When Pancreatitis Strikes the Colon: A Rare Case Report of Sigmoid Perforation

Introduction Management of complicated acute pancreatitis (AP) has changed significantly in the last decades, especially in terms of step-up approach introduction, delayed surgery, early enteral feeding, restrictions in antibiotic prophylaxis and volume therapy. Severe colonic complications—ischemia and perforation—remain a rare but extremely challenging complication of severe acute pancreatitis. World literature reports mostly about individual case reports, and there is no current guideline for treatment of this complication. Methods Records of Bratislava University Hospital were searched for all treated cases of acute pancreatitis in a 15 years period (2009–2023). In the next step, all patients who required major abdominal surgery for complications of acute pancreatitis were selected, and their surgery records were analyzed for signs of colon ischemia and/or colon perforation. Data on surgical therapy, previous surgeries, outcome, interval since the onset of AP and hospital length were collected. Results 1386 cases of AP were treated in the analyzed period (735 males, 53%). 35 (2.53%) required major surgery. In seven of these (5 males, 2 females, age 27–71) AP associated colonic ischemia and/or perforation occurred. 5 of these patients died, 2 survived (female 27 years, male 40 years). Colonic resection with ileostomy was performed in 4 cases, simple ileostomy in 3 cases. 1 case was diagnosed by CT scan, the resting 6 were diagnosed during surgery. The period of occurrence since the onset of AP varied from 1day to 8 months. Hospital stay varied from 18 days to 230 and 256 days (both survivors). In 3 cases, colonic complication occurred in the early phase of AP (within the first 7 days). In 4 cases colonic complication was observed during the first surgery. Conclusion Our data underwrite huge variability and rareness of this issue, hindering statistical analysis and consensus on universal recommendation. Colonic perforation should be considered following sepsis outbreak during the early aseptic phase of AP, as well as following backsets during the course of the disease. Due to its rareness and severity, colonic perforation and ischemia remains a dark field in the management of AP. Early onset perforation might be a pitfall of strict guideline adherence—delayed CT staging, restriction of antibiotics and early enteral feeding, as well as delayed open surgery.

Complex colovesicular fistula: A severe complication caused by biliary stent migration

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

Background/objectivesThe most important risk factor for recurrent pancreatitis after an episode of acute alcoholic pancreatitis is continuation of alcohol use. Current guidelines do not recommend any specific treatment strategy regarding alcohol cessation. The PANDA trial investigates whether implementation of a structured alcohol cessation support program prevents pancreatitis recurrence after a first episode of acute alcoholic pancreatitis. MethodsPANDA is a nationwide cluster randomised superiority trial. Participating hospitals are randomised for the investigational management, consisting of a structured alcohol cessation support program, or current practice. Patients with a first episode of acute pancreatitis caused by harmful drinking (AUDIT score >7 and < 16 for men and >6 and < 14 for women) will be included. The primary endpoint is recurrence of acute pancreatitis. Secondary endpoints include cessation or reduction of alcohol use, other alcohol-related diseases, mortality, quality of life, quality-adjusted life years (QALYs) and costs. The follow-up period comprises one year after inclusion. DiscussionThis is the first multicentre trial with a cluster randomised trial design to investigate whether a structured alcohol cessation support program reduces recurrent acute pancreatitis in patients after a first episode of acute alcoholic pancreatitis, as compared with current practice. Trial registrationNetherlands Trial Registry (NL8852). Prospectively registered.

Among children who suffer from acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP), acute pancreatitis (AP) episodes are painful, often require hospitalization, and contribute to disease complications and progression. Despite this recognition, there are currently no interventions to prevent AP episodes. In this retrospective cohort study, we assessed the impact of pancreatic enzyme therapy (PERT) use on clinical outcomes among children with pancreatic-sufficient ARP or CP. Children with pancreatic-sufficient ARP or CP in the INSPPIRE-2 cohort were included. Clinical outcomes were compared for those receiving vs not receiving PERT, as well as frequency of AP before and after PERT. Logistic regression was used to study the association between development of AP episodes after starting PERT and response predictors. Among 356 pancreatic-sufficient participants, 270 (76%) had ARP, and 60 (17%) received PERT. Among those on PERT, 42% did not have a subsequent AP episode, during a mean 2.1 years of follow-up. Children with a SPINK1 mutation ( P = 0.005) and those with ARP (compared with CP, P = 0.008) were less likely to have an AP episode after starting PERT. After initiation of PERT, the mean AP annual incidence rate decreased from 3.14 down to 0.71 ( P < 0.001). In a retrospective analysis, use of PERT was associated with a reduction in the incidence rate of AP among children with pancreatic-sufficient ARP or CP. These results support the need for a clinical trial to evaluate the efficacy of PERT to improve clinical outcomes among children with ARP or CP.

