Showing papers on "Pancreatitis published in 2004"

Histopathological features of diagnostic and clinical relevance in autoimmune pancreatitis: a study on 53 resection specimens and 9 biopsy specimens

Abstract: Background and Aims Autoimmune pancreatitis seems to be a disease with a heterogeneous appearance. Our intention was to establish key diagnostic criteria, define grades of severity and activity, identify features of potential subtypes and evaluate the diagnostic relevance of biopsy specimens.

Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis

Abstract: Background: In predicted severe acute pancreatitis, many patients develop organ failure and recover without local complications, and mortality is only 14–30%. It has been suggested that half of patients with progressive early organ failure may die, but there are no data to relate death or local complications to duration of early (week 1) organ failure. Aims: To determine mortality rates in patients with transient ( 48 hours) early organ failure and to show whether persistent organ failure predicts death or local complications. Patients: A total of 290 patients with predicted severe acute pancreatitis previously studied in a trial of lexipafant, recruited from 78 hospitals through 18 centres in the UK. Method: Manual review of trial database to determine: the presence of organ failure (Marshall score ⩾2) on each of the first seven days in hospital, duration of organ failure, and outcome of pancreatitis (death, complications by Atlanta criteria). Results: Early organ failure was present in 174 (60%) patients. After transient organ failure (n = 71), outcome was good: one death and 29% local complications. Persistent organ failure (n = 103) was followed by 36 deaths and 77% local complications, irrespective of onset of organ failure on admission or later during the first week. Conclusion: Duration of organ failure during the first week of predicted severe acute pancreatitis is strongly associated with the risk of death or local complications. Resolution of organ failure within 48 hours suggests a good prognosis; persistent organ failure is a marker for subsequent death or local complications.

IgG4-related sclerosing cholangitis with and without hepatic inflammatory pseudotumor, and sclerosing pancreatitis-associated sclerosing cholangitis : Do they belong to a spectrum of sclerosing pancreatitis?

Abstract: Sclerosing cholangitis (SC) is a heterogeneous disease entity. Different etiologies such as choledocholithiasis, biliary tumor, or pericholangitis can manifest as SC. Hepatic inflammatory pseudotumor (IP) is rarely associated with SC (sclerosing cholangitis associated with hepatic inflammatory pseudotumor; SC-hepatic IP), but sclerosing pancreatitis (SP) is not infrequently associated with bile duct lesions (sclerosing pancreatitis-associated sclerosing cholangitis; SP-SC). In this study, we compared the histologic changes of hepatic hilar and extrahepatic bile duct lesions of SC (7 cases), SC-hepatic IP (5 cases), SP-SC (5 cases), and typical primary sclerosing cholangitis (PSC) (5 cases). Histologically, all SP-SC cases showed extensive and dense fibrosis with marked lymphoplasmacytic infiltration, many eosinophils, and obliterative phlebitis. Four cases of SC showed bile duct lesions similar to those of SP-SC, whereas other three cases of SC showed milder lymphoplasmacytic infiltration, scant eosinophilic cell infiltration, and no obliterative phlebitis. All SC-hepatic IP cases showed bile duct lesions identical to those of SP-SC. Immunohistochemically, many IgG4-positive plasma cells were found in the bile duct lesions of all SP-SC cases, 4 SC cases with marked lymphoplasmacytic infiltration, and all SC-hepatic IP cases. By contrast, IgG4-positive plasma cells were scarce or hardly found in the remaining 3 SC cases and all PSC cases. In conclusion, 4 SC cases and all SC-hepatic IP cases showed bile duct lesions identical to those of SP-SC, suggesting that these three conditions may be a single disease entity. Their pathogenesis may be similar or closely related to that of SP, and in that respect they may represent an IgG4-related biliary disease. They may respond to steroid therapy as SP does.

Meta-analysis of Parenteral Nutrition Versus Enteral Nutrition in Patients With Acute Pancreatitis

Abstract: Objective To compare the safety and clinical outcomes of enteral and parenteral nutrition in patients with acute pancreatitis. Data sources Medline, Embase, Cochrane controlled trials register, and citation review of relevant primary and review articles. Study selection Randomised controlled studies that compared enteral nutrition with parenteral nutrition in patients with acute pancreatitis. From 117 articles screened, six were identified as randomised controlled trials and were included for data extraction. Data extraction Six studies with 263 participants were analysed. Descriptive and outcome data were extracted. Main outcome measures were infections, complications other than infections, operative interventions, length of hospital stay, and mortality. The meta-analysis was performed with the random effects model. Data synthesis Enteral nutrition was associated with a significantly lower incidence of infections (relative risk 0.45; 95% confidence interval 0.26 to 0.78, P = 0.004), reduced surgical interventions to control pancreatitis (0.48, 0.22 to 1.0, P = 0.05), and a reduced length of hospital stay (mean reduction 2.9 days, 1.6 days to 4.3 days, P Conclusions Enteral nutrition should be the preferred route of nutritional support in patients with acute pancreatitis.

