Aggressive Hydration Research Articles

Aggressive hydration for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: trial sequential analysis.

Randomized controlled trials (RCTs) have demonstrated that aggressive hydration with lactated Ringer's (LR) solution reduces the frequency and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In this trial sequential analysis (TSA), we aimed to evaluate the prophylactic effect of aggressive hydration on PEP in specific patient subgroups and to determine the need for additional RCTs. We conducted a systematic and comprehensive search to identify all randomized controlled studies published through August 2021 that examined the effectiveness of aggressive hydration for preventing PEP. The primary outcome was the frequency of PEP. We also performed TSA to calculate the required information size and assess whether our results were conclusive. The analysis included 12 studies involving 2,501 patients. According to the TSA, the overall frequency of PEP was significantly lower in the aggressive hydration group (5.6%; 74 of 1,327 patients) than in the control group (13.1%; 154 of 1,174 patients) (risk ratio [RR]: 0.458; 95% confidence interval [CI]: 0.350-0.599). In the subgroup analysis of patients with average risk, the cumulative Z curve crossed both the conventional test boundary and the trial sequential monitoring boundary. However, in the high-risk group and in patients with moderate-to-severe PEP, the Z curve did not cross the trial sequential monitoring boundary. This TSA indicates that aggressive hydration is effective in the overall prevention of PEP. However, additional RCTs are required to examine the prophylactic effect of aggressive hydration with LR on PEP in high-risk populations.

Fluidoterapia en pancreatitis aguda

La pancreatitis aguda es un proceso inflamatorio local causado por activación del tripsinógeno que degrada el parénquima pancreático, se ha estimado cada año 300.000 visitas a sala de emergencias en Estados Unidos; en Ecuador en el 2019 el Instituto Nacional de Estadística y Censos informó 5.478 casos de pancreatitis. El objetivo de este estudio es determinar si el lactato Ringer e hidratación agresiva representan un beneficio en el manejo de pancreatitis aguda. Se realizó una revisión teórica en Pubmed, Scopus y Biomed Central, entre el 2018 al 2022, de revisiones sistemáticas, metaanálisis, ensayos clínicos controlados y estudios retrospectivos. Se incluyeron 17 estudios, 10 corresponden a solución salina versus lactato Ringer, 70 % sustenta el beneficio del uso de lactato, por resultados estadísticamente significativos con relación a menor estancia hospitalaria, menor tasa de ingreso a terapia intensiva y menor progresión a complicaciones. La comparación de hidratación agresiva versus no agresiva incluyó 7 estudios que no recomiendan el uso de hidratación agresiva por riesgo de lesión renal e insuficiencia respiratoria aguda con soporte ventilatorio. Se recomienda la utilización de lactato Ringer en el manejo de pancreatitis aguda, pero no de la hidratación agresiva. En definitiva, es preciso el desarrollo de investigaciones con un diseño más robusto, que aporten evidencia de mayor peso acerca de la efectividad de fluidoterapia en el manejo de pancreatitis aguda.

