Elevated Lipase Levels Research Articles

Pancreatic abscess within hepato-gastric ligament: case report of an extremely rare disease

BackgroundPancreatic pseudocyst is a very common benign cystic lesion of the pancreas. It develops in 5–15% of patients with peri-pancreatic fluid collection following acute pancreatitis. Collection usually occurs within the lesser sac of the omentum (near the pancreatic head and body region). But in 20–22% cases, that may be extra-pancreatic like in the mediastinum, pleura, in the peritoneal cavity including the pelvis. The pancreatic pseudocyst typically contains brownish fluid with necrotic tissue sludge which may get infected giving rise to infected pseudocyst or pancreatic abscess. The present case is an unusual condition of a young alcoholic subject who was finally diagnosed as a case of a pancreatic abscess within hepato-gastric ligament and was managed with operative intervention.To the best of the author’s knowledge, it is the first-ever reported case of a pancreatic abscess within the hepato-gastric ligament in the world. Literature was reviewed to explore potential etiopathogenesis and therapeutic strategies of this extremely rare condition.Case presentationA 38 years old gentleman, chronic alcoholic, having a previous history of acute pancreatitis 3 months back, presented with fever (102 degrees Fahrenheit) and a huge [20 cm (horizontal) X 15 cm (vertical)] severely painful swelling in the epigastric region. The swelling was round-shaped, intra-abdominal, fixed to deeper tissue, tense-cystic, poorly trans-illuminant, non-pulsatile and irreducible. Routine blood tests showed leucocytosis (14,500/mm3) with neutrophilia and elevated plasma pancreatic amylase and lipase levels. USG and MDCT scan of the whole abdomen revealed a thick-walled echogenic cystic swelling of size 18 cm × 12 cm in the epigastric region. USG guided aspiration of the cyst revealed mixed purulent brownish fluid. The cyst fluid was negative for mucin stain and contained high amylase level with low CEA level, suggesting infected pancreatic pseudocyst.An open drainage procedure was considered through an upper midline laparotomy. Aspiration of the pus mixed cyst fluid along with tissue debris was done. Through irrigation of the cyst was done with normal saline. The cyst wall was de-roofed leaving a small part adherent to the inferior surface of the left lobe of the liver. Later the cyst fluid culture showed significant growth of Escherichia coli. He was put on IV antibiotics. The patient was discharged in a stable condition after 5 days. The histopathological examination confirmed pancreatic abscess.Six months after the operation, the patient is doing well, remaining asymptomatic and there is no sign of recurrence.ConclusionsDue to extreme rarity, pancreatic abscess formation within hepato-gastric ligament may be a diagnostic dilemma and requires a high index of suspicion. Surgeons should be aware of this rare clinical entity for prompt management of potential morbidity.

A Cutaneous Clue to a Tropical Cause of Acute Pancreatitis: Scrub Typhus

A 48-year-old man presented with 2-week history of epigastric pain with radiation to back and fever. He was referred for elevated amylase (794 U/L) and lipase (550 U/L) levels and evidence of peripancreatic stranding on ultrasound. At presentation he was febrile (39.5°C) and had tachycardia (118/min) and tachypnea (respiratory rate, 28/min). On clinical examination, he had hepatomegaly, no lymphadenopathy, and no abdominal lump. An eschar was also noted over the right anterior axillary line (Figure A).

Pseudo-Wellens syndrome, acute pancreatitis, and an anomalous coronary artery: a case report

BackgroundChest pain associated with transient electrocardiogram changes mimicking an acute myocardial infarction have been described in acute pancreatitis. These ischemic electrocardiogram changes can present a diagnostic dilemma, especially when patients present with concurrent angina pectoris and epigastric pain warranting noninvasive or invasive imaging studies.Case presentationA 45-year-old African-American man with a history of alcohol use disorder presented to the emergency department of our institution with 36 hours of concurrent epigastric pain and left-sided chest pain radiating to his left arm and associated with nausea and dyspnea. On physical examination, he was afebrile; his blood pressure was elevated; and he had epigastric tenderness. His laboratory test results were significant for hypokalemia, normal troponin, and elevated serum lipase and amylase levels. Serial electrocardiograms for persistent chest pain showed ST-segment elevations with dynamic T-wave changes in the right precordial electrocardiogram leads, consistent with Wellens syndrome. He was immediately taken to the cardiac catheterization laboratory, where selective coronary angiography showed normal coronary arteries with an anomalous origin of the right coronary artery from the opposite sinus. Given his elevated lipase and amylase levels, the patient was treated for acute alcohol-induced pancreatitis with intravenous fluids and pain control. His chest pain and ischemic electrocardiogram changes resolved within 24 hours of admission, and coronary computed tomography angiography showed an interarterial course of the right coronary artery without high-risk features.ConclusionsClinicians may consider deferring immediate cardiac catheterization and attribute electrocardiogram changes to acute pancreatitis in patients presenting with angina pectoris and acute pancreatitis if confirmed by normal cardiac enzymes and elevated levels of lipase and amylase. However, when clinical signs and electrocardiogram findings are highly suggestive of myocardial ischemia/injury, immediate noninvasive coronary computed tomography angiography may be the best approach to make an early diagnosis.

