Acute Edematous Pancreatitis Research Articles

Fentanyl but Not Morphine or Buprenorphine Improves the Severity of Necrotizing Acute Pancreatitis in Rats.

Opioids are widely used for the pain management of acute pancreatitis (AP), but their impact on disease progression is unclear. Therefore, our aim was to study the effects of clinically relevant opioids on the severity of experimental AP. Various doses of fentanyl, morphine, or buprenorphine were administered as pre- and/or post-treatments in rats. Necrotizing AP was induced by the intraperitoneal injection of L-ornithine-HCl or intra-ductal injection of Na-taurocholate, while intraperitoneal caerulein administration caused edematous AP. Disease severity was determined by laboratory and histological measurements. Mu opioid receptor (MOR) expression and function was assessed in control and AP animals. MOR was expressed in both the pancreas and brain. The pancreatic expression and function of MOR were reduced in AP. Fentanyl post-treatment reduced necrotizing AP severity, whereas pre-treatment exacerbated it. Fentanyl did not affect the outcome of edematous AP. Morphine decreased vacuolization in edematous AP, while buprenorphine pre-treatment increased pancreatic edema during AP. The overall effects of morphine on disease severity were negligible. In conclusion, the type, dosing, administration route, and timing of opioid treatment can influence the effects of opioids on AP severity. Fentanyl post-treatment proved to be beneficial in AP. Clinical studies are needed to determine which opioids are best in AP.

Oral cholangioscopy for biliary system diseases

To improve the results of treatment of obstructive jaundice by using of oral cholangioscopy. There were 321 patients with obstructive jaundice between October 2020 and November 2021. Of these, cholangioscopy (SpyGlass video system) was used in 18 patients. Patients were divided into two groups: group 1 (n=9) - malignant biliary strictures; group 2 (n=9) - choledocholithiasis with large calculi (≥1.2 cm). At admission, all patients underwent laboratory and instrumental examination. In the first group, bilioduodenal stenting with plastic stents 7 and 10 Fr in diameter, 7 to 12 cm long or self-expanding nitinol stents 0.8-1.0 cm in diameter, 6 to 10 cm long was carried out. Patients with large calculi underwent targeted laser lithotripsy under endoscopic control until formation of 1-cm fragments. These fragments were removed using a lithoextraction balloon and Dormia basket. Cholangioscopy (SpyGlass system) was performed within 2 days after admission. In group 1, tumor tissue overgrowths were found during cholangioscopy. Five out of 9 (55.6%) patients underwent bilioduodenal stenting for adequate biliary drainage. Of these, 4 (44.5%) patients developed acute edematous pancreatitis on the first postoperative day. This complication regressed after 3-4 days under therapy. Four (44.5%) patients died from cancer-related multiple organ failure. In group 2, cholangioscopy effectively visualized the calculus and ensured its destruction by laser contact lithotripsy. Intraoperative and postoperative complications were not revealed in both groups. SpyGlass system is effective and safe for diagnosis and treatment in 100% of patients with extrahepatic biliary strictures and/or large calculi.

Analysis of the clinical characteristics of olanzapine-induced acute pancreatitis.

Numerous case reports of acute pancreatitis (AP) induced by olanzapine have been published. Little is, however, known about the clinical features of olanzapine-induced AP. The aim of the study was to explore the clinical characteristics of olanzapine-induced AP. We collected literature on AP cases induced by olanzapine from 1996 to April 2021 for retrospective analysis in Chinese and English. The median time to onset of olanzapine-induced acute pancreatic symptoms was 12 (range = 0.86–216) weeks in 25 patients. The clinical features of AP range from asymptomatic elevation of blood amylase/lipase levels to digestive system symptoms (abdominal pain, vomiting, and nausea) and even death in a small number of patients. Laboratory tests showed varying degrees of elevated serum amylase and lipase levels, along with high blood sugar and high triglyceride levels in some patients. Computed tomography showed acute edematous pancreatitis, acute hemorrhagic pancreatitis, and acute necrotizing pancreatitis in the patients. The patients’ symptoms were completely relieved and high triglyceride levels gradually returned to normal levels after olanzapine was stopped. Some patients with hyperglycemia still needed hypoglycemic therapy. AP is a rare adverse effect of olanzapine. Clinicians should be aware of such complications and monitor pancreatin.

