Clinical significance of ultrasonography, computed tomography, and biochemical tests in the rapid diagnosis of gallstone-related pancreatitis: a prospective study

Usefulness of Endoscopic Retrograde Cholangiopancreatography (ERCP)-Related Procedures for Gallstone Pancreatitis

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are said to be useful procedures for gallstone pancreatitis. However, there have been few reports on a large number of patients to whom they were used. The clinical usefulness of ERCP and EST is herein examined retrospectively.

METHODS

ERCP and EST were performed to evaluate their clinical usefulness and safety in 108 patients who had gallbladder stones from December 1985 to October 2017 and were diagnosed as having gallstone pancreatitis. Of 108 patients, 83 were mild, and 25 were severe. Following the procedures, clinical courses were observed for three years in 108 patients who underwent the treatments.

RESULTS

Cholangiogram was successfully conducted in 108 patients. Bile duct stones were noted in 90 patients, and the stones were removed after EST. Of 18 patients who did not show bile duct stone in cholangiogram, 13 patients underwent EST, while five patients taking anticoagulants completed procedures only with cholangiogram. Accidental symptom was hemorrhage in three patients (2.7%; 3/108), but it was mild and conservatively resolving. During the three-year observation period, acute cholangitis was noted in three patients (2.7%; 3/108), but no relapsing pancreatitis was noted.

CONCLUSIONS

It was suggested that ERCP and EST could be useful therapies for gallstone pancreatitis.

Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.

Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.

Multidisciplinary Management of Complicated Pancreatitis: What Every Interventional Radiologist Should Know

Management of acute pancreatitis is challenging in the presence of local complications that include pancreatic and peripancreatic collections and vascular complications. This review, targeted for interventional radiologists, describes minimally invasive endoscopic, image-guided percutaneous, and surgical procedures for management of complicated pancreatitis and provides insight into the procedures' algorithmic application. Local complications are optimally managed in a multidisciplinary team setting that includes advanced endoscopists; pancreatic surgeons; diagnostic and interventional radiologists; and specialists in infectious disease, nutrition, and critical care medicine. Large symptomatic or complicated sterile collections and secondary infected collections warrant drainage or débridement. The drainage is usually delayed for 4-6 weeks unless clinical deterioration warrants early intervention. If collections are accessible by endoscopy, endoscopic procedures are preferred to avoid pancreaticocutaneous fistulas. Image-guided percutaneous drainage is indicated for symptomatic collections that are not accessible for endoscopic drainage or that present in the acute setting before developing a mature wall. Peripancreatic arterial pseudoaneurysms should be embolized before necrosectomy procedures to prevent potentially life-threatening hemorrhage. Surgical procedures are reserved for symptomatic collections that persist despite endoscopic or interventional drainage attempts. Understanding these procedures facilitates their integration by interventional radiologists into the complex longitudinal care of patients with complicated pancreatitis.

Pearl-white gallstones: A report of a case and a chemical analysis by FTIR and XRD

Introduction

Gallstones' color is usually yellow, brown, black or more commonly a mixture of two or more of these colors in different proportions, depending on their composition, with yellow being the most commonly encountered color. Pearl-white gallstones are a very rare entity that has not been studied and reported sufficiently.

Case presentation

Our patient is a 44-year-old lady who was suffering from recurrent attacks of epigastric and right hypochondrial abdominal pain that was aggravated by consumption of fatty meals. Ultrasound Imaging revealed multiple gallbladder stones. After an elective cholecystectomy unusual pearl-white gallstones were found inside a distended gallbladder filled with transparent thick fluid.

Chemical analysis

To evaluate the chemical composition of these stones Fourier-transform infrared (FTIR) spectroscopy and X-Ray Diffraction (XRD) tests were performed and revealed that these stones are composed of cholesterol (99.6%) and calcium carbonate (0.4%).

Discussion

Gallstones are bile depositions of a solid consistency formed inside the gallbladder. Cholesterol, bilirubin, and other substances are involved in the composition of different kinds of gallstones. The presence of gallstones alone inside the gallbladder is usually presented as colicky abdominal pain. Cholecystectomy is a simple surgical removal of the gallbladder from it bed and is the definitive treatment of gallstone disease.

Conclusion

Pearl-white gallstones are rarely encountered and lack information about their pathogenesis, thus prompting further evaluation and studying.

•

Pearl-white coloration of gallstones in extremely rare.

•

FTIR and XRD are useful tools to analyze the chemical composition of gallstones.

•

Cholesterol is the major component of pearl-white gallstones.

Dyslipemias and pregnancy, an update

During pregnancy there is a physiological increase in total cholesterol (TC) and triglycerides (TG) plasma concentrations, due to increased insulin resistance, oestrogens, progesterone, and placental lactogen, although their reference values are not exactly known, TG levels can increase up to 300mg/dL, and TC can go as high as 350mg/dL. When the cholesterol concentration exceeds the 95^th percentile (familial hypercholesterolaemia (FH) and transient maternal hypercholesterolaemia), there is a predisposition to oxidative stress in foetal vessels, exposing the newborn to a greater fatty streaks formation and a higher risk of atherosclerosis. However, the current treatment of pregnant women with hyperlipidaemia consists of a diet and suspension of lipid-lowering drugs. The most prevalent maternal hypertriglyceridaemia (HTG) is due to secondary causes, like diabetes, obesity, drugs, etc. The case of severe HTG due to genetic causes is less prevalent, and can be a higher risk of maternal-foetal complications, such as, acute pancreatitis (AP), pre-eclampsia, preterm labour, and gestational diabetes. Severe HTG-AP is a rare but potentially lethal pregnancy complication, for the mother and the foetus, usually occurs during the third trimester or in the immediate postpartum period, and there are no specific protocols for its diagnosis and treatment. In conclusion, it is crucial that dyslipidaemia during pregnancy must be carefully evaluated, not just because of the acute complications, but also because of the future cardiovascular morbidity and mortality of the newborn child. That is why the establishment of consensus protocols or guidelines is essential for its management.