Autoimmune pancreatitis: imaging features.

Abstract: PURPOSE: To retrospectively determine imaging findings in patients with autoimmune pancreatitis. MATERIALS AND METHODS: Twenty-nine patients (25 male and four female; mean age, 56 years; range, 15–82 years) with histopathologic diagnosis of autoimmune pancreatitis were examined. Data were reviewed by two radiologists in consensus. Imaging findings for review included those from helical computed tomography (CT), 25 patients; magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP), four patients; endoscopic ultrasonography (US), 21 patients; endoscopic retrograde cholangiopancreatography (ERCP), 19 patients; and percutaneous transhepatic cholangiography, one patient. Images were analyzed for appearances of pancreas, biliary and pancreatic ducts, and other findings, such as peripancreatic inflammation, encasement of vessels, mass effect, pancreatic calcification, peripancreatic nodes, and peripancreatic fluid collection. Follow-up images were available in nine patients. Serologic markers such...

A modified CT severity index for evaluating acute pancreatitis: Improved correlation with patient outcome

Abstract: OBJECTIVE. This study was conducted to assess the correlation with patient outcome and interobserver variability of a modified CT severity index in the evaluation of patients with acute pancreatitis compared with the currently accepted CT severity index.MATERIALS AND METHODS. Of 266 consecutive patients diagnosed with acute pancreatitis during a 1-year period, 66 underwent contrast-enhanced MDCT within 1 week of the onset of symptoms. Three radiologists who were blinded to patient outcome independently scored the severity of the pancreatitis using both the currently accepted and modified CT severity indexes. The modified index included a simplified assessment of pancreatic inflammation and necrosis as well as an assessment of extrapancreatic complications. Outcome parameters included the length of hospital stay; the need for surgery or percutaneous intervention; and the occurrences of infection, organ failure, and death. For both the current and modified indexes, correlation between the severity of the pa...

Protein Expression Profiles in Pancreatic Adenocarcinoma Compared with Normal Pancreatic Tissue and Tissue Affected by Pancreatitis as Detected by Two-Dimensional Gel Electrophoresis and Mass Spectrometry

Abstract: Pancreatic cancer is a rapidly fatal disease, and there is an urgent need for early detection markers and novel therapeutic targets. The current study has used a proteomic approach of two-dimensional (2D) gel electrophoresis and mass spectrometry (MS) to identify differentially expressed proteins in six cases of pancreatic adenocarcinoma, two normal adjacent tissues, seven cases of pancreatitis, and six normal pancreatic tissues. Protein extracts of individual sample and pooled samples of each type of tissues were separated on 2D gels using two different pH ranges. Differentially expressed protein spots were in-gel digested and identified by MS. Forty proteins were identified, of which five [i.e., alpha-amylase; copper zinc superoxide dismutase; protein disulfide isomerase, pancreatic; tropomyosin 2 (TM2); and galectin-1] had been associated previously with pancreatic disease in gene expression studies. The identified proteins include antioxidant enzymes, chaperones and/or chaperone-like proteins, calcium-binding proteins, proteases, signal transduction proteins, and extracellular matrix proteins. Among these proteins, annexin A4, cyclophilin A, cathepsin D, galectin-1, 14-3-3zeta, alpha-enolase, peroxiredoxin I, TM2, and S100A8 were specifically overexpressed in tumors compared with normal and pancreatitis tissues. Differential expression of some of the identified proteins was further confirmed by Western blot analyses and/or immunohistochemical analysis. These results show the value of a proteomic approach in identifying potential markers for early diagnosis and therapeutic manipulation. The newly identified proteins in pancreatic tumors may eventually serve as diagnostic markers or therapeutic targets.

Severe acute pancreatitis.