Аpplication of shear wave elastography for differential diagnosis of clinical and morphological types of acute pancreatitis

Introduction. The incidence of acute pancreatitis increases every year. Early diagnosis of the necrotic type of acute pancreatitis is still relevant.Purpose. To reveal the informativeness of Elasticity Imaging Techniques for differential diagnosis of clinical and morphological types of acute pancreatitis.Material and methods. Shear wave sonoelastometry (ElastPQ-pSWE) was performed for 19 patients with acute edematous pancreatitis, and 13 patients with acute necrotizing pancreatitis. The control group consisted of 30 healthy volunteers.Results. In comparison with the control group, the stiffness of the pancreatic parenchyma was 1,3 times higher in the edematous form of AP (p3=0,0013, p6=0,007, p8=0,0024) and 5,3 times in the necrotic form of AP (p3=3,3e-5, p6=8e-07, p8=7,1e-8) and amounted to 5,16±1,34 kPa and 20,55±8,39 kPa, respectively, versus 3,86±1,04 kPa.Conclusions. Elasticity Imaging Techniques with shear wave technology provides an additional criterion for differential diagnosis of clinical and morphological types of acute pancreatitis.

Beyond acute cholecystitis—gallstone-related complications and what the emergency radiologist should know

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

Abdominal and gastrointestinal manifestations in COVID-19 patients: Is imaging useful?

Coronavirus disease 2019 (COVID-19) can be considered a systemic disease with a specific tropism for the vascular system, in which the alterations of the microcirculation have an important pathogenetic role. The lungs are the main organ involved in COVID-19, and severe progressive respiratory failure is the leading cause of death in the affected patients; however, many other organs can be involved with variable clinical manifestations. Concerning abdominal manifestations, the gastrointestinal tract and the hepatobiliary system are mainly affected, although the pancreas, urinary tract and spleen may also be involved. The most common gastrointestinal symptoms are loss of appetite, followed by nausea and vomiting, diarrhea and abdominal pain. Gastrointestinal imaging findings include bowel wall thickening, sometimes associated with hyperemia and mesenteric thickening, fluid-filled segments of the large bowel and rarely intestinal pneumatosis and ischemia. Hepatic involvement manifests as an increase in the enzymatic levels of alanine aminotransferase, aspartate aminotransferase, serum bilirubin and γ-glutamyl transferase with clinical manifestations in most cases mild and transient. The most frequent radiological features are hepatic steatosis, biliary sludge and gallstones. Edematous acute pancreatitis, kidney infarct and acute kidney injury from acute tubular necrosis have been described more rarely in COVID-19. Lastly, splenic involvement is characterized by splenomegaly and by the development of solitary or multifocal splenic infarcts with classic wedge-shaped or even rounded morphology, with irregular or smooth profiles. In summary, the abdominal radiological findings of COVID-19 are nonspecific and with poor pathological correlation reported in the literature. Ultrasound and particularly computed tomography with multiphasic acquisition are the diagnostic methods mainly utilized in COVID-19 patients with abdominal clinical symptoms and signs. Although radiological signs are not specific of abdominal and gastrointestinal involvement, the diagnostic imaging modalities and in particular computed tomography are helpful for the clinician in the management, evaluation of the severity and evolution of the COVID-19 patients.

PSD-95 protects the pancreas against pathological damage through p38 MAPK signaling pathway in acute pancreatitis.

Acute pancreatitis is one of the leading causes of gastrointestinal disorder-related hospitalizations, yet its pathogenesis remains to be fully elucidated. Postsynaptic density protein-95 (PSD-95) is closely associated with tissue inflammation and injury. We aimed to investigate the expression of PSD-95 in pancreatic acinar cells, and its function in regulating the inflammatory response and pancreatic pathological damage in acute pancreatitis. A mouse model of edematous acute pancreatitis was induced with caerulein and lipopolysaccharide in C57BL/6 mice. Tat-N-dimer was injected to inhibit the PSD-95 activity separately, or simultaneously with SB203580, inhibitor of p38 MAPK phosphorylation. Rat pancreatic acinar cells AR42J were cultured with 1 μM caerulein to build a cell model of acute pancreatitis. PSD-95-knockdown and negative control cell lines were constructed by lentiviral transfection of AR42J cells. Paraffin-embedded pancreatic tissue samples were processed for routine HE staining to evaluate the pathological changes of human and mouse pancreatic tissues. Serum amylase and inflammatory cytokine levels were detected with specific ELISA kits. Immunofluorescence, immunohistochemical, Western-blot, and qRT-PCR were used to detect the expression levels of PSD-95, p38, and phosphorylated p38. Our findings showed that PSD-95 is expressed in the pancreatic tissues of humans, C57BL/6 mice, and AR42J cells, primarily in the cytoplasm. PSD-95 expression increased at 2 h, reaching the peak at 6 h in mice and 12 h in AR42J cells. IL-6, IL-8, and TNF-α increased within 2 h of disease induction. The pancreatic histopathologic score was greater in the PSD-95 inhibition group compared with the control (P < 0.05), while it was lesser when phosphorylation of p38 MAPK was inhibited compared with the PSD-95 inhibition group (P < 0.05). Moreover, phosphorylation of p38 MAPK increased statistically after PSD-95 knocked-down. In conclusion, PSD-95 effectively influences the pathological damage of the pancreas in acute pancreatitis by affecting the phosphorylation of p38 MAPK.

