Prevalence of Splanchnic Vein Thrombosis in Pancreatitis: A Systematic Review and Meta-Analysis of Observational Studies

Incidence and impact of venous thromboembolism in hospitalized patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) and venous thromboembolism (VTE) remain common and potentially lethal disease entities. AP might be an important trigger of systemic inflammtion and may activate the coagulation system with increased VTE risk.

METHODS

The German nationwide inpatient sample was screened for patients admitted due to AP (ICD-code K85) 2005-2019. AP hospitalizations were stratified for VTE as well as risk-factors and the impact of VTE on in-hospital case-fatality rate were investigated.

RESULTS

Overall, 797,364 hospitalizations of patients due to AP (aged in median 56.0 [IQR 44.0-71.0] years), 39.2 % females) were detected in Germany 2005-2019. Incidence of VTE in hospitalized AP patients was 1764.8 per 100,000 hospitalizations (1.8 %) with highest VTE rate between 5th and 6th decade. Cancer (OR 1.656 [95 %CI 1.513-1.812], P < 0.001), any surgery (OR 4.063 [95 %CI 3.854-4.284], P < 0.001), and heart failure (OR 1.723 [95 %CI 1.619-1.833], P < 0.001) were independently associated with VTE occurrence. Case-fatality (8.8 % vs. 2.7 %, P < 0.001) was more than 3-fold higher in AP patients with than without VTE. VTE was associated with increased case-fatality in AP patients (OR 3.925 [95 %CI 3.684-4.181], P < 0.001).

CONCLUSIONS

VTE is a life-threatening event in hospitalized AP patients associated with an almost 4-fold increased case-fatality rate. Cancer, any surgery, thrombophilia and heart failure were important risk factors for occurrence of VTE in AP.

The risk of developing splanchnic vein thrombosis in acute pancreatitis increases 3 days after symptom onset: A systematic review and meta-analysis

BACKGROUND

Splanchnic vein thrombosis is a complication of acute pancreatitis (AP) and is likely often underdiagnosed.

OBJECTIVES

We aimed to understand the time course and risk factors of splanchnic vein thrombosis in the early phase of AP.

METHODS

A systematic search was conducted using the PRISMA guidelines (PROSPERO registration CRD42022367578). Inclusion criteria were appropriate imaging techniques in adult AP patients, studies that reported splanchnic vein thrombosis data from the early phase, and reliable information on the timing of imaging in relation to the onset of pancreatitis symptoms or hospital admission. The proportion of patients with thrombosis with 95% confidence intervals (CI) was calculated using random-effects meta-analyses, and multiple subgroup analyses were performed.

RESULTS

Data from 1951 patients from 14 studies were analyzed. The proportion of patients with splanchnic vein thrombosis within 12 days after symptom onset was 0.13 (CI 0.07-0.23). The occurrence was lowest at 0.06 (CI 0.03-0.1) between 0 and 3 days after symptom onset, and increased fourfold to 0.23 (CI 0.16-0.31) between 3 and 11 days. On hospital admission, the proportion of patients affected was 0.12 (CI 0.02-0.49); it was 0.17 (CI 0.03-0.58) 1-5 days after admission. The prevalence in mild, moderate, and severe AP was 0.15 (CI 0.05-0.36), 0.26 (CI 0.15-0.43), and 0.27 (CI 0.17-0.4), respectively. Alcoholic etiology (0.31, CI 0.13-0.58) and pancreatic necrosis (0.55, CI 0.29-0.78, necrosis above 30%) correlated with increased SVT prevalence.

CONCLUSION

The risk of developing splanchnic vein thrombosis is significant in the early stages of AP and may affect up to a quarter of patients. Alcoholic etiology, pancreatic necrosis, and severity may increase the prevalence of splanchnic vein thrombosis.

Falciform ligament thrombosis after umbilical vein recanalization in the setting of acute pancreatitis, a rare entity

We present the case of a 79-year-old man who presents falciform ligament thrombosis after umbilical vein recanalization as an uncommon complication of acute pancreatitis. The performance of abdomino-pelvic CT with contrast, allowed its diagnosis, as well as the establishment of an adequate treatment with favorable evolution.

Prevalence, treatment efficacy, and risk factors of vascular complications in acute pancreatitis: A case-control study

OBJECTIVE

We aimed to investigate the prevalence of vascular complications in acute pancreatitis (AP), to compare patient outcomes using various treatments, and to explore the related risk factors.

METHODS

Consecutive AP patients admitted from January 2010 to July 2017 were retrospectively included. Demographics, vascular complications, laboratory indices, and imaging findings were collected. Univariate and multivariate analyses were used to explore potential risk factors of vascular complications.

RESULTS

Of 3048 AP patients, 808 (26.5%) had vascular complications, including visceral vein thrombosis, sinistral portal hypertension, and arterial complications. And 38 (4.7%) patients received anticoagulant therapy and had a higher rate of recanalization (P < 0.001). Bleeding occurred in 95 (11.8%) patients, who received further treatment. Multivariate analysis identified male gender (odds ratio [OR] 1.650, 95% confidence interval [CI] 1.101-2.472), hyperlipidemia (OR 1.714, 95% CI 1.356-2.165), disease recurrence (OR 3.727, 95% CI 2.713-5.118), smoking (OR 1.519, 95% CI 1.011-2.283), hemoglobin level (OR 0.987, 95% CI 0.981-0.993), white blood cell (WBC) count (OR 1.094, 95% CI 1.068-1.122), non-vascular local complications (OR 3.018, 95% CI 1.992-4.573), computed tomography severity index (CTSI) (OR 1.425, 95% CI 1.273-1.596), and acute physiology and chronic health evaluation (APACHE) II score (OR 1.057, 95% CI 1.025-1.090) were related to vascular complications.

CONCLUSIONS

Vascular complications in AP is prevalent and their treatment is challenging. Further investigations are warranted to determine the optimal treatment strategy. Independent risk factors included male gender, hyperlipidemia, disease recurrence, smoking, WBC count, non-vascular local complications, CTSI, and APACHE II score.

Venous Thrombosis in Acute Pancreatitis: What to and Not to Do?

Acute pancreatitis is an acute inflammatory condition of the pancreas that has not only local but systemic effects as well. Venous thrombosis is one such complication which can give rise to thrombosis of the peripheral vasculature in the form of deep vein thrombosis, pulmonary embolism, and splanchnic vein thrombosis. The prevalence of these complications increases with the severity of the disease and adds to the adverse outcomes profile. With better imaging and awareness, more cases are being detected, although many at times it can be an incidental finding. However, it remains understudied and strangely, most of the guidelines on the management of acute pancreatitis are silent on this aspect. This review offers an overview of the incidence, pathophysiology, symptomatology, diagnostic work-up, and management of venous thrombosis that develops in AP.

Splanchnic vein thrombosis in necrotizing pancreatitis: a post-hoc analysis of a nationwide prospective cohort

BACKGROUND

Treatment guidelines for splanchnic vein thrombosis in necrotizing pancreatitis are lacking due to insufficient data on the full clinical spectrum.

METHODS

We performed a post-hoc analysis of a nationwide prospective necrotizing pancreatitis cohort. Multivariable analyses were used to identify risk factors and compare the clinical course of patients with and without SVT.

