Etiology of recurrent acute pancreatitis, with special emphasis on pancreaticobiliary malformation

A systematic review of the predictive factors for the recurrence of acute pancreatitis

PURPOSE

Acute Pancreatitis (AP) is a prevalent clinical pancreatic disorder characterized by acute inflammation of the pancreas, frequently associated with biliary or alcoholic events. If not treated with cholecystectomy after the first episode, patients may experience a recurrence of AP, with consequent need for emergency surgery and increased risk of death. Analyzing the risk factors that may contribute to the recurrence of Biliary and Alcoholic Pancreatitis (BAP and AAP), future research can be driven toward new solutions for preventing and treating this pancreatic disease.

METHODS

A systematic review was conducted selecting studies from BiomedCentral, PubMed, Scopus and Web of Science by two independent reviewers. Publications were considered only if written in English in the time interval between January 2000 and June 2024 and investigated the risk factors for the recurrence of BAP and AAP. At the end of the selection, a quality assessment phase was conducted using the PROBAST tool.

RESULTS

In this systematic review, 8 articles were selected out of 6.945, involving a total sample of 11.271 patients of which 38.77% developed recurrence episodes. 37.5% of the included studies focus on recurrent acute biliary pancreatitis (RBAP), while 62.5% are dedicated to recurrent acute alcoholic pancreatitis (RAAP). The risk factors for the recurrence of AP showed a clear differentiation between the alcoholic and biliary etiology. Most of the considered studies adopted a retrospective design, characterized by a susceptibility to potential methodological biases. However, the trend indicated a more recent increase in prospective studies, together with a greater focus on identifying and understanding the possible risk factors associated with the recurrence of acute pancreatitis (RAP). This result highlighted the progress in the scientific approach toward a more rigorous and systematic assessment of the causes and dynamics that influence the recurrence of the disease.

CONCLUSION

Studies highlighted the importance of lifestyle factors, clinical complications, and surgical interventions that can impact the risk of biliary or alcoholic recurrent acute pancreatitis. Increased and systematic adoption of artificial intelligence-based tools could significantly impact future knowledge relating to the risks of recurrence and relative possibilities of prevention.

A Nomogram for Predicting the Transition From Recurrent Acute Pancreatitis to Chronic Pancreatitis

OBJECTIVES

Acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis are recognized as a continuum of pancreatic diseases. Recurrence increases the risk of progression to chronic pancreatitis. The aim of this study was to search for clinical features that may promote the progression of chronic pancreatitis in patients with recurrent acute pancreatitis.

MATERIALS AND METHODS

We retrospectively reviewed patients with recurrent acute pancreatitis from Medical Information Mart for Intensive Care-IV database. They were divided into a training cohort and a validation cohort. A nomogram was constructed based on clinical features during the second hospitalization. The discrimination and calibration of the nomogram were evaluated using the concordance index, area under the time-dependent receiver operating characteristic curve, and calibration plots.

RESULTS

A total of 432 recurrent acute pancreatitis patients were evaluated, of which 93 (21.53%) were diagnosed with chronic pancreatitis later. Age, biliary pancreatitis, admission interval, alcohol dependence, lipase, and platelet were selected. The concordance index was 0.717 (95% confidence interval: 0.691-0.743) for the training cohort and 0.718 (95% confidence interval: 0.662-0.774) for the validation cohort. The area under the time-dependent receiver operating characteristic curve was >0.7 over 1000 days.

CONCLUSIONS

A nomogram was developed and validated to evaluate the transition from recurrent acute pancreatitis to chronic pancreatitis.

Determining the value of endoscopic retrograde cholangiopancreatography in the management of patients with acute pancreatitis and related complications

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic to a therapeutic tool in acute pancreatitis management, largely due to the availability of less invasive diagnostic modalities such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP).

AREAS COVERED

This review explores the therapeutic applications of ERCP across various acute pancreatitis etiologies and its role in managing complications such as bile duct obstructions, pancreatic duct disruptions, and infected necrosis. The discussion highlights the procedure's expanding indications and its critical role in addressing complex cases.

EXPERT OPINION

ERCP remains central to the management of acute pancreatitis complications. As endoscopic techniques and devices continue to advance, its therapeutic scope is likely to grow. Performing ERCP for appropriate indications and optimizing its use is essential for minimizing risks and improving outcomes.