Ultrasonographic Evaluation of Fatty Pancreas in Serbian Patients with Non Alcoholic Fatty Liver Disease-A Cross Sectional Study.

Background and Objectives: The aim of the study was to determine the association between presences of fatty pancreas (FP) with the features of metabolic syndrome (MeS) in patients with non–alcoholic fatty liver disease (NAFLD) and to establish a new noninvasive scoring system for the prediction of FP in patients with NAFLD. Material and Methods: 143 patients with NAFLD were classified according to FP severity grade into the two groups and evaluated for diagnostic criteria of MeS. All patients underwent sonographic examination with adiposity measurements and the liver biopsy. Liver fibrosis was evaluated semi-quantitatively according to the METAVIR scoring system and using non-invasive markers of hepatic fibrosis. Results: Waist circumference (WC) was predictive for increased risk of FP in NAFLD patients. Elevated fasting plasma glucose, total cholesterol, serum amylase and lipase levels were associated with presence of severe FP (p value = 0.052, p value = 0.007, p value = 0.014; p value = 0.024, respectively). Presence of increased amounts of mesenteric fat was associated with severe FP (p value = 0.013). The results of this study demonstrated highly significant association between NAFLD and presence of FP. The model for predicting the presence of FP was designed with probability value above 6.5. Conclusion: Pancreatic fat accumulation leads to worsening of pancreatic function which in turns exacerbates severity of metabolic syndrome associated with both, NAFLD and NAFPD.

3036 Alcohol Consumption Increases Risk of Pancreatitis in Celiac Disease: A Case Report

INTRODUCTION: Celiac disease is an autoimmune disorder of small intestine that improves significantly with gluten free diet. It is reported that patients with celiac disease are associated with increased risk of hepatobiliary and pancreatic diseases. In patients with celiac disease, alcohol further increases the risk of pancreatitis. CASE DESCRIPTION/METHODS: 35 year old female with history of celiac disease and alcohol abuse presented to us with abdominal pain, nausea and vomiting for 1 week. Pain was generalized, characterized as sharp and stabbing. She admitted drinking half a bottle of vodka daily for pevious few weeks and has been dealing with alcohol abuse for many years. Initial labs showed hyponatremia 125, Hypokalemia 2.4, Ethanol 280 and lipase 500. CT Abdomen was unremarkable. Patient IGA was elevated with Tissue transglutaminase IgA level more than 250. Patient was diagnosed with acute pancreatitis and was treated with supportive management. Patient previous pathology showed villous blunting and intraepithelial lymphocytes suspected for non-compliance with gluten free diet. Patient symptoms and labs improved significantly during hospitalization and was discharged home. Unfortunately, patient was admitted within a week with similar symptoms of abdominal pain with hyponatremia, hypokalemia, and elevated lipase but Ethanol level was less than 10. Patient was again treated conservatively for recurrent pancreatitis and discharged home with counselling for gluten free diet and alcohol cessation. DISCUSSION: Celiac disease is an autoimmune disease with abnormal response of the small intestine to the gluten, widely present in our diet. Patient may present with vomiting, abdominal pain, nausea, flatulence, weight loss or diarrhea. It has been reported that almost 20% of the patients with celiac disease are associated with pancreatitis and pancreatic inflammation. It is believed that impaired release of pancreatic stimulating hormones from the pancreas due to inflammed proximal small bowel may be responsible. However, it has also been reported that papillary stenosis may be responsible for the pancreatic inflammation present in the celiac disease. Alcoholic patients with celiac disease have several fold increased risk of development of pancreatitis and pancreatic inflammation and are counselled to avoid or reduce the alcohol intake.

