Computed Tomography Severity Index Score Research Articles

Mortality indicators and risk factors for intra-abdominal hypertension in severe acute pancreatitis.

This study assessed the risk factors associated with mortality and the development of intra-abdominal hypertension (IAH) in patients with severe acute pancreatitis (SAP). To identify significant risk factors, we assessed the following variables in 102 patients with SAP: age, gender, etiology, serum amylase level, white blood cell (WBC) count, serum calcium level, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, computed tomography severity index (CTSI) score, pancreatic necrosis, surgical interventions, and multiple organ dysfunction syndrome (MODS). Statistically significant differences were identified using the Student t test and the χ (2) test. Independent risk factors for survival were analyzed by Cox proportional hazards regression. The following variables were significantly related to both mortality and IAH: WBC count, serum calcium level, serum amylase level, APACHE-II score, CTSI score, pancreatic necrosis, pancreatic necrosis >50%, and MODS. However, it was found that surgical intervention had no significant association with mortality. MODS and pancreatic necrosis >50% were found to be independent risk factors for survival in patients with SAP. Mortality and IAH from SAP were significantly related to WBC count, serum calcium level, serum amylase level, APACHE-II score, CTSI score, pancreatic necrosis, and MODS. However, Surgical intervention did not result in higher mortality. Moreover, MODS and pancreatic necrosis >50% predicted a worse prognosis in SAP patients.

Clinical characteristics of intraductal papillary mucinous neoplasm manifesting as acute pancreatitis or acute recurrent pancreatitis

Comparatively little is known about acute pancreatitis or acute recurrent pancreatitis (AP/ARP) with intraductal papillary mucinous neoplasm of the pancreas (IPMN) as the causative lesion although there have been many reports about the malignant potential of IPMN as a premalignant lesion. From 2000 to 2008, in a single tertiary referral center, out of 784 patients coded by the International Classification of Disease-10 with IPMN, 489 patients fulfilled our diagnostic criteria of IPMN. After careful exclusion of all known causes of AP/ARP, 34 patients with IPMN as the cause of AP/ARP were enrolled. AP/ARP caused by IPMN occurred in 34 (7%) out of 488 patients with IPMN, and the prevalence rate of AP/ARP was higher in the main-duct/combined type than in the branch-duct type (14% [16/111] vs 5% [18/378], respectively, P = 0.002). The severity of pancreatitis was mild, based on the computed tomography severity index score (median 2, range 0-4). Histologic review of 24 patients with surgical resection revealed four adenomas (17%), 17 borderline malignancies (71%), two carcinomas in situ (8%), and one invasive carcinoma (4%). AP/ARP did not recur in any of the 24 surgically resected patients during the follow-up period (median 52 months, range 38-115 months). AP/ARP caused by IPMN was of infrequent occurrence. AP/ARP caused by IPMN occurred more frequently in the main-duct/combined type than in the branch-duct type. Most cases were mild in severity and benign in histopathology. AP/ARP can be an initial manifestation of IPMN, though uncommon, which leads to diagnosis.

Evaluation of the BISAP Score in Predicting Severity and Prognoses of Acute Pancreatitis in Chinese Patients

The present study was to evaluate the accuracy of bedside index for severity in acute pancreatitis (BISAP) in predicting the severity and prognoses of acute pancreatitis (AP) in Chinese patients. Clinical data for 497 patients with AP were analyzed retrospectively to compare BISAP with acute physiology and chronic health evaluation II, Ranson, and computed tomography severity index scores in predicting the severity of AP and the occurrence of pancreatic necrosis, mortality, and organ failure in patients with severe AP (SAP) using the area under the receiver-operating characteristic curve. Of the 497 patients, 396 had mild AP and 101 had SAP. There were significant correlations between the scores of any two systems. BISAP performed similarly to other scoring systems in predicting SAP, as well as pancreatic necrosis, mortality, and organ failure in SAP patients, in terms of the area under the receiver-operating characteristic curve. BISAP score is valuable in predicting the severity of AP and prognoses of SAP in Chinese patients.