ODP136 A Rare Case of Necrotizing Myopathy after Statin Use

Abstract Introduction Statin associated necrotizing autoimmune myopathy is an extremely rare side effects of stain use. The incidence is approximately 2-3/100,000 Patients treated with statins. It usually associated with significant proximal muscle weakness, strikingly elevated creatine kinase (CK) levels and persistent symptoms despitestatin discontinuation. Here, we present a case with necrotizing myopathy after statin use as a reminder to clinicians for appropriately suspicious of this phenomenon while on treatment of statins. Clinical case: A 35 year old male with a past medical history of Autism, Type 2 Diabetes Mellitus, Hyperlipidemia, and Hypertension was brought to emergency room for right leg pain. Family states he had difficulty walking for a few weeks and had a fall from couch a week ago. Initial Vitals showed HR at 134 bpm, temp 35.9, BP 157/85 mmHg, RR 19 breaths/min. Labs showed Creatinine. 3.29 mg/dL, CO2 24 mmol/L, Na 141 mmol/L, K 4.2 mmol/L, Ca 9.5 mg/dL, glucose 265 mg/dL, AST/ALT 914/919 units/L, CK>14,000 units/L, WBC 9.2 thou/mcL, Hb 12.6 g/dL, TSH 9.42 mcIU/mL, Free T3 1.41 pg/mL, Free T4 0.95 mcg/dL. Urinalysis showed large blood with RBC of 1. Myoglobin>8750 mcg/L. Neuro motor exam showed strength 4/5 in bilateral lower extremities. His home medications including atorvastatin 20 mg nightly for 2 years, metformin and olmesartan, which all had been held. He was treated for rhabdomyolysis with aggressive hydration and Creatinine was improving. However, CK continued trending up to 42,915 units/L on day 5 with unreleased symptoms of lower extremity weakness. Neurology was consulted. Differential diagnosis of myopathy were suspected. His CK was continue to trend up to 45,585 units/L on day 10. Decision was made to have muscle biopsy with pathology showed: necrotizing myopathy without any clear evidence of inflammation. Although some autoimmune necrotizing myopathy may not show inflammation like those seen with HMG-CR antibodies or signal recognition antigen antibodies. Autoantibodies against 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (HMGCR Ab) was above 550. Following the biopsy, he received IV Solu-medrol 1g daily×4 doses, and then PO Prednisone 80 mg daily and then tapered down to 40 mg daily. He was also promptly started on IVIG 400 mg/kg/day for 5 days and methotrexate 7.5 mg weekly. His CK started to improve, down to 5815 units/L three weeks later. No significant improvement of strength. Conclusion Our case demonstrates that the appropriate diagnosis of statin induced necrotizing autoimmune myopathy with muscle biopsy and HMGCR Ab. We also wanted to alert future clinicians to have an early suspicious of such rare side effect and initiate treatment as early as possible which may bring the maximum benefit for patients. Presentation: No date and time listed

LBODP065 Rare Cause Of Bone Pain In MEN Syndrome

Abstract Introduction: MEN 1 syndrome is a rare disease in children and young adults, with prevalence reported as 2 per 100,000. MEN 1 caused by mutations in the MEN1 tumor suppressor gene, characterized by 2 or more MEN1 tumors: parathyroid, anterior pituitary, pancreatic islet tumors. To the best of our knowledge, osteomyelitis of the pelvis has not been reported as a complication in the literature in patients who were diagnosed with MEN1Case21 yo male from Honduras with PMHx of remote asthma presented with a common complaint of abdomen pain but found to have a rare diagnosis. He had 2 days of lower abdomen pain associated with non-bilious non bloody vomiting. Initial were significant for calcium 12.9, phosphorus 1.5 magnesium 1.8 and PTH 360. 4 mm renal stone 4 mm was detected on CT abdomen/pelvis. The initial EKG demonstrated J point elevation due to the hypercalcemia. He was admitted to the PICU for continuous telemetry monitoring due to the abnormal EKG related to electrolyte abnormalities. Hypercalcemia treatment was initiated with aggressive hydration, calcitonin administration as well as zoledronic acid administration. The patient's calcium levels improved as well as EKG. The parathyroid scan was positive for a right-sided parathyroid adenoma. He underwent right Inferior Parathyroidectomy, Intraoperative Nerve Monitoring, Cryopreservation of Parathyroid Tissue. As part of his diagnostic work-up for hyperparathyroidism, he was screened for MEN. His pituitary function was abnormal: ACTH and cortisol levels were high, his testosterone and gonadotropins were inappropriately low as well as TSH and T4. A microadenoma was present on brain MRI. No Pancreatic Neuroendocrine Neoplasia was found. The diagnosis of MEN 1 was made. Despite the improvements in his endocrinopathies, he continued to have lower abdomen pain associated with intermittent fevers. He was seen by urology and orthopedics. Initially MRI demonstrated bone erosion thought to be secondary to hypercalcemia but repeat MRI imaging of the pelvis was suspicious for phlegmon vs. developing abscess secondary to osteitis pubis. His blood cultures were positive for MSSA. He was started on antibiotics with continued clinical improvementThis patient presented with one of the most common complaints in the ED, abdomen pain and was found to have two rare and potentially fatal diagnosis which was identified and treated with a good clinical outcome Discussion: This case highlights a rare disease in the setting of osteomyelitis which could easily be missed as a manifestation of bone pain from hypercalcemia. The patient did experience fevers and malaise that was initially attributed to zoledronic acid administration. When his pain did not resolve MRI found osteomyelitis, allowing early antibiotic administration and prevention of sepsis. Presentation: No date and time listed

ODP110 Parathyroid Hormone Independent Hypercalcaemia Secondary to Granulomatous Inflammation: Could This Be Melioidosis?