Recurrent Acute Pancreatitis in the Setting of Abnormal Pancreaticobiliary Junction

Anomalous or abnormal pancreaticobiliary junction (APBJ) is an important structural cause of recurrent acute pancreatitis. Outside of the common causes of recurrent acute pancreatitis, such as alcohol, gallstones, or hypertriglyceridemia, this anatomical variant can often be overlooked and lead to delays in patient care and even mismanagement. It can be defined as the abnormal junction of the pancreatic duct and common bile duct that occurs outside the duodenal wall to form a long common channel (>8 mm). We describe a case of a 51-year-old female with multiple episodes of acute pancreatitis. Further investigation led to the diagnosis of an aberrant pancreatic duct anatomy with the common bile duct measuring around 20 mm. This report will include a discussion about the pancreaticobiliary junction, how it can be diagnosed, and what complications it can precipitate.

Anomalous Pancreatobiliary Ductal Union Presenting as Recurrent Acute and Chronic Pancreatitis in Children and Adolescents With Response to Endotherapy

Introduction Anomalous pancreaticobiliary duct union (APBDU) is defined by the abnormal position of the junctional union of the common bile duct and the pancreatic duct, outside the duodenal wall above the influence of sphincter of Oddi, associated with choledochal cysts and biliary malignancies. APBDU may rarely present as recurrent acute pancreatitis (RAP) or chronic pancreatitis (CP). We aimed to study the prevalence of patients with APBDU presenting as RAP or CP and their response to endotherapy. Methods A retrospective audit of the prospectively maintained endoscopy database at our institute between January 2018 and November 2020 was conducted to identify cases of APBDU presenting as RAP or CP. Details of investigations, endoscopic retrograde cholangiopancreatography (ERCP) findings, and follow-up till six months were noted. Results We identified 26 cases of APBDU, of which five (19.2%) cases presented as RAP or CP. Of these five patients, two had RAP, while three presented with CP (median: 11 years; range: 4-25 years). Magnetic resonance cholangiopancreatography (MRCP) showed APBDU in three patients. One patient with RAP had a Komi type IIIB anomaly. Another patient with RAP had a rare anomaly with absent ventral PD, with the bile duct communicating and draining through the dorsal duct. Two patients with CP had a long common channel with Komi IIA anomaly. One patient with CP had IIIC2 anomaly. Pancreas divisum was noted in three patients, all of whom underwent minor-papilla sphincterotomy. Successful pancreatic stent placement was performed in all patients. Over one year of follow-up, patients with CP had a significant decrease in pain as measured by the visual analog scale. Those with RAP had no further episodes of pancreatitis. Conclusion APBDU is a rare cause of RAP and CP in young patients, occasionally missed on MRCP. RAP and CP caused by APBDU show good response to endotherapy.

Risk Factors Associated with Acute Pancreatitis after Percutaneous Biliary Intervention: We Do Not Know Nearly Enough

Percutaneous transhepatic cholangiodrainage (PTCD) and percutaneous transhepatic biliary stenting (PTBS) may be used as a palliative treatment for inoperable patients with malignant biliary obstruction (MBO) to improve the prognosis and their quality of life. However, acute pancreatitis is a common and severe complication that cannot be ignored after PTCD and PTBS in patients with MBO. A few cases may develop severe pancreatitis with a higher mortality rate. In this study, we summarize the known risk factors for acute pancreatitis after percutaneous biliary interventional procedures and investigate possible risk factors to reduce its occurrence by early identifying high-risk patients and taking appropriate measures.

Diagnosis, severity stratification and management of adult acute pancreatitis-current evidence and controversies

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.

Different clinical characteristics between recurrent and non-recurrent acute pancreatitis: A retrospective cohort study from a tertiary hospital

BACKGROUND

Acute pancreatitis (AP) is a common digestive disorder with different clinical outcomes, some of which develop into recurrent acute pancreatitis (RAP). This study aimed to explore the differences between AP and RAP.

METHODS

All patients with AP admitted to Changsha Central Hospital between January 2015 and December 2020 were included. Characteristics between RAP and non-RAP groups were compared. Independent factors associated with RAP were identified by multivariate logistic regression analyses.

RESULTS

This was a retrospective study. A total of 1567 patients, including 262 patients in the RAP group and 1305 patients in the non-RAP group, were enrolled. Compared to the non-RAP group, results indicated that the RAP group was younger (P < 0.001), had a male predominance (P < 0.001), and had higher incidences of diabetes (P < 0.001) and hypertriglyceridemia (HTG) (P < 0.001). Lower incidences of cholelithiasis (P < 0.001) and acute liver injury (P < 0.001) were also noted in the RAP group. Scores of Ranson, BISAP, SOFA, and APACHE II were significantly higher in the non-RAP group (P < 0.001 for all). Three independent factors associated with RAP, including male gender (P = 0.006), diabetes (P < 0.001), and HTG (P < 0.001), were identified by multivariate logistic regression.

CONCLUSION

Compared to the non-RAP, the incidence of cholelithiasis and acute liver injury was lower in RAP. Three independent factors associated with RAP, namely male, diabetes, and HTG, were identified.