RESULTS

SVT was detected in 97 of the 432 included patients (22%) (median onset: 4 days). Risk factors were left, central, or subtotal necrosis (OR 28.52; 95% CI 20.11-40.45), right or diffuse necrosis (OR 5.76; 95% CI 3.89-8.51), and younger age (OR 0.94; 95% CI 0.90-0.97). Patients with SVT had higher rates of bleeding (n = 10,11%) and bowel ischemia (n = 4,4%) compared to patients without SVT (n = 14,4% and n = 2,0.6%; OR 3.24; 95% CI 1.27-8.23 and OR 7.29; 95% CI 1.31-40.4, respectively), and were independently associated with ICU admission (adjusted OR 2.53; 95% CI 1.37-4.68). Spontaneous recanalization occurred in 62% of patients (n = 40/71). Radiological and clinical outcomes did not differ between patients treated with and without anticoagulants.

DISCUSSION

SVT is a common and early complication of necrotizing pancreatitis, associated with parenchymal necrosis and younger age. SVT is associated with increased complications and a worse clinical course, whereas anticoagulant use does not appear to affect outcomes.

Renal vein thrombosis in pancreatitis: a rare vascular complication

Extrasplanchnic venous thrombosis is a rare complication of chronic pancreatitis. Thrombosis of inferior vena cava and renal vein, in particular, is extremely rare. We present our recent experience of managing two patients of chronic pancreatitis who presented with renal vein thrombosis. We also highlight the treatment dilemmas facing a clinician managing patients with this atypical and rare vascular complication.

[Acute necrotizing pancreatitis with hemorrhagic shock in secondary splenic rupture: a case report and literature review]

Atraumatic splenic rupture is a rare complication of acute and chronic pancreatitis. It arises due to its anatomical proximity to the pancreas, for instance, due to erosion of large pseudocysts or walled-of-necrosis (WON).Following we describe the case of a 62-year-old woman who presented for further diagnostics and treatment of acute pancreatitis with the development of large walled-of necrosis (WON) in the pancreatic corpus and tail. During the course, the patient developed a hemorrhagic shock. An emergency computer tomography (CT) of the abdomen revealed a ruptured spleen with a large capsular hematoma with no evidence of active bleeding. In contrast to previous published case reports, our treatment was exclusively minimal-invasive: by radiological guided embolization of the splenic artery and by endosonographic guided implantation of a lumen apposing metal stent (LAMS). The splenic hematoma was spontaneously regressive without secondary drainage.

Splanchnic vein thrombosis in acute pancreatitis: a review of treatment indications, methods, and outcomes in a single institution

BACKGROUND

Splanchnic vein thrombosis (SVT) is a well-recognized complication of acute pancreatitis. The question of whether or not to treat SVT with systemic therapeutic anticoagulation (STA) remains to be seen. The universal use of anticoagulation may lead to an increased risk of bleeding complications associated with acute pancreatitis. Literature on this subject is sparse and there is no clear guideline on how to treat SVT. Our research demonstrates local practice where therapeutic anticoagulation in SVT varies.

METHODS

A retrospective review of patients presenting with acute pancreatitis admitted over a five-year period to a single tertiary hospital with splanchnic vein thrombosis was performed.

RESULTS

Of the 1408 patients admitted with acute pancreatitis, 42 were diagnosed with splanchnic vein thrombosis, with a male dominance of 34 (81%). A total of 25 patients received anticoagulation. The use of anticoagulation was dependent on the location of the thrombus, P < 0.01. Anticoagulation use was most common in cases of combination mesenteric, splenic, and portal vein thrombus (100%), isolated mesenteric vein (100%), isolated portal vein (89%), combination portal and splenic vein (87%), and combination mesenteric and splenic vein (75%). The rate of anticoagulation use was lowest in isolated splenic vein thrombus (23%).

CONCLUSION

The early commencement of STA in patients with acute pancreatitis and triple-vessel SVT or with portal vein involvement is supported by our data. Isolated splenic vein thrombus does not require systemic therapy. Further research is needed to establish a clear clinical guideline.

Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas, resulting in recurrent abdominal pain, diabetes mellitus, and malnutrition. It may lead to various other complications such as pseudocyst formation, benign biliary stricture, gastric outlet obstruction; and vascular complications like venous thrombosis, variceal and pseudoaneurysmal bleed. Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy. Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration, or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations. Procedure-related bleed is usually venous and mostly managed conservatively. Procedure-related arterial bleed, however, may require radiological interventions.

Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis: A case report and literature review

BACKGROUND

Splenic vein thrombosis is a known complication of pancreatitis. It can lead to increased blood flow through mesenteric collaterals. This segmental hypertension may result in the development of colonic varices (CV) with a high risk of severe gastrointestinal bleeding. While clear guidelines for treatment are lacking, splenectomy or splenic artery embolization are often used to treat bleeding. Splenic vein stenting has been shown to be a safe option.

CASE SUMMARY

A 45-year-old female patient was admitted due to recurrent gastrointestinal bleeding. She was anemic with a hemoglobin of 8.0 g/dL. As a source of bleeding, CV were identified. Computed tomography scans revealed thrombotic occlusion of the splenic vein, presumably as a result of a severe acute pancreatitis 8 years prior. In a selective angiography, a dilated mesenterial collateral leading from the spleen to enlarged vessels in the right colonic flexure and draining into the superior mesenteric vein could be confirmed. The hepatic venous pressure gradient was within normal range. In an interdisciplinary board, transhepatic recanalization of the splenic vein via balloon dilatation and consecutive stenting, as well as coiling of the aberrant veins was discussed and successfully performed. Consecutive evaluation revealed complete regression of CV and splenomegaly as well as normalization of the red blood cell count during follow-up.

CONCLUSION

Recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to CV. However, a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.

Mortality Trends, Outcomes, and Predictors of Portal Vein Thrombosis in Acute Pancreatitis Patients: A Propensity-Matched National Study

BACKGROUND

Portal vein thrombosis (PVT) is a rare complication of acute pancreatitis (AP) and might be associated with worse outcomes. We aimed to study trends, outcomes, and predictors of PVT in AP patients.

METHODS

The National Inpatient Sample database was utilized to identify the adult patients (≥ 18 years) with primary diagnosis of AP from 2004 to 2013 using International Classification of Disease, Ninth Revision. Patients with and without PVT were entered into propensity matching model based on baseline variables. Outcomes were compared between both groups and predictors of PVT in AP were identified.

RESULTS

Among the total of 2,389,337 AP cases, 7046 (0.3%) had associated PVT. The overall mortality of AP decreased throughout the study period (p trend ≤ 0.0001), whereas mortality of AP with PVT remained stable (1-5.7%, p trend = 0.3). After propensity matching, AP patients with PVT patients had significantly higher in-hospital mortality (3.3% vs. 1.2%), AKI (13.4% vs. 7.7%), shock (6.9% vs. 2.5%), and need for mechanical ventilation (9.2% vs. 2.5%) along with mean higher cost of hospitalization and length of stay (p < 0.001 for all). Lower age (Odd ratio [OR] 0.99), female (OR 0.75), and gallstone pancreatitis (OR 0.79) were negative predictors, whereas alcoholic pancreatitis (OR 1.51), cirrhosis (OR 2.19), CCI > 2 (OR 1.81), and chronic pancreatitis (OR 2.28) were positive predictors of PVT (p < 0.001 for all) in AP patients.

CONCLUSION

PVT in AP is associated with significantly higher risk of death, AKI, shock, and need for mechanical ventilation. Chronic and alcoholic pancreatitis is associated with higher risk of PVT in AP.

Acute pancreatitis induces a transient hypercoagulable state in murine models

BACKGROUND/OBJECTIVES

Although understudied, risk of venous thromboembolism (VTE) appears to be increased during acute pancreatitis (AP). We aimed to further characterize a hypercoagulable state associated with AP utilizing thromboelastography (TEG), a readily available, point of care test.

