Clarifying the Diagnostic Pathway in Idiopathic Acute Pancreatitis.

Covering the Cover

<h3>Introduction</h3> Idiopathic acute pancreatitis (IAP) represents a diagnostic and therapeutic challenge. IAP is prone to high recurrence and understanding its aetiology may assist in preventing recurrent episodes and its related morbidity and mortality. Appropriate investigations help to determine the underlying aetiology and can guide further effective management. We describe our experience to evaluate the role of endoscopic ultrasound (EUS) in patients with unexplained acute pancreatitis in whom cross sectional imaging and conventional laboratory testing had failed to identify the aetiology in a tertiary pancreatico-biliary referral centre. <h3>Method</h3> We retrospectively identified all patients who underwent EUS for assessment of idiopathic acute or recurrent pancreatitis during the period Jan 2007–Dec 2013. All patients had appropriate radiological investigations and no underlying cause identified on transabdominal ultrasound, computed tomography (CT) and on magnetic resonance cholangiopancreatography (MRCP). Patients with risk factors known to precipitate pancreatitis including alcohol excess, medications, metabolic or autoimmune conditions, were excluded. <h3>Results</h3> 44 patients (male 32, female 12) were identified with a mean age of 50 years (range 21–79 years). 33 (75%) patients had recurrent attacks of acute pancreatitis whereas 11 (25%) patients were referred for EUS after a single attack of acute pancreatitis. EUS revealed a cause of pancreatitis in 21/44 (47.7%) patients. Pancreatic duct stones were detected in 10 (22.7%); biliary duct microlithiasis in 4 (9%); pancreatic divisum in 3 (6.8%) and peri-ampullary lesions in 2 (4.5%) patients. One each had a pancreatic duct stricture, biliary duct stricture and one patient was diagnosed with IPMN (intra-papillary mucinous neoplasm). No underlying cause could be found in 23 (52.3%) patients. <h3>Conclusion</h3> EUS demonstrated aetiology in almost half of patients with unexplained acute or recurrent pancreatitis. Our findings support the emerging evidence that EUS is a valuable diagnostic tool in the evaluation of patients with idiopathic pancreatitis and should be considered where initial diagnostic workup including cross sectional imaging remains inconclusive. <h3>Disclosure of interest</h3> None Declared.

The hunt for microlithiasis in idiopathic acute recurrent pancreatitis: Should we abandon the search or intensify our efforts?

BackgroundThis study aimed to identify pathogenic variants of PRSS1, SPINK1, CFTR, and CTRC genes in Korean patients with idiopathic pancreatitis.MethodsThe study population consisted of 116 Korean subjects (65 males, 51 females; mean age, 30.4 yr, range, 1-88 yr) diagnosed with idiopathic chronic pancreatitis (ICP), idiopathic recurrent acute pancreatitis (IRAP), or idiopathic acute pancreatitis (IAP). We analyzed sequences of targeted regions in the PRSS1, SPINK1, CFTR, and CTRC genes, copy numbers of PRSS1 and SPINK1, and clinical data from medical records.ResultsWe identified three types of pathogenic PRSS1 variants in 11 patients, including p.N29I (n=1), p.R122H (n=1), and p.G208A (n=9). Sixteen patients exhibited heterozygous pathogenic variants of SPINK1, including c.194+2T>C (n=12), p.N34S (n=3), and a novel pathogenic splicing variation c.194+1G>A. A heterozygous CFTR p.Q1352H pathogenic variant was detected in eight patients. One patient carried a heterozygous CTRC p.P249L pathogenic variant, which is a known high-risk variant for pancreatitis. All patients had normal PRSS1 and SPINK1 gene copy numbers. Weight loss occurred more frequently in patients carrying the p.G208A pathogenic variant, while pancreatic duct stones occurred more frequently in patients with the c.194+2T>C pathogenic variant.ConclusionsPathogenic variants of PRSS1, SPINK1, and CFTR were associated with idiopathic pancreatitis, while pathogenic variants of CTRC were not. Copy number variations of PRSS1 and SPINK1 were not detected.