Abstract: IN THE UNITED STATES, OF THE APproximately 210000 patients admitted to hospitals each year with acute pancreatitis, about 20% have severe acute pancreatitis (SAP), and primary care physicians and internists are often the first clinicians to care for these patients. In contrast to mild acute pancreatitis, which has a mortality rate of less than 1%, the death rate for SAP is much higher: 10% with sterile and 25% with infected pancreatic necrosis. Hospitalization for patients with SAP may extend beyond 2 weeks and frequently involves an intensive care unit (ICU) stay. This review article addresses recent trends in the diagnosis and management of SAP. We searched MEDLINE from 1990 to the present using the Medical Subject Headings terms pancreatitis, acute necrotizing pancreatitis, and alcoholic pancreatitis, and the key word pancreatitis. Important clinical guidelines, randomized controlled trials (RCTs), meta-analyses, large case series from centers of excellence, and consensus conference reports form the basis of this article.

Current standards of surgery for pancreatic cancer.

Abstract: Background: Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade. Methods: An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years. Results: Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival. Conclusion: The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Management of the critically ill patient with severe acute pancreatitis.

Abstract: Objective:Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this c

Serum Macrophage Inhibitory Cytokine 1 as a Marker of Pancreatic and Other Periampullary Cancers

Abstract: Purpose: Patients with pancreatic ductal adenocarcinoma usually present with advanced-stage disease and a dismal prognosis. One effective strategy likely to improve the morbidity and mortality from pancreatic cancer would be the identification of accurate, noninvasive diagnostic markers that would enable earlier diagnosis of symptomatic patients and earlier detection of cancer in asymptomatic individuals at high risk for developing pancreatic cancer. In this study, we evaluated serum macrophage inhibitory cytokine-1 (MIC-1) as a marker of pancreatic cancer. Experimental Design: MIC-1 expression in primary pancreatic cancers, intraductal papillary mucinous neoplasms, and pancreatic cancer cell lines was determined using the National Center for Biotechnology Information serial analysis of gene expression database, oligonucleotide microarrays analysis, in situ hybridization, and immunohistochemistry. Serum MIC-1 levels were determined by ELISA in 80 patients with pancreatic adenocarcinomas, in 30 patients with ampullary and cholangiocellular carcinomas, in 42 patients with benign pancreatic tumors, in 76 patients with chronic pancreatitis, and in 97 healthy control subjects. The diagnostic performance of serum MIC-1 as a marker of pancreatic cancer was compared with that of serum CA19–9. Results: Oligonucleotide microarray and serial analysis of gene expression data demonstrated that MIC-1 RNA levels were higher in primary pancreatic cancers, intraductal papillary mucinous neoplasms, and pancreatic cancer cell lines than in nonneoplastic pancreatic ductal epithelium. MIC-1 expression was localized to the malignant epithelium in pancreatic adenocarcinomas by in situ hybridization. MIC-1 protein was expressed in 14 of 16 primary pancreatic adenocarcinomas (88%) by immunohistochemistry and was also expressed in some pancreata affected by pancreatitis but not in normal pancreas. Serum MIC-1 levels were significantly higher in patients with pancreatic ductal adenocarcinoma (mean ± SD, 2428 ± 2324 pg/ml) and in patients with ampullary and cholangiocellular carcinomas (2123 ± 2387 pg/ml) than in those with benign pancreatic neoplasms (940 ± 469 pg/ml), chronic pancreatitis (1364 ± 1236 pg/ml), or in healthy controls (546 ± 262 pg/ml). An elevated serum MIC-1 (defined as 2 SD above the mean for healthy controls) performed as well as CA19–9 (area under the receiver operating characteristic curve, 0.81 and 0.77, respectively), and the combination of MIC-1 and CA19–9 significantly improved diagnostic accuracy ( P Conclusion: Serum MIC-1 measurement can aid in the diagnosis of pancreatic adenocarcinoma.

Canine and Feline Diabetes Mellitus: Nature or Nurture?