Abstract Background Hypercalcemia has been described in patients with most granulomatous disorders, most commonly in sarcoidosis and tuberculosis, but never in melioidosis. Clinical Case A 45-year-old woman presented with two-day history of abdominal pain, nausea, lethargy and intermittent fevers during Darwin's wet season. Medications included daily methadone, diazepam and mirtazapine. On examination she was febrile with stable hemodynamics and left upper quadrant tenderness. Investigations revealed pancytopenia, deranged liver function tests with a cholestatic pattern, raised CRP of 53 (<5mg/L) and normal serum calcium. Blood cultures were negative but melioidosis serology was positive (indirect hemagglutination antibody (IHA) titer 1: 1280). Abdominal computed tomography demonstrated hepatosplenomegaly with peripheral splenic infarcts and a 7mm intrasplenic aneurysm, but no abscesses. PET showed no hypermetabolic lesions. After extensive investigation, she was treated for presumptive culture-negative melioidosis with intravenous meropenem. Clinically she improved despite gradual elevation in serum calcium which peaked at 3.31 (2.1-2.6mmol/L) five weeks after presentation. Initial biochemical investigations revealed suppressed PTH at 0.5 (1.4-9.1pmol/L), low 25-hydroxy-Vitamin D of 26 (50-150nmol/L), elevated phosphate at 2.43 (0.75-1.5mmol/L) and moderate renal impairment (eGFR 34mL/min/1.73m 2). Hypercalciuria was present with urine calcium to creatinine ratio of 812 (100-580mmol/mol). Her 1,25-dihydroxy-Vitamin D (calcitriol) was elevated at 219 (48-190pmol/L) suggestive of PTH-independent hypercalcemia. The patient remained asymptomatic of hypercalcemia and aggressive intravenous hydration produced minimal biochemical improvement. Renal impairment precluded bisphosphonate use. She was commenced on prednisolone 50mg while continuing intravenous meropenem. Serum calcium normalized in 10 days and prednisolone dose was gradually tapered. A liver biopsy was performed due to persistent liver derangement and histology showed granulomatous inflammation. She completed six weeks of antibiotics for melioidosis and was discharged on day 50, with a planned six months of eradication therapy. Outpatient follow-up demonstrated normal serum calcium after cessation of prednisolone with decreasing IHA titer (1: 320). We hypothesize that this case reflects PTH-independent hypercalcemia secondary to granulomatous inflammation, presumptively caused by melioidosis. The rise in calcium after commencement of antibiotics and normalization following initiation of glucocorticoid therapy, with no rebound post cessation, is consistent with successful therapy of an infection with granulomatous inflammation. Activated macrophages within granulomas have unregulated 1-alpha-hydroxylase expression which is thought to increase conversion of 25-hydroxy-Vitamin D to calcitriol and therefore increase intestinal calcium absorption. Treatment with glucocorticoids inhibits calcitriol synthesis leading to quick resolution of hypercalcemia. While use of glucocorticoids are commonplace in the management of granulomatous disease due to sarcoidosis, they have been increasingly recognized as an important risk factor for melioidosis, considered to result from suppression of innate immunity. However, use of glucocorticoids if required is not contraindicated once antibiotic therapy for melioidosis has commenced. Conclusion In areas where melioidosis is endemic, clinicians should be aware of hypercalcemia and the potential risks associated with its treatment. Presentation: No date and time listed

S66 Aggressive Intravenous Hydration in Patients With Acute Pancreatitis Is Beneficial Only During the First 24 Hours: A Meta-Analysis