Quality of Care Indicators in Patients with Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common and expensive condition. Improving quality of care in AP is vital to minimizing cost and improving patient outcomes. However, there has been little work accomplished toward developing and validating explicit quality indicators (QIs) in AP.

AIMS

To define quality of care in patients with AP by developing explicit QIs using standardized techniques.

METHODS

We used the UCLA/RAND Delphi panel approach to combine a comprehensive literature review with the collective judgment of experts to identify a defined set of process measures for AP.

RESULTS

We produced 164 candidate QIs after a comprehensive literature review. After Delphi review, 75 had a median rating ≥ 7. We excluded 11 QIs where the disagreement index exceeded 1.0 and combined indicators overlapping in content to produce a final list of 22 QIs. Overall, 8 QIs related to diagnosis, prevention, or determination of etiology, 2 QIs focused on determination of severity, 3 QIs captured fluid resuscitation, 2 QIs measured nutrition, 1 QI use of antibiotics, and 6 QIs captured endoscopic or surgical management.

CONCLUSIONS

We have developed 22 QIs spanning the spectrum of AP management including diagnosis, risk stratification, and pharmacological and endoscopic therapy. These QIs will facilitate future quality improvement by practitioners and organizations who treat patients with AP and further identify areas that are amenable to improvement to enhance patient care. We anticipate that this QI set will represent the first step in determining a framework for demonstrating value in the care of patients with AP.

Critical Care Aspects of Gallstone Disease

Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals. This review deals with the important critical care aspects associated with a gallstone-related disease.

Predictive biomarkers for acute gallstone pancreatitis in the pediatric population

BACKGROUND

Early biomarkers for diagnosis of gallstone pancreatitis (GP) in pediatrics have not been well studied. Reliably differentiating GP from other causes of acute pancreatitis (AP) would allow for early diagnosis and prompt management. We sought to assess biomarkers and clinical variables for early GP diagnosis from a prospectively-enrolled registry of pediatric patients presenting with first AP episode.

METHODS

Cross-sectional analysis of a prospective acute pancreatitis registry of children enrolled from March 2013 through October 2016 was performed. Fisher's exact test and Wilcoxon rank sum test were used to compare demographic and clinical variables between GP and non-GP groups. A multivariable logistic regression model was derived, and receiver operating characteristic (ROC) curve was built using stepwise selection.

RESULTS

114 subjects were enrolled (21 with GP, 93 as non-GP). Median was statistically higher for GP patients in lipase values X upper limit of normal (ULN) on admission, weight percentile for age, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase. By multivariable analysis, significant predictors were ALT and Lipase xULN. A model built using these two variables for prediction of GP identified an AUROC of 0.85. At a predictive probability of 0.35, the model had an 80% sensitivity, 93% specificity, 76% positive predictive value and 95% negative predictive value.

CONCLUSIONS

We have developed a model for predicting GP in children that could help guide clinical management of AP patients. Future studies are needed to validate use of laboratory findings and clinical variables in evaluation of gallstone etiology in pediatric AP patients.

Repeated transabdominal ultrasonography is a simple and accurate strategy to diagnose a biliary etiology of acute pancreatitis

OBJECTIVES

Transabdominal ultrasonography (US) usually reveals diagnosis of biliary acute pancreatitis (AP). Guidelines suggest repeating US in AP patients without cause at first examination. This approach has been poorly investigated, as well as the accuracy of repeated US as compared with that of magnetic resonance cholangiopancreatography. This study aims at evaluating the diagnostic accuracy of repeated US for biliary AP.

METHODS

The accuracy of each test for diagnosis of biliary AP was evaluated according to the final diagnosis. Comparison between tests was obtained by examining the areas under the receiver operating characteristic curves.

RESULTS

Among 155 patients, the etiology was biliary in 52% and alcoholic in 20%. The accuracy of the first US alone and of the 2 combined examinations for a biliary etiology were 66% and 83%, respectively. Comparison of receiver operating characteristic curves showed a better performance of repeated US (difference between areas under the curve, 0.135; 95% confidence interval, 0.02-0.24; P = 0.021). Magnetic resonance cholangiopancreatography had high specificity (93%) but low sensitivity (62%), with 76% accuracy. The accuracy of the combination of the 2 US examinations and of elevated alanine transferase was 87%.

CONCLUSIONS

Repeated US is effective for biliary AP diagnosis. The combination of repeated US examinations and biochemical tests seems an effective approach, whereas magnetic resonance cholangiopancreatography might be restricted to selected cases.

Does the presence of obesity and/or metabolic syndrome affect the course of acute pancreatitis?: A prospective study

OBJECTIVE

The incidence of acute pancreatitis (AP) is rising with increased prevalence of obesity, which exacerbates pancreatic injury. Metabolic syndrome (MS) is defined as a cluster condition of cardiovascular risk factors, including hyperglycemia, dyslipidemia, hypertension, and central obesity. We analyze if the presence of obesity and/or MS affects the course of pancreatitis.

METHODS

Data were collected from 140 patients with AP between January 2010 and February 2013. Anthropometric data, including body mass index and waist circumference, were measured. Biochemical tests were used including fasting glucose, triglyceride, low- and high-density lipoprotein cholesterol levels, and total cholesterol level. Atlanta criteria, Acute Physiology and Chronic Health Evaluation II, and Ranson scoring system were used to define severe AP. Patients were classified as having MS based on the International Diabetic Federation criteria.