Abstract: There is evidence for the role of genetic and environmental factors in feline and canine diabetes. Type 2 diabetes is the most common form of diabetes in cats. Evidence for genetic factors in feline diabetes includes the overrepresentation of Burmese cats with diabetes. Environmental risk factors in domestic or Burmese cats include advancing age, obesity, male gender, neutering, drug treatment, physical inactivity, and indoor confinement. High-carbohydrate diets increase blood glucose and insulin levels and may predispose cats to obesity and diabetes. Low-carbohydrate, high-protein diets may help prevent diabetes in cats at risk such as obese cats or lean cats with underlying low insulin sensitivity. Evidence exists for a genetic basis and altered immune response in the pathogenesis of canine diabetes. Seasonal effects on the incidence of diagnosis indicate that there are environmental influences on disease progression. At least 50% of diabetic dogs have type 1 diabetes based on present evidence of immune destruction of β-cells. Epidemiological factors closely match those of the latent autoimmune diabetes of adults form of human type 1 diabetes. Extensive pancreatic damage, likely from chronic pancreatitis, causes ∼28% of canine diabetes cases. Environmental factors such as feeding of high-fat diets are potentially associated with pancreatitis and likely play a role in the development of pancreatitis in diabetic dogs. There are no published data showing that overt type 2 diabetes occurs in dogs or that obesity is a risk factor for canine diabetes. Diabetes diagnosed in a bitch during either pregnancy or diestrus is comparable to human gestational diabetes.

Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality

Abstract: Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998. Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates. Setting Southern England. Subjects 5312 people admitted to hospital with acute pancreatitis. Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission. Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women. Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.

IgG4-associated idiopathic tubulointerstitial nephritis complicating autoimmune pancreatitis

Abstract: It has been well documented that autoimmune pancreatitis (AIP) [1], also known as sclerosing pancreatitis [2], is frequently associated with fibrosclerotic diseases, such as Sjögren’s syndrome [3,4], primary biliary cirrhosis [5], primary sclerosing cholangitis [3–5] or retroperitoneal fibrosis [6]. However, as yet, there have been no reports on renal complications of AIP, except for hydronephrosis, caused by retroperitoneal fibrosis. Recently, Hamano et al. [2] reported that the pathogenesis of sclerosing pancreatitis is closely related to the presence of immunoglobulin (Ig) G4. We describe here a patient with AIP in association with tubulointerstitial nephritis (TIN), which is strongly suspected to be induced by immune complexes containing IgG4.

Apoptosis versus necrosis in acute pancreatitis.

Abstract: Acute pancreatitis is a disease of variable severity in which some patients experience mild, self-limited attacks, whereas others manifest a severe, highly morbid, and frequently lethal attack. The...

Inflammation and Cancer V. Chronic pancreatitis and pancreatic cancer

Abstract: Pancreatic inflammation appears to increase the risk of pancreatic cancer. This observation is striking in the hereditary pancreatitis kindreds but also occurs in alcoholic, idiopathic, and tropical chronic pancreatitis and cystic fibrosis. However, the mutations associated with hereditary pancreatitis or cystic fibrosis are not found in sporadic pancreatic adenocarcinomas, suggesting that the effects are indirect by causing recurrent pancreatitis and chronic inflammation. The process of mutation accumulation and clonal expansion that is required for development of invasive pancreatic adenocarcinoma must therefore be accelerated in chronic pancreatitis to account for the high incidence of pancreatic cancer in these patients.

Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis.

Abstract: Injuries of the pancreas, gallbladder, and bile ducts due to blunt trauma are relatively uncommon and difficult to detect but are associated with high morbidity and mortality, especially if diagnosis is delayed. Accurate and early diagnosis is imperative, and imaging plays a key role in detection. Knowledge of the mechanisms of injury, the types of injuries, and the roles of various imaging modalities is essential for prompt and accurate diagnosis. Early recognition of disruption of the main pancreatic duct is important because such disruption is the principal cause of delayed complications. Computed tomography (CT) can demonstrate pancreatic parenchymal injuries and complications such as abscess, fistula, pancreatitis, and pseudocyst. CT findings can also suggest disruption of the pancreatic duct; however, the ability of CT to indicate this finding depends on the degree of parenchymal injury. Magnetic resonance (MR) cholangiopancreatography allows direct imaging of the pancreatic duct and sites of disruption. Gallbladder injuries can be detected with CT, ultrasonography, hepatobiliary scintigraphy, or MR cholangiopancreatography. CT findings include a collapsed gallbladder, wall thickening, inhomogeneous mural enhancement, and pericholecystic fluid. Bile duct injuries can be suggested with CT, which may show ascites and associated liver injuries, and can be confirmed with hepatobiliary scintigraphy.

Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections.