METHODS

AP was induced in C57/Bl6 mice using l-arginine and caerulein. TEG was performed with citrated native samples. The maximum amplitude (MA) and coagulation index (CI), a composite marker of coagulability, were evaluated. Platelet aggregation was assessed using whole blood collagen-activated platelet impedance aggregometry. Circulating tissue factor (TF), the initiator of extrinsic coagulation, was measured with ELISA. A VTE model using IVC ligation followed by measurement of clot size and weight was evaluated. After IRB approval and consent, blood samples from patients hospitalized with a diagnosis of AP were evaluated by TEG.

RESULTS

Mice with AP displayed a significant increase in MA and CI, consistent with hypercoagulability. Hypercoagulability peaked at 24 h after induction of pancreatitis, then returned to baseline by 72 h. AP resulted in significantly increased platelet aggregation and elevated circulating TF. Increased clot formation with AP was observed in an in vivo model of deep vein thrombosis. In a proof of concept, correlative study, over two thirds of patients with AP demonstrated an elevated MA and CI compared to the normal range, consistent with hypercoagulability.

CONCLUSIONS

Murine acute pancreatitis results in a transient hypercoagulable state that can be assessed by TEG. Correlative evidence for hypercoagulability was also demonstrated in human pancreatitis. Further study to correlate coagulation measures to incidence of VTE in AP is warranted.

Incidence and factors associated with portal vein thrombosis in patients with acute pancreatitis: A United States national retrospective study

BACKGROUND/OBJECTIVE

Portal vein thrombosis (PVT) is a well-known complication in patients with acute pancreatitis (AP). Limited data exist on the incidence and factors of PVT in patients with AP. We investigate the incidence and clinical predictors of PVT in AP.

METHODS

We queried the 2016-2019 National Inpatient Sample database to identify patients with AP. Patients with chronic pancreatitis or pancreatic cancer were excluded. We studied demographics, comorbidities, complications, and interventions in these patients and stratified the results by the presence of PVT. A multivariate regression model was used to identify factors associated with PVT in patients with AP. We also assessed the mortality and resource utilization in patients with PVT and AP.

RESULTS

Of the 1,386,389 adult patients admitted with AP, 11,135 (0.8%) patients had PVT. Women had a 15% lower risk of developing PVT (aOR-0.85, p < 0.001). There was no significant difference between the age groups in the risk of developing PVT. Hispanic patients had the lowest risk of PVT (aOR-0.74, p < 0.001). PVT was associated with pancreatic pseudocyst (aOR-4.15, p < 0.001), bacteremia (aOR-2.66, p < 0.001), sepsis (aOR-1.55, p < 0.001), shock (aOR-1.68, p < 0.001) and ileus (aOR-1.38, p < 0.001). A higher incidence of in-hospital mortality and ICU admissions was also noted in patients with PVT and AP.

CONCLUSION

This study demonstrated a significant association between PVT and factors such as pancreatic pseudocyst, bacteremia, and ileus in patients with AP.

Characteristics of mass-forming autoimmune pancreatitis commonly misdiagnosed as a malignant tumor

Objective

This study aimed to explore the clinical characteristics and differential diagnosis of patients with autoimmune pancreatitis (AIP) and pancreatic cancer to prevent misdiagnosis and mistreatment.

Methods

The clinical data of patients with AIP with suspected pancreatic or bile duct malignancy and pancreatic cancer were retrospectively analyzed. The risk factors and the diagnostic value of IgG4 and Tbil levels before treatment for AIP was investigated. Moreover, the imaging features and response to hormone therapy were analyzed.

Results

AIP was commonly observed in men. Compared to patients with pancreatic cancer, the incidence of poor appetite and weight loss and carbohydrate antigen 19-9 (CA19-9) level was lower in patients with AIP, while the immunoglobulin G4 (IgG4) level was higher (p < 0.05). After treatment, the IgG4 and CA19-9 levels in patients with AIP were decreased (p < 0.001). IgG4 level before treatment (OR = 2.452, 95%CI: 1.180-5.096, P = 0.016) and total bilirubin (Tbil) level before treatment (OR = 0.992, 95%CI: 0.985-0.998, P = 0.013) were independent risk factors of AIP. Furthermore, the diagnostic value of IgG4 level before treatment, Tbil level before treatment, IgG4/Tbil before treatment, and a combination of these indicators was high. Moreover, 15 (68.18%) patients with AIP had space-occupying lesions of the pancreas, and 16 (72.73%) had autoimmune cholangitis. Most patients with AIP were sensitive to hormone therapy.

Conclusions

The Tbil and IgG4 levels, imaging findings, and hormone therapy reactivity could differentiate AIP from pancreatic cancer. A combination of IgG4, Tbil, and IgG4/Tbil before treatment might be a promising diagnostic biomarker for AIP.

Emphysematous pancreatitis with pulmonary embolism: A case report

Background

Emphysematous pancreatitis is a severe systemic inflammatory process with reports of pulmonary embolism in the setting of acute pancreatitis rarely described.

Case presentation

A 61-year-old woman presented with severe abdominal pain of 1 day duration. She was found to have acute interstitial pancreatitis. During her hospitalization, the patient developed worsening abdominal pain associated with increasing oxygen demands, requiring supplemental oxygen through nasal cannula. Workup showed pulmonary embolism in the posterior segmental branch of the left lower lobar artery and development of emphysematous pancreatitis was noted on imaging. The patient was started on intravenous antibiotics and therapeutic anticoagulation; her condition improved and was discharged home.

Conclusion

Patients with severe acute pancreatitis may be at risk for pulmonary embolism due to immobilization and other inflammatory mechanisms. Mitigating individualized risk factors and anticoagulation use as prophylaxis should be considered in patients with pancreatitis to prevent embolism. Early detection by clinicians is critical to reduce misdiagnosis and mortality rates.

Anticoagulation Therapy for Splanchnic Vein Thrombosis Associated With Acute Pancreatitis: A Systematic Review and Meta-Analysis

Splanchnic vein thrombosis (SVT) is not rare in patients with acute pancreatitis. It remains unclear about whether anticoagulation should be given for acute pancreatitis-associated SVT. The PubMed, EMBASE, and Cochrane Library databases were searched. Rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were pooled and compared between patients with acute pancreatitis-associated SVT who received and did not receive therapeutic anticoagulation. Pooled rates and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Heterogeneity among studies was evaluated. Overall, 16 studies including 698 patients with acute pancreatitis-associated SVT were eligible. After therapeutic anticoagulation, the pooled rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were 44.3% (95%CI = 32.3%-56.6%), 10.7% (95%CI = 4.9%-18.5%), 13.3% (95%CI = 6.9%-21.4%), 16.8% (95%CI = 6.9%-29.9%), 21.2% (95%CI = 7.5%-39.5%), and 29.1% (95%CI = 16.1%-44.1%), respectively. Anticoagulation therapy significantly increased the rate of SVT recanalization (RR = 1.69; 95%CI = 1.29-2.19; P < .01), and marginally increased the risk of bleeding (RR = 1.98; 95%CI = 0.93-4.22; P = .07). The rates of death (RR = 1.42; 95%CI = 0.62-3.25; P = .40), intestinal ischemia (RR = 2.55; 95%CI = 0.23-28.16; P = .45), portal cavernoma (RR = 0.51; 95%CI = 0.21-1.22; P = .13), and gastroesophageal varices (RR = 0.71; 95%CI = 0.38-1.32; P = .28) were not significantly different between patients who received and did not receive anticoagulation therapy. Heterogeneity was statistically significant in the meta-analysis of intestinal ischemia, but not in those of SVT recanalization, any bleeding, death, portal cavernoma, or gastroesophageal varices. Anticoagulation may be effective for recanalization of acute pancreatitis-associated SVT, but cannot improve the survival. Randomized controlled trials are warranted to further investigate the clinical significance of anticoagulation therapy in such patients.

