Idiopathic Acute Pancreatitis Research Articles

Comparison of idiopathic recurrent acute pancreatitis [IRAP] and recurrent acute pancreatitis with genetic mutations

BackgroundIdiopathic recurrent acute pancreatitis (IRAP) describes frequent episodes of pancreatitis without an etiology found using current testing. We compared the natural history of IRAP with recurrent acute pancreatitis with genetic mutations. MethodsRetrospective cohort of patients with recurrent acute pancreatitis (≥2 episodes) and negative conventional testing. All patients had ≥1 episode after cholecystectomy and completed genetic testing. Primary outcomes were chronic pancreatitis incidence, pancreatic cancer, and mortality. Secondary outcomes included opioid and ERCP utilization. Results128 patients met criteria for presumed IRAP. 35 patients met criteria for true IRAP. 12 patients had recurrent acute pancreatitis with gene mutations. Chronic pancreatitis developed in 27 (77.1%) IRAP patients over a median of 6 years. Chronic pancreatitis incidence was similar in IRAP and CFTR mutation carriers; but developed later in SPINK1 carriers. No patients developed pancreatic cancer or died from pancreatic-related causes. Patients were frequently treated with oral opioids and ERCP, without significant differences within or between groups. ConclusionIRAP and pancreatitis in mutation carriers is associated with chronic pancreatitis. Important differences in natural history were observed, but no association was found with cancer or pancreas-related mortality. Efforts to understand the genetic contributions to IRAP, minimize opioids and unnecessary ERCPs are encouraged.

Disfunción del esfínter de Oddi: un reporte de caso

La disfunción del esfínter de Oddi es un síndrome clínico causado por una enfermedad funcional (discinesia) o estructural (estenosis). La prevalencia estimada de disfunción del esfínter de Oddi en la población en general es del 1 %; aumentando a 20 % para pacientes con dolor persistente posterior a colecistectomía y a 70 % en pacientes con pancreatitis aguda recurrente idiopática. Se caracteriza clínicamente por la presencia de dolor abdominal, similar al cólico biliar o dolor tipo pancreático en ausencia de patología biliar orgánica; así como en pacientes con pancreatitis recurrente idiopática asociada con elevación de enzimas pancreáticas o hepáticas, y dilatación del conducto biliar o pancreático. El tratamiento para la disfunción del esfínter de Oddi tipo I se basa en la realización de esfinterotomía endoscópica, pero existe controversia en el manejo de la disfunción del esfínter de Oddi tipo II y III. En este artículo se presenta el caso clínico de una paciente de 67 años con antecedente de colecistectomía por laparotomía. Después del procedimiento quirúrgico refirió un dolor abdominal de predominio en el hipocondrio derecho tipo cólico asociado con emesis de características biliares. En el reporte de colangiorresonancia se encontró una ligera dilatación de la vía biliar intrahepática y gammagrafía con ácido iminodiacético hepatobiliar (HIDA) diagnóstica de disfunción del esfínter de Oddi. Se realizó una esfinterotomía endoscópica. En el seguimiento, dos años después, la paciente se encontraba asintomática con la disfunción del esfínter de Oddi resuelta.

Recurrency of an Idiopathic Triple Transient Jejuno-Jejunal Intussusception and Acute Pancreatitis in an Adult A Case Report

Recurrency of an Idiopathic Triple Transient Jejuno-Jejunal Intussusception and Acute Pancreatitis in an Adult A Case Report

Utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis

Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without...

Hyperemesis Gravidarum: Looking Beyond Pregnancy

Hyperemesis gravidarum is defined variably as vomiting being sufficiently severe enough to produce weight loss, dehydration, ketosis, alkalosis from loss of hydrochloric acid and hypokalemia. It is not common for a patient affected with hyperemesis gravidarum to present with idiopathic acute pancreatitis in the same time period. This case pertains to a 22-year-old pregnant woman, admitted to our hospital with complaint of severe and frequent episodes of vomiting and severe epigastric pain at 14 weeks of gestation. After treatment with parenteral fluid and antiemetics, the patient’s condition failed to improve. Further investigations confirmed a diagnosis of idiopathic acute pancreatitis. Patient was managed conservatively. Early and rapid diagnosis and supportive treatment play a vital role in the management of such cases.

