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Kugathasan L, Zhuang T, Cheeley J, Khan H, Jernigan AB, Kobaidze K. Pancreatitis, Panniculitis, and Polyarthritis Syndrome in Two Patients: A Case Series and Literature Review. Cureus 2024; 16:e59471. [PMID: 38826929 PMCID: PMC11140439 DOI: 10.7759/cureus.59471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome presents a unique challenge in diagnosis and management because of its rarity and heterogeneous initial presentation. This manuscript presents a case series of two patients with PPP syndrome, shedding light on the diagnostic process and care for this uncommon condition. PPP syndrome is characterized by the simultaneous occurrence of pancreatitis or pseudocysts alongside polyarthritis and panniculitis. While its exact pathophysiology remains obscure, pancreatic inflammation is assumed to trigger the hematogenous dissemination of pancreatic enzymes, leading to fat necrosis and subsequent panniculitis, as well as chondronecrosis and/or osteonecrosis causing polyarthritis. Despite its recognition in medical literature since the late 1980s, PPP syndrome remains poorly understood, with only a limited number of cases reported globally. Its rarity and varied initial manifestations often result in misdiagnosis, causing delays in appropriate treatment. The presented case series highlights key clinical features and diagnostic clues of PPP syndrome. Both patients exhibited initial symptoms of inflammatory polyarthritis, accompanied by characteristic findings of "ghost cells" on skin biopsy. Additionally, radiographic and laboratory evidence revealed pancreatic changes consistent with this syndrome. This case series underscores the importance of multidisciplinary collaboration in managing PPP syndrome. Early recognition and accurate diagnosis are pivotal in initiating prompt and effective therapeutic interventions, thereby improving patient outcomes and minimizing long-term sequelae.
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Affiliation(s)
- Logan Kugathasan
- Department of Medicine, Emory University School of Medicine, Atlanta, USA
| | - Tony Zhuang
- J. Willis Hurst Internal Medicine Residency Program, Emory University School of Medicine, Atlanta, USA
| | - Justin Cheeley
- Department of Dermatology, Emory University School of Medicine, Atlanta, USA
| | - Hope Khan
- Department of Nursing, Emory Healthcare, Atlanta, USA
| | - Audrey B Jernigan
- Department of Medicine, Division of Hospital Medicine, Emory University School of Medicine, Atlanta, USA
| | - Ketino Kobaidze
- Department of Medicine, Division of Hospital Medicine, Emory University School of Medicine, Atlanta, USA
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Liu Z, Ke H, Xiong Y, Liu H, Yue M, Liu P. Gastrointestinal Fistulas in Necrotizing Pancreatitis Receiving a Step-Up Approach Incidence, Risk Factors, Outcomes and Treatment. J Inflamm Res 2023; 16:5531-5543. [PMID: 38026251 PMCID: PMC10676678 DOI: 10.2147/jir.s433682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Necrotizing pancreatitis (NP) complicated by gastrointestinal fistula is challenging and understudied. As the treatment of necrotizing pancreatitis changed to a step-up strategy, we attempted to evaluate the incidence, risk factors, clinical outcomes and treatment of gastrointestinal fistulas in patients receiving a step-up approach. Methods Clinical data from 1274 patients with NP from 2014-2022 were retrospectively analyzed. Multivariable logistic regression analysis was conducted to identify risk factors and propensity score matching (PSM) to explore clinical outcomes in patients with gastrointestinal fistulas. Results Gastrointestinal fistulas occurred in 8.01% (102/1274) of patients. Of these, 10 were gastric fistulas, 52 were duodenal fistulas, 14 were jejunal or ileal fistulas and 41 were colonic fistulas. Low albumin on admission (OR, 0.936), higher CTSI (OR, 1.143) and invasive intervention prior to diagnosis of gastrointestinal fistula (OR, 5.84) were independent risk factors for the occurrence of gastrointestinal fistula, and early enteral nutrition (OR, 0.191) was a protective factor. Patients who developed a gastrointestinal fistula were in a worse condition on admission and had a poorer clinical outcome (p<0.05). After PSM, both groups of patients had similar baseline information and clinical characteristics at admission. The development of gastrointestinal fistulas resulted in new-onset persistent organ failure, increased open surgery, prolonged parenteral nutrition and hospitalization, but not increased mortality. The majority of patients received only conservative treatment and minimally invasive interventions, with 7 patients (11.3%) receiving surgery for upper gastrointestinal fistulas and 11 patients (26.9%) for colonic fistulas. Conclusion Gastrointestinal fistulas occurred in 8.01% of NP patients. Independent risk factors were low albumin, high CTSI and early intervention, while early enteral nutrition was a protective factor. After PSM, gastrointestinal fistulas resulted in an increased proportion of NP patients receiving open surgery and prolonged hospitalization. The majority of patients with gastrointestinal fistulas treated with step-up therapy could avoid surgery.
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Affiliation(s)
- Zheyu Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Huajing Ke
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Yuwen Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Hui Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Mengli Yue
- Affiliated Longhua People’s Hospital, The Third School of Clinical Medicine, Southern Medical University, Shenzhen, People’s Republic of China
| | - Pi Liu
- Department of Gastroenterology, Affiliated Longhua People’s Hospital, Southern Medical University, Shenzhen, People’s Republic of China
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Chaudhry H, Sohal A, Bains K, Dhaliwal A, Dukovic D, Singla P, Sharma R, Kohli I, Chintanaboina J. Incidence and factors associated with portal vein thrombosis in patients with acute pancreatitis: A United States national retrospective study. Pancreatology 2023:S1424-3903(23)00072-8. [PMID: 37012176 DOI: 10.1016/j.pan.2023.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/15/2023] [Accepted: 03/24/2023] [Indexed: 04/05/2023]
Abstract
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.