32-Year-Old-Woman With Abdominal Pain

Pancreas divisum is implicated as an obstructive cause for acute pancreatitis. Observational data suggest endoscopic retrograde cholangiopancreatography (ERCP) with minor papillotomy reduces the risk of pancreatitis episodes. Even though this endoscopic procedure is widely used in practice, clinical trials are lacking. To determine whether ERCP with minor papillotomy reduces the risk of acute pancreatitis among adults with unexplained acute recurrent pancreatitis and pancreas divisum. This multicenter, sham-controlled, double-blind randomized clinical trial enrolled adults with 2 or more episodes of acute pancreatitis and pancreas divisum. Adults with other etiologies for acute pancreatitis or concomitant chronic calcific pancreatitis were excluded. The trial was conducted between September 1, 2018, and August 30, 2024, at 21 referral centers in the US and Canada. Last follow-up occurred on February 15, 2025. Participants were randomized in a 1:1 ratio to ERCP with minor papillotomy or sham ERCP. The primary outcome was development of acute pancreatitis more than 30 days after randomization as a time-to-event outcome. The secondary outcomes included acute pancreatitis episode frequency and development of chronic calcific pancreatitis, diabetes, and exocrine pancreatic dysfunction. A total of 148 participants were randomized (mean age, 54 [SD, 19.5] years; 68.2% female; 95.3% non-Hispanic or Latino and 87.2% White; mean lifetime acute pancreatitis episodes, 3 [SD, 2]; mean duct diameter, 2.2 [SD, 1.3] mm) and followed up for a median of 34 months (IQR, 21.7-45.7 months). Of the 75 participants in the ERCP with minor papillotomy group, 26 (34.7%) developed acute pancreatitis compared with 32 of 73 participants (43.8%) in the sham ERCP group (adjusted hazard ratio, 0.83 [95% CI, 0.49 to 1.41]). The incidence rate ratio for acute recurrent pancreatitis episode frequency was 0.25 (95% CI, 0.18 to 0.34) in the ERCP with minor papillotomy group vs 0.30 (95% CI, 0.23 to 0.41) in the sham ERCP group. There were no between-group differences in frequency and incidence of chronic calcific pancreatitis (4.0% in the ERCP with minor papillotomy group vs 2.7% in the sham ERCP group; risk difference [RD], 0.01 [95% CI, -0.05 to 0.07]), diabetes (15.8% vs 12.8%, respectively; RD, 0.03 [95% CI, -0.13 to 0.19]), and exocrine pancreatic dysfunction (7.7% vs 17.2%; RD, -0.10 [95% CI, -0.27 to 0.08]). The adverse event of acute pancreatitis within 30 days of randomization occurred more frequently in the ERCP with minor papillotomy group (14.7%) vs the sham ERCP group (8.2%) (RD, 0.06 [95% CI, -0.04 to 0.17]). Among patients with unexplained acute recurrent pancreatitis and pancreas divisum, ERCP with minor papillotomy does not reduce the risk of another episode of acute pancreatitis or related sequelae. ClinicalTrials.gov Identifier: NCT03609944.

Pre-Existing Pancreatitis and Elevated Risks of COVID-19 Severity and Mortality

Surgical Management of Acute Pancreatitis

Acute and Chronic Pancreatic Inflammation

Long-Term Prognosis of Acute Pancreatitis in Japan

To investigate the incidence, risk factors, and outcomes of colon involvement in patients with necrotizing pancreatitis. Necrotizing pancreatitis is characterized by a profound inflammatory response with local and systemic implications. Mesocolic involvement can compromise colonic blood supply leading to ischemic complications; however, few data exist regarding this problem. We hypothesized that the development of colon involvement in necrotizing pancreatitis (NP) negatively affects morbidity and mortality. Six hundred forty-seven NP patients treated between 2005 and 2017 were retrospectively reviewed to identify patients with colon complications, including ischemia, perforation, fistula, stricture/obstruction, and fulminant Clostridium difficile colitis. Clinical characteristics were analyzed to identify risk factors and effect of colon involvement on morbidity and mortality. Colon involvement was seen in 11% (69/647) of NP patients. Ischemia was the most common pathology (n = 29) followed by perforation (n = 18), fistula (n = 12), inflammatory stricture (n = 7), and fulminant C difficile colitis (n = 3). Statistically significant risk factors for developing colon pathology include tobacco use (odds ratio (OR), 2.0; 95% confidence interval (CI), 1.2-3.4, P = 0.009), coronary artery disease (OR, 1.9; 95% CI, 1.1-3.7; P = 0.04), and respiratory failure (OR, 4.7; 95% CI, 1.1-26.3; P = 0.049). When compared with patients without colon involvement, NP patients with colon involvement had significantly increased overall morbidity (86% vs 96%, P = 0.03) and mortality (8% vs 19%, P = 0.002). Colon involvement in necrotizing pancreatitis is common; clinical deterioration should prompt its evaluation. Risk factors include tobacco use, coronary artery disease, and respiratory failure. Colon involvement in necrotizing pancreatitis is associated with substantial morbidity and mortality.