Recurrent pancreatitis and sepsis in glycogen storage disease type Ia caused by complex heterozygous mutations in 2 sisters: Case report

RATIONALE

Glycogen storage disease (GSD) is a glycogen metabolism disorder caused by congenital enzyme defects, with type I being the most common. Owing to the rarity of glycogen storage disease type Ia (GSD Ia) and the involvement of diverse systems, patients are prone to delayed diagnosis and inappropriate treatment. Additional studies are required to standardize the diagnosis and treatment of GSD Ia.

PATIENT CONCERNS

We report 2 cases of GSD Ia that occurred in 2 sisters. The elder sister also had recurrent pancreatitis, and the pancreatic pseudocyst rupture resulted in sepsis, portal hypertension, and splenic infarction. The younger sister had the same mutation site, but the clinical phenotypes were not identical.

DIAGNOSIS

Abdominal computed tomography and laboratory examinations revealed regional portal hypertension, splenic infarction, and sepsis in the elder sister; diagnosis was confirmed by whole exome sequencing. Sanger sequencing was used to confirm that the younger sister and their parents also had the mutation site.

INTERVENTIONS

The elder sister was treated with corn starch therapy, and medication for antiinfection and reducing hypertriglyceridemia, inhibiting trypsin activity, relieving hyperuricemia. The younger sister was treated with raw cornstarch-based nutritional therapy and sodium bicarbonate.

OUTCOMES

The elder sister's infection was controlled and she gradually returned to a normal diet. After discharge, hyperlipidemia was not controlled satisfactorily, but hypoglycemia, hyperuricemia, hyperlactatemia, and anemia improved.

LESSONS

GSD should be considered in childhood patients with hypoglycemia, hypertriglyceridemia, hyperuricemia, and hyperlactatemia. Gene sequencing can enable quick identification of GSD subtypes. This case report highlights the common clinical manifestations can be linked to rare diseases. Clinical work requires careful observation of the correlations between patient history, physical examinations, and laboratory examinations.

Acute Necrotizing Pancreatitis Complicated by Multiple Splanchnic Venous Thromboses and Bilateral Renal Infarctions in a Patient With Recent COVID-19 Infection: A Case Report

Splanchnic vein thrombosis (SVT) is a well-known complication of pancreatitis, but extra-splanchnic thrombosis is rarely seen. We report a case of acute necrotizing pancreatitis complicated by portal vein thrombosis and resultant hepatic infarction, splenic vein thrombosis, bilateral renal infarction, and bowel hypoperfusion in an 81-year-old man with recent coronavirus disease 2019 (COVID-19) infection. To the best of our knowledge, this is the first documented case of such extensive intra-abdominal thromboses complicating severe acute pancreatitis. Despite multi-organ support and systemic anticoagulation, he deteriorated into multiple organ failure and died after 72 hours. He had no prior history of thrombotic disorders. COVID-19 infection can cause sustained prothrombotic changes, while severe acute pancreatitis also produces an inflammatory response that promotes coagulation. Together, the two concurrent disease processes may have resulted in the particularly extensive intra-abdominal thromboses and infarctions seen in this patient. Physicians should be mindful of the elevated risk of severe vascular complications in acute pancreatitis patients with concurrent or recent COVID-19 infection.

Clinical predictors for thrombus progression in cirrhotic patients with untreated splanchnic vein thrombosis

INTRODUCTION

Splanchnic vein thrombosis (SVT) occurs in a heterogenous group of patients secondary to a variety of risk factors including liver disease. Minimal data regarding natural history and outcomes of SVT exists to inform management decisions. As such, there is equipoise regarding the utility of anticoagulation in cirrhotic patients with SVT. We sought to identify clinical factors predictive of new or progressive thrombosis in a cohort of patients with untreated SVT.

METHODS

We conducted a retrospective cohort study of cirrhotic patients over 18 years of age diagnosed with SVT at the Oregon Health & Science University from 2015 to 2020, excluding those initially treated with anticoagulation. The primary study endpoint was a composite of the following: imaging-confirmed progression of SVT, development of cavernous transformation, intestinal ischemia, portal cholangiopathy or new venous or arterial thrombosis.

RESULTS

261 patients were included in the analysis (median age 61 years, 68% male, 32% female). Forty percent of all patients experienced the primary composite endpoint. Multivariable logistic regression found that only the presence of pancreatitis or abdominal infection at diagnosis was associated with an increased likelihood of experiencing thrombus progression in patients with untreated SVT (OR 3.61, P = 0.02). There was a statistically significant overall survival difference between patients that did and did not experience the primary composite endpoint after controlling for confounding variables. (p = 0.0068).

CONCLUSIONS

Overall, only the presence of pancreatitis or intrabdominal infection were found to be significantly associated with thrombotic progression, with varices identified as marginally non-significant risk factor. Notably, thrombotic progression was associated with a significant reduction in overall survival.

Triglyceride to HDL-C ratio is associated with plasma D-dimer levels in different types of pancreatitis

This study aims to evaluate levels of D-dimer and serum lipid in different types of pancreatitis, and the relationship between D-dimer and dyslipidemia, especially triglyceride to HDL-C ratio (TG/HDL-C) in different types of pancreatitis. We analyzed the D-dimer and dyslipidemia levels in acute pancreatitis (AP), recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP). A single-centered retrospective study was conducted on 1013 patients diagnosed with AP, RAP or CP. Only patients hospitalized within 24 h of onset were included, and 204 patients were enrolled in pancreatitis groups. 68 normal persons without pancreatitis, malignant diseases, pregnancy, or organ failure, who had health check-ups, were enrolled in the control group. Blood samples were taken within 24 h of admission. The relevant information on epidemiology and etiology was collected. D-dimer and serum lipid levels in different types of pancreatitis were analyzed. Furthermore, the area under the receiver-operating characteristic curve (AUC) was used to estimate the validity of the predictor and to define optimal cut-off points for prediction. We found that D-dimer and TG/HDL-C ratio could distinguish mild AP (MAP) and non-MAP in AP and RAP patients. The D-dimer level was related to TG/HDL-C ratio and severity of pancreatitis, with the coefficient correlation of 0.379 and 0.427(p < 0.05), respectively. TG/HDL-C was related to D-dimer in different types of pancreatitis. Logistic regression analysis was conducted in the parameters at admission like alcohol abuse, dyslipidemia and coagulation disturbance in distinguishing AP and RAP groups from the control group, and the parameter like diabetes in RAP and CP groups significantly increased compared with that of the control group. The value of D-dimer level and TG/HDL-C ratio in predicting the severity of AP and RAP was confirmed but there was no significant difference between CP group and the control group. The D-dimer level was related to dyslipidemia and TG/HDL-C ratio.

Guidelines for the management of patients with severe acute pancreatitis, 2021

OBJECTIVE

To provide guidelines for the management of the intensive care patient with severe acute pancreatitis.

DESIGN

A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations.

CONCLUSIONS

There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.

Ascites in Acute Pancreatitis: Clinical Implications and Management

Clinically significant ascites in acute pancreatitis (AP) is rarely encountered and is a result of multifactorial pathogenesis. Early reactionary ascites in AP usually does not require any treatment and resolves spontaneously in majority of patients. A diagnostic analysis should be performed in case of ascites developing in the latter stages with increasing pain or worsening organ failure. Low serum albumin-ascites gradient ascites with amylase > 1000 U/l is highly suggestive of pancreatic ascites that is usually associated with duct disruption. A combination of nasojejunal feeding, subcutaneous octreotide, endoscopic drainage and rarely, surgery are employed in managing this difficult to treat condition. There is a need of further studies to better understand the clinical role of ascites as well as contribution of other factors like hypoalbuminemia and portal hypertension to its development in AP.