English

BACKGROUND Acute pancreatitis (AP) is described as acute inflammation of the pancreas with or without peripancreatic abnormalities. The present study describes the role of computed tomography in the evaluation and grading of acute pancreatitis. Acute pancreatitis is a dynamic disease having biphasic mortality peaks due to two overlapping phases, which include early and late due to increased obesity, ageing of population, alcohol abuse, increased gall stone incidence, the worldwide AP incidence is increasing. Most important causes of AP in developing countries such as India include increased alcohol consumption. Contrast enhanced computed tomography plays an important role in diagnosis of the disease and helps in determining the prognosis of the disease. Modified CT severity index scoring system is the most commonly used scoring system for assessment of the severity of the disease. METHODS The present study is a prospective study of patients presenting with signs and symptoms of acute pancreatitis referred to the Department of Radio Diagnosis at Katuri medical college. This study comprised of 50 patients with clinical suspicion / diagnosis of acute pancreatitis, raised pancreatic biochemical parameters like serum amylase and serum lipase. Contrast enhanced computed tomography was performed in these patients, findings reported, and the disease was classified using modified CT scoring index system (MCTSI). RESULTS The mean age of the patients in the present study was 42.3 ± 12.28 years. Most of the patients presented with abdominal epigastric pain, abdominal distension. Acute pancreatitis was divided into acute oedematous pancreatitis and necrotising pancreatitis, the former being common. Complications included, ascites, pleural effusions, splenic vein thrombosis, portal venous thrombosis, and haemorrhages. CONCLUSIONS Contrast enhanced CT is useful to differentiate between oedematous and necrotising types of pancreatitis. The MCTSI helps in better evaluation of pancreatic necrosis grading. The modified computed tomography score index correlation with the development of local and systemic complications in acute pancreatitis is well established. Ideally, conducting contrast enhanced computed tomography (CECT) after 48 - 72 hours of acute attack, increases the probability of identifying necrotising pancreatitis. CT in particular has an overall accuracy of about 87 % and sensitivity and specificity of 100 % in the recognition of pancreatic necrosis. KEYWORDS Computed Tomography, Acute Pancreatitis, Pseudocyst, Modified CT Score Index

Fentanyl ameliorates the severity of necrotizing, but not edematous acute pancreatitis in rats

Fentanyl ameliorates the severity of necrotizing, but not edematous acute pancreatitis in rats

Role of Computed Tomography in Predicting Severity of Acute Pancreatitis

The current study was based on Computed Tomography (CT) findings and results. We found 63% of patients with acute interstitial edematous pancreatitis, and we found 37% of patients with acute necrotic pancreatitis in 46 cases. Based on our findings, we observed bulky pancreas among 26 cases (56.52%), 17 cases (36.95%) of pancreatic necrosis, 9 cases of pancreatic atrophy, 11 cases of pseudocyst, and 9 cases of peri-pancreatic fluid. When we evaluated the Modified CT Severity index among the study cases, we observed that 19.56% cases have mild index, the majority (56.52% cases) have moderate index while 23.91% have severe index. We also found that majority of the cases were clinically cured and discharged, i.e., 47.82%. 19.56% of the total study subjects reported recurrence of episodes of pancreatitis, while 30.43% of the total patients turned into chronic pancreatitis. This study presents a cross-sectional hospital-based analytical study carried out among 46 cases of AP referred to under the radiology department for further diagnostic evaluation, in a tertiary healthcare facility in Maharashtra. The present study Data Source included all the AP patients referred to the radiological department in a tertiary health research center. They met the standards for inclusiveness, which assented to the analysis. Type of study is Hospital analytical based study. The study duration is 18 months. Data collection was done through semi-structured, pre-designed, and pre-validated proformas in patients meeting inclusion requirements that included disease history, clinical outcomes, investigative records, and descriptions of surgical interventions.