Ansa Pancreatica, an Uncommon Cause of Acute, Recurrent Pancreatitis

The pancreatic duct is vulnerable to developmental anomalies which may produce variations in its course and/or its configuration. Ansa pancreatica is the least common anatomic variant. It is characterized by the formation of an “S-shaped loop” from the main pancreatic duct to the minor papilla. Ansa pancreatica has been implicated as a cause of recurrent acute pancreatitis. We review existing literature on pancreatitis secondary to the ansa deformity and present a case of recurrent acute pancreatitis in a patient who was ultimately found to have the ansa deformity on endoscopic ultrasound.

Individualized Prediction of Acute Pancreatitis Recurrence Using a Nomogram

OBJECTIVES

The objective of this study was to develop and validate a model, based on the blood biochemical (BBC) indexes, to predict the recurrence of acute pancreatitis patients.

METHODS

We retrospectively enrolled 923 acute pancreatitis patients (586 in the primary cohort and 337 in the validation cohort) from January 2014 to December 2016. Aiming for an extreme imbalance between recurrent acute pancreatitis (RAP) and non-RAP patients (about 1:4), we designed BBC index selection using least absolute shrinkage and selection operator regression, along with an ensemble-learning strategy to obtain a BBC signature. Multivariable logistic regression was used to build the RAP predictive model.

RESULTS

The BBC signature, consisting of 35 selected BBC indexes, was significantly higher in patients with RAP (P < 0.001). The area under the curve of the receiver operating characteristic curve of BBC signature model was 0.6534 in the primary cohort and 0.7173 in the validation cohort. The RAP predictive nomogram incorporating the BBC signature, age, hypertension, and diabetes showed better discrimination, with an area under the curve of 0.6538 in the primary cohort and 0.7212 in the validation cohort.

CONCLUSIONS

Our study developed a RAP predictive nomogram with good performance, which could be conveniently and efficiently used to optimize individualized prediction of RAP.

Meta-analysis of risk factors for recurrent acute pancreatitis

BACKGROUND

With the continuous improvement of living standards, the incidence of recurrent acute pancreatitis is also increasing year by year, and this disease has become a hot research topic in recent years. Understanding the etiology of recurrent acute pancreatitis has become an urgent problem to be solved in clinical practice.

AIM

To explore the risk factors for recurrent acute pancreatitis (RAP) by means of systematic evaluation, and provide evidence for better prevention of RAP.

METHODS

We searched CNKI, CBM, VIP, Wanfang, The Cochrane Library, PubMed, Embase, and Web of Science databases to collect case-control and cohort studies on the risk factors associated with RAP from January 1, 2000 to February 29, 2020. "Pancreatitis", "recurrence", "risk factors", and their free words were selected as keywords. The retrieved articles were evaluated and filtrated using the Newcastle-Ottawa Scale (NOS). Meta-analysis was performed based on the articles scored above 6 by using Revman5.3 software.

RESULTS

A total of 15 articles were included, with the cumulative number of cases and controls reaching 2258 and 8482, respectively. The results of meta-analysis showed that alcohol consumption [odds ratio [OR] = 1.83, 95%CI (1.30, 2.59), P = 0.0006], smoking [OR = 2.09, 95%CI (1.61, 2.73), P < 0.00001], biliary AP [OR = 1.82, 95%CI (1.28, 2.57), P = 0.0008], hypertriacylglyceremic AP [OR = 2.24, 95%CI (1.76, 2.85), P < 0.00001], alcoholic AP [OR = 2.68, 95%CI (2.03, 3.55), P < 0.00001], diabetes [OR = 1.57, 95%CI (1.48, 1.66), P < 0.00001], fatty liver [OR = 2.05, 95%CI (1.22, 3.47), P = 0.007], and CT score [OR = 3.52, 95%CI (2.28, 5.43), P < 0.00001] were statistically significant risk factors for RAP.

CONCLUSION

Current evidence shows that the risk factors for RAP include disease factors (biliary, alcoholic, and hypertriacylglyceremic AP, fatty liver, and diabetes), behavioral factors (alcohol consumption and smoking), and related indicators (CT score). Due to the limited quantity and quality of included studies, more prospective high-quality clinical studies are needed to verify the above conclusion.

Risk factors of recurrent acute pancreatitis after conservative treatment in pediatric population: a single-center study

Background

Although complete resolution and recovery occurs in most children with an initial attack of acute pancreatitis (AP), a subset of children may progress to recurrent AP (RAP). RAP has serious effects to the individual and the socioeconomic burden. The aim of this project was to identify the independent risk factors for pediatric RAP so as to provide evidence for its prevention, early diagnosis and treatment.