Akut Pankreatit ve Akut Tekrarlayan Pankreatit: Klinik ve Etyolojik Faktörlerin Araştırılması

INTRODUCTION: It was aimed to evaluate the etiology, clinical, laboratory and imaging findings and treatment methods of patients who have admitted with acute pancreatitis (AP) and progressed to chronic pancreatitis (CP) with ARP (acute recurrent pancreatitis). METHODS: The data of children under the age of 18 years who were admitted to our hospital between January 2013-July 2020 and were diagnosed with acute, acute recurrent or chronic pancreatitis according to INSPPIRE diagnostic criteria were evaluated retrospectively. RESULTS: There were 77 patients who were followed-up with the diagnosis of acute pancreatitis. Pancreatitis attack did not recur in 53/77 patients and no underlying cause was found in 35.84% (19/53) of the patients. The most common factor in those whose cause could be determined was gallstones (15.1%) (8/53). The pancreatitis attack recurred in 24 (31%) of the patients. Congenital anomalies (9/24) and hereditary pancreatitis (5/24) were the most common causes of pancreatitis in these patients and these factors were a risk factor for the recurrence of pancreatitis attack. There was no difference between the groups in terms of complications (p=0.423); however, chronicity was more common in the group with ARP (p=0.003). DISCUSSION AND CONCLUSION: Beside the pancreatitis is a rare disease in childhood, with the increase of awareness and increased accessibility to diagnostic imaging methods, more and more pancreatitis is diagnosed day by day. Idiopathic acute pancreatitis cases still constitute the largest group. If other causes are excluded in these cases, it is important to investigate congenital anomalies, genetic and metabolic etiologies

Genetic Abnormalities in Pancreatitis: An Update on Diagnosis, Clinical Features, and Treatment.

Several pancreatitis susceptibility genes have been identified to date. A relationship between a mutation in the cationic trypsinogen (protease serine 1, PRSS1) gene and hereditary pancreatitis (HP) was first identified in 1996. Currently, HP has been defined as either two or more individuals within a family exhibiting pancreatitis for two or more generations, or pancreatitis linked to mutation of the PRSS1 gene. In 2000, a mutation in the serine protease inhibitor gene (Kazal type 1: SPINK1) was reported to be related to sporadic pancreatitis of unknown etiology. This paper reviews and summarizes the current published data on the pancreatitis susceptibility genes, mainly PRSS1 and SPINK1 genes, and introduces a diagnostic and therapeutic approach for dealing with patients with these gene mutations. Patients with these genetic predispositions, both children and adults, have often been initially diagnosed with idiopathic acute pancreatitis, in approximately 20–50% of pediatric cases and 28–80% of adult cases. In such patients, where the etiology is unknown, genetic testing, which requires pre-test and post-test genetic counselling, may prove helpful. Patients with chronic pancreatitis (CP) due to SPINK1 gene mutation and HP patients have a potentially high risk of pancreatic exocrine insufficiency, diabetes mellitus, and, of particular importance, pancreatic cancer. Thus, these patients require careful long-term follow-up and management. Specifically, symptomatic CP patients often need endoscopic therapy or surgery, often following a step-up approach beginning with endoscopic therapy and progressing to surgery if necessary, which is similar to the therapeutic approach for patients with CP due to other etiologies. It is important that clinicians are aware of the characteristics of patients with pancreatitis susceptibility genetic abnormalities.

Author commentary on Devica S. Umans et al.

