Acute Pancreatitis Induced by Azathioprine and 6-mercaptopurine Proven by Single and Low Dose Challenge Testing in a Child with Crohn Disease

Pancreatic Involvement in the Course of Inflammatory Bowel Disease in Children-A Multi-Center Study

The coexistence of inflammatory bowel disease (IBD) with pancreatic pathology is rare in children. A retrospective analysis of data from 1538 children diagnosed with IBD in 2014-2021 was conducted to determine the frequency and causes of pancreatitis and asymptomatic hyperlipasemia (HL) or hyperamylasemia (HA) in this group of patients. Among the 176 children (11.4%) with pancreatic involvement (PI), acute pancreatitis (AP) was diagnosed in 77 children (43.8%), and HA or HL was observed in 88 children (50.0%). Only a few patients were diagnosed with autoimmune or chronic pancreatitis (6.2%). PI was observed at the time of the IBD diagnosis in 26.1% of the cases. A total of 54.5% of the patients had moderate to severe IBD, and 96% had colonic involvement at the time of diagnosis of PI. Idiopathic PI was the most common (57%), followed by drug-induced PI (37%) and azathioprine (AZA). In patients with AZA-induced AP, the successful introduction of 6-mercaptopurine (6-MP) to therapy was noted in 62.5% of the children. Our results suggest that routine monitoring of pancreatic enzymes in patients with IBD should be performed, especially after the initiation of the AZA treatment. The presence of transient HA/HL in IBD does not necessarily indicate pancreatic pathology.

Stomach Pain Upon Stomach Pain: Medication-Induced Pancreatitis

As a first-line immunosuppressant to maintain remission in Crohn's disease, 6-mercaptopurine (6-MP) has been commonly used. A rare, unpredictable, dose-independent and idiosyncratic reaction to this medication is acute pancreatitis. Unlike other side effects of this drug which have been well characterized and are often dose-dependent, acute pancreatitis is an uncommon adverse effect not frequently encountered in clinical practice. In this case report, we describe a 40-year-old man with Crohn's disease who developed acute pancreatitis within two weeks of starting 6-MP. Discontinuation of the drug followed by fluid resuscitation led to the overall improvement of symptoms within 72 hours. No complications were noted during the follow-up. It is our intention to raise awareness for this lesser-known side effect with this case report and to urge physicians to provide thorough counseling prior to starting on this medication, especially in patients with inflammatory bowel disease (IBD). Additionally, we hope to reinforce this disease entity as a differential for acute pancreatitis and aim to emphasize the importance of detailed medication reconciliations with this report, especially in the emergency department, to enable quick diagnoses and limit unnecessary treatments.

Inflammatory bowel disease does not alter the clinical features and the management of acute pancreatitis: A prospective, multicentre, exact-matched cohort analysis

OBJECTIVE AND AIMS

Acute pancreatitis in inflammatory bowel disease occurs mainly as an extraintestinal manifestation or a side effect of medications. We aimed to investigate the prognostic factors and severity indicators of acute pancreatitis and the treatment of patients with both diseases.

DESIGN

We performed a matched case-control registry analysis of a multicentre, prospective, international acute pancreatitis registry. Patients with both diseases were matched to patients with acute pancreatitis only in a 1:3 ratio by age and gender. Subgroup analyses were also carried out based on disease type, activity, and treatment of inflammatory bowel disease.

RESULTS

No difference in prognostic factors (laboratory parameters, bedside index of severity in acute pancreatitis, imaging results) and outcomes of acute pancreatitis (length of hospitalization, severity, and local or systemic complications) were detected between groups. Significantly lower analgesic use was observed in the inflammatory bowel disease population. Antibiotic use during acute pancreatitis was significantly more common in the immunosuppressed group than in the non-immunosuppressed group (p = 0.017). However, none of the prognostic parameters or the severity indicators showed a significant difference between any subgroup of patients with inflammatory bowel disease.

CONCLUSION

No significant differences in the prognosis and severity of acute pancreatitis could be detected between patients with both diseases and with pancreatitis only. The need for different acute pancreatitis management is not justified in the coexistence of inflammatory bowel disease, and antibiotic overuse should be avoided.