RESULTS

The mean body mass index was 30.15 kg/m(2). Sixteen (11.4%) patients had severe AP, whereas 124 (88.6%) patients had mild AP. We found that 62.8% of patients with AP fulfilled the criteria of MS (P = 0.000). Body weight can be used to predict clinical severity of AP with significant P value (P = 0.009).

CONCLUSIONS

The presence of MS in patients with pancreatitis is noticeable, but it does not affect the course of disease severity, whereas obesity correlates with pancreatitis severity.

Gallstone pancreatitis: a review

Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.

Endoscopic management of acute biliary pancreatitis

Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to severe acute illness with a significant risk of death. Urgent endoscopic treatment of acute pancreatitis is considered when there is causal evidence of biliary pancreatitis. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.

Acute pancreatitis in pregnancy: review of three cases and anaesthetic management

Acute pancreatitis is rare in pregnancy, with an estimated incidence of 1 in 1000-3000 pregnancies. Gallstones are the commonest cause. Mortality and morbidity associated with pancreatitis have declined as diagnosis and management options improve. Presentation usually occurs in the third trimester or early postpartum period with severe epigastric pain, nausea, vomiting, anorexia and fever. Blood investigations show an elevated white cell count and increased liver enzyme concentrations. Ultrasound is safe but has lower sensitivity than computerised tomography for detecting gallstones. Management during pregnancy has traditionally been conservative, followed by cholecystectomy after delivery. Recurrence of pancreatitis during pregnancy may necessitate more urgent surgery. The second trimester is considered the safest for surgery, with early involvement of intensive care as the condition can deteriorate rapidly. We present three cases managed in our unit over a six-month period that illustrate the spectrum of disease and the successful use of a multidisciplinary team approach.

Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis

BACKGROUND

The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis remains controversial. A number of clinical trials and meta-analyses have provided conflicting evidence.

OBJECTIVES

To systematically review evidence from randomized controlled trials (RCTs) assessing the clinical effectiveness and safety of the early routine ERCP strategy compared to the early conservative management with or without selective use of ERCP strategy, based on all important, clinically relevant and standardized outcomes including mortality, local and systemic complications as defined by the Atlanta Classification (Bradley 1993) and by authors of the primary study, and ERCP-related complications in unselected patients with acute gallstone pancreatitis.

SEARCH METHODS

We searched the CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and LILACS databases and major conference proceedings up to January 2012, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions.

SELECTION CRITERIA

RCTs comparing the early routine ERCP strategy versus the early conservative management with or without selective use of ERCP strategy in patients with suspected acute gallstone pancreatitis. We included studies in which the population with acute gallstone pancreatitis was a subgroup within a larger group of patients. We only included studies involving only a selected subgroup of patients with acute gallstone pancreatitis (actual severe pancreatitis) in subgroup analyses.

DATA COLLECTION AND ANALYSIS

Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test and I² statistic. To explore sources of heterogeneity, we conducted a priori subgroup analyses according to predicted severity of pancreatitis, cholangitis, biliary obstruction, time to ERCP in routine ERCP strategy, use of selective ERCP in conservative management strategy, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed versus random-effects), and per-protocol analysis. We performed influence analysis by exclusion of each study.

MAIN RESULTS

Five RCTs comprising 644 participants were included in the main analyses. Two additional RCTs, comprising only patients with actual severe acute gallstone pancreatitis, were included only in subgroup analyses. There was statistical heterogeneity among trials for mortality, but not for other outcomes. In unselected patients with acute gallstone pancreatitis, there were no statistically significant differences between the two strategies in mortality (RR 0.74, 95% CI 0.18 to 3.03), local and systemic complications as defined by the Atlanta Classification (RR 0.86, 95% CI 0.52 to 1.43; and RR 0.59, 95% CI 0.31 to 1.11 respectively) and by authors of the primary study (RR 0.80, 95% CI 0.51 to 1.26; and RR 0.76, 95% CI 0.53 to 1.09 respectively). The results were robust to sensitivity and influence analyses except for systemic complications as defined by the Atlanta Classification. There was no evidence to suggest that the results were dependent on predicted severity of pancreatitis. Among trials that included patients with cholangitis, the early routine ERCP strategy significantly reduced mortality (RR 0.20, 95% CI 0.06 to 0.68), local and systemic complications as defined by the Atlanta Classification (RR 0.45, 95% CI 0.20 to 0.99; and RR 0.37, 95% CI 0.18 to 0.78 respectively) and by authors of the primary study (RR 0.50, 95% CI 0.29 to 0.87; and RR 0.41, 95% CI 0.21 to 0.82 respectively). Among trials that included patients with biliary obstruction, the early routine ERCP strategy was associated with a significant reduction in local complications as defined by authors of the primary study (RR 0.54, 95% CI 0.32 to 0.91), and a non-significant trend towards reduction of local and systemic complications as defined by the Atlanta Classification (RR 0.53, 95% CI 0.26 to 1.07; and RR 0.56, 95% CI 0.30 to 1.02 respectively) and systemic complications as defined by authors of the primary study (RR 0.59, 95% CI 0.35 to 1.01). ERCP complications were infrequent.

AUTHORS' CONCLUSIONS

In patients with acute gallstone pancreatitis, there is no evidence that early routine ERCP significantly affects mortality, and local or systemic complications of pancreatitis, regardless of predicted severity. Our results, however, provide support for current recommendations that early ERCP should be considered in patients with co-existing cholangitis or biliary obstruction.

Incidence of acute pancreatitis does not increase during Oktoberfest, but is higher than previously described in Germany

BACKGROUND & AIMS

Increased alcohol consumption can lead to acute pancreatitis (AP). We investigated whether the incidence of alcohol-induced AP increased during the Munich Oktoberfest in 2008, at which 6.6 million liters of beer were sold within 16 days.