Devica S. Umans et al. Endoscopic ultrasonography can detect a cause in the majority of patients with idiopathic acute pancreatitis: a systematic review and meta-analysis

S0017 Causes and Predictors of 30-Day Readmissions in Patients With Idiopathic Acute Pancreatitis: A Nationwide Cohort Study

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.

S0021 Cannabis-Induced Acute Pancreatitis: A Systematic Review

INTRODUCTION: Acute pancreatitis (AP) is a leading gastrointestinal cause of hospitalization in the United States, and 20% of AP is considered idiopathic. Cannabis has now become the most commonly used illicit drug with increasing prevalence as well as legalization. Cannabis has been reported in several case reports as a possible etiology of idiopathic AP. The aim of this critical analysis is to systematically review the literature and analyze cannabis as an etiology of idiopathic and recurrent AP. Another aim is to identify any risk factors or demographics associated with this population and a correlation with the severity of AP. METHODS: Case reports with cannabis induced acute pancreatitis, as well as retrospective and prospective reviews, were identified systematically through a detailed PubMed search. For each case report, the Naranjo Adverse Drug Reaction (ADR) score as well as severity of the pancreatitis were calculated, the latter with scores such as modified CT severity index (CTSI) and revised Atlanta classification (RAC) among others. RESULTS: Eighteen case reports were included along two large studies. Fourteen of the cases (77.78%), 87.5% (Culetto et al) and 71.7% (Simons-Linares et al) of the study patients were male. Fourteen of the cases (77.78%), and 80% (Culetto et al, Simons-Linares et al) of the study patients were under the age of 35. Eight of the cases (44.44%) and 100% (Simons-Linares et al) of study patients had recurrent cannabis induced acute pancreatitis. None of the patients who were followed up with experienced recurrent pancreatitis after stopping cannabis use. In the cases, as severity worsened using both CTSI and RAC scores, the proportion of males increased from 76.92% to 100% and from 71.43% to 100% respectively. There was also an increase in proportion of patients under 35 years with increase in severity, from 69.23% to 100% and from 71.43% to 100% respectively. CONCLUSION: This study demonstrates a higher proportion of cannabis induced pancreatitis cases were males. In addition, there was an increase in the proportion of males and proportion of patients under 35 years with an increase in severity. In all followup cases, no patients had recurrent pancreatitis after stopping cannabis. Since widespread cannabis use is becoming steadily more prevalent, especially in a younger population, and may be an etiology in idiopathic acute pancreatitis, cannabis use should be documented in acute pancreatitis for future analysis and any new treatment.

EUS is superior to secretin-enhanced cholangio-MRI to establish the etiology of idiopathic acute pancreatitis.

Background and study aims The etiology of idiopathic acute pancreatitis (IAP) should always be defined. Our aim was to compare the diagnostic value of endoscopic ultrasound (EUS) versus secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) in patients with IAP. Patients and Methods Patients admitted to a single tertiary care University hospital with IAP were invited to participate in the study. Enrolled patients underwent EUS and S-MRCP in a single-blinded comparative study. EUS and S-MRCP were performed no sooner than 4 weeks after discharge. The diagnostic yield of EUS and S-MRCP and demographic variables were included in the analysis. Additional follow-up, results of subsequent serology, radiographic exams, and relevant histological analysis were considered in determination of the final diagnosis. Results A total of 34 patients were enrolled; EUS was normal in six, cholelithiasis was defined in 15, choledocholithiasis in two, pancreas divisum in three, branch-type intraductal papillary mucinous tumor (IPMT) in three, and chronic pancreatitis in five. S-MRCP identified choledocholithiasis in one, divisum in four, branch-type IPMT in three, chronic pancreatitis in two; 24 subjects diagnosed as normal by S-MRCP. Diagnostic correlation between EUS and S-MRCP was slight (kappa = 0.236, 95 % confidence interval: 0.055–0.416). EUS provided a statistically significantly higher diagnostic yield than S-MRCP: 79.4 % (CI95 %: 65 %–94 %) vs 29.4 % (CI95 %: 13 %–46 %) (P = 0.0002). The sensitivity, specificity, and positive and negative predictive values of EUS and S-MRCP were 90 %, 80 %, 96 %, 57 % and 33 %, 100 %, 100 % and 16 %, respectively. Conclusion The diagnostic yield of EUS is higher than S-MRCP in patients with IAP.

