Elevated Pancreatic Enzymes Research Articles

Prevalence and clinical characteristics of increased pancreatic enzymes in patients with severe fever with thrombocytopenia syndrome.

The increased pancreatic enzymes have recently been reported in patients with severe fever with thrombocytopenia syndrome (SFTS). However, its significance has not been elucidated clearly. The aim of this study was to explore the prevalence, clinical characteristics of elevated pancreatic enzymes (amylase and lipase) and its association with AP in patients with SFTS. Data of demographics, comorbid conditions, clinical symptoms, laboratory parameters and survival time of patients with SFTS were collected. Patients were assigned into the non-AP and AP groups according to the diagnostic criteria of AP. Patients in the non-AP group were divided into the normal (<upper limit of normal [ULN]), elevated pancreatic enzymes (EPE) (1-3×ULN) and high pancreatic enzymes (HPE) (>3×ULN) groups according to the serum amylase and lipase levels, and then their clinical data were compared. A total of 284 patients diagnosed with SFTS were retrospectively enrolled, including 248 patients in the non-AP group and 36 patients in the AP group. Patients in the non-AP group were composed of 48, 116 and 84 patients in the normal, EPE and HPE groups, respectively. Compared with patients in the normal and EPE groups, patients in the HPE group had higher serum levels of laboratory parameters referring to liver, kidney, heart and coagulation system injury, as well as higher viral load. The cumulative survival rate of patients in the HPE group was significantly lower than that of patients in the normal group. In addition, patients in the AP group also had higher serum levels of laboratory variables reflecting liver, heart, coagulation dysfunction and viral load than patients in the HPE group. The cumulative survival rate of patients in the AP group was significantly lower than that of patients in the HPE group. The increased pancreatic enzymes are very common in patients with SFTS, but they are not always associated with AP. Though AP accounts for the majority of deaths for patients with elevated pancreatic enzymes, patients with pancreatic enzymes >3×ULN except for AP also have a high in-hospital mortality rate.

Long-term outcomes and adverse effects of teduglutide in patients with short bowel syndrome: Highlighting hyperamylasemia and hyperlipasemia.

Short bowel syndrome is a malabsorptive condition that occurs due to surgical removal or a congenital absence of a significant portion of the small intestine. Patients with short bowel syndrome often rely on parenteral support for extended periods or even their entire lives. Teduglutide, a glucagon-like peptide-2 analog, has shown promising results in reducing dependency on parenteral support in these patients by promoting intestinal adaptation and enhancing nutrient absorption. However, the long-term safety of teduglutide remains a concern, particularly with respect to its potential for the development of hyperamylasemia and hyperlipasemia. This study involved patients who received teduglutide from December 2012 to December 2022 at Boston Medical Center. We evaluated outcomes and adverse events, focusing on hyperamylasemia and hyperlipasemia, through chart review. Thirteen eligible patients were identified who had used teduglutide. Of these, the majority (84.6%) experienced a reduction in parenteral support. A high incidence (72.7%) of nonpathological pancreatic enzyme elevation was observed in patients treated with teduglutide. These elevations were often dose dependent and were not associated with any clinical signs of acute pancreatitis or abnormal imaging findings. This study highlights the need for further investigations into the long-term safety of teduglutide and the importance of closely monitoring amylase and lipase levels in patients undergoing treatment with teduglutide.

A Case Report of Abdominal Pain with Acute Kidney Injury and Elevated Pancreatic Enzymes

Objectives: The aim of this study is to report the effectiveness and safety of herbal medicine treatment for abdominal pain with acute kidney injury.Methods: A 80-year-old female patient presented with abdominal pain. Blood test results showed increased blood urea nitrogen, serum creatinine, amylase, and lipase. The patient was treated with acupuncture and herbal medicine, specifically &lt;i&gt;Hyangsayukgunja-tang-gahwangryeon&lt;/i&gt; for 4 days and &lt;i&gt;Gagam-gunbi-tang&lt;/i&gt; for 11 days. Gastrointestinal symptoms were assessed using the Numerical Rating Scale, Gastrointestinal Symptom Rating Scale, and abdominal examination.Results: Gastrointestinal symptoms improved after taking Korean herbal medicine. Additionally, blood urea nitrogen, serum creatinine, amylase, and lipase levels showed improvement compared to values before treatment.Conclusions: Korean medicine treatment can improve clinical symptoms without damaging the kidneys of patients with acute kidney injuries.