Case Report: Splanchnic Vein Thrombosis as a Complication of Necrotizing Acute Pancreatitis in a Pediatric Patient

Splanchnic vein thrombosis is an unusual manifestation of venous thromboembolism and includes portal vein thrombosis, mesenteric veins thrombosis, splenic vein thrombosis, and the Budd-Chiari syndrome. The most common risk factors include hematologic and autoimmune disorders, hormonal therapy, liver cirrhosis, solid abdominal cancer, recent abdominal surgery, and abdominal infections or inflammatory conditions, such as pancreatitis. Splanchnic vein thrombosis in acute pancreatitis is most commonly associated with the severe form of the disease and pancreatic necrosis. This report describes a case of splanchnic vein thrombosis as a complication of necrotizing acute pancreatitis in a pediatric patient. Splanchnic vein thrombosis was incidentally detected on contrast-enhanced computed tomography to assess the pancreas. There was no evidence of prior risk factors for the thrombotic condition. The patient was treated with anticoagulation and showed complete resolution after recovery from necrotizing acute pancreatitis, at a 16-month follow-up. The complication of necrotizing acute pancreatitis with splanchnic vein thrombosis in pediatric age is a rare presentation.

Gastroduodenal artery pseudoaneurysm and chronic superior mesenteric vein thrombosis treated with transcatheter embolization and stent dilatation, respectively: 7 year clinical and imaging follow-up

Pancreatic pseudocyst formation, arterial pseudoaneurysm, and splanchnic vein thrombosis are complications of chronic pancreatitis that account for significant morbidity and mortality in this patient population. While the short-term utility of timely endovascular intervention for treating the vascular complications of chronic pancreatitis have been relatively well documented, there is a paucity of longitudinal follow-up in this patient population, therefore making it difficult to predict the long-term efficacy of these interventions. This report details a case of a gastroduodenal artery pseudoaneurysm embolization followed by symptomatic superior mesenteric vein chronic thrombosis treated by stent dilatation in a patient with chronic pancreatitis, with 7 years clinical and imaging follow-up.

Incidence and treatment of splanchnic vein thrombosis in patients with acute pancreatitis: A systematic review and meta-analysis

BACKGROUND AND AIM

This meta-analysis aimed to estimate the incidence of splanchnic vein thrombosis (SVT) in patients with acute pancreatitis and assess the effects of therapeutic anticoagulation.

METHODS

Systematic searches of the Medline, Embase, and Cochrane databases were undertaken to identify studies reporting the incidence and outcomes associated with SVT in patients with acute pancreatitis. The pooled incidence, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. PROSPERO database registration no. CRD 42021230912.

RESULTS

Only 18 of the 238 studies identified met the inclusion criteria. Of the 943 patients who had SVT, 264 (28.0%) received anticoagulation. The pooled incidence of SVT at first presentation of acute pancreatitis was 15% (95% CI 5 to 26%), but was 17% (95% CI 14 to 20%) in all studies. Recanalization was more likely to occur in the anticoagulation-treated than in the untreated group (OR 0.51, 95% CI 0.31 to 0.83, P = 0.007). There were no differences in hemorrhagic complications (OR 2.27, 95% CI 0.81 to 6.37, P = 0.12) or overall mortality (OR 2.37, 95% CI 0.86 to 6.52, P = 0.10) in relation to the use of anticoagulation. The overall incidence of portal hypertension in patients was 60% (95% CI 55 to 65%). However, it was not possible to determine the incidence in each group.

CONCLUSIONS

The incidence of SVT in patients with acute pancreatitis is significant. Treatment with anticoagulants improved the odds of recanalization but did not increase the risk of hemorrhagic complications or overall mortality.

Progress in research of minimally invasive therapy of local complications of acute pancreatitis

Acute pancreatitis is an inflammatory disease of the pancreas that can be life-threatening. Patients with severe acute pancreatitis require further rescue treatment in the intensive care unit. In recent years, treatment of local complications of acute pancreatitis has undergone considerable changes, including multidisciplinary team mode and individualized treatment scheme, and traditional open surgery has been gradually replaced by minimally invasive treatment. This article summarizes the progress in research on minimally invasive therapy of the local complications of acute pancreatitis in recent years.

Laparoscopic transgastric necrosectomy in treatment of walled-off pancreatic necrosis with sinistral portal hypertension

Background

Laparoscopic transgastric necrosectomy (LTGN) has been used in treatment of walled-off pancreatic necrosis (WON) for more than a decade. However, the safety and effectiveness of LTGN for WON with sinistral portal hypertension was still unclear.

Methods

WON patients with sinistral portal hypertension treated in our department between January 2011 and December 2018 were included and retrospectively analyzed in this study. Patients were divided into two groups according to different surgical approaches, LTNG or laparoscopic assisted trans-lesser sac necrosectomy (LATLSN). Perioperative and long-term outcomes were compared between two groups.

Results

312 cases diagnosed with WON were screened and 53 were finally included in this study. Of the included patients, 21 and 32 cases were received LTGN and LATLSN, respectively. LTGN was associated with significantly lower morbidity than LATLSN (19.0% vs 46.9%, p = 0.04) and similar severe complication (Clavien–Dindo ≥ III) rate (12.5% vs 19.0%, p = 0.70). LTGN did not increase the rate of postoperative hemorrhage (9.5% vs 6.3%, p = 1.00) and mortality (9.5% vs 9.4%, p = 1.00). After 39 (11–108) months follow-up, the recurrence rate of WON and long-term complications were also comparable between groups.

Conclusion

From current data, LTGN was safe and effective in treatment of WON patients with sinistral portal hypertension in terms of short- and long-term outcomes.

Vascular Complications in Patients with Chronic Pancreatitis

Introduction: Chronic pancreatitis (CP) is a long-standing progressive inflammation of the pancreas, which can lead to a variety of vascular complications, such as splanchnic venous thrombosis (VT) and arterial pseudoaneurysm (PA). There is a lack of studies on vascular complications in Scandinavian countries. Methods: We performed a retrospective analysis of medical records of patients with CP identified from the Karolinska University Hospital database between 2003 and 2018. A total of 394 patients with definite CP were included in the study. Results: There were 33 patients with vascular complications, with a median age of 62 (IQR 55–72) years. The cumulative incidence of vascular events was 3.2% at 5 years. Thirty patients had isolated VT, whereas three patients had PA (7.6% and 0.8%, respectively). Isolated splenic vein thrombosis was most common (53.3%), followed by a combination with other splanchnic veins. PA was found in the splenic artery in two patients and in the left gastric artery in one patient. Varices were present in three (10%) patients; variceal bleeding was not recorded. All patients had asymptomatic splanchnic VT, most with chronic VT with developed collaterals (83.3% had abdominal collateral vessels). Nearly two-thirds of patients with VT (63.3%) received no treatment, whereas 11 (36.6%) were treated with anticoagulants. Pseudocysts and alcoholic etiology of CP are risk factors for vascular complications. Conclusions: The cumulative incidence of vascular complications was 3.2% at 5 years. Splanchnic VT is more common than PA. Patients were asymptomatic with no variceal bleeding, explained by well-developed collateral vessels and strong study inclusion criteria.