Methods

A retrospective cohort study of children discharged from Tianjin Children’s Hospital from June 2017 to January 2020 was performed. Demographic and clinical variables, treatment strategies, clinical course and outcomes were collected. Independent risk factors of RAP were identified using the logistic regression model.

Results

Of the total 96 enrolled children, 30 (31.3%) developed RAP during the follow-up period. The majority (27/30, 90%) of the children with AP developed RAP within 6 months of their first AP attack. The presence of systemic inflammatory response syndrome (SIRS) [odds ratio (OR)=6.652, 95% confidence interval (CI) 1.989 to 22.247], fasting time (OR=1.267, 95% CI 1.104 to 1.583), whether meet all three AP diagnostic criteria (OR=7.438, 95% CI 1.346 to 41.103) and abnormal amylase/lipase value on the seventh day of hospitalization (OR=3.601, 95% CI 0.972 to 13.342) were independent risk factors of RAP in children.

Conclusions

Most children who developed RAP had progressed within 6 months after their first episode of AP. RAP was more common in children who met all three AP diagnostic criteria at initial attack and in children with SIRS, long fasting time and abnormal amylase/lipase value on the seventh day of hospitalization.

Clinical Characteristics of Paediatric Pancreatitis Caused by Pancreaticobiliary Malformation: A Single-Centre Retrospective Analysis

Background/Aims: To investigate the clinical profiles of children with pancreatitis caused by pancreaticobiliary malformation. Methods: We retrospectively analysed the clinical data of children diagnosed with pancreatitis at our institute from June 2017 to January 2021. Results: A total of 195 patients and 169 control subjects were included in this study. Twenty-six (13.3%) patients had pancreaticobiliary malformation-related pancreatitis. The average age of onset in the pancreaticobiliary malformation pancreatitis (PMP) group was lower than that in the non-PMP group, and the difference was statistically significant. The number of patients in the PMP group that had jaundice was significantly higher than that of the non-PMP group (P < 0.05). Logistic regression analysis showed that total bilirubin (TB) and γ-glutamyltransferase (GGT) (odds ratio = 1.096, P < 0.01) were independent predictors of pancreaticobiliary malformation-related pancreatitis in children. The positive detection rate of pancreaticobiliary malformation was 68% for abdominal ultrasound, 38.4% for abdominal enhanced computed tomography, and 91.3% for magnetic resonance cholangiopancreatography (MRCP). The recurrence rate (34.6%) in the PMP group was higher than that in the non-PMP group (15.4%, P < 0.05); surgical therapy had the lowest recurrence rate. Age at initial onset of pancreatitis was younger and the period to recurrence was shorter in the PMP group than in the non-PMP group (P < 0.05). Conclusion: Pancreaticobiliary malformation is one of the major causes of paediatric pancreatitis. Elevated TB and GGT in patients with pancreatitis may be suggestive for underlying pancreaticobiliary malformation not solely to pancreatitis. MRCP should be used when pancreatitis due to pancreaticobiliary malformation is suspected. Surgery or endoscopic retrograde cholangiopancreatography-guided intervention may be helpful but further study is needed.

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55–4.65 and 2.22–4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04–2.84 and 0.96–2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08–2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Risk factors of recurrent pancreatitis after first acute pancreatitis attack: a retrospective cohort study

Background and aims: Few studies have been conducted in Asia on the recurrence of acute pancreatitis (AP). This study was designed to investigate characteristics of the disease to predict recurrence.Methods: We retrospectively analyzed 617 patients that experienced a first AP attack between January 2009 and December 2014. Based on reviews of clinical and follow-up data, we attempted to identify risk factors of recurrence using Cox regression analysis.Results: During a median follow-up of 3.2 years (range 3-72 months), 100(16.2%) of the 617 study subjects experienced one or more episodes of recurrent acute pancreatitis (RAP). Of these 100 patients, 75(75%) experienced one relapse, 12(12%) two relapses, and 13(13%) three or more relapses. The etiologies of RAP were an alcohol (48%), gallstone (31%), idiopathic (14%), and others (7%). Univariate analysis showed that an age of <60 years, male gender, smoking, an alcohol-associated etiology, and a local complication at index admission were significant risk factors of RAP. Cox regression analysis showed that an age of <60 years (HR = 1.602, 95% CI: 1.029-2.493), male gender (HR = 1.927, 95% CI: 1.127-3.295), and the presence of a local complication (HR = 3.334, 95% CI: 2.211-5.026) were significant risk factors of RAP development.Conclusion: A local complication at index admission was found to be the strongest risk factor of RAP, and a male gender and an age of <60 years were significantly associated with RAP. Special attention and close follow-up should be afforded to patients with a local complication at index admission or male patients <60 years old.

Identification and management of pancreas divisum

Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.