Severity Scores in Children With Acute Pancreatitis

Severity scores are used to predict the outcome of acute pancreatitis (AP). Several scores are used in adult patients, but none has been thoroughly validated for specific use in paediatric patients. We retrospectively collected data from 48 children with AP (13 severe and 35 mild). The main causes were trauma (23%), idiopathic (23%), lithiasis (12.5%), and virus (10.5%). We evaluated 3 clinical scores (Ranson, Glasgow modified, and DeBanto) and Balthazar computed tomography severity index. The clinical scores had a good specificity (approximately 85%) but a low sensitivity (approximately 55%) in predicting the severity of paediatric AP. The radiological score is better (sensitivity 80%, specificity 86%). The area under the receiver operator characteristic curve was 0.699 (95% CI 0.508%-0.891%, P = 0.054) for the DeBanto score, 0.846 (95% CI 0.69%-1%, P = 0.001) for the Ranson score, and 0.774 (95% CI 0.584%-0.964%, P = 0.008) for the Glasgow and 0.898 (95% CI 0.73%-1%, P = 0.011) for the Balthazar computed tomography severity index score. In our paediatric cohort, the severity of AP was best predicted by Balthazar computed tomography-based scoring scale. Our results confirm previously reported low sensitivity of adult-based clinical scoring scales.

Influence of Black and Brown Pigment Stone in Cholecystectomized Patients With Acute Biliary Pancreatitis.

BackgroundBiliary tract stones account for the majority of cases with acute pancreatitis, and include black and brown pigment stones. The aim of the study was to compare the presentation and outcome in cholecystectomized patients with acute biliary pancreatits caused by black and brown pigment stones.MethodData from patients with prior cholecystectomy and acute biliary pancreatitis were collected from January 2009 to August 2011. These cases were assigned to black or brown pigment stone groups according to the stone pattern. The general data, laboratory data, image findings and outcomes of the two groups were collected and analyzed.ResultsA total of 98 enrolled patients, with 30 (30.6%) and 68 cases (69.4%) assigned to the black and brown pigment stone groups, respectively. The cases with black pigment stone had higher CT Severity Index scores, bilirubin, ALP, ALT, rates of cholangitis, and positive blood culture. In those with brown pigment stone, there was a higher number of ERCP evaluations performed.ConclusionCholecystectomized cases with biliary pancreatitis due to black pigment stone had a higher prevalence of laboratory cholestasis and a higher rate of cholangitis.

Severe Acute Pancreatitis Requiring Drainage Therapy: Findings on Computed Tomography as Predictor of Patient Outcome

Background/Aims: To evaluate whether morphologic features on computed tomography (CT) correlate with outcome of patients with severe acute pancreatitis (SAP). Methods: 80 patients with SAP requiring percutaneous drainage therapy were retrospectively analyzed. Twelve CT features beyond the CT severity index (CTSI) were studied. Endpoints for patient outcome were patient death, length of hospital and ICU stay. The twelve features and the CTSI score were correlated with mortality using Kaplan-Meier estimator and correlated with length of hospital and ICU stay using the χ2 test. A p value ≤0.05 was considered statistically significant. Results: Two CT features exhibited a significant correlation with mortality: (1) the number of parts of pancreas (head, corpus, tail) that exhibited areas of necrosis and (2) the presence of distant fluid collections (posterior para renal space and/or paracolic gutter). Mortality was 42% (21 of 50 patients) and 20% (6 of 30 patients) if two/all three parts or none/one part of the pancreas exhibited necrosis, respectively. Mortality was 46% (18 of 39 patients) and 22% (9 of 41 patients) if distant fluid collections were present or absent, respectively. All other imaging features including the CTSI showed no significant correlation with patient outcome. Conclusion: We identified two morphologic features on CT that might be helpful to predict prognosis of patients suffering from SAP.

Clinical, Biochemical, and Radiologic Parameters at Admission Predicting Formation of a Pseudocyst in Acute Pancreatitis