Comprehensive Mechanism, Novel Markers and Multidisciplinary Treatment of Severe Acute Pancreatitis-Associated Cardiac Injury - A Narrative Review

Acute pancreatitis (AP) is one of the common acute abdominal inflammatory diseases in clinic with acute onset and rapid progress. About 20% of the patients will eventually develop into severe acute pancreatitis (SAP) characterized by a large number of inflammatory cells infiltration, gland flocculus flaky necrosis and hemorrhage, finally inducing systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). Pancreatic enzyme activation, intestinal endotoxemia (IETM), cytokine activation, microcirculation disturbance, autonomic nerve dysfunction and autophagy dysregulation all play an essential role in the occurrence and progression of SAP. Organ dysfunction is the main cause of early death in SAP. Acute kidney injury (AKI) and acute lung injury (ALI) are common, while cardiac injury (CI) is not, but the case fatality risk is high. Many basic studies have observed obvious ultrastructure change of heart in SAP, including myocardial edema, cardiac hypertrophy, myocardial interstitial collagen deposition. Moreover, in clinical practice, patients with SAP often presented various abnormal electrocardiogram (ECG) and cardiac function. Cases complicated with acute myocardial infarction and pericardial tamponade have also been reported and even result in stress cardiomyopathy. Due to the molecular mechanisms underlying SAP-associated cardiac injury (SACI) remain poorly understood, and there is no complete, unified treatment and sovereign remedy at present, this article reviews reports referring to the pathogenesis, potential markers and treatment methods of SACI in recent years, in order to improve the understanding of cardiac injury in severe pancreatitis.

The in situ near-total pancreatectomy (LIVOCADO procedure) for end-staged chronic pancreatitis

PURPOSE

Total pancreatectomy for severe pain in end-stage chronic pancreatitis may be the only option, but with vascular involvement, this is usually too high risk and/or technically not feasible. The purpose of the study was to present the clinical outcomes of a novel procedure in severe chronic pancreatitis complicated by uncontrollable pain and vascular involvement.

METHODS

We describe an in situ near-total pancreatectomy that avoids peripancreatic vascular dissection (Livocado procedure) and report on surgical and clinical outcomes.

RESULTS

The Livocado procedure was carried out on 18 (3.9%) of 465 patients undergoing surgery for chronic pancreatitis. There were 13 men and 5 women with a median (IQR) age of 48.5 (42.4-57) years and weight of 60.7 (58.0-75.0) kg. All had severe pain and vascular involvement; 17 had pancreatic parenchymal calcification; the median (IQR) oral morphine equivalent dose requirement was 86 (33-195) mg/day. The median (IQR) maximal pain scores were 9 (9-10); the average pain score was 6 (IQR 4-7). There was no peri-operative or 90-day mortality. At a median (IQR) follow-up of 32.5 (21-45.75) months, both maximal and average pain scores were significantly improved post-operatively, and at 12 months, two-thirds of patients were completely pain free. Six (33%) patients had employment pre-operatively versus 13 (72%) post-operatively (p = 0.01).

CONCLUSIONS

The Livocado procedure was safe and carried out successfully in patients with chronic pancreatitis with vascular involvement where other procedures would be contraindicated. Perioperative outcomes, post-operative pain scores, and employment rehabilitation were comparable with other procedures carried out in patients without vascular involvement.

Splanchnic Vein Thrombosis in Acute Pancreatitis and Its Consequences

Splanchnic vein thrombosis (SVT) is a serious vascular complication that can occur in patients with acute pancreatitis. We assessed the incidence of SVT and its relationship with acute pancreatitis (AP) and associated complications. We carried out a retrospective analysis of medical histories from patients hospitalized with AP in a single surgical center. Histories were acquired from patients with abdominal and pelvic computed tomography scans performed between the 2nd and 3rd day of hospitalization. We assessed the impact and extent of thrombosis over the disease course. We found a strong positive correlation (Cramer’s V coefficient = 0.34) between SVT and disease severity. Mortality in the study group was 7.2% (8 patients) of which 5 patients (62.5%) were diagnosed with SVT. We observed an increased incidence of death among patients with thrombosis, with results approaching significance (P = 0.056). In our study, we found that SVT has a negative effect on the course of AP and is associated with more severe disease and increased mortality.

Treatment of portal vein thrombosis: an updated narrative review

Portal vein thrombosis (PVT) is the most frequent among the splanchnic vein thrombosis, accounting for 90% of cases. More than half of PVT are provoked by liver cirrhosis, solid cancer or myeloproliferative neoplasms. The remaining cases are non-malignant non-cirrhotic PVT and include either unprovoked events or thrombosis secondary to other less common risk factors (e.g. abdominal surgery, intrabdominal inflammations/infections, or hormonal stimuli). Anticoagulant therapy in patients with acute symptomatic PVT should be started early after diagnosis, if no active bleeding, to obtain greater vessel recanalization and reduce the occurrence of portal-hypertension related complications. Gastroesophageal varices do not represent a contraindication to anticoagulant treatment, as long as adequate measures have been undertaken for the prophylaxis of gastroesophageal bleeding. Different treatment options (unfractionated or low molecular weight heparin, vitamin K antagonists and direct oral anticoagulants [DOACs]) can be considered. In this narrative review we will discuss the treatment of PVT in the three most common scenarios (cirrhosis-associated, cancer-associated and non-malignant non-cirrhotic PVT). We will also discuss the role of the DOACs and summarise recent guidelines on this topic.

Epidemiology and Risk Factors of Portal Venous System Thrombosis in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with inflammatory bowel disease (IBD) may be at risk of developing portal venous system thrombosis (PVST) with worse outcomes. This study aims to explore the prevalence, incidence, and risk factors of PVST among patients with IBD.

METHODS

PubMed, Embase, and Cochrane Library databases were searched. All the eligible studies were divided according to the history of colorectal surgery. Only the prevalence of PVST in patients with IBD was pooled if the history of colorectal surgery was unclear. The incidence of PVST in patients with IBD after colorectal surgery was pooled if the history of colorectal surgery was clear. Prevalence, incidence, and risk factors of PVST were pooled by only a random-effects model. Subgroup analyses were performed in patients undergoing imaging examinations. Odds ratios (ORs) with 95% CIs were calculated.

RESULTS

A total of 36 studies with 143,659 patients with IBD were included. Among the studies where the history of colorectal surgery was unclear, the prevalence of PVST was 0.99, 1.45, and 0.40% in ulcerative colitis (UC), Crohn's disease (CD), and unclassified IBD, respectively. Among the studies where all the patients underwent colorectal surgery, the incidence of PVST was 6.95, 2.55, and 3.95% in UC, CD, and unclassified IBD after colorectal surgery, respectively. Both the prevalence and incidence of PVST became higher in patients with IBD undergoing imaging examinations. Preoperative corticosteroids therapy (OR = 3.112, 95% CI: 1.017-9.525; p = 0.047) and urgent surgery (OR = 1.799, 95% CI: 1.079-2.998; p = 0.024) are significant risk factors of PVST in patients with IBD after colorectal surgery. The mortality of patients with IBD with PVST after colorectal surgery was 4.31% (34/789).

CONCLUSION

PVST is not rare, but potentially lethal in patients with IBD after colorectal surgery. More severe IBD, indicated by preoperative corticosteroids and urgent surgery, is associated with a higher risk of PVST after colorectal surgery. Therefore, screening for PVST by imaging examinations and antithrombotic prophylaxis in high-risk patients should be actively considered.

SYSTEMATIC REVIEW REGISTRATION

Registered on PROSPERO, Identifier: CRD42020159579.

Frey's plus versus Frey's procedure for chronic pancreatitis: Analysis of postoperative outcomes and quality of life

Backgrounds/Aims

Additional surgical procedures are often required in patients with chronic pancreatitis (CP) related complications. The present study aims to analyze the type of additional procedures required in patients who underwent Frey’s procedure (Frey’s plus) and to compare the short-term outcomes and quality of life with patients who underwent only Frey’s procedure.