Pancreatic Disorders in Children with Inflammatory Bowel Disease

Background and Objectives: Inflammatory bowel disease (IBD) is a chronic condition and mainly affects the intestines, however, the involvement of the other organs of the gastrointestinal tract (upper part, pancreas, and liver) have been observed. The coexistence of IBD with pancreatic pathology is rare, however, it has been diagnosed more frequently during recent years in the pediatric population. This article reviews the current literature on the most common pancreatic diseases associated with IBD in the pediatric population and their relationship with IBD activity and treatment. Materials and Methods: We performed a systematic review of data from published studies on pancreatic disorders, also reported as extraintestinal manifestations (EIMs), among children with IBD. We searched PubMed and Web of Science to identify eligible studies published prior to 25 April 2020. Results: Forty-four papers were chosen for analysis after a detailed inspection, which aimed to keep only the research studies (case control studies and cohort studies) or case reports on children and only those which were written in English. The manifestations of IBD-associated pancreatic disorders range from asymptomatic increase in pancreatic enzymes activity to severe disease such as acute pancreatitis. Acute pancreatitis (AP) induced by drugs, mainly thiopurine, seems to be the most- often-reported pancreatic disease associated with IBD in children. AP associated with other than drug etiologies, and chronic pancreatitis (CP), are rarely observed in the course of pediatric IBD. The pancreatic involvement can be strictly related to the activity of IBD and can also precede the diagnosis of IBD in some pediatric patients. The course of AP is mild in most cases and may occasionally lead to the development of CP, mainly in cases with a genetic predisposition. Conclusions: The involvement of the pancreas in the course of IBD may be considered as an EIM or a separate co-morbid disease, but it can also be a side effect of IBD therapy, therefore a differential diagnosis should always be performed. As the number of IBD incidences with concomitant pancreatic diseases is constantly increasing in the pediatric population, it is important to include pancreatic enzymes level measurement in the workup of IBD.

A Drug-Induced Acute Pancreatitis Retrospective Study

BACKGROUND AND AIMS

Drugs are considered a relatively rare and understudied cause of acute pancreatitis (AP). The lack of convincing and conclusive data on drug-induced AP (DIAP) complicates the diagnosis as well as the identification of the causative drug. The aim of this study is to document causes of DIAP cases that occurred in the Saguenay-Lac-Saint-Jean (SLSJ) population.

METHODS

We have conducted a retrospective and descriptive population-based study of DIAP cases that occurred between 2006 and 2014 in the six hospitals serving the entire SLSJ population. Cases were selected from the Quebec Ministry of Health hospitalizations registry (MED-ECHO) administrative public database. A medical chart review was performed in an attempt to characterize DIAP hospitalizations and to identify the imputable drugs.

RESULTS

During the studied period, 75 cases (30.7% male, 69.3% female) were included totaling 90 hospitalizations for DIAP. Among them, 50 causative drugs were identified and were distributed in 17 different drug classes. Recurrent DIAPs were documented in 13 cases, and among them, 6 cases have experimented a positive rechallenge. Six drugs (5-fluorouracil, atorvastatin, bortezomib, nilotinib, rosuvastatin, and triamcinolone) were associated with the highest degree of evidence. The most common causative drugs of DIAP hospitalization were azathioprine (n = 7), followed by atorvastatin (n = 6), hydrochlorothiazide (n = 5), rosuvastatin (n = 4), and codeine (n = 4).

CONCLUSIONS

This study has added new evidences about potentially pancreatitis-associated drugs in literature. This is the first study to report definite 5-fluorouracil- and triamcinolone-induced AP. An updated version of the evidence-based literature review is needed to support the clinicians in the identification of the causative drugs.

Vedolizumab-induced acute pancreatitis: the first reported clinical case

Drug-induced acute pancreatitis (DIAP) is a rare, but clinically significant diagnosis. Vedolizumab, an α₄β₇ integrin inhibitor, which was approved in 2015 for treatment of moderate to severe inflammatory bowel disease, is a well-tolerated medication with a favourable safety profile and minimal serious adverse events in premarketing clinical trials. We present the first reported case of acute pancreatitis directly attributable to vedolizumab.

MR enterography: how to deliver added value

MR enterography (MRE) is increasingly vital to the diagnosis and follow-up of children with Crohn disease. This diagnostic test, which can provide valuable information regarding the presence of intestinal inflammation, intestinal and intra-abdominal complications, and extra-intestinal disease-related manifestations, has the potential to directly impact both medical and surgical decision-making. Consequently, it is imperative that the interpretation and reporting of these examinations provide as much clinical information as possible. This article reviews specific ways radiologists can provide added value when interpreting MRE examinations in the setting of pediatric Crohn disease by (1) establishing the true extent of disease involvement, (2) subjectively and objectively assessing response to medical treatment and (3) accurately characterizing disease-related complications.

Inpatient Costs for Patients with Inflammatory Bowel Disease and Acute Pancreatitis

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increased risk of acute pancreatitis (AP). Our group examined differences in length of stay and costs for patients with IBD hospitalized for AP and the general population.

