Acute biliary pancreatitis: does the pancreas change morphologically in the long term?

Demographic and clinicopathological profile of patients with chronic pancreatitis in a tertiary referral teaching hospital of West Bengal: Personal experience

BACKGROUND

There is a paucity of data on the demographic and clinicopathological profiles of patients with chronic pancreatitis from the eastern part of India. This study documents the demographic and clinicopathological profiles of patients with chronic pancreatitis presenting to a general surgery unit of a tertiary referral hospital of Kolkata.

METHODS

The records of 145 patients presenting with chronic pancreatitis over a 5-year period were scrutinized and their demographics, clinical profile, and complications and morphological changes of the pancreas are described.

RESULTS

Of the 145 patients, more than 50% were under the age of 30 years. Males were affected more frequently than females (M/F = 3.8:1). While idiopathic pancreatitis was the most common form of chronic pancreatitis (41.4%), alcohol was found to be the most common etiology (37.9%). Pain was the most common presenting symptom (n = 143; 98.6%). Sixty-five subjects (45%) had diabetes of which 32 subjects were insulin-dependent. On contrast-enhanced computed tomography, ductal dilatation was seen in 80 (55.17%) subjects, while ductal calculi and ductal dilatation in 54 cases (37.2%). Parenchymal calcification was seen in 45 patients of whom 40 patients (89%) were under the age of 30 years. Pseudocyst was the most common complication (n = 16) followed by biliary obstruction (n = 8) and portal hypertension (n = 4). Patients with alcoholic pancreatitis had significantly higher frequency of severe abdominal pain, diabetes, and local complications as compared to the other forms of pancreatitis in our study.

CONCLUSION

Idiopathic pancreatitis was the most common form of chronic pancreatitis in this study, followed by alcoholic pancreatitis and then tropical pancreatitis.

Severe acute pancreatitis: the life after

BACKGROUND

The present study reports functional and morphological changes noted over long-term follow-up in patients with severe acute pancreatitis.

METHODS

Thirty patients who had completed at least 6 months after recovery were included. Fecal fat, urinary D-xylose, blood sugar, C-peptide, pancreatic changes, and recurrences were studied.

RESULTS

Etiology was gallstones (12), alcohol (10), both gallstone and alcohol (3), and idiopathic (5). Five patients were managed conservatively while 25 underwent surgery. Mean follow-up was 31.3 months. Exocrine and endocrine insufficiencies were noted in 12 (40%) and were more common in no-necrosis group compared to necrosis group (p = 0.04 and 0.28, respectively) and infected compared to sterile pancreatitis (45% vs. 25%, p = 0.55 and 50% vs. 12%, p = 0.15, respectively). Higher frequency was noted in nonvisualized, partly visualized, and dilated segment of duct. Significant proportion (8/12) had both exocrine and endocrine abnormalities and their incidence decreased as duration of follow-up increased. Urinary D-xylose excretion was abnormal in 16% and noted >1 year postrecovery. Thirty percent required >1 readmission and pain was the commonest cause.

CONCLUSIONS

Forty percent had functional abnormality; 16% had mucosal absorption abnormality while 30% required >1 readmission. Exocrine and endocrine insufficiencies were more prevalent in first year, and a significant proportion had both. A trend for higher functional insufficiency was observed in infected necrosis, complete or incomplete visualization of main pancreatic duct (MPD), dilated segment of MPD, and pseudocyst.

The selective use of magnetic resonance cholangiopancreatography in the imaging of the axial biliary tree in patients with acute gallstone pancreatitis

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is an emerging modality in the management of acute gallstone pancreatitis (AGP). The aim of this study was to assess the impact following the introduction of MRCP in the management of AGP in a tertiary referral unit.

METHODS

Patients presenting with AGP from January 2002 to December 2004 were reviewed to assess the impact of the introduction of MRCP in June 2003. The indication for MRCP was suspected common bile duct (CBD) stones in the absence of biliary sepsis. Definitive treatment for AGP was laparoscopic cholecystectomy, with endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy reserved for patients unfit for cholecystectomy and those with biliary sepsis.

RESULTS

249 patients were identified of whom 36 (14.5%) underwent ERCP and sphincterotomy as definitive treatment. 96 patients with a non-dilated CBD and normal or resolving liver function tests proceeded to laparosocopic cholecystectomy and intraoperative cholangiogram (IOC), 8 (8.5%) of whom had CBD stones intraoperatively. Eleven patients underwent cholecystectomy during pancreatic necrosectomy. Of those undergoing preoperative diagnostic biliary tract imaging, ERCP was undertaken in 57 patients and MRCP in 49 patients. There was no significant difference in serum bilirubin levels [ERCP 43 mmol/l (18-204) vs. MRCP 39 mmol/l (24-180), p = NS] or the proportion of patients with CBD stones [ERCP 10 (17.5%) vs. MRCP 7 (14.2%), p = NS] between the two groups. Patients who underwent MRCP had a shorter median hospital stay [MRCP 5 days (range: 3-14) vs. ERCP 9 days (range: 4-20), p < 0.01] and higher rate of cholecystectomy during the index admission (MRCP 83.3% vs. ERCP 67.2%, p < 0.05). There was a high degree of correlation between preoperative MRCP results and findings of subsequent IOC or therapeutic ERCP (area under ROC curve: 0.94).

CONCLUSIONS

MRCP is an accurate modality for imaging the axial biliary tree in patients with AGP. Selective use of MRCP reduces the need for ERCP and results in shorter hospital stay. and IAP.

Gall stones and chronic pancreatitis: the black box in between

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

Acute biliary pancreatitis: does the pancreas change morphologically in the long term?

The objective of the study was to assess by means of magnetic resonance cholangiopancreatography whether acute biliary pancreatitis leads to alterations in pancreatic morphology and the main pancreatic duct; to establish whether such alterations are related to the severity of the acute episode and if they are to be considered as sequelae of the illness or on the contrary the findings constitute diagnostic morphological criteria of chronic pancreatitis. Forty patients with acute biliary pancreatitis were prospectively and consecutively studied, 15 female (37.5%) and 25 male (62.5%). During the acute phase the severity was assessed according to the Atlanta criteria. During subsequent follow-up,we assessed the morphology of the gland and the main pancreatic duct with magnetic resonance cholangiopancreatography 5 years after the episode of pancreatitis, and compared the findings with the findings from a control group. We administered secretin in 16 of the study group cases when visualization of the duct was incomplete or absent. The statistical study of diameter and length showed significant differences in the main pancreatic duct of the case and control groups. No relationship was found between the severity of the illness and morphological alterations of the pancreas after pancreatitis. The statistical analysis, which compared the diameter and the length of the main pancreatic duct before and after the injection of secretin in the study group showed significant differences. We conclude that after acute biliary pancreatitis, in the long term, scarring lesions are detected, which are considered to be sequelae of the acute episode, unrelated to its severity. Secretin stimulation improved visualization of the main pancreatic duct in the magnetic resonance cholangiopancreatography.