1262 A Rare Case of Pleural Effusion Due to a Pancreatico-Pleural Fistula in the Setting of Pancreas Divisum

INTRODUCTION: A pancreatico pleural fistula is a rare complication of pancreatitis which classically results from a pancreatic duct disruption or a pseudocyst extension into the pleural cavity. The literature present on this condition continues to remain sparse. We attempt to present a rare case of a pancreatico-pleural fistula in the setting of a congenital pancreatic anomaly which initially presented as a recurrent pleural effusion in the setting of chronic pancreatitis. CASE DESCRIPTION/METHODS: Our patient was a 51-year-old female who presented with intractable abdominal pain and shortness of breath with a confirmed diagnosis of a pancreatic pseudocyst. On admission, her chest Xray was significant for pleural effusion. Further analysis of the pleural fluid revealed the presence of elevated lipase and amylase levels. The patient eventually underwent an ERCP with contrast that revealed contrast leakage tracking upwards from the dorsal pancreatic duct suggesting a pancreatico-pleural fistula. This was in addition to the inability to fill the ventral pancreatic duct, suggesting a complete pancreatic divisum. A pancreatic duct plastic stent was placed and the pleural effusion gradually subsequently subsided. DISCUSSION: The case allows us to consider one of the lesser known etiologies of pleural effusion in the setting of pancreatitis (the other one being transdiaphragmatic lymphatic blockage) and provides us with an opportunity to develop a step to manage the same. This is the only known case report of a pancreatico-pleural fistula with a concomitant complete pancreatic divisum.

Linoleic acid in diets of mice increases total endocannabinoid levels in bowel and liver: modification by dietary glucose.

SummaryAimLinoleic acid (LA) is an essential fatty acid involved in the biosynthesis of arachidonic acid and prostaglandins. LA is known to induce obesity and insulin resistance. In this study, two concentrations of LA with or without added glucose (G) were fed to mice to investigate their effects on endocannabinoid (EC) biology.Materials and MethodsFour groups of C57BL/6 mice were provided with diets containing 1% or 8% LA with or without added G (LAG) for 8 weeks. Body weights, food intake, circulating glucose and insulin levels were measured throughout the study. Following euthanasia, plasma, bowel and hepatic ECs, monoacylglycerol lipase and fatty acid amide hydroxylase protein levels (enzymes responsible for EC degradation) and transcriptional activity of PPARα in liver were quantified. Liver was probed for evidence of insulin receptor activity perturbation.ResultsIncreasing dietary LA from 1% to 8% significantly increased circulating, small bowel and hepatic ECs. 1%LAG fed mice had lowest feed efficiency, and only liver levels of both ECs were reduced by addition of G. Addition of G to 1% LA diets resulted in elevated monoacylglycerol lipase and fatty acid amide hydroxylase protein levels (p < 0.001 and p < 0.001, respectively) in liver due to increased transcriptional activity of PPARα (p < 0.05). The reduced EC levels with addition of G also correlated with a measure of enhanced insulin action.ConclusionIn conclusion, body weight of mice is influenced by the source of calorie intake. Furthermore, tissue EC/g are dependent on tissue‐specific synthesis and degradation that are modulated by dietary LA and G which also influence food efficiency, and down‐stream insulin signalling pathways. The findings could potentially be useful information for weight management efforts in humans.

Antidiabetic and Hypolipidemic Effects of a Novel Dual Peroxisome Proliferator-Activated Receptor (PPAR) α/γ Agonist, E3030, in db/db Mice and Beagle Dogs

We investigated the antidiabetic effects of E3030, which is a potent dual activator of peroxisome proliferator-activated receptor (PPAR) α and PPARγ, in an animal model of diabetes, C57BL/KsJ-db/db mice (db/db mice), and the lipidemic effects of E3030 in beagle dogs, whose PPARα and PPARγ transactivation responses to E3030 were similar to those of humans. E3030 activated human PPARα, mouse PPARα, dog PPARα, human PPARγ, mouse PPARγ, and dog PPARγ with EC50 values of 65, 920, 87, 34, 73, and 34 nM, respectively, in the chimeric GAL4-PPAR receptor transactivation reporter assay. In db/db mice orally administered E3030 decreased blood glucose, triglyceride (TG), non-esterified fatty acids (NEFA), and insulin levels and increased blood adiponectin levels during a 14-day experimental period. Significant effects on blood glucose and adiponectin levels were observed at a dose of 3 mg/kg or greater. Furthermore, significant effects on blood TG, NEFA, and insulin levels were observed at doses of 1 mg/kg or more. An oral glucose tolerance test (OGTT) performed on Day 15 showed that E3030 at 3 mg/kg improved glucose tolerance in this model. Fourteen days of oral treatment with E3030 at a dose of 0.03 mg/kg or greater showed remarkable TG- and non high-density lipoprotein (non-HDL) cholesterol–lowering effects in beagle dogs. These results were similar to those observed for the PPARα agonist fenofibrate. E3030 also reduced apo C-III levels on Days 7 and 14, and elevated lipoprotein lipase (LPL) levels on Day 15. These results indicate that the TG- and non-HDL cholesterol-lowering actions of E3030 involve combined effects on reduction of apo C-III and elevation of LPL, resulting in increased lipolysis. The experimental results in animals suggest that E3030 has potential for use in the treatment of various aspects of metabolic dysfunction in type 2 diabetes, including dyslipidemia, hyperglycemia, hyperinsulinemia, and impaired glucose disposal.