Gene expression profiling reveals upregulated FUT1 and MYBPC1 in children with pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is associated with high risk of epithelial atypical growth and malignant transformation of the bile duct or gallbladder. However, overall changes in genetic expression have not been examined in children with PBM. Genome-wide expression was analyzed using peripheral blood samples from 10 children with PBM and 15 pediatric controls. Differentially expressed genes (DEGs) were identified using microarray. Bioinformatics analysis was conducted using Gene Ontology and KEGG analyses. The top 5 in the up-regulated genes in PBM were verified with qRT-PCR. Receiver operator characteristic curve analysis was conducted to evaluate the predictive accuracy of selected genes for PBM. The microarray experiments identified a total of 876 DEGs in PBM, among which 530 were up-regulated and the remaining 346 were down-regulated. Verification of the top 5 up-regulated genes (TYMS, MYBPC1, FUT1, XAGE2, and GREB1L) by qRT-PCR confirmed the up-regulation of MYBPC1 and FUT1. Receiver operating characteristic curve analysis suggested that FUT1 and MYBPC1 up-regulation could be used to predict PBM, with the area under the curve of 0.873 (95%CI=0.735-1.000) and 0.960 (95%CI=0.891-1.000), respectively. FUT1 and MYBPC1 were up-regulated in children with PBM, and could be used as potential biomarkers for PBM.

Comparison of left side or right side vagotomy in the rat subjected to acute pancreatitis

PURPOSE

We aimed to evaluate the effects of unilateral vagotomy (right-VR or left-VL) on the severity of caerulein-induced acute pancreatitis (AP).

MATERIAL AND METHODS

VR or VL was done in Wistar rats 4 days before AP, except in control, sham operated group. Following 5 h administration of subcutaneous injections of caerulein, the pancreatic blood flow (PBF), serum lipase and IL-10 in caval blood samples were measured. The pancreatic specimens were taken from sacrificed rats for the assessment of MDA-4-HNE and morphology.

RESULTS

PBF decreased from 310 ± 20 ml/min/100 g of tissue in control rats to 130 ± 12 units in AP (p < 0.01). VR and VL alleviated this effect to 234 ± 22 and 229 ± 26 units, respectively, (p < 0.01). There was an immense increase of serum lipase in AP, from 100 ± 7 U/L up to 5220 ± 210 U/L (p < 0.01). Only VL limited this increase to 3469 ± 300 U/L (p < 0.01). Serum IL-10 increased uniformly in AP, without any effect of preceding VR or VL. VL performed in rats subjected subsequently to AP resulted in stronger reduction of histological changes, such as pancreatic edema and leukocyte infiltration, than the above parameters in AP rats with VR. MDA+4-HNE increased from 7.5 ± 0.1 pmol/g of tissue in control group to 30.6 ± 3 units in AP group (p < 0.01). Concentration of MDA+4-HNE in pancreatic tissue achieved 16.48 ± 3 pmol/g after VR and 13.84 ± 4 pmol/g following VL.

CONCLUSION

Our observation might suggest that protective effect of VL could be stronger than VR in the protection on AP. However changes of PBF seem to be similar in both groups of rats.

Pancreas divisum: a reemerging risk factor for pancreatic diseases

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. The attention towards the PD has grown significantly since there are reports that this condition may cause acute relapsing pancreatitis, chronic pancreatitis and chronic abdominal pain syndrome. Furthermore, over the years, there have been multiple reports of PD associated with different types of tumors. There is evidence that PD can be associated with pancreatic tumors (up to 12.5% of cases). The golden standard for diagnosing PD is endoscopic retrograde cholangiopancreatography, but since it is an invasive procedure magnetic resonance cholangiopancreatography with secretin is a good alternative. In case the patient is symptomatic, endoscopic or surgical treatment should be performed. This review describes the key points of the pathophysiology, diagnostic modalities, risks of pancreatitis and tumors, as well as treatment options of PD.

Recurrent Acute Pancreatitis: International State-of-the-Science Conference With Recommendations

Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.

Factors affecting the operating time for complete cyst excision and Roux-en-Y hepaticojejunostomy in paediatric cases of congenital choledochal malformation: a retrospective case study in Southeast China

OBJECTIVE

The aim of this study was to evaluate factors affecting the operating time for complete cyst excision and Roux-en-Y hepaticojejunostomy in paediatric cases of congenital choledochal malformation (CCM).

DESIGN

A 3-year retrospective study was undertaken between January 2013 and December 2015 in four centres in China.

SETTING

This involved a retrospective chart review of paediatric patients with CCM in four large hospitals in Southeast China.

PARTICIPANTS

Sixty-five paediatric patients with CCM were included in this study. We derived all available information on patient demographics, clinical characteristics, preoperative complications and surgical methods from the charts of all these patients.