To evaluate clinical, biochemical, and radiologic parameters at admission, which predict the development of acute pseudocyst (AP) after acute pancreatitis. There is limited data on factors that predict the development of AP. Seventy-five consecutive patients with AP were prospectively enrolled and subjected to clinical, laboratory, and radiologic investigation. The patients were followed up for a period of 4 weeks and then investigated radiologically for the development of AP. After exclusion, 65 patients (44 males) were studied. The median age was 37 years (40.9±15.5 y). Etiology of acute pancreatitis was alcohol in 24 patients, gallstones in 18, both in 4, drugs in 4, pancreas divisum in 2, postendoscopic retrograde cholangiopancreatography in 1, trauma in 1, and idiopathic in 11 patients. On admission, acute fluid collections were observed in 34 (52.31%) patients. Necrosis was noted in 38 (58.46%) patients (<30% necrosis, 30% to 50% necrosis, and >50% necrosis was observed in 36.8%, 26.3%, and 36.8% patients, respectively). On follow-up, 34 (52.3%) patients developed a pseudocyst. On univariate analysis, the factors significantly associated with pseudocyst formation were male sex, palpable mass, blood sugar greater than 150 mg/dL, necrosis, sepsis, acute fluid collections, presence of ascites, pleural effusion, a high grade of pancreatitis, and a high computed tomography severity index (CTSI) score. Multivariate regression analysis showed that male sex, presence of a palpable abdominal mass, ascites, and a high CTSI score were associated with the development of AP. Male sex, palpable mass, ascites, and a high CTSI score at admission can predict the development of a pseudocyst after an attack of acute pancreatitis. Acute pancreatitis patients with these parameters at admission should be closely followed for the development of a pseudocyst.

Comparison of Serum Procalcitonin with Ranson, APACHE-II, Glasgow and Balthazar CT Severity Index Scores in Predicting Severity of Acute Pancreatitis

The aim of this study is to assess serum procalcitonin (PCT) for early prediction of severe acute pancreatitis compared with multiple scoring systems and biomarkers. Forty-four patients with acute pancreatitis confirmed by radiological evidences, laboratory assessments, and clinical manifestation were prospectively enrolled. All blood samples and image studies were obtained within 24 hours of admission. Acute pancreatitis was graded as severe in 19 patients and mild in 25 patients according to the Atlanta criteria. Levels of serum PCT were significantly higher in severe acute pancreatitis (p=0.001). The accuracy of serum PCT as a predicting marker was 77.3%, which was similar to the acute physiology and chronic health examination (APACHE)-II score, worse than the Ranson score (93.2%) and better than the Balthazar CT index (65.9%). The most effective cut-off level of serum PCT was estimated at 1.77 ng/mL (AUC=0.797, 95% CI=0.658-0.935). In comparision to other simple biomarkers, serum PCT had more accurate value (77.3%) than C-reactive protein (68.2%), urea (75.0%) and lactic dehydrogenase (72.7%). Logistic regression analysis revealed that serum PCT has statistical significance in acute severe pancreatitis. Assessment of serum PCT levels and length of hospital stay by simple linear regression analysis revealed effective p-value with low R square level, which could make only possibilty for affection of serum PCT to admission duration (r2=0.127, p=0.021). Serum PCT was a promising simple biomarker and had similar accuracy of APACHE-II scores as predicting severity of acute pancreatitis.