METHODS

We performed a multicenter, prospective study of 188 patients with AP (36.7% alcohol-induced, 34.6% biliary), treated at 27 hospitals in the greater area of Munich, Germany (2,970,000 inhabitants) during the 2008 Oktoberfest. Data were compared with that from two 18-day control periods.

RESULTS

During the Oktoberfest, the overall incidence of AP was 42.8/100,000 person-years, which is 117% higher than previously reported. The incidence of acute attacks of alcoholic pancreatitis (AAP) did not increase during the Oktoberfest, compared with control periods. AAP was independently associated with repeated episodes of AP (P = .001), high levels of chronic alcohol intake (P = .001), low body-mass index (P = .007), male gender (P = .033), and acute alcohol excess (P = .037). Biliary AP was associated with increased levels of alanine-aminotransferase and aspartate-aminotransferase (P = .003), old age (P = .014), and low levels of chronic alcohol intake (P = .032). Death (5/188 patients) was associated with baseline levels of blood urea nitrogen, receiver operating characteristic-area under the curve (ROC-AUC = 0.918), alkaline phosphatase (ROC-AUC = 0.861), and C-reactive protein (ROC-AUC = 0.855).

CONCLUSIONS

The incidence of AP does not increase during the Oktoberfest, compared with other time periods; the incidence of AP in Munich is higher than previously described in Germany. AAP was associated with long-term, heavy alcohol exposure rather than short-term, excessive alcohol drinking. Levels of blood urea nitrogen were associated with mortality.

Gallstone-induced acute pancreatitis

In the care of acute pancreatitis, a prompt search for the etiologic condition of the disease should be conducted. A differentiation of gallstone-induced acute pancreatitis should be given top priority in its etiologic diagnosis because it is related to the decision of treatment policy. Examinations necessary for diagnosing gallstone-induced acute pancreatitis include blood tests and ultrasonography. Early ERCP/ES should be performed in patients with gallstone-induced acute pancreatitis if a complication of cholangitis and a prolonged passage disorder of the biliary tract are suspected. The treatment for bile duct stones with the use of ERCP/ES alone is not recommended in cases of gallstone-induced pancreatitis with gallbladder stones. Cholecystectomy for gallstone-induced acute pancreatitis should be performed using a laparoscopic procedure as the first option as soon as the disease has subsided.

New diagnostic criteria of acute pancreatitis

Practical guidelines for the diagnosis of acute pancreatitis are presented so that a rapid and adequate diagnosis can be made. When acute pancreatitis is suspected in patients with acute onset of abdominal pain and tenderness mainly in the upper abdomen, the diagnosis of acute pancreatitis is made on the basis of elevated levels of pancreatic enzymes in the blood and/or urine. Furthermore, other acute abdominal diseases are ruled out if local findings associated with pancreatitis are confirmed by diagnostic imaging. According to the diagnostic criteria established in Japan, patients who present with two of the following three manifestations are diagnosed as having acute pancreatitis: characteristic upper abdominal pain, elevated levels of pancreatic enzymes, and findings of ultrasonography (US), CT or MRI suggesting acute pancreatitis. Detection of elevated levels of blood pancreatic enzymes is crucial in the diagnosis of acute pancreatitis. Measurement of blood lipase is recommended, because it is reported to be superior to all other pancreatic enzymes in terms of sensitivity and specificity. For measurements of the blood amylase level widely used in Japan, it should be cautioned that, because of its low specificity, abnormal high values are also often obtained in diseases other than pancreatitis. The cut-off level of blood pancreatic enzymes for the diagnosis of acute pancreatitis is not able to be set because of lack of sufficient evidence and consensus to date. CT study is the most appropriate procedure to confirm image findings of acute pancreatitis. Elucidation of the etiology of acute pancreatitis should be continued after a diagnosis of acute pancreatitis. In the process of the etiologic elucidation of acute pancreatitis, judgment whether it is gallstone-induced or not is most urgent and crucial for deciding treatment policy including the assessment of whether endoscopic papillary treatment should be conducted or not. The diagnosis of gallstone-induced acute pancreatitis can be made by combining detection of elevated levels of bilirubin, transamylase (ALT, AST) and ALP detected by hematological examination and the visualization of gallstones by US.

Treatment strategy for acute pancreatitis

When a diagnosis of acute pancreatitis (AP) is made, fundamental medical treatment consisting of fasting, intravenous (IV) fluid replacement, and analgesics with a close monitoring of vital signs should be immediately started. In parallel with fundamental medical treatment, assessment of severity based on clinical signs, blood test, urinalysis and imaging tests should be performed to determine the way of treatment for each patient. A repeat evaluation of severity is important since the condition is unstable especially in the early stage of AP. At the time of initial diagnosis, the etiology should be investigated by means of blood test, urinalysis and diagnostic imaging. If a biliary pancreatitis accompanied with acute cholangitis or biliary stasis is diagnosed or suspected, an early endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy (ERCP/ES) is recommended in addition to the fundamental medical treatment. In mild cases, the fundamental medical treatment should be continued until clinical symptom is subsided with normal laboratory data. In cases with severe acute pancreatitis (SAP) referral should be considered to medical centers experienced in the treatment of SAP, and intensive care is recommended for preventing both organ failures and infectious complications. Hemodynamic stabilization with vigorous fluid resuscitation, respiratory support and antibiotics are the major parts of intensive care in the early period of SAP. Continuous hemodiafiltration (CHDF) and continuous regional arterial infusion (CRAI) of protease inhibitor and/or antibiotics may be effective to improve pathophysiology of AP especially in the early stage of the disease. In the late stage of AP, infectious complications are critical. If an infectious complication is suspected based on clinical signs, blood test and imaging, a fine needle aspiration (FNA) is recommended to establish a diagnosis. The accuracy of FNA is reported to be 89 ~ 100%. For patients with sterile pancreatitis, non-surgical treatment should be indicated. For patients with infected pancreatic necrosis, therapeutic intervention either by percutaneous, endoscopic, laparoscopic or surgical approach are indicated. The most preferred surgical intervention is necrosectomy, however, non-surgical treatment with antibiotics is still the treatment of choice if the general condition is stable. Necrosectomy should be performed as late as possible. For patients with pancreatic abscess, drainage is recommended.