INTERVENTIONS

Univariate and multivariate logistic regression analyses were used to evaluate factors significantly affecting the operating time for complete cyst excision and Roux-en-Y hepaticojejunostomy in paediatric cases of CCM.

RESULTS

Twenty-three of the 65 case surgeries were performed using laparoscopic technique, and 42 surgeries were performed by conventional open surgery. The median operating time was 215 min (range 120-430 min). The morphological subtype of CCM and the presence of cholecystitis or cholangitis were the only factors found to affect the operating time (p<0.05). Logistic regression analysis confirmed cholangitis as an independent risk factor.

CONCLUSIONS

The morphological subtype of CMM and the presence of cholecystitis or cholangitis are factors affecting the operating time for complete cyst excision and Roux-en-Y hepaticojejunostomy in paediatric cases of CCM, whereas cholangitis is an independent risk factor.

The Diagnostic Usefulness of Serum Total Bile Acid Concentrations in the Early Phase of Acute Pancreatitis of Varied Etiologies

The most common causes of acute pancreatitis (AP) are biliary tract diseases with cholestasis and alcohol consumption. In 10%-15% of patients, etiology determination is difficult. Identification of the etiology allows for the implementation of adequate treatment. The aim of this study was to assess the utility of the serum concentrations of total bile acids (TBA) to diagnose AP etiology in the early phase of the disease. We included 66 patients with AP, admitted within the first 24 h from the onset of symptoms. TBA were measured in serum at 24, 48, and 72 h from the onset of AP, using an automated fifth generation assay. The bilirubin-to-TBA ratio (B/TBA) was calculated. TBA was highest on the first day of AP and decreased subsequently. In patients with biliary etiology, serum TBA was significantly higher compared to those with alcoholic and other etiologies. B/TBA was significantly higher in patients with alcoholic etiology. At admission, the cut-off values of 4.7 µmol/L for TBA and 4.22 for the B/TBA ratio allowed for a differentiation between biliary and other etiologies of AP with a diagnostic accuracy of 85 and 83%. Both TBA and B/TBA may help in the diagnosis of AP etiology in the early phase of AP.

Factors Interfering with Delineation on MRCP of Pancreaticobiliary Maljunction in Paediatric Patients

Background

The aim of this study was to assess factors for delineating the pancreaticobiliary junction in the presence of pediatric congenital choledochal cysts (CCC) using Magnetic resonance cholangiopancreatography (MRCP).

Methods

Retrospective review of medical records for 48 patients with CCC was conducted, including demographics, biliary amylase and MRCP findings if available. With univariate and multivariate logistic regression, we measured significant factors affecting pancreaticobiliary maljunction(PBM) diagnoses by MRCP.

Results

Of the subjects enrolled with CCC. Twenty-eight cases had PBM according to MRCP. Univariate analysis confirmed that age, cyst diameter > 30 mm and cysts that descended to the introitus pelvis affected junctional delineation and detection of PBM (P<0.05). Stepwise logistic regression analysis confirmed large cysts in the introitus pelvis predicted pancreaticobiliary junctional delineation in MRCP and these data agreed with the literature. A correlation between cyst diameter and the length of the common channel was found as was cyst diameter and biliary amylase although there were no significant differences between them.

Conclusions

Age, cyst diameter >30 mm and descending cysts into the introitus pelvis affected junctional delineation of the pancreatic and bile duct in PBM with MRCP. Large cyst descension into the introitus pelvis was an independent factors affecting PBM detection.

Recurrent pancreatitis after unremarkable colonoscopy, temporalised by CT imaging: an unusual case

Acute pancreatitis is a common surgical presentation, frequently caused by gallstones and alcohol. Here we present an unusual case of a recurrent episode of pancreatitis after an unremarkable colonoscopy, in a patient with several pre-existing risk factors for pancreatitis. Before and after abdominal CT scans clearly demonstrate the acute inflammatory process affecting the pancreas and temporalise its development. Early resuscitation and appropriate involvement of high dependency care is advocated by all current guidelines to improve patient outcome. We consider possible aetiology and how early diagnosis and recognition of possible high-risk situations can expedite its investigation and management, helping to provide the best possible care.

Endoscopic Treatment of Recurrent Acute Pancreatitis and Smoldering Acute Pancreatitis

Recurrent acute pancreatitis (RAP) is a challenging condition that can lead to chronic pancreatitis and long-term morbidity. Etiology-based treatment can potentially have an impact on the natural history of RAP and its progression to chronic pancreatitis. In cases of divisum-associated RAP and idiopathic RAP, several studies have been performed to evaluate the efficacy of endoscopic therapy in alleviation of symptoms and frequency of AP events. This review discusses the literature available on these topic as well as touching on the role of endoscopic therapy in smoldering acute pancreatitis.