Antibiotic therapy in acute pancreatitis: From global overuse to evidence based recommendations

BackgroundUnwarranted administration of antibiotics in acute pancreatitis presents a global challenge. The clinical reasoning behind the misuse is poorly understood. Our aim was to investigate current clinical practices and develop recommendations that guide clinicians in prescribing antibiotic treatment in acute pancreatitis. MethodsFour methods were used. 1) Systematic data collection was performed to summarize current evidence; 2) a retrospective questionnaire was developed to understand the current global clinical practice; 3) five years of prospectively collected data were analysed to identify the clinical parameters used by medical teams in the decision making process, and finally; 4) the UpToDate Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was applied to provide evidence based recommendations for healthcare professionals. ResultsThe systematic literature search revealed no consensus on the start of AB therapy in patients with no bacterial culture test. Retrospective data collection on 9728 patients from 22 countries indicated a wide range (31–82%) of antibiotic use frequency in AP. Analysis of 56 variables from 962 patients showed that clinicians initiate antibiotic therapy based on increased WBC and/or elevated CRP, lipase and amylase levels. The above mentioned four laboratory parameters showed no association with infection in the early phase of acute pancreatitis. Instead, procalcitonin levels proved to be a better biomarker of early infection. Patients with suspected infection because of fever had no benefit from antibiotic therapy. ConclusionsThe authors formulated four consensus statements to urge reduction of unjustified antibiotic treatment in acute pancreatitis and to use procalcitonin rather than WBC or CRP as biomarkers to guide decision-making.

Management of Acute Necrotizing Pancreatitis through Ayurveda Regimen: A Case Report

Necrotizing pancreatitis is an extreme complication of acute pancreatitis. Acute pancreatitis is an inflammation of the pancreas. Pancreas sits behind the stomach. One of its main functionsis to make enzymes that help in digest the food. Normally, those enzymes flow through a small opening into small intestines. If pancreas becomes inflamed, the enzymes can start to leak into parts of the pancreas instead. These enzymes can sometimes kill pancreatic tissue, resulting in necrotizing pancreatitis. The dead tissue can get infected and cause life-threatening complications. Cardinal symptoms are abdominal pain (boring nature), nausea, vomiting, and tenderness in abdomen, pain worsened after eating, steatorrhea and weight loss. Assessments were made using Elevated levels of Serum Amylase and Lipase. In modern science, management is Lifelong enzymes, Periodical Emergency hospitalisation, IV fluids, painkillers, anti-inflammatory, andantibiotics, ERCP stunting, surgical intervention. It involves high cost, side effects and in many cases, there is progression of disease leading to fear, frustration and debility among sufferers. In Ayurveda three doshas are described as Vata, Pitta, Kapha. Pitta dosha we have substances exactly similar to enzymes. The features of acute pancreatitis are similar to the features of pitta where tikshna and ushna guna of pitta are aggravated. The observations reveal that, Ayurvedic regimen can play a key role in the management of conditions like pancreatitis. A 25years old male patient diagnosed with acute necrotizing pancreatitis. At the end of the treatment, there was considerable improvement in the subjective and objective criterias. The treatment strategies followed in this study can be safely adopted under the supervision of competent specialist.

Cerulein-induced chronic pancreatitis in Swiss albino mice: An improved short-term model for pharmacological screening