Methods

Retrospective analysis of a prospectively maintained database of patients who underwent surgery for CP between January 2012 and February 2018 and completed at least one year of follow-up. Patients who underwent non-Frey’s surgical procedures were excluded. Clinical parameters, postoperative pain relief (using Izbicki pain score) and functioning scale score (EORTC QLQ C30) of patients who underwent Frey’s plus procedure and only Frey’s procedure were compared.

Results

Of the 146 patients who underwent surgery for CP during the study period, 100 patients (Frey’s procedure–68, Frey’s plus procedure–32) were included in this study. Roux-en-Y hepaticojejunostomy was the commonly performed additional procedure (n=12). The demographic and clinical parameters were comparable, except for more patients with jaundice (28.1% vs. 2.9%, p=0.01) and prolonged operative time (374.6 mins vs. 326.3 mins, p=0.01) in Frey’s plus group. However, there was no significant difference in mean intraoperative blood loss, postoperative morbidity or duration of hospital stay. At median (range) follow up of 34 (12-86) months, there was no significant difference in the pain control and quality of life between two groups.

Conclusions

Frey’s plus procedure for chronic pancreatitis can be safely performed wherever indicated without adversely affecting the postoperative outcome or quality of life.

International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club

BACKGROUND/OBJECTIVES

This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy.

METHODS

An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements.

RESULTS

Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.

Anticoagulant therapy in the treatment of splanchnic vein thrombosis associated to acute pancreatitis: a 3-year single-centre experience

Splanchnic vein thrombosis (SVT) is a possible complication of acute pancreatitis (AP). There are no precise guidelines on the use of anticoagulant therapy (AT) in these patients. The aim of the study was to determine the safety and the efficacy of AT in AP-associated SVT. Two hundred twenty-one patients were retrospectively and consecutively enrolled from the Pancreatic Outpatient Clinic of the "A. Gemelli" hospital. Patients had a diagnosis of AP and a diagnostic imaging to evaluate whether they had or not SVT. Twenty-seven out of 221 AP patients had SVT (12.21%) and AT therapy was administered to 16 patients (59.3%), for 5.2 ± 2.2 months. A therapeutic dose of low molecular weight heparin was administered (100 UI/kg b.i.d.) at the diagnosis, with fondaparinux 7.5 mg/day, or vitamin K antagonist, or the novel direct oral anti-coagulants, upon discharge. The presence of SVT resulted significantly associated to male sex (p = 0.002). The recanalization rates were 11/16 (68.7%) in patients who received AT, and 3/11 (27.3%) in patients who did not receive it. There was a significant difference between the recanalization rates with and without AT (p = 0.03, OR 5.87). No SVT recurrence was registered during follow-up. No treated patient developed haemorrhagic complications after AT. No deaths were recorded, either in the group undergoing AT or in the one that was not. In conclusion, AT in AP-associated SVT appears to be safe and effective; yet prospective clinical trials are needed to confirm our results.

Portal Vein Thrombosis and Intra-Abdominal Hypertension Presenting as Complications of Hypertriglyceridemia-Induced Severe Acute Pancreatitis

A 44-year-old male without any significant past medical history presented to the emergency department (ED) with the chief complaint of severe constant epigastric pain for three hours. On physical examination, the abdomen was distended and tender, particularly in the epigastric region. The lab work showed an elevation of the lipase (12,405 U/L) and triglycerides (5,837 mg/dL). An abdominal CT scan with contrast was ordered, which revealed non-necrotic pancreatitis. In addition, the liver ultrasound showed no evidence of gallstones. Subsequently, fluid infusion, meropenem, pain medication, and an insulin drip were started, and the patient was transferred to the intensive care unit (ICU). After six hours in the ICU, he complained of abdominal pain despite taking a high hydromorphone dose.

On further physical examination, the abdomen was tender and distended but without rebound tenderness. The gastric distention on kidneys, ureter, and bladder (KUB) and a bladder pressure of 34 mmHg raised the suspicion for intra-abdominal hypertension (IAH), which led us to place a nasogastric tube (NGT) and consult the surgical team. The patient's symptoms and bladder pressure were closely followed and showed significant improvement. On day seven in the ICU, the patient responded well to medications; feeding through the Dobhoff tube was started, and his triglycerides decreased to approximately 1,000 mg/dL. Despite his general improvement and meropenem regimen, the patient spiked a fever of 38.5 °C. Due to the possibility of pancreatitis complications, a CT abdomen with contrast was ordered, which showed partial portal vein thrombosis (PVT). Subsequently, enoxaparin was started, and the patient was closely observed for gastrointestinal bleeding. Eventually, after 17 days in the ICU, the patient was transferred to the floor and then discharged from the hospital with normal lab tests and without evidence of portal thrombosis on abdominal CT.

In this report, we illustrate and discuss a case of hypertriglyceridemia (HTG)-induced pancreatitis (HTGP), which progressed to PVT and IAH. Physicians should be aware that patients with HTG are inclined to have severe pancreatitis. In addition, the degree of triglyceride elevation is correlated with the severity of acute pancreatitis.

Clinical Characteristics and Risk Factors for Sinistral Portal Hypertension Associated with Moderate and Severe Acute Pancreatitis: A Seven-Year Single-Center Retrospective Study

Background

This study aimed to assess the prevalence, clinical characteristics, and risk factors for sinistral portal hypertension in patients with moderate or severe acute pancreatitis.

Material/Methods

A retrospective study included 825 patients with moderate or severe acute pancreatitis. Clinical and demographic data, the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Ranson scores for severity of acute pancreatitis, and the computed tomography (CT) severity index (CTSI) were evaluated. The formation of collateral vessels, bleeding, splenomegaly, hypersplenism during hospitalization or follow-up, and early anticoagulation and the occurrence of sinistral portal hypertension were evaluated.

Results

Of the 825 patients with moderate or severe acute pancreatitis, 103 patients (12.5%) developed sinistral portal hypertension. The median time to diagnosis was 8 months, and the median patient age was 39 years. The most common causes of pancreatitis were biliary (46.3%), hypertriglyceridemia (31.5%), alcohol (14.9%), and others (7.3%). Independent risk factors for sinistral portal hypertension were male gender (OR, 4.666; 95% CI, 2.54–8.572; P<0.001), recurrent acute pancreatitis (OR, 9.556; 95% CI, 5.218–17.5; P<0.001), hypertriglyceridemia (OR, 2.056; 95% CI, 1.184–3.57; P=0.001), glucose >10 mmol/L (OR, 6.965; 95% CI, 4.027–12.045; P<0.001), smoking (OR, 6.32; 95% CI, 3.544–11.269; P<0.001), and infection of walled-off necrosis (OR=1.637; 95% CI, 1.061–2.524; P=0.015). Anticoagulation during hospitalization was not significantly associated with sinistral portal hypertension.

Conclusions

Hypertriglyceridemia, hyperglycemia, infection of walled-off necrosis, recurrent acute pancreatitis, and smoking were risk factors for sinistral portal hypertension, and early anticoagulation did not prevent the occurrence.

Atraumatic Splenic Hemorrhage as a Rare Complication of Pancreatitis: Case Report and Literature Review

Splenic hemorrhage (hematoma and rupture) is a rare complication of pancreatitis. In this article, we present a rare case of spontaneous splenic rupture as a complication of acute pancreatitis. A literature review was also completed to describe the patient characteristics, associated pancreatitis etiology, clinical presentations, risk factors, diagnostic and treatment modalities, and outcomes.