The angle of pancreaticobiliary junction correlates with acute pancreatitis: a magnetic resonance cholangiopancreatography study

OBJECTIVE

To study the correlation between the angle of the pancreaticobiliary junction (APJ) and the prevalence of acute pancreatitis using magnetic resonance cholangiopancreatography (MRCP).

MATERIALS AND METHODS

From February 2014 to October 2014, thirty two subjects with normal pancreas (group A) and 40 patients with acute pancreatitis (group B) who underwent MRCP were enrolled into our study. The type of biliary duct and main pancreatic duct joining the duodenal wall was reviewed and divided into V, B-P and P-B type. The V type is the pancreatic duct and biliary duct joining the duodenal wall without a common channel; the B-P type is the biliary duct draining into the pancreatic duct and forming a common channel; and the P-B type is the pancreatic duct draining into the biliary duct and forming a common channel. APJ was measured on MRCP. The correlation between the APJ and the prevalence of acute pancreatitis was analyzed.

RESULTS

The APJ in group A was smaller than in group B (51.45°±13.51° vs. 65.76°±15.61°, P<0.05). According to the type of biliary duct and main pancreatic duct joining the duodenal wall, the prevalence of acute pancreatitis in the V type and in the B-P type was higher than in the P-B type (12/17 vs. 10/29, or 18/26 vs. 10/29, respectively, all P<0.05), whereas there were no significant difference for the prevalence of acute pancreatitis between the V type and B-P type (P>0.05). The APJ were 59.32°±20.04°, 60.22°±11.06°, 57.13°±17.27°, respectively in V type, B-P type and P-B type joining of main pancreatic duct (P>0.05).

CONCLUSIONS

A larger APJ is related to a higher prevalence of acute pancreatitis.

Liver, biliary and pancreatic injuries in pancreaticobiliary maljunction model in cats

BACKGROUND

Pancreaticobiliary maljunction is a high risk factor of pancreatitis and biliary tract cancer. How this maljunction affects the liver remains obscure. This study aimed to examine the effects of pancreaticobiliary maljunction on the liver, pancreas and gallbladder in a cat model.

METHODS

A model of choledocho-pancreatic side-to-side ductal anastomosis was created in ten cats. Before the procedure, a small piece of tissue from the liver, pancreas and gallbladder was collected as a control. The common channel formation was checked by cholecystography. The livers, pancreases and gallbladders of these cats were harvested for histological examination. The expression of proliferating cell nuclear antigen in the gallbladder was examined with immunohistochemistry.

RESULTS

Seven of the 10 cats survived for 6 months after surgery. The color of the liver was darker in the PBM model than the control specimen, with nodules on the surface. Histological examination showed ballooning changes and inflammatory infiltrations and the histopathological score increased significantly (P<0.05). Also, mitochondria swelling and lipid droplet in cytoplasm were observed under an electron microscope. The pancreas also appeared darker in the PBM model than the control specimen and dilated pancreatic ducts were found in three cats. Histopathological examination revealed vascular proliferation and inflammatory infiltration with numerous neutrophils. Gallbladder epithelial cells were featured by expanded endoplasmic reticulum, increased intercellular space and cellular nucleus deformation. The positive cells of proliferating cell nuclear antigen were increased significantly (P<0.05).

CONCLUSION

The present study demonstrated that pancreaticobiliary maljunction can lead to the injuries of the liver, pancreas and gallbladder.

Etiology, clinical features and management of acute recurrent pancreatitis

OBJECTIVE

To study the etiology and clinical features of acute recurrent pancreatitis (ARP) and to determine its optimal management and outcomes.

METHODS

ARP cases among acute pancreatitis patients who were admitted to the West China Hospital, Sichuan University from January 2008 to December 2012 were retrospectively collected. Their etiology, clinical features, treatments and outcomes were analyzed.

RESULTS

Of all pancreatitis patients, 8.9% were classified as ARP. The proportions of mild and severe diseases were 85.7% and 14.3%, respectively. The common etiological factors were biliogenic (31.0%), alcohol (26.2%), hyperlipidemia (21.4%) and pancreaticobiliary malformation (15.4%). At first 46 cases were cryptogenic and among them 36 were subsequently confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Among the hyperlipidemic ARP patients, 72.2% failed to routinely monitor and control serum lipids. ERCP was performed in 88 cases, and 48 also required an endoscopic sphincterotomy or calculus removal. Twenty-two patients underwent cholangiopancreatic duct stent placement, and pancreatic necrosectomy was performed on eight severe cases. The overall outcomes indicate that 8.3% of the cases progressed to chronic pancreatitis and 33.3% of the cases receiving etiological treatment were recurrence-free. There were no deaths in this study.