Management of Inflammatory Pancreatic Fluid Collections and Walled-off Pancreatic Necrosis: A Retrospective Study Over Five Years

Background and objective: Acute pancreatitis (AP) is an inflammatory process of the pancreas, with variable involvement of peri-pancreatic tissues and remote organ systems. In this study we discuss surgical and conservative management of acute pancreatitis and its local complication. Methods: This retrospective study was carried out on 128 patients, who were admitted to Gastrointestinal Surgery Unit, Main Alexandria University Hospital, Alexandria University, and who were complaining of acute pancreatitis with fluid collections and sequels (PP, ANC and walled-off pancreatic necrosis (WOPN). Medical information was retrieved retrospectively from patient’s files recorded in Main Alexandria University Hospital and from computerized data system in Gastrointestinal Surgery Department, between October 2013 – October 2018. Results: Forty-five patients with acute edematous pancreatitis with free collection were managed conservatively successfully. Thirty-two patients with PP underwent drainage, endoscopic (n=17), or open (n=15) approach. Twentythree patients with WON underwent drainage and debridement whether by open (n=11), endoscopic (n=9), or PCD (n=3) approaches. Twenty-eight patients with necrotizing pancreatitis, 16 patients were managed conservatively, 12 patients needed intervention either, PCD (n=9) or open surgical necrosectomy (n=3). Conclusions: The operative management of acute pancreatitis is focused on managing the acute complications, and the long-term sequelae. However, the evolution of videoscopic and endoscopic techniques have greatly expanded the tools available.

Atypical presentation of acute pancreatitis: a single center case-match analysis of clinical outcomes.

Acute pancreatitis (AP) may present an aspecific clinical picture without abdominal symptoms (atypical AP). We compared clinical outcomes between typical and atypical AP. Thirty out of 1163 patients (2.6%) presented an atypical AP. Demographic, clinical data, laboratory and radiological findings, management type, length of hospital stay (LOS) and mortality rate were retrospectively reviewed. A case match analysis 2:1 was performed. The final groups comprised 50 typical APs (TAP group) and 25 atypical APs (AAP group). The AAP patients presented fever (36%), syncope (32%) and dyspnea (16%) as the most frequent symptoms. Laboratory values showed similarity between the two groups. We noted a comparable edematous AP rate in both groups (p=0.36). Ten (20%) TAP and 3 (12%) AAP patients needed ERCP, respectively (p=0.38). Cholecystectomy was similarly performed in both cohorts (p=0.81). One TAP patient underwent a percutaneous drainage and subsequent surgical necrosectomy compared to none in the AAP cohort (p=0.47). LOS and mortality rate were comparable (p=0.76 and 0.3, respectively). Similar outcomes have been reached in the two groups. Routine evaluation of the serum amylase values fundamentally contributed to early diagnosis and appropriate treatment.

Non-surgical treatment of acute pancreatitis with colonic fistula

Objective: To examine the effectiveness of non-operative of colonic fistula following acute pancreatitis. Methods: Retrospective analysis of 354 patients with acute pancreatitis who were admitted to Department of Hepatobiliary Surgery of Chinese People's Liberation Army General Hospital from January 2013 to December 2018. Age of the patients was (46±14) years (range: 14-85 years); 249 cases (70.3%) were males. There were 41 cases of acute edematous pancreatitis and 313 cases of acute necrotising pancreatitis. Two hundred and fifteen cases were diagnosed as moderate severe acute pancreatitis and 139 were diagnosed as severe acute pancreatitis. Among 313 cases of acute necrotising pancreatitis, 62 cases underwent non-surgical treatment, 251 cases underwent surgical treatment in which 218 of minimal access retroperitoneal pancreatic necrosectomy underwent percutaneous nephroliguectomy with peripancreatic necrotic tissue removal technique. Results: There were 15 cases of colon fistula following acute necrotising pancreatitis, and the incidence rate was 4.2%(15/354). There were 7 males and 8 females, with age of (39±8) years (range: 27 to 50 years). The median interval between acute pancreatitis onset and diagnosis of colonic fistula was 71 days(27-134) days. Two cases occurred at the hepatic flexure of the colon, 4 cases at transverse colon, and 9 cases at splenic flexure of colon. Of the 354 patients, 39 cases died and the mortality was 11.0%. Two patients underwent laparotomy, and one of them died. The remaining 13 patients underwent non-surgical treatment and were discharged. Conclusion: Acute pancreatitis with colonic fistula can be treated with non-surgical treatment and can achieve good prognosis.