Acute pancreatitis in pregnancy

Acute pancreatitis (AP) is a rare event in pregnancy, occurring in approximately 3 in 10 000 pregnancies. The spectrum of AP in pregnancy ranges from mild pancreatitis to serious pancreatitis associated with necrosis, abscesses, pseudocysts and multiple organ dysfunction syndromes. Pregnancy related hematological and biochemical alterations influence the interpretation of diagnostic tests and assessment of severity of AP. As in any other disease associated with pregnancy, AP is associated with greater concerns as it deals with two lives rather than just one as in the non-pregnant population. The recent advances in clinical gastroenterology have improved the early diagnosis and effective management of biliary pancreatitis. Diagnostic studies such as endoscopic ultrasound, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography and therapeutic modalities that include endoscopic sphincterotomy, biliary stenting, common bile duct stone extraction and laparoscopic cholecystectomy are major milestones in gastroenterology. When properly managed AP in pregnancy does not carry a dismal prognosis as in the past.

Lipase/amylase ratio distinguishes mild acute biliary pancreatitis from nonpancreatitis

The report by Gumaste et al. [Gastroenterology 1991;101:1361–1366] that the lipase/amylase ratio (Lip/Amy) could be a new index distinguishing acute episodes of alcoholic (Lip/Amy >2) from nonalcoholic pancreatitis (Lip/Amy <2), with the critical value being Lip/Amy =2, has been followed by some debate between supporters and opponents. By comparing the Lip/Amy in a group of 16 carefully selected patients with mild acute gallstone-related (biliary) pancreatitis with that in a reference group of 44 controls, this study examines whether or not this ratio could be a useful index for diagnosing biliary pancreatitis. Considering that both pancreatic and hepatobiliary systems are blocked by stones, hepatic biochemical parameters such as serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and total bilirubin (TB) were also included in fitting the regression equation. The average value of Lip/Amy in the biliary pancreatitis group was 2.29 ± 0.93, while that in the control group was 1.30 ± 0.99. Thus, Lip/Amy was found to be a significant index for distinguishing mild acute biliary pancreatitis from nonpancreatitis. However, the critical value of Lip/Amy seemed to depend on the diet pattern and cultural background.

Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis

Gallstone disease is encountered commonly in clinical practice. The diagnosis of biliary stones has become less problematic with current, less-invasive imaging methods. The relatively invasive endoscopic techniques should be reserved for therapy and not used for diagnosis. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence. Appropriate noninvasive diagnostic studies, adequate monitoring/supportive care, and proper patient selection for invasive therapeutic procedures are elements of good clinical practice.

Early percutaneous transhepatic gallbladder drainage compared with endoscopic retrograde cholangiopancreatography and papillotomy treatment for severe gallstone associated acute pancreatitis

OBJECTIVE

Percutaneous transhepatic gallbladder drainage (PTGD) was compared with endoscopic treatment (within 72 hours after the onset of symptoms) in patients with severe biliary pancreatitis to evaluate the curative effect of PTGD in preventing bile track complications in these patients.

METHODS

Eligible patients were randomised to receive early treatment with PTGD or endoscopic treatment. If the initial emergency endoscopic or PTGD treatment failed, patients received another drainage treatment within 24 hours. From November 2001 to August 2005, 101 patients were randomly assigned to early PTGD (n = 51) or endoscopic retrograde cholangiopancreatography (ERCP) (n = 50). Overall mortality, mortality due to pancreatitis and complications were compared in these two groups.

RESULTS

48 of 52 patients were successfully treated with ERCP and 53 of 55 with PTGD. Seven patients (6.9%; three in the endoscopic treatment group and four in the PTGD group) died within four months after the onset of pancreatitis (p = 0.798); three patients in the endoscopic group and three in the PTGD group died from acute biliary pancreatitis. The overall rate of complications was similar in the two groups and there were no major differences in the incidence of local or systemic complications.

CONCLUSIONS

PTGD treatment is a simple, convenient and effective treatment of severe gallstone associated acute pancreatitis when endoscopic treatment fails.

Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction

BACKGROUND AND AIM

The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared.

RESULTS

A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality.

CONCLUSION

Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.

Endoscopic management of acute pancreatitis

Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to devastating acute illness with a significant risk of death. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.

Consensus of primary care in acute pancreatitis in Japan

The incidence of acute pancreatitis in Japan is increasing and ranges from 187 to 347 cases per million populations. Case fatality was 0.2% for mild to moderate, and 9.0% for severe acute pancreatitis in Japan in 2003. Experts in pancreatitis in Japan made this document focusing on the practical aspects in the early management of patients with acute pancreatitis. The correct diagnosis of acute pancreatitis and severity stratification should be made in all patients using the criteria for the diagnosis of acute pancreatitis and the multifactor scoring system proposed by the Research Committee of Intractable Diseases of the Pancreas as early as possible. All patients diagnosed with acute pancreatitis should be managed in the hospital. Monitoring of blood pressure, pulse and respiratory rate, body temperature, hourly urinary volume, and blood oxygen saturation level is essential in the management of such patients. Early vigorous intravenous hydration is of foremost importance to stabilize circulatory dynamics. Adequate pain relief with opiates is also important. In severe acute pancreatitis, prophylactic intravenous administration of antibiotics at an early stage is recommended. Administration of protease inhibitors should be initiated as soon as the diagnosis of acute pancreatitis is confirmed. A combination of enteral feeding with parenteral nutrition from early stage is recommended if there are no clear signs and symptoms of ileus and gastrointestinal bleeding. Patients with severe acute pancreatitis should be transferred to ICU as early as possible to perform special measures such as continuous regional arterial infusion of protease inhibitors and antibiotics, and continuous hemodiafiltration. The Japanese Government covers medical care expense for severe acute pancreatitis as one of the projects of Research on Measures for Intractable Diseases.