CONCLUSIONS

The etiological factors of ARP are similar to those of acute pancreatitis at the first attack. The management of ARP should be fully considered based on etiological investigation.

Bilateral vagotomy attenuates the severity of secretagogue-induced acute pancreatitis in the rat

PURPOSE

We assessed the effect of bilateral vagotomy (BV) on the course of acute caerulein-induced pancreatitis (AP) in the rat.

MATERIAL/METHODS

The study was performed on Wistar rats surgically prepared by subdiaphragmatic BV. Control group underwent sham operation. Four days later, AP was induced by subcutaneous injection of caerulein (25 μg/kg/5h) to the conscious animals with or without BV. After administration of caerulein the blood samples were taken for determination of serum lipase activity and interleukin-10 (IL-10) concentration. Pancreatic tissue samples were subjected to histological examinations and to the measurement of lipid peroxidation products (MDA+4-HNE) concentration and the activity of an antioxidant enzyme - glutathione peroxidase (GPx). After application of caerulein pancreatic blood flow was measured by laser Doppler flowmetry.

RESULTS

AP was manifested by oedema and neutrophil infiltration of the pancreatic tissue and accompanied by significant increases of serum lipase activity, serum concentration of IL-10 and pancreatic concentration of MDA+4HNE (ca. 50×, 2× and 4× respectively p ≥ 0.05). Pancreatic activity of GPx and pancreatic blood flow were decreased (both by 60%). In vagotomised rats with AP serum lipase activity and pancreatic concentration of MDA+4-HNE were lower whereas Il-10 concentration and pancreatic activity of GPx, as well as pancreatic blood flow were significantly higher as compared to AP rats with intact vagal nerves. In AP rats with vagotomy all histological signs of pancreatitis were significantly reduced.

CONCLUSIONS

Bilateral vagotomy resulted in the significant attenuation of caerulein-induced pancreatitis in the rat.

Complex role for the immune system in initiation and progression of pancreatic cancer

The immune system plays a complex role in the development and progression of pancreatic cancer. Inflammation can promote the formation of premalignant lesions and accelerate pancreatic cancer development. Conversely, pancreatic cancer is characterized by an immunosuppressive environment, which is thought to promote tumor progression and invasion. Here we review the current literature describing the role of the immune response in the progressive development of pancreatic cancer, with a focus on the mechanisms that drive recruitment and activation of immune cells at the tumor site, and our current understanding of the function of the immune cell types at the tumor. Recent clinical and preclinical data are reviewed, detailing the involvement of the immune response in pancreatitis and pancreatic cancer, including the role of specific cytokines and implications for disease outcome. Acute pancreatitis is characterized by a predominantly innate immune response, while chronic pancreatitis elicits an immune response that involves both innate and adaptive immune cells, and often results in profound systemic immune-suppression. Pancreatic adenocarcinoma is characterized by marked immune dysfunction driven by immunosuppressive cell types, tumor-promoting immune cells, and defective or absent inflammatory cells. Recent studies reveal that immune cells interact with cancer stem cells and tumor stromal cells, and these interactions have an impact on development and progression of pancreatic ductal adenocarcinoma (PDAC). Finally, current PDAC therapies are reviewed and the potential for harnessing the actions of the immune response to assist in targeting pancreatic cancer using immunotherapy is discussed.

Endoscopic therapy for acute recurrent pancreatitis

Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.

Endoscopic approach to the diagnosis and treatment of pancreatic disease

PURPOSE OF REVIEW

The purpose of this review is to examine the recent developments in the use of endoscopic retrograde cholangio-pancreatography (ERCP) and endoscopic ultrasound (EUS) in the management of patients with pancreatic-biliary disease.

RECENT FINDINGS

The use of ERCP to guide selective placement of pancreatic sphincterotomes, stone extraction balloons, and stents enables clinicians to treat pancreatic sphincteric and ductal disorders. Pancreatic stones are a remediable cause of recurrent pancreatitis and small calculi can be easily removed. The gold standard for the diagnosis of pancreas divisum remains ERCP and sphincterotomy is highly effective in the treatment of relapsing pancreatitis. Intraductal papillary mucinous neoplasms are the most common pancreatic malignancy and ERCP, as well as EUS can identify and sample the solid and cystic lesions. Mural nodules can be detected and sampled effectively by EUS-fine needle aspiration (FNA). The sensitivity of EUS-FNA for pancreatic adenocarcinoma is excellent (more than 85%). Although cyst fluid carcinoembryonic antigen is a very good marker for the presence of a mucinous cystic lesion, it is not an indicator of malignancy.

SUMMARY

In summary, ERCP and EUS are important tools for the management of benign and malignant lesions of the pancreas.