S1414 Successful Endoscopic Management of Necrotizing Pancreatitis Due to Rare Anatomical Variants

INTRODUCTION: Pancreatic divisum (PD) is an embryological failure of fusion of the ventral and dorsal pancreatic ducts. Meandering main pancreatic duct (MMPD) is another rare developmental loop-type anomaly in the main duct. PD and MMPD are more prevalent in idiopathic recurrent acute pancreatitis (IRAP). We report a case of recurrent necrotizing pancreatitis in a patient with these anatomical variants, fascinatingly resulting in complete resolution after staged direct endoscopic necrosectomies. CASE DESCRIPTION/METHODS: A 51-year-old male presented with epigastric pain and vomiting. Physical examination, complete blood count, complete metabolic panel, lipase and lactic acid were unremarkable. Abdominal CT showed acute pancreatitis with 10% parenchymal necrosis and 7 × 8 × 15 cm peripancreatic walled-off necrosis. He was managed with fluids, pain and anti-emetics and tolerated diet advancement. The etiology of his pancreatitis was unclear given absence of alcohol abuse and biliary pathology and negative autoimmune work-up. He was discharged with plans to repeat imaging 6 weeks later at which time he was readmitted for fevers and pain recurrence. Abdominal CT showed increase in size of the walled-off necrosis to 15 × 10 × 20 cm (Figure 1). He was treated with antibiotics and underwent endoscopic cystogastrostomy. His clinical course was complicated by splenic vein and upper extremity deep venous thrombi and a pulmonary embolism requiring anticoagulation. While on anticoagulation, he underwent 14 careful staged endoscopic necrosectomies over two months until complete resolution (Figure 2). Subsequent ERCP demonstrated incomplete PD and reverse-Z MMPD (Figure 3). A stent was placed into the ventral pancreatic duct and he was managed with pancreatic enzyme replacement, remaining asymptomatic on 1-year follow-up. DISCUSSION: PD and MMPD are rare embryological errors, carrying ∼40% prevalence in cases of IRAP and are thought to play a role in disease onset. Necrosis complicates 20% of acute pancreatitis cases with a 25% mortality rate. While two thirds of cases resolve with conservative measures, the remainder require intervention with endoscopic necrosectomy to avoid open surgical approaches with high mortality. Large multi-center studies have demonstrated successful resolution with endoscopic necrosectomy in ∼90% of cases with significantly lower mortality. This case serves to illustrate the effectiveness of endoscopic necrosectomy even in the face of anticoagulation and to prompt physicians to consider PD and MMPD in IRAP.Figure 1.: CT showing necrotic collection.Figure 2.: Endoscopic necrosectomy.Figure 3.: ERCP showing PD and MMPD anatomical variants.

A 5-Year Retrospective Cohort Study: Epidemiology, Etiology, Severity, and Outcomes of Acute Pancreatitis.

The aim of this study was to evaluate the epidemiology, etiology, severity, and outcomes of acute pancreatitis (AP) in the southern Sichuan region of China. All patients with first-attack AP between 2013 and 2018 in the Affiliated Hospital of Southwest Medical University were retrospectively identified. The etiology tendency was analyzed, and the relationship was defined with sex, aging, severity, length of stay, and mortality. Three thousand twenty-eight patients were enrolled for analysis. Acute biliary pancreatitis had the highest incidence rate; the second and third most common causes were hypertriglyceridemic (14.4%) and alcoholic (14.2%), followed by idiopathic (13.6%), mixed etiology (12.9%), and miscellaneous (2.31%). Patients with alcoholic AP were more likely to be middle-aged males, whereas patients with acute biliary pancreatitis were more likely to be elderly females (P < 0.05). The overall mortality in the hospital was 1%, and there was no difference in each etiological groups (P > 0.05). Biliary disease was the predominant etiology of AP in southern Sichuan of China, and hypertriglyceridemia ranked second. The proportion of hypertriglyceridemic AP and mixed etiology AP gradually increased, whereas idiopathic AP decreased. There were different etiology proportion of AP according age, sex, and severity.