The biochemical detection of biliary etiology of acute pancreatitis on admission: a revisit in the modern era of biliary imaging

INTRODUCTION

Compared with traditional radiologic methods for the detection of cholelithiasis, early transient hypertransaminasemia had provided a useful prediction of biliary etiology in patients with acute pancreatitis.

AIM

To investigate whether this application remains valid in the modern era of imaging for microlithiasis.

METHODOLOGY

The biochemical detection (LFT) of cholelithiasis was based on an increase in serum alanine transaminase of >or=80 IU/L (normal range, 0-45 IU/L) within 24 hours of admission. We have taken the collective findings of abdominal ultrasound (USS), endoscopic ultrasound (EUS), and postmortem examination to represent the denominator for the diagnosis of cholelithiasis against which comparison with LFT was made.

RESULTS

Of 68 patients with acute pancreatitis who were treated between October 2000 and December 2001, cholelithiasis was the etiological factor in 44 patients (65%). EUS detected microlithiasis in 5 of 10 patients examined. The etiology remained idiopathic in 3 patients (4.4%). The sensitivity, specificity, and positive and negative predictive values for USS were 86%, 100%, 100%, and 80% respectively; for LFT, they were 91%, 100%, 100%, and 86%; and for USS and LFT combined, they were 98%, 100%, 100%, and 96%, respectively.

CONCLUSIONS

In patients with acute pancreatitis, the biochemical analysis within 24 hours of admission provided a simple, rapid, and more accurate prediction of cholelithiasis than USS. The combination of LFT and USS detected or excluded a biliary etiology in almost all patients.

A critical evaluation of laboratory tests in acute pancreatitis

An ideal laboratory test in the evaluation of a patient with acute pancreatitis (AP) should, in addition to accurately establishing the diagnosis of AP, provide early assessment of its severity and identify the etiology. None of the tests available today meet all these criteria, and presently there is no biochemical test that can be considered the "gold standard" for the diagnosis and assessment of severity of AP. In the diagnosis of AP, serum amylase and lipase remain important tests. Advantages of amylase estimation are its technical simplicity, easy availability, and high sensitivity. However, its greatest disadvantage is its low specificity. A normal amylase would usually exclude the diagnosis of AP, with the exception of AP secondary to hyperlipidemia, acute exacerbation of chronic pancreatitis, and when the estimation of amylase is delayed in the course of the disease. The major advantage of lipase is an increased sensitivity in acute alcoholic pancreatitis and in patients who initially present to the emergency room days after the onset of the disease, as lipase remains elevated longer than amylase. Although once considered to be specific for AP, nonspecific elevations of lipase have been reported in almost as many disorders as amylase, thus decreasing its specificity. Simultaneous estimation of amylase and lipase does not improve the accuracy. Other enzymes for the diagnosis of AP--pancreatic isoamylase, immunoreactive trypsin, and elastase--are more cumbersome and expensive and have no clear role in the diagnosis of AP. No enzyme assay has a predictive role in determining the severity or etiology of AP. Once the diagnosis of AP is established, daily measurements of enzymes have no value in assessing the clinical progress of the patient or ultimate prognosis and should be discouraged. A host of new serological and urinary markers have been investigated in the last few years. Their main use is in predicting the severity of AP. At present, serum C-reactive protein at 48 h is the best available laboratory marker of severity. Urinary trypsinogen activation peptides within 12-24 h of onset of AP are able to predict the severity but are not widely available. Serum interleukins 6 and 8 seem promising but remain experimental.

Evidence-based approach to idiopathic pancreatitis

The causes of recurrent acute pancreatitis, including the newly recognized genetic causes, are reviewed. The pitfalls of overcalling the diagnosis of pancreatitis in patients with abdominal pain or other symptoms and the role of a careful history are emphasized. The presence of undetectable microlithiasis in patients with unexplained pancreatitis is discussed. The popular notion of pancreas divisum and sphincter of Oddi dysfunction as causes of pancreatitis is challenged, as is the role of endotherapy in these conditions.

Laboratory diagnostic tests in acute pancreatitis

The diagnosis of acute pancreatitis depends on a combination of clinical assessment and laboratory testing. Although the serum amylase is the cornerstone laboratory test used in establishing the diagnosis of acute pancreatitis, there are limitations in the sensitivity and specificity that may be important for the clinician to recognize. The serum lipase level may be especially useful in patients with alcohol-induced acute pancreatitis. A new urinary test strip that uses trypsinogen-2 may have a role in establishing the diagnosis of acute pancreatitis. In addition, several new laboratory tests and new interpretations of old laboratory tests may assist in establishing the etiology and severity of acute pancreatitis. This review summarizes important aspects of standard laboratory tests and novel laboratory approaches in establishing the diagnosis, etiology, and severity of acute pancreatitis.

Acute and chronic pancreatitis

Acute pancreatitis has multiple causes, an unpredictable course, and myriad complications. The diagnosis relies on a combination of history, physical examination, serologic markers, and radiologic findings. The mainstay of therapy includes aggressive hydration, maintenance of NPO, and adequate analgesia with narcotics. Antibiotic and nutritional support with total parenteral nutrition should be used when appropriate.