METHODS

Using the National Inpatient Sample, we examined all admissions during 2005 to 2011 with a primary diagnosis of AP and codiagnosis of IBD. Continuous variables were reported as mean ± SD and compared between IBD and controls. To compare the outcomes of interest, we conducted a 1:3 propensity score matching using a greedy algorithm based on age, gender, race, number of comorbidities, procedures, insurance, income quartiles, hospital bed size, hospital location, and teaching status. Statistical analyses were performed on SAS 9.3 (Cary, NC).

RESULTS

There were 4291 hospitalizations of patients with IBD and AP over the 7-year period and 379,627 hospitalizations of patients without IBD and with AP. More patients with Crohn's disease developed AP than patients with ulcerative colitis (2145 versus 1219). The length of stay and costs for patients with AP and IBD were significantly higher than controls (5.7 days versus 4.9 days, P < 0.0001 and $29,724.89 versus $27,916.76, P < 0.0001). The percentage of patients with alcohol abuse was lower in patients with IBD than that of controls (11.8% versus 21.7%, P < 0.0001). However, the percentage of patients with IBD who were drug abusers was higher than controls (5.8% versus 4.3%, P < 0.0005).

CONCLUSIONS

Our study suggests that a codiagnosis of Crohn's disease or ulcerative colitis incurs a greater economic burden in patients with AP.

Toxic-metabolic Risk Factors in Pediatric Pancreatitis: Recommendations for Diagnosis, Management, and Future Research

Pancreatitis in children can result from metabolic and toxic risk factors, but the evidence linking these factors is sparse. We review the evidence for association or causality of these risk factors in pancreatitis, discuss management strategies, and their rationale. We conducted a review of the pediatric pancreatitis literature with respect to the following risk factors: hyperlipidemia, hypercalcemia, chronic renal failure, smoking exposure, alcohol, and medications. Areas of additional research were identified. Hypertriglyceridemia of 1000 mg/dL or greater poses an absolute risk for pancreatitis; persistent elevations of calcium are predisposing. Further research is necessary to determine whether end-stage renal disease leads to increased pancreatitis in children similar to adults. It is unknown whether cigarette smoking exposure, which clearly increases risk in adults, also increases risk in children. The role of alcohol in pediatric pancreatitis, whether direct or modifying, needs to be elucidated. The evidence supporting most cases of medication-induced pancreatitis is poor. Drug structure, improper handling of drug by host, and bystander status may be implicated. Other pancreatitis risk factors must be sought in all cases. The quality of evidence supporting causative role of various toxic and metabolic factors in pediatric pancreatitis is variable. Careful phenotyping is essential, including search for other etiologic risk factors. Directed therapy includes correction/removal of any agent identified, and general supportive measures. Further research is necessary to improve our understanding of these pancreatitis risk factors in children.

Probing the Association of Pancreatitis in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) has been increasingly diagnosed in children and adults. Similarly, acute and chronic pancreatitis are increasingly prevalent conditions with potentially devastating consequences. There is a growing body of literature linking these 2 conditions. The purpose of this review is to provide a comprehensive outline of the association between IBD and pancreatitis and to explore their putative pathophysiology. Based on the collective reports, 2 outstanding reasons for pancreatitis in patients with IBD are medications and IBD complications.

Possible Sulfamethoxazole/Trimethoprim-Induced Pancreatitis in a Complicated Adolescent Patient Posttraumatic Injury

Introduction:

Multiple medications have been associated with pancreatitis, however, data in the pediatric population are scarce secondary to the nonspecific presentation and infrequent diagnosis. The aim of this report is to characterize drug-induced pancreatitis in an adolescent patient.

Case Presentation:

A 16-year-old African-American female presented with a surgical site infection 8 weeks after a motor vehicle accident with multiple traumas. Two weeks prior to the admission, the patient was hospitalized for a urinary tract infection (UTI) and was initiated on sulfamethoxazole/trimethoprim (TMP/SMX) daily for UTI prophylaxis. On day 13, the patient was diagnosed with acute pancreatitis with an amylase level of 187 units/L (normal = 30-110) and a lipase level of 987 units/L (normal = 23-208). TMP/SMX was discontinued, and pancreatic enzyme levels decreased but did not reach normal. The patient was asymptomatic at discharge.

Discussion:

TMP/SMX was identified as the likely etiology of pancreatitis by the medical team. Evaluation with the Naranjo algorithm indicated a “possible” adverse drug reaction.

Conclusion:

Acute pancreatitis can have significant morbidity and mortality in the pediatric population but can go undiagnosed due to its lower incidence. Pediatric patients presenting with idiopathic abdominal pain should be evaluated for pancreatitis and drug therapy should be reviewed for potential causative agents.