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Affiliation(s)
- Hunza Chaudhry
- Department of Internal Medicine, University of California, San Francisco, Fresno, California, USA
| | - Aalam Sohal
- Liver Institute Northwest, Seattle, WA, USA.
| | - Kanwal Bains
- Department of Internal Medicine, University of Arizona, Tucson, AZ, USA
| | - Armaan Dhaliwal
- Department of Internal Medicine, University of Arizona, Tucson, AZ, USA
| | | | | | | | - Isha Kohli
- Graduate Program in Public Health, Icahn School of Medicine, Mount Sinai, NewYork, NY, USA
| | - Jayakrishna Chintanaboina
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, California, USA
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Together We Stand, Divided We Fall: A Multidisciplinary Approach in Complicated Acute Pancreatitis. J Clin Med 2019; 8:jcm8101607. [PMID: 31623392 PMCID: PMC6832928 DOI: 10.3390/jcm8101607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/22/2019] [Accepted: 09/29/2019] [Indexed: 12/12/2022] Open
Abstract
Acute pancreatitis (AP) is an inflammatory condition with a mild course in most patients, but 20-30% evolve to single or multiple organ dysfunction and pancreatic/peripancreatic necrosis, with potentially infected collections. In the first weeks of disease, a systemic inflammatory syndrome (SIRS) dominates the clinical setting, and early management decisions in this precocious phase can change the course of the disease. Imaging is crucial in the diagnosis, and since the adoption of the revised Atlanta classification, four different types of pancreatic/peripancreatic collections have been defined. The management of the complicated forms of AP has been defined by several treatment guidelines, and the main indication for intervention is local infection, preferably in walled-off necrosis. Open surgery necrosectomy is associated with a very high rate of morbimortality, giving a place to different multidisciplinary methodologies, emphasizing drainage and necrosectomy techniques in a "step-up" approach starting from mini-invasive endoscopic drainage and moving, if needed, to progressively more invasive techniques, including interventional radiology and mini-invasive surgery. With the advent of several new technologies in the specialties involved, the complicated AP cases which need drainage and necrosectomy benefit from a new era of multidisciplinary cooperation, permitting higher efficacy with lower levels of morbimortality and reducing hospital stay and costs.
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Acute Small Bowel Obstruction Secondary to a Pancreatic Pseudocyst. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1845-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Jang DK, Moon JY, Lee SH, Lee JK. Severe necrotizing pancreatitis after endoscopic papillectomy in a patient with ampullary adenoma. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dong Kee Jang
- Department Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jeong Yeon Moon
- Department Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Jun Kyu Lee
- Department Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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Bansal A, Gupta P, Singh H, Samanta J, Mandavdhare H, Sharma V, Sinha SK, Dutta U, Kochhar R. Gastrointestinal complications in acute and chronic pancreatitis. JGH OPEN 2019; 3:450-455. [PMID: 31832543 PMCID: PMC6891019 DOI: 10.1002/jgh3.12185] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/06/2019] [Accepted: 03/21/2019] [Indexed: 01/09/2023]
Abstract
Pancreatitis is one of the important medical conditions. Gastrointestinal (GI) complications of pancreatitis are important and lead to significant morbidity and mortality. Diagnosis of these complications is difficult and may require a strong clinical suspicion coupled with various imaging features. This review provides an extensive update of the whole spectrum of GI complication of pancreatitis, both acute and chronic, from inflammation, ischemia, and necrosis to obstruction, perforation, and GI fistulae. The focus is on the clinical and imaging features of this less commonly described aspect of pancreatitis.
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Affiliation(s)
- Akash Bansal
- Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Pankaj Gupta
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Harjeet Singh
- Department of Surgery Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Jayanta Samanta
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Harshal Mandavdhare
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Vishal Sharma
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Saroj K Sinha
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Usha Dutta
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Rakesh Kochhar
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh India
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Ng PC, Long B, Koyfman A. Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning. Intern Emerg Med 2018; 13:223-229. [PMID: 29435715 DOI: 10.1007/s11739-018-1798-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 02/01/2018] [Indexed: 12/21/2022]
Abstract
Carbon monoxide (CO) is a colorless, odorless gas that is found in the environment, in the home, and in the human body as a normal part of mammalian metabolism. Poisoning from CO, a common exposure, is associated with significant morbidity and mortality if not recognized and treated in a timely manner. This review evaluates the signs and symptoms of CO poisoning, conditions that present similar to CO poisoning, and an approach to the recognition and management for CO poisoning. CO poisoning accounts for thousands of emergency department visits annually. If not promptly recognized and treated, it leads to significant morbidity and mortality. CO poisoning poses a challenge to the emergency physician because it classically presents with non-specific symptoms such as headache, dizziness, nausea, and vomiting. Due to nonspecific presentations, it is easily mistaken for other, more benign diagnoses such as viral infection. The use of specific historical clues such as exposure to non-conventional heat sources or suicide attempts in garages, as well as the use of targeted diagnostic testing with CO-oximetry, can confirm the diagnosis of CO poisoning. Once diagnosed, treatment options range from observation to the use of hyperbaric oxygen. CO poisoning is an elusive diagnosis. This review evaluates the signs and symptoms CO poisoning, common chameleons or mimics, and an approach to management of CO poisoning.
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Affiliation(s)
- Patrick Chow Ng
- Medical Toxicology, Rocky Mountain Poison and Drug Center, Denver Health and Hospital, 1391 Speer Blvd, Denver, CO, 80204, USA.
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
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