Introduction: Early aggressive intravenous hydration (EAIH) remains the only initial treatment specifically for patients with acute pancreatitis. The timing, type, and amount of fluid remains the subject of study, debate, and controversy. In order to define our current state of knowledge of the clinical evidence behind the recommendation for EAIH, we performed a meta-analysis of the published literature. Methods: A Pubmed search to identify all clinical trials evaluating the role of EAIH in patients with acute pancreatitis resulted acute pancreatitis 25 studies, 17 prospective, 18 retrospective, 13 randomized controlled clinical trials (RCT). Studies that evaluated NS to LR were not included. In order to be included in the final analysis, the study needed to have two or more groups defined by different rates of hydration. One group must have included EAIH and define the outcome(s) studied. Outcomes used in our analysis included SIRS, pancreatic necrosis, persistent organ failure, length of stay, ICU admission, and mortality. Any decrease in these outcomes compared to the “control” groups was considered a “benefit”. The weighted mean for each study was defined by the sample size. Results: In a pooled analysis of all studies (n=1865), there was no difference in morbidity or mortality between EAIH and the “control group” (RR 1.1, 95% CI 0.66-1.8). When including only RCT (n=987), there was also no difference in morbidity or mortality (RR 0.88, 95% CI 0.78-1.4). However, when including studies and RCT that focused only on EAIH within the first 24 hours, excluding all studies that defined EAIH as the amount of fluid provided at 48 hours, there was a “benefit” to EAIH (RR 0.62, 95% CI 0.44-0.84). Conclusion: Our results show that the benefit observed in EAIH occurs only within 24 hours of enrollment. While guidelines on the management of acute pancreatitis have generally recommended EAIH, some have suggested that “goal directed therapy” is preferred due to complications. Our study demonstrates that it is important for clinicians caring for patients with acute pancreatitis not miss the “goal” within the first day of managing patients with acute pancreatitis. Our meta-analysis shows aggressive intravenous hydration after the first 24 hours is not beneficial and may be harmful. Based on this analysis, we suggest EAIH be applied to all patients during the first 24 hours and “goal directed” hydration after the first 24 hours.

S1721 Doxycycline-Induced Pancreatitis: An Uncommon Complication of a Common Drug

Introduction: Drug induced pancreatitis (DIP) is rare but potential cause of acute pancreatitis and accounts for 0.1-5.3% of all cases. In this case series, we report 2 cases of patients with doxycycline induced pancreatitis. Case Description/Methods: A 60-year-old woman with cervical osteomyelitis on iv ceftriaxone and doxycycline presented with 2-day history of severe nausea, vomiting, and epigastric pain. On exam, she had epigastric and right upper quadrant tenderness. Laboratory evaluation was significant for serum lipase 6,699 u/l , creatinine of 1.94 mg/dl. Liver function tests and lipid panel were within normal limits. Computerized tomography (CT) of the abdomen and pelvis confirmed acute interstitial pancreatitis (Figure). Triglyceride, IgG subclasses and calcium levels were normal. Thorough review of her medications revealed doxycycline induced pancreatitis was suspected. Her symptoms gradually improved and lipase returned to 85 u/l with discontinuation of doxycycline. A 91year-old woman with recent history of left elbow fracture complicated by wound dehiscence on doxycycline therapy, presented for hospital admission with several days of increased confusion, malaise, and generalized, severe abdominal pain. She appeared ill, with dry mucous membranes and diffuse abdominal tenderness. Laboratory test results were notable for blood urea nitrogen (BUN) 56 mg/dl, creatinine 2.35 mg/dl, ALP 223 u/l, total bilirubin 1.1 mg/dl, wbc count 26.7 k/ul, calcium 6.4 mg/dl, lipase 301 u/l, AST, ALT, triglycerides and IgG subclass levels were within normal limits. CT abdomen showed extensive intrapancreatic and peripancreatic edema, the patient was diagnosed with severe pancreatitis. With careful exclusion of other etiologies, she was diagnosed with doxycycline induced pancreatitis. Her symptoms improved with aggressive hydration and discontinuation of doxycycline. Discussion: Onset of symptoms with relation to starting the offending drug is key in identifying the causative agent of DIP. The severity, onset of symptoms, dosage of doxycycline and latency have been reported as variable as in our cases. Symptom onset was at 14 days of doxycycline therapy in the first vs 22 in the second case. Treatment includes cessation of doxycycline and aggressive IV fluid resuscitation. This case series emphasizes the importance of considering doxycycline as a cause of acute pancreatitis especially with its increased use in recent years.Figure 1.: CT abdomen with extensive intrapancreatic and peripancreatic edema (second case presented).