The Risk of Acute and Chronic Pancreatitis in Celiac Disease.

Celiac disease (CD) is a chronic immune-mediated enteropathy that is precipitated by dietary gluten in genetically predisposed individuals. A few studies reported a higher incidence of pancreatitis in the CD population. Using a large US database, we sought to describe the epidemiology, risk, and outcomes of acute pancreatitis (AP) and chronic pancreatitis (CP) in CD patients. We queried a multiple health system data analytics and research platform (Explorys Inc, Cleveland, OH, USA). A cohort of patients with a diagnosis of CD was identified. Subsequently, individuals who developed a new diagnosis of AP and CP after at least 30days of being diagnosed with CD were identified. A multivariate regression model was performed to adjust for multiple confounding factors. Of the 72,965,940 individuals in the database, 133,400 (0.18%), 362,050 (0.50%), and 95,190 (0.13%) had CD, AP, and CP, respectively. New diagnosis of AP and CP after at least 30days of CD diagnosis was 1.06%, 0.52%, respectively, compared to non-CD patients with 0.49% for AP and 0.13% for CP, P < .0001. In multivariate regression analysis, patients with CD were at higher risk of developing AP [OR 2.66; 95% CI 2.55-2.77] and CP [OR 2.18; 95% CI 2.04-2.34]. Idiopathic AP was the most common etiology among CD patients [OR 1.54; 95% CI 1.34-1.77]. In this largest US population database and after adjusting for several confounders, patients with CD were at increased risk of developing AP and CP. Celiac disease patients had worse outcomes and higher medical burden compared to non-CD patients. Recurrent abdominal pain that suggests pancreatic etiology, idiopathic pancreatitis, or elevation of pancreatic enzymes should warrant investigation for CD as a potential cause of pancreatic disease.

Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study

IntroductionIdiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional...

A rare case of acute pancreatitis: a diagnostic conundrum and unusual complications

A 63-year-old man with a history of recurrent idiopathic acute pancreatitis (AP) was admitted to our surgical ward due to severe abdominal pain. He denied chronic excessive alcohol use. Other typical causes of AP, such as gallstones, hypertriglyceridemia, and trauma, were ruled out. After considering all possible etiologies, the most likely factor producing AP was medication that had been administered to him two weeks before the very first episode of the disease. Medication should always be considered as a possible trigger of AP, especially if the first episode occurs shortly after drug administration and the etiology is unclear. During patient’s hospitalization, laboratory reports revealed significant fluctuations in the serum levels of pancreatic enzymes, which can be attributed to recurrent bacteriemia. After the 30-day period of hospitalization and long-lasting antibiotic therapy, he was discharged in a good condition with normal levels of serum pancreatic enzymes.

A rare case of acute pancreatitis: a diagnostic conundrum and unusual complications.

A 63-year-old man with a history of recurrent idiopathic acute pancreatitis (AP) was admitted to our surgical ward due to severe abdominal pain. He denied chronic excessive alcohol use. Other typical causes of AP, such as gallstones, hypertriglyceridemia, and trauma, were ruled out. After considering all possible etiologies, the most likely factor producing AP was medication that had been administered to him two weeks before the very first episode of the disease. Medication should always be considered as a possible trigger of AP, especially if the first episode occurs shortly after drug administration and the etiology is unclear. During patient's hospitalization, laboratory reports revealed significant fluctuations in the serum levels of pancreatic enzymes, which can be attributed to recurrent bacteremia. After the 30-day period of hospitalization and long-lasting antibiotic therapy, he was discharged in a good condition with normal levels of serum pancreatic enzymes.