52 - Unexplained Acute Pancreatitis and Acute Recurrent Pancreatitis

51 - Unexplained acute pancreatitis and acute recurrent pancreatitis

Severity and outcome of a first episode of idiopathic acute pancreatitis is not more severe than pancreatitis of other etiologies

Idiopathic acute pancreatitis: role of ERCP in diagnosis and therapy

Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. The initial evaluation fails to detect the cause of RAP in 10%-30% of patients, whose condition is classified as idiopathic RAP (IRAP). Idiopathic acute pancreatitis (IAP) is a diagnostic challenge for gastroenterologists. In view of associated morbidity and mortality, it is important to determine the aetiology of pancreatitis to provide early treatment and prevent recurrence. Endoscopic ultrasound (EUS) is an investigation of choice for imaging of pancreas and biliary tract. In view of high diagnostic accuracy and safety of EUS, a EUS based management strategy appears to be a reasonable approach for evaluation of patients with a single/recurrent idiopathic pancreatitis. The most common diagnoses by EUS in IAP is biliary tract disease. The present review aims to discuss the role of EUS in the clinical management and diagnosis of patients with IAP. It elaborates the diagnostic approach to IAP in relation to EUS and other different modalities. Controversial issues in IAP like when to perform EUS, whether to perform after first episode or recurrent episodes, comparison among different investigations and the latest evidence significance are detailed.

Idiopathic acute pancreatitis is common. Recent evidence suggests that biliary sludge may be the etiology in many patients with this disorder. In this case-control study, admission ultrasound examinations of patients with idiopathic pancreatitis, patients with acute alcohol-associated pancreatitis and a control group were compared. Biliary sludge was found in seven of 21 patients (33%) with idiopathic pancreatitis, two of 25 (8%) with acute alcohol-associated pancreatitis and one of 63 controls (1.6%). Comparison of idiopathic pancreatitis patients with both acute alcohol-associated pancreatitis patients and controls for the presence of sludge revealed odds ratios of 31.0 (95% CI 3.5 to 273) and 5.8 (95% CI 1.1 to 32.0), respectively. Also observed was a trend towards higher levels of liver enzymes, bilirubin and amylase in patients with idiopathic pancreatitis who had sludge identified. This study provides further evidence linking biliary sludge with a significant proportion of patients with idiopathic acute pancreatitis.

The main causes of pancreatic inflammation worldwide are biliary lithiasis and alcoholism. However, 10 to 30% of patients have been considered to have "idiopathic" acute pancreatitis. Recently, some studies showed that a significant rate of the so called idiopathic pancreatitis are caused by microlithiasis and/or biliary sludge, identified by the presence of cholesterol monohidrate and/or calcium bilirubinate microcrystals in the biliary sediment. In the present study, the analysis of microcrystals from bile obtained during endoscopic retrograde cholangiopancreatography was done in patients with pancreatitis (idiopathic, biliary or alcoholic--20 in each group). Patients with idiopathic pancreatitis and microcrystals in the bile underwent cholecystectomy whenever possible. Those who refused or were inapt to surgery underwent endoscopic sphincterotomy or received continuous therapy with ursodeoxycholic acid. Patients with idiopathic pancreatitis without biliary crystals did not receive any specific treatment. The prevalence of biliary microcrystals in patients with idiopathic pancreatitis (75%) and biliary pancreatitis (90%) was significantly higher than in those with alcoholic pancreatitis (15%). In the identification of the etiology of biliary pancreatitis, the presence of microcrystals had a sensitivity of 90%, specificity of 85%, positive predictive value of 85.7%, negative predictive value of 89.4% and accuracy of 87.5%. In the patients with recurrent idiopathic pancreatitis, with biliary crystals, there was an statistically significant reduction in the number of pancreatitis episodes after specific treatment. In the follow-up of this group during 23.3 +/- 4.8 months, recurrence of pancreatitis occurred only in patients with "persistent biliary factor" (choledocholithiasis and/or persistence of cholesterol monohidrate). All patients with idiopathic pancreatitis who underwent cholecystectomy had chronic cholecystitis. Moreover, cholelithiasis was present in one case. In the ultrassonographic follow-up of the patients with idiopathic acute pancreatitis with microcrystals in the bile, cholelithiasis was detected in one case. In the subgroup of five patients with idiopathic pancreatitis without biliary microcrystals recurrence occurred in one case. Ultrassonographic study during follow-up did not reveal biliary stones in any of these patients. We concluded that the detection of biliary microcrystals in "idiopathic" pancreatitis suggested an underlying biliary etiology, even if occult. What's more, early specific therapeutic procedure (cholecystectomy, endoscopic sphincterotomy or ursodeoxycholic acid) in patients with recurrent idiopathic pancreatitis with microcrystals in the bile reduced significantly the recurrence during the follow-up. Finally, acute pancreatitis (specially recurrent) should not be called idiopathic before the microscopic analysis of the bile, aiming to detect or exclude the presence of microcrystals.

Acute recurrent pancreatitis (ARP) occurs in 10-35% of children presenting idiopathic acute pancreatitis (IAP) and can evolve to chronic pancreatitis (CP), especially if genetic mutations are present.