Hepatic Steatosis May Predispose to More Severe Acute Pancreatitis

Purpose: Obesity is implicated in the severity and outcome of acute pancreatitis. The impact of abdominal fat and the influence of hepatic steatosis on the severity and outcome of the acute pancreatitis (AP) have not been studied. Hepatic dysfunction associated with obesity might enhance the systemic inflammatory response by altering the detoxification of inflammatory mediators. We aim to study the relationship of abdominal adiposity and hepatic steatosis with the severity and outcome of acute pancreatitis. Methods: A retrospective chart review on 108 (mean age 53 yrs, male 52%) of 257 patients with AP seen between January 2002 and December 2009 meeting the inclusion criteria were included. Ranson's and CT severity index score calculations were performed. Hepatic attenuation index (HSA) was obtained by calculating the ratio of hepatic to splenic attenuation (Hounsfield units); HSA < 1.0 was used to diagnose moderate to severe macrovesicular steatosis. Total abdominal fat was calculated using sagital and coronal reformation images on CT of the abdomen and pelvis using data from the superior end plate of T10 to the inferior symphysis pubis. Hounsfield units < - 200 HU and > -20 HU were excluded yielding total abdominal fat content; a histogram profile of this remaining volume using a post processing Workstation, GE AW 4.2 (GE Milwaukee, WI) was used to calculate the fat volume. Results: Etiology of AP was alcohol in 19 (17.6%), ERCP-induced 8 (7.4%), gallstone 42 (38.9%) and other etiologies 39 (36.1%). Based on Ranson's score at 48 hrs, 22 (20.4%) had severe AP (score ≥3), and of the 87(80.6%) subjects whose CT severity index was available 20 (23%) had severe AP (score ≥3). HSA < 1.0 was noted in 44 (40.7%) patients. The severity of pancreatitis on Ranson's criteria at 48 hrs (1.57±1.43 vs. 1.20±1.3, p=0.14) and by CT severity index (3.13±2.51 vs. 2.15±1.75, p=0.08) trended to be higher in patients with low-HSA (with fatty liver) compared to high-HSA (without fatty liver). When patients with ERCP induced pancreatitis were excluded, subjects with low-HSA had significantly more severe AP on CT severity index (3.21±2.5 vs. 2.12±1.8, p=0.04). Mean total abdominal fat content was not significantly different in patients with severe (score > 3) vs. milder (score < 3) pancreatitis by Ranson's criteria (15.6±6.7 vs. 13±4.7 liters, p=0.14). No significant difference was noted in the need for ICU admission (31.8% vs. 28.1%), fraction of patients with necrosis (13.6% vs. 12.5%) or pseudocyst formation (9.1 vs. 7.8%), or length of hospital stay (11.6±9.4 vs. 12.2±19.2, p=0.07) in patients with low-HSA and high-HSA. Conclusion: Patients with hepatic steatosis may be predisposed to more severe acute pancreatitis.

Safety and Efficacy of Video-Assisted Retroperitoneal Debridement for Infected Pancreatic Collections

The feasibility of video-assisted retroperitoneal debridement (VARD) for infected pancreatic walled-off necrosis is established. We provide prospective data on the safety and efficacy of VARD. Multicenter, prospective, single-arm phase 2 study. Six academic medical centers. We evaluated 40 patients with pancreatic necrosis who had infection determined using Gram stain or culture. Percutaneous drains were placed at enrollment, and computed tomographic scans were repeated at 10 days. Patients who had more than a 75% reduction in collection size were treated with drains. Other patients were treated with VARD. Crossover to open surgery was performed for technical reasons and/or according to surgeon judgment. Efficacy (ie, successful VARD treatment without crossover to open surgery or death) and safety (based on mortality and complication rates). Patients received follow-up care for 6 months. We enrolled 40 patients (24 men and 16 women) during a 51-month period. Median age was 53 years (range, 32-82 years). Mean (SD) Acute Physiology and Chronic Health Evaluation II score at enrollment was 8.0 (5.1), and median computed tomography severity index score was 8. Of the 40 patients, 24 (60%) were treated with minimally invasive intervention (drains with or without VARD). Nine patients (23%) did not require surgery (drains only). For 31 surgical patients, VARD was possible in 60% of patients. Most patients (81%) required 1 operation. In-hospital 30-day mortality was 2.5% (intent-to-treat). Bleeding complications occurred in 7.5% of patients; enteric fistulas occurred in 17.5%. This prospective cohort study supports the safety and efficacy of VARD for infected pancreatic walled-off necrosis. Of the patients, 85% were eligible for a minimally invasive approach. We were able to use VARD in 60% of surgical patients. The low mortality and complication rates compare favorably with open debridement. An unexpected finding was that a reduction in collection size of 75% according to the results of computed tomographic scans at 10 to 14 days predicted the success of percutaneous drainage alone.

Comparison of BISAP, Ranson's, APACHE-II, and CTSI Scores in Predicting Organ Failure, Complications, and Mortality in Acute Pancreatitis