S1848 Testosterone Supplement-Induced Pancreatitis

Introduction: Common causes of acute pancreatitis (AP) in the United States are gallstone pancreatitis and alcohol use. However, about 2% of AP cases are attributed to Drug-induced pancreatitis (DIP). Though infrequent, the pathology is associated with substantial morbidity and mortality, which makes timely identification of the inflicting agent important. Supplements that enhance athletic performance and libido are commonplace in today’s community and remain largely unregulated. The lack of understanding and awareness of the detrimental adverse effects of such drugs can affect physical and mental health. Case Description/Methods: A 51-year-old gentleman with a history of chronic kidney disease Stage II, hyperlipidemia on statin, diverticulosis, and GERD on omeprazole presented to the ER with acute abdominal pain associated with nausea and vomiting for a day. The epigastric pain was described as 10/10 in intensity, sharp with radiation to the back and associated with 3 episodes of non-projectile, bilious, non-bloody vomiting. He is a non-smoker and drinks alcohol occasionally, his last drink being a can of beer 1 week prior. He denied recent infections, abdominal procedures, or trauma. On examination, his vitals were normal, and was in minimal distress. Tenderness was elicited in the epigastric region. Initial labs showed leukocytosis with left shift, elevated AST of 225, ALT of 202, LDH of 274, and a significant increase in levels of lipase >3000. A CT scan of the abdomen showed findings consistent with acute interstitial pancreatitis. Imaging and laboratory investigations were negative for biliary disease and IgG4 disease. On asking further history, he reported taking over the counter testosterone supplements to enhance his libido for 2 weeks. A diagnosis of DIP was made and was treated appropriately with aggressive hydration and pain management. Discussion: DIP is attributed to four classes of drugs (I to IV) and steroids like testosterone are placed under Class I. The possible mechanism for causing AP include pancreatic duct constriction, cytotoxic and metabolic effects, accumulation of a toxic metabolite or intermediary, and hypersensitivity reactions. Prevalent use of testosterone in the male community for bodybuilding and increasing libido warrant the need to create awareness. Additionally, these drugs are difficult to study due to the varied consumption patterns, unknown origin and ingestion of high doses.

37-Year-Old Man With Headache and Nasal Congestion

37-Year-Old Man With Headache and Nasal Congestion

Rhabdomyolysis in Pediatric Patients with SARS-CoV-2 Infection.

Background: Rhabdomyolysis is a rare but severe complication in adult patients with Coronavirus disease 2019 (COVID-19), which can result in acute kidney injury and death; however, it is rarely reported in pediatric patients. Methods: In this study, we retrospectively reviewed the clinical features and outcomes of rhabdomyolysis in pediatric patients aged 0–18 years with COVID-19 who were hospitalized at Taipei Tzu Chi Hospital, an epicenter of COVID-19 in northern Taiwan. Results: We treated eight patients with rhabdomyolysis during the omicron variant-Severe acute respiratory syndrome coronavirus 2 (omicron variant-SARS-CoV-2) community outbreak and none during the alpha variant endemic. These eight patients shared stereotypical presentations, including the presence of bilateral calf pain after defervescence. The creatinine kinase (CK) levels were between 1346 and 6937 U/L on admission, and clinical course was uneventful after aggressive saline hydration. Conclusion: Rhabdomyolysis is not a rare complication in pediatric patients with the omicron-SARS-CoV-2 infection, and reassurance of a good prognosis is important to alleviate family anxiety.

Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis

BackgroundEarly aggressive hydration is widely recommended for the management of acute pancreatitis, but evidence for this practice is limited.MethodsAt 18 centers, we randomly assigned patients who presented with acute pancreatitis to receive goal-directed aggressive or moderate resuscitation with lactated Ringer’s solution. Aggressive fluid resuscitation consisted of a bolus of 20 ml per kilogram of body weight, followed by 3 ml per kilogram per hour. Moderate fluid resuscitation consisted of a bolus of 10 ml per kilogram in patients with hypovolemia or no bolus in patients with normovolemia, followed by 1.5 ml per kilogram per hour in all patients in this group. Patients were assessed at 12, 24, 48, and 72 hours, and fluid resuscitation was adjusted according to the patient’s clinical status. The primary outcome was the development of moderately severe or severe pancreatitis during the hospitalization. The main safety outcome was fluid overload. The planned sample size was 744, with a first planned interim analysis after the enrollment of 248 patients.ResultsA total of 249 patients were included in the interim analysis. The trial was halted owing to between-group differences in the safety outcomes without a significant difference in the incidence of moderately severe or severe pancreatitis (22.1% in the aggressive-resuscitation group and 17.3% in the moderate-resuscitation group; adjusted relative risk, 1.30; 95% confidence interval [CI], 0.78 to 2.18; P=0.32). Fluid overload developed in 20.5% of the patients who received aggressive resuscitation and in 6.3% of those who received moderate resuscitation (adjusted relative risk, 2.85; 95% CI, 1.36 to 5.94, P=0.004). The median duration of hospitalization was 6 days (interquartile range, 4 to 8) in the aggressive-resuscitation group and 5 days (interquartile range, 3 to 7) in the moderate-resuscitation group.ConclusionsIn this randomized trial involving patients with acute pancreatitis, early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes. (Funded by Instituto de Salud Carlos III and others; WATERFALL ClinicalTrials.gov number, NCT04381169.)

