 patients in 10 cites of China who were admitted to hospitals for acute pancreatitis from January 1992 to December 2002. Data for each patient were collected on a standardized form.

RESULTS

Of the 1471 patients (854 men, 617 women; mean age 43.3 years; range 13-82 years), 1280 had mild pancreatitis and 191 had the severe form. Cholelithiasis (20.2%), alcohol (17.3%) and diet-induced (12.4%) were the most frequent etiological factors, followed by biliary tract infections (5.6%), hyperlipidemia (2.3%) and other factors (5.1%). However, in about 36.1% of cases, the etiology of acute pancreatitis still remained unexplained. In coastal regions, cholelithiasis was the most frequent factor but alcohol ranked first in interior regions. In males, a small predominance of alcohol over cholelithiasis was seen (27.4%vs 14.3%) and there was a clear predominance of cholelithiasis over alcohol (28.4%vs 3.2%) in females. The differences in the frequency of cholelithiasis and alcohol between coastal regions and interior regions and males and females were statistically significant (P < 0.01). According to their frequency, complications of acute pancreatitis were pancreatic pseudocyst, pancreatic ascites and bacterial peritonitis, pulmonary infections, multiple organ failure, diabetes mellitus type 2 and shock.

CONCLUSION

Cholelithiasis, alcohol and diet-induced factors were the main etiological factors seen in China, whereas cholelithiasis alone predominated in females and alcohol ranked first in males. In about 36.1% of cases, the etiology of acute pancreatitis remained unknown. More attention should be paid to studying the etiologies of acute pancreatitis that remain unknown.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of the clinical features of recurrent acute pancreatitis in China

BACKGROUND

Since few systematic studies have focused on recurrent acute pancreatitis in China, we sought to investigate its clinical features, including etiological factors and relative frequency.

METHODS

Patients were selected from a total 1471 patients with acute pancreatitis in ten cities of China. All had been admitted to a hospital with an attack of acute pancreatitis between January 1992 and December 2002. Data for each patient was recorded on a standardized form.

RESULTS

Of the 1471 patients with acute pancreatitis, 157 (10.7%) had recurrent acute pancreatitis. The majority (63%) were male, with a mean age of 41 years (range, 13-82 years). Regarding the etiology, alcohol (20.4%) and cholelithiasis (20.4%) were the most frequent causes, followed by diet (13.4%), hypertriglyceridemia (8.3%), biliary tract infection (5.7%), other (5.1%), and idiopathic factors (26.8%). Alcohol was most frequent in male patients (30.3%), whereas cholelithiasis was most frequent (34.5%) in female patients. The majority of patients (79.6%) presented with their second attack of pancreatitis. Complications of recurrent acute pancreatitis in order of frequency were pancreatic pseudocyst, multiple organ failure, diabetes mellitus type 2, and shock.

CONCLUSIONS

Recurrent acute pancreatitis remains a frequent disease, with cholelithiasis and alcohol being the most usual etiological factors. Alcohol is the primary etiological factor in male patients. In about 26.8% of cases, the etiology remains unknown.

Role of endoscopic evaluation in idiopathic pancreatitis: a systematic review

In approximately 20% of patients with acute pancreatitis, a cause is not established by history, physical examination, routine laboratory testing, and abdominal imaging. For those with a single unexplained attack, the role of invasive evaluation with endoscopic retrograde cholangiopancreatography is unsettled but has been generally limited to those patients with suspected bile duct stones or malignancy. Recent studies suggest that microlithiasis is causative in up to 75% of patients with an unexplained attack and gallbladder in situ, whereas sphincter of Oddi dysfunction is most prevalent in those with recurrent attacks who have previously undergone cholecystectomy. EUS has been shown to be highly accurate for the identification of gallbladder sludge, common bile duct stones, and pancreatic diseases. Given this apparent diagnostic utility, an EUS-based strategy may be a reasonable approach to evaluate patients with a single idiopathic attack. ERCP and sphincter of Oddi manometry should generally be reserved for patients with multiple unexplained attacks and negative EUS results, especially for those patients who have previously undergone cholecystectomy.