There is a need for short-term, reliable and reproducible animal model of chronic pancreatitis (CP) in small animals like mice. This study was aimed to establish the 9 exposures of cerulein-induced CP in mice. Repeated intraperitoneal cerulein injections were performed at 6 consecutive doses (50 μg/kg)/day, 3 days a week for 3 weeks to induce chronic pancreatitis in Swiss albino mice. The severity of damage was assessed by biochemical assays and histopathology. The expression of pro-inflammatory cytokine and fibrotic proteins was assessed by IHC and western blotting. The cerulein treated mice showed significantly elevated plasma amylase (p < .0285) and lipase levels (p < .0022) and resulted in significantly increased pancreatic oxidative (p < .0022) and nitrosative (p < .0022) stress. The hydroxyproline levels were 3.06 fold increased in the cerulein treated mice. The expressions of fibrotic cytokine TGF-β1 by 1.8 folds and pro-inflammatory cytokines TNF-α by 2.3 fold, IL-6 by 2.2 fold and IL-1β by 3.7 fold were markedly increased in cerulein treated mice. The histological evaluations indicated increased inflammatory cells infiltration and deposition of collagen. Moreover, the expression of fibrotic markers such as α-SMA increased by 2.5 folds (p < .00014), collagen1a by 1.3 folds (p < .0258) and fibronectin by 3.5 folds (p < .00014) were significantly increased. Our study demonstrates the superiority of 9 exposures of cerulein-induced CP model in mice with the reduction of duration, cerulein exposure, more economical and mortality rate of mice over the available models. Therefore, our model may be suitable to evaluate the pharmacological effects of new drugs in chronic pancreatitis.

Superfluous Amylase/Lipase Testing at a University-Affiliated Teaching Hospital: A Retrospective Review.

Background: The combination of amylase and lipase tests for diagnosing acute pancreatitis is not better than a lipase test alone; however, both tests are commonly ordered simultaneously. Further, although no data indicate usefulness of monitoring changes in elevated amylase and lipase levels, the tests are often ordered multiple times during the same clinical encounter. Methods: We retrospectively reviewed all amylase and lipase tests performed at a university-affiliated teaching hospital during a 6-month period. We considered amylase and lipase results diagnostic if they were >3 times the upper limit of normal and borderline if they were ≤3 times the upper limit of normal. During a single clinical encounter, we considered amylase tests superfluous if ordered simultaneously with lipase tests or repeated after diagnostic results, questionably superfluous if repeated alone, and nonsuperfluous otherwise. Lipase tests were considered superfluous if repeated after diagnostic results, questionably superfluous if repeated after nondiagnostic results, and nonsuperfluous otherwise. Results: In this study, 3,502 patients had 8,801 tests (4,926 lipase, 3,875 amylase), 4% of which were diagnostic and 10% borderline. Of the 8,801 tests, 45% were superfluous and 9% were questionably superfluous. Nonsuperfluous testing was less frequent (P<0.0001) in the intensive care/stepdown units (22% of 748 tests) than in the emergency department (54% of 6,000 tests) or other settings (31% of 2,053 tests). Among 3,545 simultaneous amylase/lipase tests with nondiagnostic lipase results, 0.6% amylase results were diagnostic. Of the 190 lipase tests repeated after nondiagnostic lipase results, 12% were diagnostic. Conclusion: Superfluous amylase/lipase testing in one teaching hospital is substantial, suggesting significant potential for reducing healthcare costs without compromising the quality of care when evaluating patients for acute pancreatitis.

Hedgehog Pathway Inhibitor for Treatment of Steroid-Refractory Sclerodermatous Chronic Graft-Versus-Host Disease (GVHD)

Background: Sclerodermatous chronic GVHD (scGVHD) is a unique form of cutaneous GVHD that predominantly involves the skin, subcutaneous tissue, fascia and joints. Steroid-refractory scGVHD is especially challenging to manage since it is usually a progressive condition with devastating effects on the quality of life of affected patients. Inhibition of hedgehog signaling has been shown to be effective in the treatment of murine scGVHD. Here, we report a retrospective review of patients with scGVHD who were treated with hedgehog pathway inhibitor, Vismodegib, at Stanford University.Results: A total of n=8 patients with steroid-refractory scGVHD were treated with Vismodegib 150 mg daily as an off-label use since 2016. The male:female ratio is 5:3 and median age was 49 (range 39-62) at time of start of Vismodegib. The median time from transplant to diagnosis of scGVHD was 26.9 months (range 8.9-37.5) and the median time from diagnosis of scGVHD to Vismodegib treatment was 14.4 months (range 2.7-45.2). All patients had GVHD involvement of other organ besides scGVHD and have received multiple lines of therapy prior to Vismodegib.Hair thinning/alopecia and muscle cramps were noted in 100% of the patients. 75% (6/8) had dysgeusia, 88% (7/8) had fatigue (gr 2) and 1 patient had an asymptomatic elevated lipase level. All patients required dose reduction or drug holiday due to side effects (mainly muscle cramps). Four patients (50%) stopped the drug due to side effects (2/4) or lack of response (2/4). All Vismodegib-related side effects resolved after discontinuation of the drug. The median duration of Vismodegib treatment was 6.1 months (range 2.3-17.1) for the entire group. One patient received multiple courses of Vismodegib with benefit noted with each course.Five patients (63%) had partial response including 1 patient responded to multiple courses of Vismodegib and 1 patient had subjective symptom improvement. The median time to clinical response was 103 days (range 24-145) and the duration of response was 7.8 months (range 1.6-13.4). Three patients had experienced prolonged clinical response off the Vismodegib. At the last follow-up visit, all patients were alive and 4 patients continued to take Vismodegib including 1 patient who had been tapered off systemic steroid.Conclusion: Steroid-refractory scGVHD is an extremely difficult disease to manage with a high rate of morbidity. Our experience with hedgehog pathway inhibitor, Vismodegib, is very encouraging. Additional study to evaluate the optimal dosing, side effects and its efficacy is under way. DisclosuresNo relevant conflicts of interest to declare.