Identification of patients at risk for severe disease early in the course of acute pancreatitis (AP) is an important step to guiding management and improving outcomes. A new prognostic scoring system, the bedside index for severity in AP (BISAP), has been proposed as an accurate method for early identification of patients at risk for in-hospital mortality. The aim of this study was to compare BISAP (blood urea nitrogen >25 mg/dl, impaired mental status, systemic inflammatory response syndrome (SIRS), age>60 years, and pleural effusions) with the "traditional" multifactorial scoring systems: Ranson's, Acute Physiology and Chronic Health Examination (APACHE)-II, and computed tomography severity index (CTSI) in predicting severity, pancreatic necrosis (PNec), and mortality in a prospective cohort of patients with AP. Extensive demographic, radiographic, and laboratory data from consecutive patients with AP admitted or transferred to our institution was collected between June 2003 and September 2007. The BISAP and APACHE-II scores were calculated using data from the first 24 h from admission. Predictive accuracy of the scoring systems was measured by the area under the receiver-operating curve (AUC). There were 185 patients with AP (mean age 51.7, 51% males), of which 73% underwent contrast-enhanced CT scan. Forty patients developed organ failure and were classified as severe AP (SAP; 22%). Thirty-six developed PNec (19%), and 7 died (mortality 3.8%). The number of patients with a BISAP score of > or =3 was 26; Ranson's > or =3 was 47, APACHE-II > or =8 was 66, and CTSI > or =3 was 59. Of the seven patients that died, one had a BISAP score of 1, two had a score of 2, and four had a score of 3. AUCs for BISAP, Ranson's, APACHE-II, and CTSI in predicting SAP are 0.81 (confidence interval (CI) 0.74-0.87), 0.94 (CI 0.89-0.97), 0.78 (CI 0.71-0.84), and 0.84 (CI 0.76-0.89), respectively. We confirmed that the BISAP score is an accurate means for risk stratification in patients with AP. Its components are clinically relevant and easy to obtain. The prognostic accuracy of BISAP is similar to those of the other scoring systems. We conclude that simple scoring systems may have reached their maximal utility and novel models are needed to further improve predictive accuracy.

Percutaneous necrosectomy in patients with acute, necrotizing pancreatitis

The objective of this retrospective study was to evaluate the outcome of patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy. By searching the radiological, surgical and internal medicine databases, all patients with acute necrotizing pancreatitis treated by active percutaneous necrosectomy between 1992 and 2004 were identified. Demographic, laboratory, and clinical data, and details about invasive procedures were collected by reviewing patient charts, radiological and surgical reports. The computed tomography severity index (CTSI) scores were determined by reviewing CT images. Eighteen patients were identified. Median Ranson score on admission was 2. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was median 22. Median CTSI score was 7. Initially all patients were treated with CT-guided drainage placement. Because passive drainage proved not to be effective, subsequent minimally invasive, percutaneous necrosectomy was performed. Eight out of 18 patients recovered fully without the need for surgery. Ten of 18 patients required additional surgical necrosectomy. For one of ten patients, percutaneous necrosectomy allowed postponing surgery by 39 days. Four of ten surgically treated patients died: three from septic multiorgan failure, one from pulmonary embolism. Percutaneous minimally invasive necrosectomy can be regarded as a safe and effective complementary treatment modality in patients with necrotizing pancreatitis. It is suitable for a subset of patients to avoid or delay surgery.

Case‐Matched Comparison of the Retroperitoneal Approach With Laparotomy for Necrotizing Pancreatitis

Minimally invasive necrosectomy through a retroperitoneal approach is gaining popularity for the treatment of necrotizing pancreatitis. There is, however, no substantial evidence from comparative studies in favor of this technique over laparotomy. The aim of this case-matched study was to perform the first head-to-head comparison of necrosectomy by the retroperitoneal approach with laparotomy in patients with necrotizing pancreatitis. Between 2001 and 2005, there were 15 of 841 consecutive acute pancreatitis patients who underwent necrosectomy by the retroperitoneal approach using a small flank incision. These patients were matched for the presence of preoperative organ failure, status of infection, timing of surgery, age, and computed tomography severity index score with 15 of 46 patients treated with necrosectomy by laparotomy and continuous postoperative lavage (CPL). In addition to all matched preoperative characteristics, there were no significant differences in sex, preoperative intensive care unit (ICU) admission, preoperative ICU stay, preoperative APACHE-II scores, and preoperative multiple organ failure (MOF). Postoperative complications requiring reintervention occurred in six patients in each group (p = 1.000). Postoperative new-onset MOF occurred in 10 patients in the laparotomy/CPL group versus 2 patients in the retroperitoneal approach group (p = 0.008). Six patients died in the laparotomy/CPL group versus 1 patient in the retroperitoneal approach group (p = 0.080). The less postoperative organ failure and the trend toward lower mortality may point to a benefit of the retroperitoneal approach over laparotomy. A randomized controlled design is, however, still required to answer definitively the question of which operative technique is preferably for patients with (infected) necrotizing pancreatitis.