Acute pancreatitis following COVID-19 vaccine: A Vietnamese case report

Several vaccines against the coronavirus 2 that causes severe acute respiratory syndrome have been developed in response to the global coronavirus infectious disease 2019 (COVID-19) pandemic. The FDA has established that the available vaccine is effective against both the original and current SARS-CoV-2 variant infections. The vaccine’s effectiveness and adverse effects also need to be evaluated comprehensively. Although the list of side effects of the mRNA COVID-19 vaccine has been reported, only a few cases of pancreatitis have been documented and published. The mechanism in this situation is unknown, and the onset time from the vaccination to symptom onset is variable through several case reports, so healthcare workers need to be suspicious of pancreatitis to make an early diagnosis and deliver the appropriate treatment. We report a 73-year-old man with controlled chronic hepatitis C and uncomplicated gastritis who presented to the hospital with a 4-day fever accompanied by chills, generalized myalgia, a bilateral temporal dull headache, and no abdominal discomfort or pain. A review of other systems was clinically negative after the second dose of the Pfizer/BioNTech mRNA COVID-19 vaccine. He had no history of alcohol consumption, pancreatitis, or allergic reactions to vaccines and had received the uncomplicated first dose of the Pfizer/BioNTech mRNA COVID-19 vaccine previously. Laboratory tests revealed elevated serum pancreatic enzymes. An abdominal magnetic resonance imaging study showed tail segment enlargement of the pancreas with fat stranding and fluid accumulation surrounding the tail of the pancreas, without any local or systemic complications detected. Other laboratory and imaging tests for the detected source of infections are negative, and acute pancreatitis was diagnosed based on the 2012 revision of the Atlanta classification and definitions by international consensus. The patient was diagnosed with COVID-19 vaccination-induced acute pancreatitis. The patient had an uneventful recovery with no complications. After administering the mRNA COVID-19 vaccine, acute pancreatitis could develop. Therefore, it is crucial to recognize acute pancreatitis when abdominal pain and/or abnormally increased pancreatic enzymes occur following a COVID-19 mRNA immunization.

SAT129 Clinical Conundrum Of Suspected Pancreatitis Masking Diabetic Ketoacidosis

Abstract Disclosure: A. Sood: None. O. Syed: None. A. Sood: None. P. Patel: None. M.M. Alosiyus: None. ​​Abstract: Patients with End-Stage-Renal-Disease (ESRD) have poor renal excretion which can cause false elevation in pancreatic enzymes. We present a case of a pregnant woman on hemodialysis (HD) with elevated lipase levels concerning for acute pancreatitis. Case Presentation: A 25-year-old African American female with history of type 1 diabetes mellitus, ESRD secondary to diabetic nephropathy, diabetic gastroparesis, hypertension presented to the hospital with diffuse severe abdominal pain following HD. Lab showed Anion gap 15, Glucose 304 mg/dL, Creatinine 4.6 mg/dL, Triglyceride 130 mg/dL, Lipase 390 mg/dL, with urine negative for ketones. The abdominal US was negative for gallstones, and revealed a normal size common bile duct. CT scan was deferred due to a positive urine pregnancy test. She was started on IV fluids for suspected pancreatitis. Patient had worsening blood glucose levels as well as anion gap despite being on Humalog and correctional scale insulin. Patient was started on an insulin drip with resolution of the anion gap. Discussion: Patient met 2 of 3 criteria for pancreatitis, with CT and MRI deferred in this case due to pregnancy and low suspicion secondary to negative US result.[5] Pancreatic enzymes can be falsely elevated in ESRD patients. Lipase can be elevated in HD[3] patients due to the lipolytic effect of heparin used during dialysis, while elevation of lipase in DKA remains unclear[2]. Acidosis is common in ESRD patients, thus masking the diagnosis of DKA which also presents with abdominal pain, nausea, vomiting, which can potentially cause a delay in the treatment. The mimicking and masking of these conditions by each other can thereby result in a diagnostic dilemma, which is why a prompt diagnosis of pancreatitis should be made in a patient presenting with DKA. Conclusion: Elevated levels of amylase and lipase are concerning for pancreatitis, however, metabolic processes could also be masked by underlying chronic diseases. While fluid resuscitation is the mainstay treatment for DKA and pancreatitis, it is extremely important to be cautious when a patient has an underlying ESRD. The diagnostic dilemma due to the overlapping diagnosis should be taken into consideration early during the hospitalization, and a high index of clinical suspicion can prevent the unnecessary delay in the treatment.