Superfluous Amylase/lipase Testing at University-Affiliated Teaching Hospital: Retrospective Review: Presidential Poster Award

Introduction: The combination of amylase and lipase in diagnosing acute pancreatitis is not better than lipase alone, however, both tests are commonly ordered simultaneously. Further, although there are no data to indicate usefulness of monitoring changes in elevated amylase and lipase levels, they are often ordered multiple times throughout the same single clinical encounter. The clinical utility of repeating amylase and lipase tests after an initially non-diagnostic result is not well studied. We explored the extent of superfluous amylase/lipase testing at the Boca Raton Regional hospital (BRRH), a university-affiliated teaching hospital in Florida. Methods: We retrospectively reviewed all amylase and lipase tests that were performed at the BRRH laboratory over a 6-month period. We considered amylase and lipase results diagnostic or borderline if they were ? or ≤ 3 x upper normal limits, respectively. During a single clinical encounter, we considered amylase tests superfluous if they were ordered simultaneously with lipase tests or repeated after diagnostic results, questionably superfluous if they were repeated alone, and non-superfluous otherwise, and lipase tests superfluous if they were repeated after diagnostic results, questionably superfluous if they were repeated after non-diagnostic results, and non-superfluous otherwise. Results: During up to 10 clinical encounters, 3502 patients had 8801 tests (4926 lipase, 3875 amylase), 4% of which were diagnostic and 10% borderline. Out of the 8801 tests, 45% were superfluous and 9% questionably superfluous. Non-superfluous testing was less frequent (p <0.0001) in the intensive care/step down units (22% of 748 tests) than emergency department (54% of 6000 tests) or other settings (31% of 2053 tests). Among 3545 simultaneous amylase/lipase tests with non-diagnostic lipase results, 0.6% of amylase results were diagnostic. Of the 190 lipase tests repeated after non-diagnostic lipase results, 13% were diagnostic. Conclusion: Superfluous amylase/lipase testing in one teaching hospital is substantial; there is large room for reducing healthcare cost without compromising quality of care when evaluating patient for pancreatitis.

Cannabis as an Overlooked Cause of Acute Pancreatitis: A Case Report and Literature Review

Biliary tract disease, ethanol abuse, infections, autoimmunity, and genetics are well known causes of Acute Pancreatitis (AP). However, in 20% of acute pancreatitis cases, the workup still fails to reveal an etiology and these cases are labeled as idiopathic. Cannabis use is emerging as a rare and overlooked cause of idiopathic acute pancreatitis with few cases reported in literature to date. Here we present a case of an 18-year-old African American female with a history of Ventral Septal Defect who presented to our hospital with epigastric abdominal pain radiating to the back for 2 days associated with nausea and non-bloody emesis. On physical exam, tenderness to light palpation was noted in the epigastrium and RUQ region. The clinical presentation along with laboratory data showed an elevated lipase level of 812 U/L and amylase of 481 U/L confirming the diagnosis of an acute pancreatitis. The rest of her laboratory data was significant for Hgb 11.5g/dL, Hct 36.7%, MCV 75.3, creatine kinase 461, and calcium level of 8.9 mg/dL. Urine toxicology was positive for cannabinoids and upon further exploration, patient admitted to smoking marijuana twice a week for the past two months. Her home medications included depot-medroxyprogesterone for contraception and she denied taking over the counter supplements or any other illicit drugs. Her last alcoholic drink was 2 weeks earlier and abdominal ultrasound ruled out cholelithiasis and choledocholithiasis. Immunoglobulins with IgG4 subclass was normal and her triglyceride level was 65 mg/dL. Patient was hospitalized and treated with supportive care with resolution of her presenting symptoms without recurrence of her pancreatitis to date. Only five cases of cannabis-induced acute pancreatitis (AP) have been reported in the United States till 2017. Literature reviewed has showed that only 26 cases of cannabis-induced AP have been reported worldwide. Patients in majority of these cases were males under the age of 35 years. In our case study, the patient was an eighteen-year-old female, which is a rarely reported gender population. In conclusion, we feel that health care providers should include cannabis in their differential diagnosis of idiopathic AP cases, particularly in patients under 35 years of age.