Update on the management of acute severe pancreatitis

Acute severe pancreatitis is an aggressive disease with a mortality rate of up to 30 percent. In recent years therapy has shifted away from early surgery to intensive medical care. This article focuses on several issues of the management of acute severe pancreatitis emphasising evidence from recent clinical trials and recommendations from recent consensus conferences. Since a correct assessment of the severity of the disease is mandatory as early as possible in the treatment, several multiple scoring factor systems and individual risk factors are explained. The indications and the optimal timing of ERCP are discussed. Prophylactic administration of antibiotics, intravenously or by means of a selective digestive decontamination scheme, seems to be beneficial in decreasing morbidity but not mortality. Adequate nutritional support, preferably achieved by enteral feeding, is an important component in the supportive therapy. Protease inhibitors and anti-secretory drugs have not proven to be of benefit in improving outcome. Immunomodulating substances like platelet activating antagonists are promising but further studies are necessary to confirm the results of the early studies. Finally, indications for surgery are discussed.

Review article: the treatment of acute biliary pancreatitis

World-wide, gallstones are the commonest cause of acute pancreatitis (AP), a potentially life-threatening condition. Scoring systems based on radiologic findings and serologic markers help predict which patients may have retained bile duct stones. Endoscopic decompression of the biliary tree (by sphincterotomy and stone extraction during ERCP) is safer than surgery, which carries high morbidity and mortality in AP. Four prospective, randomized clinical trials confirm the utility of this approach, however careful patient selection is necessary. Medical therapy for AP is supportive; no agent or medical intervention has been shown consistently to abort or ameliorate the course of AP. Drugs that inhibit inflammatory cytokine production, however, are showing promise.

Usefulness of alanine and aspartate aminotransferases in the diagnosis of microlithiasis in idiopathic acute pancreatitis

CONCLUSION

Serum increases of aminotransferases, especially alanine aminotransferase (ALT), were suggestive of microlithiasis in idiopathic acute pancreatitis, particularly when assessed early after the onset of abdominal pain.

BACKGROUND

It has been shown that biochemical laboratory values only are useful parameters in distinguishing gallstone from nongallstone acute pancreatitis. We assessed the diagnostic usefulness of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) for identification of occult microlithiasis in idiopathic acute pancreatitis.

METHODS

Ninety-one patients with idiopathic acute pancreatitis who underwent microscopic examination of stimulated duodenal bile sediments were retrospectively studied. According to earliness of ALT and AST assay after the onset of abdominal pain, patients were divided into two groups: group A, within the first 24 h (n = 56) and group B, between 24 and 72 h (n = 35).

RESULTS

ALT and AST values expressed as number of elevations of the upper limits of normal were higher in group A patients with positive biliary drainage than in group B. Median (range) ALT and AST values were 2.5 (0.1-18.1) vs 0.4 (0.1-8.6) and 3 (0.3-17.4) vs 0.5 (0.3-11.9), respectively. In the univariate analysis and receiver operating characteristic (ROC) curves, ALT within the first 24 h showed a sensitivity of 73%, specificity of 86%, and positive predictive value of 92% for a cutoff of 1.2 elevations of the upper limit of normal. These values were slightly higher, although without statistically significant differences, than those of AST (73, 80, and 89%, respectively).

Biliary pancreatitis: a review. Emphasizing appropriate endoscopic intervention

Gallstones are a common cause of acute pancreatitis. This article reviews acute biliary pancreatitis and includes natural history, noting the serious nature of some cases; pathogenesis, identifying transient obstruction as the primary pathogenetic event; diagnosis, including biochemical parameters and imaging; assessment of severity, underlining the importance of early prognostic signs, organ failure, and local complications; and management. Management is reviewed in detail, giving a historical perspective to the role of surgery, highlighting the role of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy and paying particular attention to the four prospective randomized clinical trials in suggesting which patients are most likely to benefit from early endoscopic evaluation and therapy. Also discussed are additional clinical situations related to biliary pancreatitis in which endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy play a role. Finally, a suggested endoscopic approach to acute biliary pancreatitis is presented along with an algorithm incorporating severity stratification, principles of endoscopic intervention, and concepts of sterile and infected pancreatic necrosis.

A scoring system for early differentiation of the etiology of acute pancreatitis

BACKGROUND

The purpose of this study was to find a new scoring system for early differentiation between the two commonest etiologies of acute pancreatitis (biliary and alcoholic), because biliary pancreatitis can be treated early by endoscopic sphincterotomy, whereas such treatment is unnecessary in alcoholics.

METHODS

One hundred and forty-five patients satisfied the requirements for participation in the study and were divided into groups A (alcoholic pancreatitis) and B (biliary pancreatitis). Seven variables (serum and urine amylase, aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT), alkaline phosphatase (ALP), lipase/amylase (L/A) ratio, and erythrocyte mean corpuscular volume (MCV)) that differed in a statistically significant manner between patients of the two groups were included in the scoring system. Each parameter was counted as 0 or 1 on the basis of its values, so the patients reached scores from 0 to 7.

RESULTS

Scores > or =4 (P < 0.0001) were consistently present in biliary pancreatitis, whereas alcoholics scored <4, with a sensitivity of 92.04% and a specificity of 93.75%.

CONCLUSIONS

Our new scoring system could be important in the early diagnosis of the etiology of acute pancreatitis in a manner that is non-invasive, easy to calculate, inexpensive, and readily available.

Diagnostic standards for acute pancreatitis

An accurate history and thorough physical examination will often raise clinical suspicion of acute pancreatitis in the differential diagnosis of a patient presenting with acute abdominal pain. An accurate diagnosis is needed to eliminate etiologies of acute abdominal pain and to appropriately direct therapy. Confirmation of the diagnosis is most often made by evaluation of serum amylase and lipase levels. Although hyperamylasemia is found in the majority of patients with acute pancreatitis, other nonpancreatic acute abdominal conditions may be present with hyperamylasemia. CT scanning provides an accurate confirmation of clinical and laboratory findings and offers excellent anatomic and morphologic representation of the pancreas and peripancreatic tissue. The following article, written by the late John H.C. Ranson, presents a discussion of the modalities available for diagnosing acute pancreatitis.

Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis

BACKGROUND

The role of early endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy in the treatment of patients who have acute biliary pancreatitis without obstructive jaundice is uncertain.

METHODS

We conducted a prospective, multicenter study in which 126 patients were randomly assigned to early ERCP (within 72 hours after the onset of symptoms) and endoscopic papillotomy for the removal of stones in the common bile duct, when appropriate, and 112 patients were assigned to conservative treatment. In the conservative-treatment group, ERCP was performed within three weeks if signs of biliary obstruction or sepsis developed. Overall mortality, mortality due to pancreatitis, and complications were compared in the two groups.

RESULTS

Early ERCP was successful in 121 of the 126 patients in the invasive-treatment group. Endoscopic papillotomy was performed to remove bile-duct stones in 58 patients; stones were successfully extracted in 57. ERCP was performed in 22 of the 112 patients in the conservative-treatment group; papillotomy for stone removal was successful in 13 patients. Fourteen patients in the invasive-treatment group and 7 in the conservative-treatment group died within three months (P=0.10); 10 patients in the invasive-treatment group and 4 in the conservative-treatment group died from acute biliary pancreatis (P=0.16). The overall rate of complications was similar in the two groups, but patients in the invasive-treatment group had more severe complications. Respiratory failure was more frequent in the invasive-treatment group, and jaundice was more frequent in the conservative-treatment group.

CONCLUSIONS

In patients with acute biliary pancreatis but without obstructive jaundice, early ERCP and sphincterotomy were not beneficial.

Serum pancreas-specific protein in acute pancreatitis. Its clinical utility in comparison with serum amylase

To compare the clinical utility of serum pancreas-specific protein and serum amylase in the diagnosis of acute pancreatitis, the study was conducted in 134 normal subjects and 70 patients (36 with acute pancreatitis and 34 with other acute abdominal diseases as control group). The serum level of pancreas-specific protein in 134 healthy adults was 29.6 +/- 1.6 micrograms/l, with 95% within 7.3-67.2 micrograms/l. The upper reference limit was set at 70 micrograms/l. Serum levels of pancreas-specific protein and amylase within 12 h of arrival were significantly higher in patients with acute pancreatitis than in the control group (647.3 +/- 79.3 versus 33.8 +/- 4.8 micrograms/l (p < 0.0001) and 2536 +/- 344 versus 175 +/- 35 IU/l (p < 0.0001)). No significant difference in the levels of pancreas-specific protein was noted between biliary and alcoholic pancreatitis or between severe and mild attacks. The sensitivity, specificity, and accuracy of diagnosing acute pancreatitis were 100%, 94.1%, and 97.1% with serum pancreas-specific protein > 70 micrograms/l and 97.2%, 91.2%, and 94.3% with serum amylase > 360 IU/l. The result demonstrated that pancreas-specific protein may be a good serum marker in the diagnosis of acute pancreatitis.

Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis

Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. Acute cholecystitis is treated by surgery in most cases. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy may become more common in the future for treatment of acute cholecystitis as well as in cases of acute cholangitis and pancreatitis if the bile ducts are cleared of gallstones. Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.

C-reactive protein and lactate dehydrogenase isoenzymes in the assessment of the prognosis of acute pancreatitis

The value of serum C-reactive protein, lactate dehydrogenase isoenzymes and erythrocyte sedimentation rate in predicting the outcome of acute pancreatitis was evaluated for 57 episodes in 54 patients. Serum C-reactive protein levels on day 2, 4 and 7 after admission were significantly higher in 19 episodes of severe attacks than in 38 episodes of mild attacks (13.71 +/- 9.68, 9.00 +/- 7.54, 6.02 +/- 3.83 vs 4.78 +/- 3.91, 3.30 +/- 3.61, 1.43 +/- 2.08 mg/dL; P less than 0.0001, P less than 0.005, P less than 0.0001, respectively). The sensitivity, specificity and accuracy of predicting a severe attack were 94, 76 and 82% using C-reactive protein greater than or equal to 8 mg/dL on day 2; 67, 92 and 84% using C-reactive protein greater than or equal to 5 mg/dL on day 7; and 59, 76 and 70% using Ranson's criteria greater than or equal to 3. Increases in LDH-4 and LDH-5 isoenzymes were found in both groups, with LDH-4 being slightly higher in severe attacks than in mild attacks. There was no significant difference of erythrocyte sedimentation rate between both groups. When compared with Ranson's criteria, lactate dehydrogenase isoenzymes and erythrocyte sedimentation rate, C-reactive protein is more valuable in the early assessment of the severity of acute pancreatitis.

Advances in the enzyme diagnosis of pancreatic diseases

This paper reviews recent developments of analytical methods for the determination of alpha-amylase, of its isoenzymes, and of lipase. The evaluation of severity and etiology of acute pancreatitis by enzyme assays, e.g., pancreatic elastase 1, phospholipase A2, and routine enzymes are discussed. The limited significance of enzyme determinations as compared to imaging and endoscopic procedures for the diagnosis of chronic pancreatitis is demonstrated. Indirect "tubeless" tests for the evaluation of pancreatic exocrine insufficiency with respect to the secretion of chymotrypsin (chymotrypsin in stool and NBT-PABA test) and cholesterol esterase (pancreolauryl test) are reviewed. Finally, the superiority of morphologic investigations over biochemical tests for the timely detection of pancreatic carcinoma is shown.