Acalculous cholecystitis and ascites in a patient with rhabdomyolysis: A case report

Introduction: Rhabdomyolysis is a muscle breakdown caused by a variety of factors. Based on a review of the literature, we are unaware of any case reports that discuss these complications of rhabdomyolysis with acalculous cholecystitis and ascites. Case Report: This patient is a 24-year-old man who had never had a chronic illness before. He was a nonsmoker and did not consume alcoholic beverages. He went to the emergency room (ER) because he was having upper abdominal pain and aches throughout his body. He was just started a rigorous physical activity-based training regimen. A total creatine kinase (CK) level more than 5 times higher than the upper normal value confirmed the diagnosis. For the upper abdominal pain, an ultrasound was performed. It reveals ascites and a thick-walled gallbladder. With a decrease in repeated total CK and clinical improvements, the patient was discharged home after aggressive hydration. The patient was asymptomatic at the follow-up appointment, and the ultrasound showed no ascites or gallbladder wall thickness. Conclusion: These are a rare complication of rhabdomyolysis. It implies that acalculous cholecystitis and ascites should be interpreted in light of the clinical scenario and presentation. The workup for ascites and acalculous differential diagnosis was uneventful. In a young patient with rhabdomyolysis, acalculous cholecystitis and ascites is an unusual occurrence.

Rhabdomyolysis and the Use of Low-Dose Amphetamine

Rhabdomyolysis ranges from being asymptomatic with elevated creatine kinase (CK) to a potentially life-threatening condition involving multiple organ systems. Muscular trauma is the most common cause, followed by enzyme deficiencies, electrolyte abnormalities, drugs, toxins, and endocrinopathies. While these risk factors are delineated, it is not clear if mild exposure to a combination of risk factors could lead to the development of rhabdomyolysis. In this case report, a 22-year-old male of Pakistani/Caucasian ethnicity presented to the emergency room with myalgias and tea-colored urine after starting a new exercise program. His serum CK level and liver function tests were significantly elevated. He was successfully treated for acute rhabdomyolysis with aggressive hydration. However, the etiology of his condition was not clear given that his exercise was not considered vigorous. The only plausible explanation for his symptoms included the use of prescribed dextroamphetamine, which may have exacerbated the physiologic responses induced by exercise. This report describes a novel case in which a patient may have developed recurrent episodes of rhabdomyolysis due to low-dose dextroamphetamine use. The combination of exercise and dextroamphetamine use may predispose patients to develop rhabdomyolysis.

Efficacy of aggressive hydration with normal saline versus lactated Ringer's solution for the prevention of post-ERCP pancreatitis in high-risk patients: a randomized controlled trial.

Background and study aims Post-ERCP pancreatitis (PEP) is a common adverse event in high-risk patients. Current intervention known to reduce the incidence and severity of PEP include pancreatic duct stent placement, nonsteroidal anti-inflammatory drugs per rectum, and intravenous (IV) fluids. We compared aggressive normal saline (NS) vs aggressive lactated Ringer’s (LR) infusion for the prevention of PEP in high-risk patients undergoing ERCP. Patients and methods Patients were randomized to receive either an aggressive infusion of NS or LR. The infusion was started at a rate of 3 mL/kg/hr and continued throughout the ERCP procedure. A 20 mL/kg bolus was given at the end of the procedure, then continued at a rate of 3 mL/kg/hr. Results A total of 136 patients were included in our analysis. The incidence of PEP was 4 % (3/72 patients) in the LR group versus 11 % (7/64 patients) in the NS group resulting in a relative risk (RR) of 0.38 (95 % confidence interval [CI] 0.10 to 1.42; P = 0.19). The relative risk reduction (RRR) was 0.62 (95 % CI –0.41 to 0.90) along with an absolute risk reduction (ARR) of 0.07 (95 % CI –0.025 to 0.17) and an number needed to treat of 15 (95 % CI –41 to 6). Conclusions To our knowledge, this is the first study comparing aggressive IV NS to aggressive IV LR in high-risk patients. The incidence of PEP was lower in the group receiving an aggressive LR infusion (4 %) compared to NS infusion (11 %). However, the difference was not statistically significant likely due to poor accrual thereby impacting the power of the study.