Immune Checkpoint Inhibitor-Induced (Type 3) Autoimmune Pancreatitis.

Immune checkpoint inhibitors (ICI) have revolutionized cancer care and work primarily by blocking CTLA-4 (cytotoxic T-lymphocyte-associated protein 4), and/or PD-1 (programmed cell death protein 1), and/or PD-L1 (programmed death-ligand 1), thereby providing highly efficacious anti-tumor activity. However, this unmitigated immune response can also trigger immune related adverse events (irAEs) in multiple organs, with pancreatic irAEs (now referred to as type 3 Autoimmune pancreatitis (AIP) being infrequent. Type 3 AIP is a drug-induced, immune mediated progressive inflammatory disease of the pancreas that may have variable clinical presentations viz., an asymptomatic pancreatic enzyme elevation, incidental imaging evidence of pancreatitis, painful pancreatitis, or any combination of these subtypes. Management is largely supportive with intravenous fluid hydration, pain control and holding the inciting medication. Steroids have not been shown to demonstrate a clear benefit in acute management. A rapid development pancreatic atrophy is observed on imaging as early as 1 year post initial injury. Type 3 AIP is a chronic inflammatory disease of the pancreas that though predominantly asymptomatic and mild in severity can lead to rapid organ volume loss regardless of type of clinical presentation and despite steroid therapy.

Acute Pancreatitis: A clinical perspective

Acute pancreatitis is one of the main gastrointestinal disorders that is characterized by an acute inflammatory process of the pancreatic tissue with variability in severity, usually with a mild and self-limiting presentation, and presenting a low mortality. Biliary etiology is the leading cause of acute pancreatitis worldwide, with greater involvement in the female gender. Within the diagnostic approach, acute abdominal pain and intense onset in the epigastrium radiating to the back is usually the most representative symptom that leads to suspicion of this entity, accompanied by elevation of pancreatic enzymes and the presence of typical image findings of inflammation of the pancreas. The objection to identifying which patients are at risk of developing local or systemic complications has led to the creation of different scales predicting the severity of pancreatitis with performances that are still debatable. Therapeutic management has two fundamental pillars, fluid resuscitation to maintain or restore tissue perfusion and adequate nutritional support to counteract the catabolic state and reduce the rate of infectious complications. In the context in which the cause is a biliary origin, its resolution is important to avoid progression to chronic pancreatitis.

Evaluation of diagnostic and therapeutic procedures in patients with acute pancreatitis

&#x0D; Introduction and purpose: Acute pancreatitis remains a clinically significant problem worldwide and in Poland, where its incidence is observed to be twice as high as in the global population. The aim of this study is to describe the latest available guidelines for managing patients diagnosed with acute pancreatitis, including diagnostic methods, radiological approaches, as well as conservative and invasive therapeutic treatment.&#x0D; &#x0D; &#x0D; Materials and Methods: The literature available on PubMed, Scopus, Google Scholar databases, and guidelines from the Polish Society of Gastroenterology was reviewed using the words: „acute pancreatitis”, „pancreas", "AP treatment", and „acute pancreatitis management”.&#x0D; &#x0D; &#x0D; Description of the state of knowledge: Patients with suspicion of acute pancreatitis are mainly diagnosed based on their symptoms using the Revised Atlanta Classification comprising of clinical symptoms, elevated pancreatic enzymes level, and imaging test results. The recommended therapeutic management for patients with acute pancreatitis underlines the importance of conservative treatment before the implementation of invasive procedures, the choice of which should be based on the severity and form of the condition. &#x0D; &#x0D; &#x0D; Summary: The existing recommendations regarding the diagnostic approach in acute pancreatitis emphasize the importance of correlating symptoms with radiological findings obtained through ultrasound, which is a quick and widely accessible diagnostic tool. In therapeutic management, conservative treatment remains significant with the early implementation of nutritional support, along with the appropriate method and timing of surgical intervention depending on the form of acute pancreatitis and the presence of infection.&#x0D;

Clinical trajectory of intraductal papillary mucinous neoplasms progressing to pancreatic carcinomas during long-term surveillance: a prospective series of 100 carcinoma cases.