BACKGROUND. Early detection of complications of pancreatic necrosis including purulent-septic ones largely predetermines the outcome of the treatment. In this article, we evaluated the role and capabilities of X-ray computed tomography in the diagnosis of acute pancreatitis complications. OBJECTIVE. Studying the capabilities of spiral computed tomography (SCT) in the diagnosis of acute severe pancreatitis complications. MATERIAL AND METHODS. Spiral CT results in 56 patients with severe acute pancreatitis and suspected septic complications have been analyzed. RESULTS. Revealed complications of the severe acute pancreatitis: circumscribed collection of fluid (32), abscesses of bursa omentalis and retroperitoneal fat (18), retroperitoneal phlegmon (6). The semiotics of revealed complications has been described, and their relation with other organs and structures has been evaluated. CONCLUSIONS. SCT conducted with contrasting techniques, reveals septic complications of severe acute pancreatitis, ascertains their form, location and amount, as well as the relation with other organs and structures which helps identify the tactics of management, indications for surgery and assess its effectiveness.

INTRODUCTION: In patients presenting with recurrent acute pancreatitis, cystic fibrosis (CF) gene variants are found at an increased frequency. Pancreatitis also occurs in patients being followed with CF mutations, generally occurring in patients with less severe mutations or in the setting of CF-related sorder (CFRD). There are no established treatment options for CF mutation-related pancreatitis. Some evidence has suggested that lung function fluctuates during the menstrual cycle, and in CF, that estradiol may inhibit chloride secretion. It has been hypothesized that hormonal contraceptives could play a role in modulating the disease process in women with CF. This study examined the impact of depot medroxyprogesterone acetate on the course of recurrent pancreatitis in female patients with established CF gene mutations. METHODS: In this single center retrospective study, medical records of all adult female patients with CF and acute recurrent pancreatitis between 2008–2018 were reviewed. Patients were included if they had experienced at least two episodes of acute pancreatitis, had been started on depot medroxyprogesterone, and had at least one CF gene mutation. Patients were excluded if they had developed pancreatitis from gallstones or heavy alcohol use. Total hospitalizations, episodes of pancreatitis, and average lipase values were examined and compared before and after the initiation of the depot medroxyprogesterone. RESULTS: A total of 13 patients met the study screening criteria and were recommended to start depot medroxyprogesterone. All patients were Caucasian females with a mean age of 45 years. The average time of treatment from which the endpoints were collected was 5.6 months. After the initiation of the depot medroxyprogesterone, there were no episodes of acute pancreatitis and one hospitalization unrelated to pancreatitis. The average lipase values were significantly decreased (261 units/L vs 41 units/L, P = 0.039) after the patients had been started on depot medroxyprogesterone. CONCLUSION: In this cohort, there were no further episodes of recurrent acute pancreatitis following the initiation of depot medroxyprogesterone in female patients with CF mutations. This data will be combined with other institutions shortly to examine the outcomes in a larger retrospective sample. A multicenter prospective study is being developed to study the outcomes being seen clinically and reported here in this sample.

Data on the prevalence of pancreatic dysfunction after an episode of acute pancreatitis are conflicting. Our aim was to evaluate the natural course of endocrine and exocrine pancreatic function in the long-term follow-up after the first episode of acute alcoholic pancreatitis (AAP). A total of 77 patients who survived their first episode of AAP between January 2001 and February 2005 were prospectively followed up for a maximum of 13 years. During the follow-up, patients were repeatedly interviewed and monitored for recurrences, new diabetes, and chronic pancreatitis. The pancreatic function was evaluated repeatedly during the follow-up. Of the patients, 35% had ≥1 recurrent acute pancreatitis (RAP) episodes during the follow-up. New pancreatogenic diabetes developed in 19% of the previously nondiabetic patients, but only in patients with RAP (13/26 vs. 0/42; OR=39; 95% CI, 4.6-327.1). In addition, 55% of the patients developed new prediabetes or diabetes, and even this was more frequent in patients with RAP (86% vs. 42%; OR=8.2; 95% CI, 1.2-54.3). Exocrine dysfunction developed in 24% of the patients and was associated with abnormal findings in the endocrine function (P=0.003). Patients with RAP had a higher overall mortality compared with patients without RAP episodes during the follow-up (36% vs. 13%; HR=4.0; 95% CI, 1.4-11.0). The risk for pancreatic endocrine dysfunction, pancreatogenic diabetes and mortality increases significantly if the patient has recurrent episodes of AAP. The risk of developing pancreatic dysfunction after AAP should be recognized and pancreatic function should be screened routinely during the years after the first episode of AAP.