1270 Unexpected Microorganism in an Unexpected Place

INTRODUCTION: Candida Parapsilosis (CP) has been implicated in several intra- and extra- vascular infections and rarely been the cause of intraabdominal infections. We describe a case of CP infection complicating acute severe necrotizing pancreatitis. CASE DESCRIPTION/METHODS: A 68-year-old man presented with acute onset epigastric pain associated with nausea and vomiting. Physical examination revealed epigastric tenderness. Lipase was elevated at 7352 mg/dl and initial abdominal CT scan revealed changes consistent with acute edematous pancreatitis with possible early necrosis. His clinical course was complicated by acute respiratory failure, septic shock, and AKI requiring hemodialysis. He was in and out of the intensive care unit despite medical management including nutrition support and broad spectrum antibiotics. A repeat CT scan 4 weeks later showed acute necrotizing pancreatitis with walled-off necrosis (WON). After an episode of acute decompensation, a percutaneous drain was placed prior to necrosectomy. The aspirated fluid grew Candida Parapsilosis and patient was started initially on Micafungin, and then transitioned to oral fluconazole. Soon after starting antifungals the patient stabilized, clinically improved and was able to be discharged home. He subsequently underwent a video assisted retroperitoneal dissection, which revealed a small amount of necrosis and a pancreatic duct leak into the WON. He underwent ERCP with pancreas duct stent bypassing the leak. Upon most recent visit, patient showed considerable improvement. DISCUSSION: The incidence of CP infections has been greatly increased over the last decade. Primarily, CP is implicated in cases of fungemia accounting for 3–27% of all cases of in large studies and to lesser extent in extravascular infections like osteomyelitis. Intraabdominal infections are unusual and mostly associated with peritonitis complicating surgery and peritoneal dialysis. Despite the organism normally colonizes the GI tract, pancreatic infections by CP are rare, and are usually complicating acute pancreatitis. They could be explained by portal extension and be predisposed by use of broad spectrum antibiotics, surgery, and instrumentation. In conclusion, it is important to consider fungal infections in cases of complicated infected pancreatitis especially those not responding to broad spectrum antibiotics as they share similar clinical features with bacterial causes and prompt diagnosis and treatment are key to a better outcome.

2244 Getting to the Root of the Matter: A Case of Valerian Root-Induced Hepatitis and Pancreatitis

INTRODUCTION: The use of herbal supplements has increased substantially in recent years for amelioration of common ailments. Valerian root, a common over-the-counter supplement (OTC) used for insomnia and anxiety, has been in rare instances linked to hepatotoxicity and pancreatitis, as depicted in the case below. CASE DESCRIPTION/METHODS: A 36-year-old gentleman with no significant medical history presented with worsening burning abdominal pain, nausea and vomiting for one day with similar symptoms three months prior. Labs were notable for elevated AST/ALT 682/619, GGT 100, and lipase 220. Abdominal ultrasound showed mildly echogenic liver with no intrahepatic or extrahepatic ductal dilatation or cholelithiasis, and patent hepatic and portal veins. CT abdomen and pelvis demonstrated acute edematous interstitial pancreatitis with a small heterogeneous area concerning for necrosis. The patient revealed routine use of multiple OTC supplements including Driftoff and Epi-dry, and Valerian root, each of which contain Valerian officinalis. The remaining workup was negative for infectious, autoimmune, and other toxic etiologies. On day two, AST/ALT peaked at 2398/3132 and N-acetylcysteine (NAC) was initiated. Labs and symptoms improved and he was discharged home on day four. At follow-up in 2 weeks, he was asymptomatic, remained off supplements, with normalization of his transaminases. DISCUSSION: Valerian officinalis is increasingly used for its sleep aid properties and anxiolytic effects. Its interaction with gamma-aminobutyric acid (GABA) receptor produces effects similar to benzodiazepines though clinical data is scant. Presentation of valerian root induced hepatotoxicity varies, ranging from no symptoms to overt jaundice, with abdominal pain as the most common symptom. Liver enzyme elevation is of hepatocellular or hepatocellular-cholestatic pattern with aberrancies seen 3-12 weeks later. While the mechanism of hepatotoxicity remains unknown, the literature suggests gallstone formation may be responsible for valerian root induced pancreatitis unlike our case which suggests a drug induced injury. Effects are self-limited though abstaining from the causative agent is paramount. Management often remains supportive. Although data is limited, NAC has been used in non-acetaminophen induced hepatotoxicity and aided in improvement in liver injury in our patient. We present this case to raise awareness of this potential toxin and consider this in the differential when evaluating concomitant hepatitis and pancreatitis.