The Latest Knowledge on Endoscopic Retrograde Cholangiopancreatography-related Pancreatitis

ERCP has been established as a golden diagnostic and therapeutic modality in various pancreatobiliary diseases, including gallstones and malignancy. On the other hand, ERCP is a relatively invasive procedure with radiation hazards and major complications. Among the major complications, ERCP-related pancreatitis has been reported in more than 14.7% of high-risk patients, which might lead to extended hospitalization and a substantial burden for both patients and physicians. Recent guidelines have defined the high-risk factors for ERCP-related pancreatitis. In addition, several outstanding studies have shown that rectal non-steroidal anti-inflammatory drugs, aggressive hydration with lactated Ringer's solution, and pancreatic stents can reduce ERCP-related pancreatitis in high-risk patients or all patients. A prevention algorithm for ERCP-related pancreatitis was provided based on advanced research.

Systemic loxoscelism induced warm autoimmune hemolytic anemia: clinical series and review

ABSTRACT Objectives Describe the development of warm autoimmune hemolytic anemia warm (AIHA) secondary to a brown recluse spider (Loxosceles reclusa) bite is known as systemic loxoscelism; and review epidemiology, clinical manifestations, diagnostic work-up, pathophysiology, and treatment options associated with warm AIHA secondary to systemic loxoscelism. Methods Cases series of two cases of warm AIHA due to systemic loxoscelism and a review of the current literature: epidemiology, clinical manifestations, diagnostic work-up, pathophysiology, and treatment options associated with warm AIHA secondary to systemic loxoscelism. Results Presented here are two cases of warm AIHA due to systemic loxoscelism. Each patient was generally healthy appearing and presented with symptomatic anemia in the setting of brown recluse spider bites. Both patients were eventually found to have warm AIHA. Upon recognition of the diagnosis, the patients were started on corticosteroids and aggressive intravenous fluid hydration. In addition, they received transfusions of packed red blood cells. Their clinical courses improved, and they recovered to eventually be discharged home. Conclusion Envenomation by a brown recluse spider, Loxosceles reclusa, can result in systemic loxoscelism which can cause warm AIHA. The diagnosis of warm AIHA is confirmed by the direct antiglobulin/Coomb's test. Warm AIHA can be a life-threatening disease process. Hemodynamic support with intravenous fluids and RBC transfusion is the initial step in the management of these patients. Corticosteroids are the mainstay of current management. Second line treatments include rituximab. Rarely patients require splenectomy for refractory disease. Corticosteroids should be tapered over a three-month period.

In vitro fertilization and hypertriglyceridemic pancreatitis: Case report

Few cases of hypertriglyceridemic pancreatitis have been reported in women during a vitro fertilization treatment (IVF) cycle. Here, we describe a 41-year-old woman with primary infertility and a history of acute pancreatitis (of unknown etiology) who was started on high dose ethinyl estradiol to prepare for transfer of cryopreserved embryos. She subsequently presented with nausea, vomiting, and abdominal pain to an emergency room and was found to have hypertriglyceridemic pancreatitis. Her hospitalization involved a prolonged intensive care unit stay in which she underwent three sessions of plasmapheresis. Eventually, with discontinuation of ethinyl estrogen, aggressive intravenous fluid hydration, plasmapheresis, a low-fat diet, and gemfibrozil, she had resolution of severe hypertriglyceridemia and all symptoms related to acute pancreatitis. Our case highlights the possibility that ethinyl estradiol, a commonly used form of estrogen for endometrial preparation during IVF cycles, may cause severe hypertriglyceridemia and acute pancreatitis in certain predisposed individuals. Only seven cases of hypertriglyceridemic pancreatitis during in vitro fertilization have been previously reported, and only one of these prior cases experienced pancreatitis during transfer of cryopreserved embryos like our patient. Our case, along with the few prior reported cases, demonstrate hypertriglyceridemic pancreatitis can occur during IVF. Further work is needed to understand the effects of exogenous estrogen on lipids for women undergoing IVF.