Changes in the Velocity of Blood in the Portal Vein in Mild Acute Pancreatitis-A Preliminary Clinical Study

Background and objective: Portal vein thrombosis is associated with a decrease in the main blood velocity in this vessel. While most studies examine etiological factors of portal vein thrombosis after its occurrence, we aimed to evaluate portal vessels and assess whether mild acute pancreatitis affects blood flow in the portal vein and increases the risk of thrombosis. Materials and methods: This prospective single centered follow-up study enrolled 66 adult participants. Fifty of them were diagnosed with mild acute pancreatitis based on the Revised Atlanta classification, and 16 healthy participants formed the control group. All participants were examined three times. The first examination was carried out at the beginning of the disease and the next two at three-month intervals. Blood samples were taken and color Doppler ultrasound performed the first time, whereas ultrasound alone was performed during the second and third visits. Mean and maximal blood velocities and resistivity index in the main portal vein and its left and right branches were evaluated. Results: Mean velocity of the blood flow in the main portal vein and its right and left branches was not significantly different from healthy individuals during the acute pancreatitis phase: 23.1 ± 8.5 cm/s vs. 24.5 ± 8.2 cm/s (p = 0.827); 16.4 ± 7.9 cm/s vs. 16.4 ± 8.1 cm/s (p = 1.000); and 8 ± 3.4 cm/s vs. 7.4 ± 2.5 cm/s (p = 0.826), respectively. The same was observed when comparing the maximal blood flow velocity: 67.9 ± 29 cm/s vs. 67.5 ± 21 cm/s (p > 0.05); 45.4 ± 27 cm/s vs. 44 ± 23.8 cm/s (p = 0.853); and 22.2 ± 9.8 cm/s vs. 20 ± 7.3 cm/s (p = 0.926), respectively. Changes in venous blood velocities were not significant during the follow-up period in separate study groups. Conclusions: Portal blood flow velocities do not change during mild acute pancreatitis in the inflammatory and postinflammatory periods. This observation suggests that mild acute pancreatitis does not increase the risk of portal vein thrombosis.

Coronary thrombosis in acute pancreatitis

The incidence of acute myocardial infarction in the setting of acute pancreatitis is very rare. The recognition of such complex diagnosis may be clinically challenging, as the symptoms of both conditions are often indistinguishable. We report a case in which we encountered both conditions concurrently, and hypothesize that the ambient inflammatory and pro-thrombotic milieu of acute pancreatitis resulted in acute coronary thrombosis despite the absence of significant coronary atherosclerosis. Among multiple coronary imaging modalities currently in use, optimal cohesion tomography provided a unique capability for direct visualization of the coronary thrombus. (1) Inflammatory processes such as acute pancreatitis promote a thrombogenic state. (2) Presentation of acute myocardial infarction is variable and can mimic a variety of medical conditions. (3) Intravascular imaging is emerging as a useful tool in delineating details of intra-coronary pathology not clear on standard fluoroscopy. (4) The above case highlights the likely concurrence of pathologies that follow common pathways such as system-wide inflammation and coagulation. Clinicians must be aware of this uncommon yet very likely possibility and keep a low threshold to perform ECG and cardiac biomarker testing if symptoms are suggestive of a myocardial infarction, even in the presence of a clear alternative diagnosis.

Comparison of clinical characteristics of radiological forms of autoimmune pancreatitis

BACKGROUND

There is limited understanding of the clinical characteristics of different radiological forms of autoimmune pancreatitis (AIP). This retrospective study compared the clinical features of radiological forms of AIP.

METHODS

A retrospective review was conducted of patients with AIP treated from 2005 to 2015. Based on radiological features, these AIP cases were classified as diffuse (D) or focal (F), and the latter further stratified as head (H), or body and/or tail (B/T). The clinical characteristics and laboratory indices were compared.

RESULTS

Among the 119 patients, 66 (55.5%), 40 (33.6%), and 13 (10.9%) were respectively classified as D-, H-, and B/T-type. Compared with the others, the B/T-type patients were younger at onset, the percentage of men was lower, loss of appetite and weight were less common, and these patients had fewer extrapancreatic lesions (P < 0.05, each). Compared with the other groups, the B/T-type patients showed significantly lower levels of liver enzymes, direct bilirubin, and total bilirubin. No B/T-type patient displayed jaundice or pruritus. Three B/T-type patients progressed to D-type during the natural course of illness.

CONCLUSIONS

D-type and H-type AIP patients had similar clinical features. The B/T-type group differed significantly from the other two types. B/T-type can progress to D-type.

Biomarkers for the risk of thrombosis in pancreatic adenocarcinoma are related to cancer process

Background

Venous thrombo-embolic events (VTE) frequently occur in patients with pancreatic ductal adenocarcinoma (PDAC) and contribute to high morbidity and mortality.

Objectives

To determine whether VTE biomarkers are related to cancer, inflammation or precancerous states and to assess their relevance to predict VTE in PDAC.

Patients and Methods

We compared VTE biomarkers in patients with PDAC (n = 42), intraductal papillary mucinous neoplasm of the pancreas (IPMN, n = 48) or chronic pancreatitis (n = 50). PDAC patients were followed-up for 6 months.

Results

Factor VIII, D-dimers, von Willebrand factor, free tissue factor pathway inhibitor and microvesicle-tissue factor (MV-TF) activity were higher in PDAC patients compared to patients with IPMN or chronic pancreatitis. PDAC patients with metastasis presented higher D-dimers and MV-TF activity compared to patients with localized lesions, but elevation of D-dimers was dependent on tumor size. In multivariate analysis, elevated D-dimers (≥2.16 µg/mL) or MV-TF activity (≥2.37 pg/mL) were significant risk factors for VTE in PDAC patients, after adjustment for age and sex (HR 4.9 [1.0-23.1] or HR 10.5 [1.5-72.4], mean [interquartile range], respectively). Cumulative probability of VTE at 6 months was higher in patients with elevated D-dimers (56.3% vs 15.6%, p = 0.009) and in patients with high MV-TF activity (74.3% vs 21.7%, p = 0.01).

Conclusions

VTE biomarkers including D-dimers and MV-TF activity are not related to inflammation but rather to cancer process and dissemination. D-dimers and MV-TF activity are associated to future VTE in PDAC patients and could help identify patients who could benefit from thromboprophylaxis.

Risk factors and outcomes of infected pancreatic necrosis: Retrospective cohort of 148 patients admitted to the ICU for acute pancreatitis

Objective

The primary objective of this article is to identify risk factors for infected pancreatic necrosis (IPN) in patients admitted to the intensive care unit (ICU) for severe acute pancreatitis. We also described outcomes of IPN.

Background

Acute pancreatitis is common and associated with multiple, potentially life-threatening complications. Over the last decade, minimally invasive procedures have been developed to treat IPN.

Methods

We retrospectively studied consecutive patients admitted for severe acute pancreatitis to the ICUs of the Nantes University Hospital in France, between 2012 and 2015. Logistic regression was used to evaluate potential associations linking IPN to baseline patient characteristics and outcomes.

Results

Of the 148 included patients, 26 (17.6%) died. IPN developed in 62 (43%) patients and consistently required radiological, endoscopic, and/or surgical intervention. By multivariate analysis, factors associated with IPN were number of organ failure (OF) (for ≥ 3: OR, 28.67 (6.23-131.96), p < 0.001) and portosplenomesenteric venous thrombosis (OR, 8.16 (3.06-21.76)).

Conclusion

IPN occurred in nearly half our ICU patients with acute pancreatitis and consistently required interventional therapy. Number of OFs and portosplenomesenteric venous thrombosis were significantly associated with IPN. Early management of OF may reduce IPN incidence, and management of portosplenomesenteric venous thrombosis should be investigated.