Clinical Significance of Pulmonary Function Tests in Patients with Acute Pancreatitis

The aim of the present study was to investigate changes in pulmonary function tests (PFTs) in patients with acute pancreatitis (AP), to compare them with those changes in healthy controls, and to analyze the relationship between these parameters and computed tomography severity index (CTSI) and Ranson's criteria scores as markers of disease severity. This study included 40 patients with AP without a diagnosis of any pulmonary disease and 40 sex- and age-matched healthy controls. All participants were evaluated with simple PFTs and single-breath carbon monoxide (CO) diffusion tests. Patients with AP were also evaluated according to their CTSI and Ranson's criteria scores as markers of disease severity. The forced vital capacity (FVC), forced expiratory volume in the first second (FEV(1)), FEV(1)/FVC, and peak expiratory flow, which determine lung capacity, were similar in the two groups. The forced expiratory volume during the middle half of the FVC (FEF(25 - 75%)), CO diffusing capacity (D(LCO)), and ratio of D(LCO) to alveolar ventilation (D(LCO)/V(A)), which determines alveolar membrane permeability, revealed a statistically significant decline in pulmonary gas exchange in patients with AP (P < 0.05). Correlation analysis showed that there is a significant negative relationship between CTSI and Ranson's criteria scores with FEF(25 - 75%), D(LCO), and D(LCO)/V(A) (P < 0.05). We suggest that AP may cause impaired alveolar gas exchange without manifest pulmonary diseases. The effect of AP on FEF(25 - 75%), D(LCO), and D(LCO)/V(A) appears to be dependent not only on the disease, but also on its severity. FEF(25 - 75%), D(LCO), and D(LCO)/V(A) may give additional prognostic information in patients with AP in the initial evaluation.

Long-Term Outcomes after Post-ERCP Pancreatitis

Purpose: The long-term sequelae of a single episode of pancreatitis is not well defined. The dogma is that once the inciting event is removed, the pancreas should fully recover and not lead to any chronic parenchymal/ductal changes or symptoms of chronic pancreatitis. Aim: To assess the clinical long-term pancreatic sequelae in patients developing acute post-ERCP pancreatitis. Methods: Endoscopic and medical records of patients undergoing ERCP during a 12 year period were reviewed. Those with post-ERCP pancreatitis were selected and clinical, laboratory and radiological information suggestive of chronic pancreatitis was sought and retrieved. Severity of post-ERCP pancreatitis was defined by clinical (presence of end-organ failure), radiological criteria (CT severity index score) and/or length of stay in the hospital. Long-term sequelae of pancreatic dysfunction including chronic pancreatitis was defined: a) clinically by the presence of either chronic pancreatic-type of pain, malabsorption (weight loss; fat in stools; chronic diarrhea); b) radiographically by the presence of pancreatic calcifications, abnormal pancreatic duct anatomy, distal CBD stricture compatible with chronic pancreatitis; and/or c) EUS criteria, developing after the index episode. Results: Of 2104 ERCPs there were 48 where patients developed post-ERCP pancreatitis (2.2%) of which 4 patients (0.1%) had severe pancreatitis based on presence of organ failure and/or CT criteria, and/or length of stay. Ten patients had prior evidence of chronic pancreatitis and thus were excluded. The mean follow up for the remaining 38 patients was 57.5 months. Of the 4 patients with severe post-ERCP pancreatitis, 2 died, 1 developed recurrent pancreatitis secondary to a suspected sphincter of Oddi dysfunction and the other did not developed any clinical long-term sequelae. Of the remaining 34 patients with post-ERCP pancreatitis, 2 were diagnosed with pancreatic cancer (one primary and the other metastatic from renal cell carcinoma) shortly after the episode. Clinically, none of the 32 remaining patients had symptoms compatible with chronic pancreatitis; 22 had plain X rays and none showed pancreatic calcifications; and 15 had repeated CT scans and none had pancreato/biliary abnormalities. Conclusions: Similar to what is described in gallstone pancreatitis, the development of chronic pancreatic sequelae after an episode of post-ERCP pancreatitis seems to be rare (non-existing in our limited series). Larger studies are required to assess the true incidence of chronic pancreatic sequelae after post-ERCP pancreatitis.