Drug-induced acute pancreatitis in a bodybuilder: a case report

BackgroundUnregulated use of a variety of drugs and supplements by bodybuilders and athletes is common and can lead to severe adverse complications. Only a small proportion of acute pancreatitis cases are drug induced, and case reports are essential for identifying potential drug-related risks for pancreatitis. Here we present the first case report published of acute pancreatitis linked to recreational use of anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol in a previously healthy male after excluding all other causes of pancreatitis.Case presentationA 31-year-old Arab male bodybuilder presented with acute abdominal pain associated with nausea and sharp pain radiating to the back. The patient was not using tobacco or alcohol but was using multiple drugs related to bodybuilding, including anabolic–androgenic steroids, subcutaneous growth hormone, clenbuterol, and multiple vitamin supplements. Laboratory studies revealed a normal white blood cell count, elevated C-reactive protein, minimally elevated aspartate aminotransferase and total bilirubin with normal remaining liver tests, and elevated amylase and lipase. The patient had no hypertriglyceridemia or hypercalcemia, and had had no recent infections, abdominal procedures, trauma, or scorpion exposure. Imaging and laboratory investigations were negative for biliary disease and IgG4 disease. Abdominal computed tomography revealed hepatomegaly and diffuse thickening and edema of the body and tail of the pancreas with peripancreatic fat stranding. An abdominal ultrasound showed slight hepatomegaly with no evidence of cholelithiasis. Genetic testing for hereditary pancreatitis-related mutations was negative. A diagnosis of drug-induced acute pancreatitis was made, and he was treated with aggressive intravenous hydration and pain management. The patient has avoided further use of these drugs and supplements and had no further episodes of pancreatitis during 1 year of follow-up.ConclusionsThis case describes a patient with drug-induced acute pancreatitis after the intake of anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol, where all other common causes of acute pancreatitis were excluded. Clinicians should be alert to the possibility of drug-induced acute pancreatitis occurring in bodybuilders and athletes using similar drug combinations.

Risk of Acute Myocardial Infarction in Patients with Gastroenteritis: A Nationwide Case-Control Study.

Gastroenteritis promotes the development of systemic inflammation and a hypercoagulable state. There are limited data regarding the association between gastroenteritis and acute myocardial infarction (AMI). We aimed to evaluate the risk of AMI after an episode of gastroenteritis. In this nested case-control study, we selected patients who were hospitalized for AMI (N = 103,584) as a case group during 2010–2017 and performed propensity score matching (case-control ratio 1:1) to select eligible controls from insurance research data in Taiwan. We applied multivariable logistic regressions to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for the risk of AMI associated with recent gastroenteritis within 14 days before AMI. We also compared the outcomes after AMI in patients with or without gastroenteritis. A total of 1381 patients (1.3%) with AMI had a prior episode of gastroenteritis compared to 829 (0.8%) among the controls. Gastroenteritis was significantly associated with a subsequent risk of AMI (adjusted OR: 1.68, 95% CI: 1.54–1.83), which was augmented in hospitalizations for gastroenteritis (adjusted OR: 2.50, 95% CI: 1.20–5.21). The outcomes after AMI were worse in patients with gastroenteritis than in those without gastroenteritis, including increased 30-day in-hospital mortality (adjusted OR: 1.28, 95% CI: 1.08–1.52), medical expenditure, and length of hospital stay. Gastroenteritis may act as a trigger for AMI and correlates with worse post-AMI outcomes. Strategies of aggressive hydration and/or increased antithrombotic therapies for this susceptible population should be further developed.

Rectal NSAIDs-based combination modalities are superior to single modalities for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a network meta-analysis.

Background/AimsDifferent modalities have been employed to reduce the risk and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, there has been a paucity of studies comparing the efficacy of various prophylactic modalities for preventing PEP. This network meta-analysis (NMA) aimed to determine the relative efficacy of pancreatic duct stents and pharmacological modalities for preventing PEP.MethodsWe performed a systematic and comprehensive search to identify and analyze all randomized controlled studies published until June 2020 that examined the effectiveness of pancreatic duct stents, rectal non-steroidal anti-inflammatory drugs (NSAIDs) based regimens, hydration, and their combinations for the prevention of PEP. The primary outcome was the frequency of PEP. An NMA was performed to combine direct and indirect comparisons of different prophylactic modalities.ResultsThe NMA included 46 studies evaluating 18 regimens in 16,241 patients. Based on integral analysis of predictive interval plots, and expected mean ranking and surface under the cumulative ranking curve values, combination prophylaxis with indomethacin + lactated Ringer’s solution (LR), followed by diclofenac + nitrate and indomethacin + normal saline, was found to be the most efficacious modality for the overall prevention of PEP. Indomethacin + LR, followed by diclofenac and pancreatic duct stents, was the most efficacious modality for high-risk groups.ConclusionsRectal NSAIDs-based combination regimens with aggressive hydration or nitrate are superior to single modalities for the prevention of PEP.