1340 Variable Effect on the Sphincter of Oddi From Narcotics

INTRODUCTION: Several studies have shown an increase in biliary pressure after administration of narcotics. Direct sphincter of Oddi (SO) manometry has demonstrated that the sphincter of Oddi is particularly sensitive to all narcotics including morphine, meperidine, pentazocine, fentanyl, and codeine. Opiates are known to increase the phasic wave (via mu receptors) as well as basal pressure (via non-mu receptors) of the SO. This case report illustrates a possible difference in affinity among narcotics to these receptors leading to SO dysfunction. CASE DESCRIPTION/METHODS: 54 years old male with a history of knee meniscal repair presented to the emergency department with epigastric pain associated with nausea and vomiting for one day. The patient described the pain as severe, sharp, and worsening with food intake. He denied alcohol use, illicit drug abuse, or taking any medication. He had a lipase of 200 U/L, with normal transaminases and bilirubin. Physical exam revealed severe tenderness on the epigastric area. CT showed acute edematous interstitial pancreatitis. Ultrasound of the liver and HIDA scan demonstrated a patent cystic and common bile duct. The patient was started on IV fluids and IV morphine. The patient reported slight relief of abdominal pain with low doses of IV morphine. Therefore, the frequency and dose of morphine were increased. Interestingly, the patient reported acute worsening of the epigastric pain a few minutes after administration of higher morphine doses lasting for approximately 2 hours. Laboratory studies drawn during pain exacerbation showed no elevation of transaminases or lipase. IV morphine was discontinued resulting in immediate abdominal pain relief. Upon further questioning, the patient reported recent use of oxycodone and tramadol for knee pain without any side effects from these medications. DISCUSSION: Opiates have been reported to incite biliary colic pain and their effect on the SO represents the most likely etiology. Our patient showed a particular susceptibility to morphine, but not to other narcotics previously prescribed suggesting a possible variable effect on the OD from different narcotics. It is worth noting that our patient denied cholecystectomy, a known risk factor that predisposes to SO dysfunction. In conclusion, SO dysfunction should be considered in patients with pancreatitis reporting worsening of abdominal pain while on opioids. SO manometry is contraindicated during acute pancreatitis, therefore discontinuation of the narcotic helps guide diagnosis.

Confocal laser endomicroscopy in the diagnosis of extrahepatic bile duct diseases

Aim. To evaluate information content of confocal laser endomicroscopy with targeted biopsy in verifying etiology of extrahepatic bile duct strictures.Material and methods. There were 28 patients with extrahepatic bile duct strictures who underwent retrograde intervention with confocal laser endomicroscopy and targeted biopsy. Data of confocal laser endomicroscopy and biopsy were compared with final postoperative and histological diagnosis. Follow-up within 1–4 years after endoscopic treatment was also considered.Results. Diagnostic sensitivity, specificity and overall accuracy of the method in differential diagnosis of common bile duct strictures were 91.7%, 93.7% and 92.8%, respectively. Complication (acute edematous pancreatitis) occurred in 1 (3.6%) case.Conclusion. Confocal laser endomicroscopy is new effective method for in vivo microscopic assessment of mucous membrane. Despite technical complexity, the method is not associated with advanced morbidity and, accordingly, has no additional contraindications in comparison with ERCP.