Remnant choledochal cyst with symptomatic cystolithiasis

Introduction: This case is a rare presentation owing to stone formation in remnant intrapancreatic choledochal cyst, causing an episode of acute pancreatitis. Case report: A 23 year old female who underwent bile duct excision with roux en y hepaticojejunostomy for type 4a choledochal cyst in 2003 at presented with recurrent episodes of abdominal pain, which Increased in severity over the last 3 months.she was diagnosed with mild acute pancreatitis with elevated lipase level (1988 IU/l) and no local complications secondary to pancreatitis. Mrcp scan at our center showed an impacted calculus in the remnant intrapancreatic choledochal cyst. Since it was a distal calculus, ercp with stone extraction was attempted twice but the ampulla could not be visualized. On exploration, the blind end of the roux limb was adherent to the remnant cyst and the stone was impacted in the intrapancreatic remnant choledochal cyst. The adherent blind end was taken down from remnant cyst and stone was extracted. The jejunal end was reinforced in two layers and remnant cyst was closed with vicryl. Conclusion: While complete excision of remnant choledochal cyst offers best curative option in terms of symptomatic relief and risk reduction for malignancy, complete excision is not always feasible particularly in isolated intrapancreatic remnant choledochal cyst. While there are case reports of stone extraction by ercp for such stones, the same failed in our patient on two occasions. Hence this case is being presented for the novel approach of stone extraction via cystolithotomy without dismantling the patent hepaticojejunostomy.

PS01.105: PANCREATITIS IN THE ESOPHAGEAL ECTOPIC PANCREAS: A RARE CONDITION WITH DIFFERENT PRESENTATIONS! TREATMENTS AND REVIEW OF THE LITERATURE

Abstract Background Ectopic pancreas is an extremely rare genetic malformation in the esophagus. It is defined by pancreatic tissue outside the pancreas and usually presents as a subepithelial lesion in the esophagus. To date, there are fewer than 15 patients reported in the literature. Methods We present 2 cases of pancreatitis in the esophageal ectopic pancreas with different presentation, treatment and development, as well as a review of the literature. Results 1. A 48-year-old woman admitted to the ER with acute dysphagia and chest pain. There were elevation of amylasemia and lipasemia, as well as presence of a tumor in the Gastroesophageal junction with hypersignal at the CT scan, suggesting acute inflammation. An echoendoscopy with biopsy, diagnosed ectopic pancreas in the distal esophagus. The patient was then submitted to laparoscopic resection of subepithelial tumor of the cardia, recovered by a fundoplication. The specimen confirmed pancreatic tissue with acute inflammation. 2. A 33-year-old woman with a history of episodic chest pain confused with GERD, nausea and vomiting pain episodes accompanied by elevated serum amylase and lipase levels. She was submitted to an ERCP without alterations to investigate the clinical complains. After some crisis she was hospitalized with a septic condition, where a CT scan revealed a cystic lesion in the lower mediastinum in the esophageal wall. Endoscopy was performed, showing a drainage orifice with purulent secretion in the cardia. She was treated with antibiotics and fasting. She had two more crises and was referred to our specialized service. Thoracoscopic subtotal esophagectomy with cervical anastomosis was performed for treatment of a suspected esophageal duplication cyst with recurrent infections. The specimen showed the presence of organized pancreatic tissue characterizing ectopic pancreas complicated with chronic pancreatitis. Conclusion The ectopic esophageal pancreas can be present as a differential of these lesions. The second case, was first admitted at a secondary care unit and the diagnosis was delayed, probably leading to a worse development and necessity of a esophagectomy. In the literature, there is only one description of 1 case of recurrent pancreatitis. We have shown that complications can range from dysphagia to abscess, requiring more invasive treatment. Disclosure All authors have declared no conflicts of interest.