Abstract: The literature regarding patients who sustain an episode of moderate to severe acute pancreatitis primarily focuses on the critical care aspects of management in these patients. As these management principles have been perfected, the survival rates for moderate to severe acute pancreatitis have improved progressively. In gallstone-related acute pancreatitis, cholecystectomy is performed after resolution of the acute event to prevent subsequent episodes. Cholecystectomy is performed during the same hospitalization. Our report focuses on patients who have had moderate to severe acute pancreatitis caused by gallstones. These patients must recover from the acute critical care component of their pancreatitis before undergoing a cholecystectomy. Patients who have recovered from moderate or severe acute pancreatitis uniformly harbor a recognized or at times unrecognized peripancreatic fluid collection.1 Although organized reviews of this issue are scant in the literature, we have become aware of risks arising when these fluid collections are either ignored or poorly managed. The timing of cholecystectomy in patients with peripancreatic fluid collections has not been determined. Early cholecystectomy raises the risk of a second general anesthetic or a risk of a second interventional procedure to manage persistent fluid collections. We additionally have encountered patients with an episode of moderate to severe acute pancreatitis who have had their cholecystectomy and are referred because of an apparent contamination of the peripancreatic fluid collection at time of that operation. These patients may require urgent or emergent management of their peripancreatic fluid collection at a time in which it is still possible that the pseudocyst or fluid collection might have resolved spontaneously had it not been contaminated. In this circumstance, our concern is that early cholecystectomy not only failed to recognize the possibility that the pseudocyst would persist but actually exposed the cyst to contamination and sepsis thus forcing an early intervention in the pseudocyst. It is generally agreed that any patient with an episode of moderate to severe acute pancreatitis should undergo early computed tomographic (CT) imaging. It is our experience that patients will be referred who have not had imaging performed and whose fluid collections simply have never been visualized. In patients whose fluid collections have been visualized, there are times in which a patient’s clinical improvement may be such that a repeat CT scan is not done. We believe patients should have confirmation of resolution of pseudocyst before cholecystectomy for the reasons mentioned. The literature regarding cholecystectomy has addressed a similar issue, the timing of cholecystectomy after severe acute pancreatitis evaluated in a retrospective fashion. These studies have documented that earlier operation for simple acute pancreatitis is safe while early operation after severe acute pancreatitis had an unacceptably high rate of infectious complications.2,3 These studies have not addressed the contribution made by peripancreatic fluid collections. All surgeons essentially agree that gallstone-induced acute pancreatitis has a significant risk of recurrence after the first episode; therefore, prompt operative intervention is the norm.4,5 Naturally, this precept is often violated in patients with moderate to severe acute pancreatitis because so much time is spent in managing the patient’s acute episode. Thus the amount of delay before consideration for cholecystectomy is longer in a patient who has had this magnitude of an attack. Following this standard, a surgeon may feel obligated to proceed promptly to cholecystectomy after the patient has stabilized. We believe that this perceived urgency prompts surgeons and referring physicians to resort to cholecystectomy soon after symptom resolution. We are unaware of any literature regarding the risk of recurrence of acute pancreatitis after moderate to severe gallstone-induced pancreatitis. Several studies have evaluated the evolution of fluid collections after acute pancreatitis. Spontaneous resolution of peripancreatic fluid collections and of pseudocyst has been documented. The frequency with which this may take place is highest in patients whose fluid collection accumulated early after an episode of acute pancreatitis compared with patients with chronic pancreatitis. Some patients never develop a true cyst with resolution of the fluid before a cyst can develop.6–8 Pseudocysts and fluid collections may be treated by percutaneous or endoscopic methods.9–13 The appropriate timing of these techniques has been reviewed carefully.13 These interventions in sterile collections may result in infected peripancreatic fluid collections. The complication of infection in the previously sterile peripancreatic fluid collection may force one to consider definitive operative management of the peripancreatic fluid collection at an earlier stage. In this case, the timing of cholecystectomy is further complicated by prematurely forcing pseudocyst management. It has been our management principle and the basis for our study that patients with moderate to severe acute pancreatitis and documented fluid collections be given a period of evaluation that takes place after the medical stabilization of their episode. Once the pseudocyst is found to resolve, then cholecystectomy is undertaken. If the pseudocyst persists, combined management of the gallbladder and the pseudocyst is performed simultaneously. We have been interested over the years in assessing the behavior of pseudocyst and the influence that ductal anatomy may play in the behavior of pseudocyst. This information has been specifically applied to the successes of nonoperative measures such as percutaneous drainage in treating pseudocysts.14,15 As we have followed the current group of patients, we have examined ductal anatomy in those patients whose cysts persist. We are interested in the possibility that ductal anatomy may well predict those patients who have persistence of pseudocyst.