Practical guide to the management of chronic pancreatitis

Engagement in GI Behavioral Health Is Associated with Reduced Portal Messages, Phone Calls, and ED Visits

BACKGROUND AND AIMS

Chronic digestive disorders are associated with increased costs for healthcare systems and often require provision of both urgent care and non-face-to-face (non-F2F) care, such as responding to patient messages. Numerous benefits of integrated gastroenterology (GI) behavioral health have been identified; however, it is unclear if integrated care impacts healthcare utilization, including urgent care and non-F2F contact. We sought to investigate the association between patient engagement with GI behavioral health and healthcare utilization.

METHODS

We performed a retrospective chart review study of adult patients who were referred for and completed at least one behavioral health appointment between January 1, 2019 and December 21, 2021 in the Gastroenterology and Hepatology department of a large academic medical center. Data on electronic medical record (EMR) messages, phone calls, and Emergency Department utilization were collected 6 months before and 9 months after patient engagement with GI behavioral health.

RESULTS

466 adult patients completed at least one behavioral health visit from 2019 to 2021. Overall, messages, phone calls, and ED visits all decreased significantly from the 6 months before behavioral health treatment to 6 months after (all P values < 0.001).

CONCLUSION

Engagement with integrated GI behavioral health is associated with reduced non-F2F care and emergency department utilization in patients with chronic digestive disorders. Increasing access to GI behavioral health may result in reduced provider workload and healthcare system costs.

Pancreatic duct stones treated by Whipple as a last resort: A case report

INTRODUCTION AND IMPORTANCE

Chronic Pancreatitis is an irreversible inflammation of the pancreas that can lead to fibrosis and scar formation. Pseudocysts are a late complication of chronic pancreatitis and abdominal pain is the most common presenting complaint.

CASE PRESENTATION

A 48-year-old male who is a known case of chronic pancreatitis presented to our department complaining of abdominal pain for a duration of three weeks. A CT scan revealed a pseudocyst in the head of the pancreas, stones in the unicate process along with dilatation of the body and tail of the pancreas.

CLINICAL DISCUSSION

After multiple ERCP failures and considering other endoscopic options, the patient was indicated for the Whipple procedure with Roux-en-y reconstruction. Postoperatively, the patient stayed in the hospital for about a week. He was asymptomatic and well but had an elevated random blood sugar level. He was discharged and recommended to follow up with an endocrinologist.

CONCLUSION

Whipple procedure can be used for patients with multiple pancreatic duct stones when endoscopic therapies are not effective.

A Case of Autoimmune Pancreatitis Presenting As Alcohol-Induced Necrotizing Pancreatitis

Autoimmune pancreatitis (AIP) is an inflammatory condition of the pancreas, commonly characterized by elevated levels of immunoglobulin G (IgG) 4. Diagnosis of this condition can be challenging in patients with risk factors for other pancreatitis etiologies and requires a comprehensive approach utilizing clinical, radiologic, and laboratory findings. Here, we present a case of an individual with a history of multiple prior hospitalizations for alcoholic pancreatitis, who presented with symptoms of abdominal pain, nausea, and vomiting. Computed tomography (CT) imaging revealed intra-abdominal abscesses and findings consistent with pancreatitis. Further laboratory results revealed elevated lipase and IgG4 levels, indicating AIP as the underlying cause. This case highlights the importance of considering AIP as a differential diagnosis in individuals presenting with pancreatic disease.

Evidence-based clinical practice guidelines for chronic pancreatitis 2021

BACKGROUND

Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress.

METHODS

The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions.

RESULTS

Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition.

CONCLUSIONS

These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.

European Guideline on IgG4-related digestive disease: UEG and SGF evidence-based recommendations

Immunoglobulin subclass 4 related disease (IgG4-RD) is an increasingly recognised autoimmune disease with the potential of affecting various organs. It has a predilection for certain anatomical hotspots and the pancreatobiliary tract is the the most common area involved. Due to the relative novelty of IgG4-RD, the understanding of the disease process continues to involve. Recent European guidelines on IgG4-RD have been published by a working group collaboration between the United European Gastroenterology and Swedish Society of Gastroenterology. In our commentary, we aim to extract the key practical points with an emphasis on diagnosis and management of IgG4-RD with specific focus on the pancreatobiliary tract.

Chronic pancreatitis with ductal stones in the pancreatic head treated by surgery: a case report

Pancreatic duct stones are direct sequelae of chronic pancreatitis (CP) and can occur in ∼50% of patients. Selection of the appropriate treatment method for pancreatic duct stones depends on location, size and number of stones. We present a patient with upper abdominal pain and weight loss for the previous 3 months. Diagnostic workup detected a chronic inflammation of the pancreas with stone in the main pancreatic duct and a nodular lesion in the head of the pancreas. Endoscopic retrograde cholangiopancreatography was performed without success. Given the rise in incidence and prevalence of CP, the potential complications and high mortality rate, it is imperative that physicians understand the risk factors, disease process and management of this disease. Pancreaticoduodenectomy in patients with CP is a feasible option for the treatment of focal cystic lesions to the head of the pancreas associated to pancreatic stone in selected cases.

Regeneration of the pancreas: proliferation and cellular conversion of surviving cells

The most common pancreas-related disorders are diabetes, pancreatitis and different types of pancreatic cancers. Diabetes is a chronic condition which results from insufficient functional β-cell mass, either as a result of an autoimmune destruction of insulin producing β-cells, or as their death or de-differentiation following years of hyperactivity to compensate for insulin resistance. Chronic pancreatitis leads to cell death and can develop into diabetes or pancreatic cancer. To stimulate regeneration in such pathologies, it is of high importance to evaluate the endogenous regeneration capacity of the pancreas, to understand the conditions needed to trigger it, and to investigate the cellular and molecular regenerative responses. This short review focuses on observations made in the last 2 years on the mechanisms enhancing pancreatic cell proliferation, notably new combinations of pharmacological agents, as well as those triggering cellular conversion.