Adenovirus-mediated overexpression of sST2 attenuates cardiac injury in the rat with severe acute pancreatitis

AimsSevere acute pancreatitis (SAP) is a serious disease associated with systematic inflammation and multiple organs dysfunction. Soluble ST2 (sST2), a member of the Toll interleukin (IL)-1 receptor (TIR) superfamily, has been demonstrated to exert immune-regulatory and anti-inflammatory properties in several inflammation-related diseases. In this study, we investigated whether transfer of sST2 gene by adenovirus vector could attenuate sodium taurocholate-induced SAP and associated cardiac injury. Main methodsA rat model of SAP was induced by retrograde injection of 5% sodium taurocholate (1 ml/kg) into the biliopancreatic duct. Rats in the treatment groups were intravenously injected with adenovirus expressing sST2 (Ad-sST2, 1 × 109 particles/rat) or green fluorescent protein (Ad-GFP) via the tail vein 48 h before SAP induction. Histological changes in the pancreatic and heart tissues, and parameters for evaluating SAP and associated cardiac injury were determined at 24 h after SAP. Key findingsSodium taurocholate induced obvious pathological changes in pancreas and elevated serum levels of amylase and lipase. Furthermore, SAP animals exhibited significant cardiac impairment, evidenced by decreased cardiac function, increased myocardial apoptosis and cardiac-related enzymes including creatine kinase isoenzyme, lactate dehydrogenase, and Troponin T. Administration of Ad-sST2 markedly improved the structure of pancreas and heart tissues, and reversed the alterations in serum amylase, lipase and cardiac-related enzymes. In addition, Ad-sST2 treatment downregulated pro-inflammatory cytokines production, demonstrating the anti-inflammatory property of sST2. SignificanceOur results suggest that administration of Ad-sST2 significantly attenuated the severity of SAP and associated cardiac damage, and the cardioprotective effect is associated with its anti-inflammatory action.

Prognostic value of serum lipase levels in patients with small bowel obstruction

ABSTRACTElevated serum pancreatic enzymes have been described among patients with small bowel obstruction (SBO) initially misdiagnosed as having pancreatitis. We studied whether serum lipase elevation carries prognostic value in patients with SBO. Patients with SBO and at least one serum lipase level measured were included. Demographic, laboratory, and imaging information, as well as need for surgery or intensive care unit and mortality, were evaluated. Of 344 patients, 38 (11%) had elevated serum lipase levels. Patients with radiographic diagnosis of pancreatitis were excluded. Patients with elevated lipase had significantly higher levels of creatinine and lactic acid levels, length of stay, need for intensive care monitoring, and death than patients with normal lipase levels. The need for surgical intervention was not significantly different between the two groups. Logistic regression analysis showed elevated serum lipase and serum creatinine >1.5 mg/dL as predictors for mortality. We conclude that, in SBO, elevated serum lipase is a risk factor for higher serum creatinine and lactate, use of intensive care unit, and mortality. The strength of this association justifies studying it prospectively.

Identification of Pancreatic Injury in Patients with Elevated Amylase or Lipase Level Using a Decision Tree Classifier: A Cross-Sectional Retrospective Analysis in a Level I Trauma Center.

Background: In trauma patients, pancreatic injury is rare; however, if undiagnosed, it is associated with high morbidity and mortality rates. Few predictive models are available for the identification of pancreatic injury in trauma patients with elevated serum pancreatic enzymes. In this study, we aimed to construct a model for predicting pancreatic injury using a decision tree (DT) algorithm, along with data obtained from a population-based trauma registry in a Level I trauma center. Methods: A total of 991 patients with elevated serum levels of amylase (>137 U/L) or lipase (>51 U/L), including 46 patients with pancreatic injury and 865 without pancreatic injury between January 2009 and December 2016, were allocated in a ratio of 7:3 to training (n = 642) or test (n = 269) sets. Using the data on patient and injury characteristics as well as laboratory data, the DT algorithm with Classification and Regression Tree (CART) analysis was performed based on the Gini impurity index, using the rpart function in the rpart package in R. Results: Among the trauma patients with elevated amylase or lipase levels, three groups of patients were identified as having a high risk of pancreatic injury, using the DT model. These included (1) 69% of the patients with lipase level ≥306 U/L; (2) 79% of the patients with lipase level between 154 U/L and 305 U/L and shock index (SI) ≥ 0.72; and (3) 80% of the patients with lipase level <154 U/L with abdomen injury, glucose level <158 mg/dL, amylase level <90 U/L, and neutrophil percentage ≥76%; they had all sustained pancreatic injury. With all variables in the model, the DT achieved an accuracy of 97.9% (sensitivity of 91.4% and specificity of 98.3%) for the training set. In the test set, the DT achieved an accuracy of 93.3%, sensitivity of 72.7%, and specificity of 94.2%. Conclusions: We established a DT model using lipase, SI, and additional conditions (injury to the abdomen, glucose level <158 mg/dL, amylase level <90 U/L, and neutrophils ≥76%) as important nodes to predict three groups of patients with a high risk of pancreatic injury. The proposed decision-making algorithm may help in identifying pancreatic injury among trauma patients with elevated serum amylase or lipase levels.