Dynamics of changes in the immune system and antioxidant protection in the treatment of acute pancreatitis

The aim of the work was to study the dynamics of changes in the immune system indices and antioxidant protection when fluoroquinolones are included in the treatment regimen for acute edematous pancreatitis. The study included 86 patients with a diagnosis of acute edematous pancreatitis. Group I (n=40) consisted of patients who received treatment according to national and local standards and protocols, group II (n=46) — patients who additionally received fluoroquinolones as part of a comprehensive treatment. The control group consisted of 48 conditionally healthy people in whom laboratory and instrumental diagnostics were carried out similarly to those in patients with acute pancreatitis. According to the purpose and objectives of the study, the state of the immune system and the antioxidant defense system was studied. In patients with acute pancreatitis, changes in the indicators of the immune status were revealed, manifested by the formation of a secondary immunodeficiency with the addition of an autoimmune component. The traditional scheme of pharmacotherapy of acute pancreatitis without the use of antibiotics made it possible to partially correct the indicators of immune status. The use of ciprofloxacin in the complex pharmacotherapy of acute pancreatitis contributed to the normalization of the studied parameters. Thus, the use of fluoroquinolones in the complex pharmacotherapy of acute pancreatitis made it possible to effectively normalize the state of the immune system, cytokine and antioxidant statuses.

Role of increased immature granulocyte percentage in the early prediction of acute necrotizing pancreatitis.

Acute necrotizing pancreatitis (ANP) is the most severe form of acute pancreatitis (AP), and it has high mortality rates. Therefore, early diagnosis and treatment are of critical importance for the prognosis. The aim of this study was to investigate the effectiveness of immature granulocyte percentage (IG%) in the early prediction of ANP. This retrospective study included 96 adult patients hospitalized with a diagnosis of AP. Demographic data of the patients were recorded. The white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR), IG%, C-reactive protein (CRP), and amylase levels were determined. Furthermore, computed abdominal tomography was applied to the patients, and the length of hospital stay was recorded. Patients were divided into two groups as those with acute edematous pancreatitis and ANP, according to the tomography results. The differences between the groups were analyzed statistically. The WBC count, NLR, CRP, and IG% were significant markers in the prediction of ANP. However, IG% had higher values with regard to the sensitivity, specificity, AUROC, and negative and positive predictive values (100%, 95%, 0.982, 78.9%, and 100%, respectively). An increased IG% is a simple, fast, and effective marker in the early prediction of ANP. This retrospective study was carried out on 96 adult patients who were hospitalized with a diagnosis of acute pancreatitis. Demographic data of the patients were recorded. White blood cell count, neutrophil/lymphocyte ratio, IG%, C-reactive protein and amylase levels were determined. Furthermore computed abdominal tomography was applied to the patients and the length of hospital stay was recorded. The patients were divided into two groups as acute edematous pancreatitis and acute necrotizing pancreatitis according to the tomography results. The differences between the groups were analyzed statistically. White blood cell count, neutrophil/lymphocyte ratio, C-reactive protein and IG% were significant markers in the prediction of acute necrotizing pancreatitis. However, IG% had higher values of sensitivity, specificity, AUROC, negative and positive predictive values ( 100%, 95%, 0.982, 78.9%, 100%,respectively). Increased IG% is a simple, fast, and effective marker in the early prediction of acute necrotizing pancreatitis.

Acute massive gastric distension in acute pancreatitis.

A 43 year old male patient presented to our emergency department with complain of severe abdominal pain for five days associated with fever, vomiting and non-passage of flatus and stool. The pain started in the epigastric region which became diffused in the subsequent days. Last two days patient had history of breathlessness and decreased urination. On examination patient was looking toxic with tachycardia (124/min) and tachypnea (26/min) with rapid and shallow breathing. Abdominal examination revealed a rigid abdomen with tympanic notes with absent bowel sound. Laboratory investigations showed leukocytosis (15,000/cmm) with raised serum urea (235mg/dl) and creatinine (5.3mg/dl). There was no gas under diaphragm on abdominal X-Ray (A). With high degree of suspicion of perforation peritonitis, a diagnostic peritoneal tapping was done from right lower abdomen and altered colored bilious fluid was aspirated. Patient was resuscitated and planned for emergency laparotomy, which revealed a massively distended stomach covering almost whole of the abdomen (B, C). Duodenum and proximal part of jejunum was also dilated without any mechanical obstruction. Pancreas appeared edematous and bulky with saponification near the root of mesentery. Post-operative serum amylase (494u/l) and lipase (211u/l) as well as peritoneal fluid amylase (826u/l) levels were high, suggestive of acute edematous pancreatitis. Peritoneal tapping is sometime used to detect sealed perforation in cases with signs of peritonitis but without evidence of free gas on radiological investigation. Massive gastric distension in acute pancreatitis is very rare, however peritoneal tapping in such conditions can give a false impression of free fluid (bilious) in the peritoneal cavity