Endoscopic Ultrasound Can Determine the Cause of Most Cases of Idiopathic Acute Pancreatitis

Cases of acute pancreatitis usually have an obvious etiology (e.g., gallstone disease, medications, alcohol, metabolic derangements), but a small

Endoscopic ultrasonography can detect a cause in the majority of patients with idiopathic acute pancreatitis: a systematic review and meta-analysis

Idiopathic acute pancreatitis (IAP) has a 25 % pancreatitis recurrence rate. Endoscopic ultrasonography (EUS) may diagnose treatable causes of IAP and hence prevent recurrence. The goal of this systematic review with meta-analysis is to determine the diagnostic yield of EUS and its impact on recurrence. PubMed, EMBASE and the Cochrane Library were systematically searched for English studies on EUS in adults with IAP. The primary outcome was diagnostic yield. Secondary outcomes included recurrence. Methodological quality was assessed using the QUADAS-2 score. Meta-analysis was performed to calculate the pooled diagnostic yield and risk ratio with 95 % confidence intervals (CI) using a random-effects model with inverse variance method. 22 studies were included, with 1490 IAP patients who underwent EUS. Overall diagnostic yield was 59 % (874 /1490; 95 %CI 52 % - 66 %). The most common etiologies were biliary (429 /1490; 30 %, 95 %CI 21 % - 41 %) and chronic pancreatitis (271 /1490; 12 %, 95 %CI 8 % - 19 %). In 2 % of patients, neoplasms were detected (45 /1490; 95 %CI 1 % - 4 %). There was no difference in yield between patients with or without recurrent IAP before EUS (risk ratio 0.89, 95 %CI 0.71 - 1.11). EUS is able to identify a potential etiology in the majority of patients with IAP, detecting mostly biliary origin or chronic pancreatitis, but also neoplasms in 2 % of patients. EUS may be associated with a reduction of recurrence rate. Future studies should include complete diagnostic work-up and preferably include patients with a first episode of IAP only.

Evaluation of 880 patients diagnosed with acute pancreatitis according to the Revised Atlanta Classification: A single-center experience.

OBJECTIVE The Revised Atlanta Classification (RAC) is increasingly used in the evaluation of patients diagnosed with acute pancreatitis (AP). In our study, we aimed to evaluate the etiology, disease severity, and mortality rates of patients diagnosed with AP in our center in the previous 6 years. METHODS Patients diagnosed with AP between 2013 and 2018 were evaluated. AP etiology, demographic data, disease severity, and mortality rates according to the RAC were evaluated. RESULTS A total of 880 patients were included in the study. Five hundred and eighteen (59%) patients were female and 362 (41%) were male. Regarding the etiology, 474 (53.9%) patients had biliary AP (BAP), 71 (8.1%) had hyperlipidemic AP (HAP), and 44 (5%) had alcoholic AP (AAP). According to the RAC, 561 (63.7%) patients were considered to be in the mild AP group (MAP), 268 (30.5%) in the moderately severe AP (MSAP), and 51 (5.8%) in the severe AP (SAP). The mortality rate was 4.8% in the MSAP group and 49% in the SAP group. Mortality was 2.3 times in patients over 65 years old and 3.7 times higher in patients with ischemic heart disease. CONCLUSIONS In our country, BAP is still the main etiology of acute pancreatitis. Over the years, we have seen a decrease in BAP and idiopathic AP cases, while there was an increase in HAP cases due to factors such as lifestyle changes and fatty nutrition. We found that mortality was associated with disease severity, advanced age (> 65 y), hypertension, and ischemic heart disease regardless of the etiology.