Introduction: Identifying the etiology is vital in management of acute pancreatitis to prevent recurrence and early detection of underlying disorder. Idiopathic acute pancreatitis (IAP) has been reported in white population to be the initial presentation of pancreatic cancer, a disease typically diagnosed at a late stage with a high mortality rate. Since investigational work up is usually deferred until the acute inflammation subsides, proper follow-up is imperative in revealing the culprit cause. This study aims to assess a real-world evaluation and causes of IAP in an Asian population. Methods: A retrospective analysis on patients discharged with a diagnosis of IAP using ICD-10 code during January 2002 to April 2020 at a tertiary care hospital was conducted. Discharge summary of the index hospitalization was reviewed to verify the diagnosis of IAP. Primary outcomes were the diagnostic modality performed and the etiology identified during the three-year follow-up period following the initial discharge. Results: Of 310 patients who were coded as IAP at discharge, 218 had an etiology identified upon discharge summary review, leaving 82 subjects (mean age 54.1 ± 17.9 years, 51.2% women) as clinically presumed IAP. 75.6% (n= 62) had at least one radiologic evaluation performed within the first year. The most common investigation was computed tomography (n= 45, 54.8 %). [Figure 1] At three-year follow-up after the first episode of IAP, 23.2% (n= 19) remained with an unknown etiology despite adherence to clinical visits and radiologic evaluation. Three patients (3.7%) were diagnosed with adenocarcinoma of the head of pancreas (2 by CT, 1 by MRI) within the first 6 months after discharge. Twenty-nine (35.4%) patients were later diagnosed with other definite cause of acute pancreatitis. [Table 1] Fourteen (17.0%) patients did not undergo further diagnostic imaging. Conclusion: Inaccurate coding of IAP at a hospital discharge substantially overestimated a true prevalence of IAP. Proper radiologic evaluation within the first year after hospitalization was crucial to identify the underlying etiology and exclude malignancy. The most common diagnostic modality done was computed tomography. Our study highlights the need of proper investigation for patients with IAP for early detection of pancreatic cancer.Figure 1.: Radiologic Evaluation during Follow-up period for presumed IAP; IAP = Idiopathic Acute Pancreatitis, CT = Computed Tomography, MRI = Magnetic Resonance Imaging, EUS = Endoscopic Ultrasound.Table 1.: Definite Cause of Acute Pancreatitis in presumed IAP Patients during Follow-up; IPMN = Intraductal Papillary Mucinous Neoplasms, PDAC = Pancreatic ductal adenocarcinoma.

Current management of acute idiopathic pancreatitis and acute recurrent pancreatitis

INTRODUCTION: Idiopathic acute pancreatitis (IAP) accounts for a considerable number of emergency room visits and subsequent hospitalization. The rate and cost readmissions due to AIP is not well known. Therefore, we sought to study the causes and predictors of 30-day readmissions after an index admission with IAP. METHODS: Using the National Readmission database (NRD) from 2016, we identified all patients admitted with IAP using ICD-10 codes. We then evaluated the causes and predictors of 30-day readmission using multivariable logistic regression analysis. RESULTS: A total of 11,517 patients (mean age 52.58 years, 58% women) were diagnosed with IAP at index admission. The most common associated comorbidities were fluid and electrolytes disorders (41.8%), followed by hypertension (40%), iron deficiency anemia (21.6%), depression (20.3%), chronic lung diseases (20.3%) and renal failure (18%). The median length of stay for the cohort was 4 days. The 30-day readmission rate post-IAP index admission was 15.4%. Unspecified acute pancreatitis and IAP comprised the majority of causes for readmission, 22% and 14.5%, respectively. These are followed by sepsis (5.2%), pulmonary disease (3.8%), diabetes mellitus (3.5%), and cardiac disease (3%). The risk of all-cause 30-day readmission was not statistically different based on gender (p = 0.8). Meanwhile, it was higher in patients with anemia, gastrointestinal bleeding, weight loss, renal failure, chronic pulmonary disease, diabetes mellitus, depression and drug abuse (p < 0.05 for all). The median cost of 30-day readmissions was $8075.80. CONCLUSION: The rate of 30-day readmissions after IAP is high especially in those with associated comorbidities. These readmissions were associated with significant health care costs. Unspecified acute pancreatitis and IAP were among the two most common causes of readmissions. Our study findings have important clinical implications and might be helpful in developing strategies to decrease readmissions and health care costs.Figure 1.: Causes of 30 days readmission in IAP.