Trajectories of serological and morphological signatures have not been documented in pancreatic carcinogenesis related to intraductal papillary mucinous neoplasms (IPMNs). Using a prospective cohort of 3437 IPMN patients, we identified 100 IPMN patients who developed pancreatic carcinomas during long-term surveillance. We examined serial changes of blood markers (carbohydrate antigen 19-9 [CA19-9], hemoglobin A1c [HbA1c], and pancreatic enzymes) and morphological features (worrisome features and high-risk stigmata) during the prediagnostic period of pancreatic carcinomas, overall and by carcinoma types (IPMN-derived vs. concomitant pancreatic carcinomas). CA19-9 elevation was observed in 39 patients and was associated with a metastatic stage. Compared to IPMN-derived carcinomas, concomitant carcinomas were more likely to represent CA19-9 elevation (60% vs. 30%, respectively; P = 0.005). HbA1c levels elevated only in 3 patients. Pancreatic enzyme elevation was observed in 18 patients with no differences in frequencies between the carcinoma types. All patients with elevated levels of blood markers had positive findings on cross-sectional imaging. High-risk stigmata or worrisome features were observed in all patients but one with concomitant carcinoma. The most common types of worrisome features were the main pancreatic duct dilatation and CA19-9 elevation in IPMN-derived and concomitant carcinomas, respectively. Compared to IPMN-derived carcinomas, concomitant carcinomas were less likely to harbor high-risk stigmata (16% vs. 86%, respectively; P < 0.001). The usefulness of currently available blood biomarkers was limited in early detection of pancreatic carcinomas related to IPMNs. Morphological alterations were well correlated with long-term risk of IPMN-derived carcinomas, but not with that of concomitant carcinomas.

Pancreatic adverse events of immune checkpoint inhibitors therapy for solid cancer patients: a systematic review and meta-analysis.

This review aims to determine the incidence and risk of pancreatic adverse events (AEs) associated with immune checkpoint inhibitors (ICIs) therapy for solid tumors. We conducted a comprehensive systematic literature search in PubMed, Embase, and Cochrane Library up to March 15, 2023, to identify all randomized controlled trials comparing ICIs with standard treatment in solid tumors. We included studies that reported immune-related pancreatitis or elevation of serum amylase or lipase levels. Following protocol registration in PROSPERO, we conducted a systematic review and meta-analysis. 59 unique randomized controlled trials with at least one ICI-containing arm (41 757 patients) were retrieved. The incidences for all-grade pancreatitis, amylase elevation and lipase elevation were 0.93% (95% CI 0.77-1.13), 2.57% (95% CI 1.83-3.60) and 2.78% (95% CI 1.83-4.19), respectively. The incidences for grade ≥3 pancreatitis, amylase elevation and lipase elevation were 0.68% (95% CI 0.54-0.85), 1.17% (95% CI 0.83-1.64) and 1.71% (95% CI 1.18-2.49), respectively. The use of ICIs was associated with an increased risk of all-grade pancreatic immune-related AEs (irAEs) including pancreatitis (OR=2.04, 95% CI 1.42-2.94, P =0.0001), amylase elevation (OR=1.91, 95% CI 1.47-2.49, P < 0.0001) and lipase elevation (OR=1.77, 95% CI 1.37-2.29, P < 0.0001). In addition to these, the post-hoc analysis found that PD-1 inhibitors had a significant higher risk of pancreatic AEs compared with PD-L1 inhibitors and the patients undergoing dual ICI therapy were at a significantly higher risk of pancreatic AEs than the patients receiving single ICI therapy. Our study provides an overview of the incidence and risk of ICI-associated pancreatitis and pancreatic enzyme elevations in the treatment of solid tumors. Our findings may help raise awareness among clinicians of the potential for ICI-associated pancreatic AEs in clinical practice. https://www.crd.york.ac.uk/PROSPERO, identifier 345350.

Is Endoscopy Mandatory In Cases Mimicking Acute Pancreatitis?

To detect the utility of nonspecific rising of pancreatic enzymes in patients with stomach discomfort, and to explore the possibility of hyperamylasemia as a differential diagnosis. The cross-sectional study was conducted from April 2020 to April 2021 at two large tertiary care centres in Kafrelsheikh and Zagazig governorates in northern Egypt, and comprised patients complaining of dull aching abdominal pain. They were classified into two groups. Patients with nonspecific rise in pancreatic enzymes less than threefold in the absence of acute pancreatitis were in group I, while those having abdominal pain without rise in pancreatic enzymes were in group II. All patients were subjected to detailed history and clinical examination followed by laboratory assessment, imaging studies and upper endoscopy. Data was analysed using SPSS 20. Of the 270 patients, 170(63%) were in group I; 120(70.5%) males and 50(29.5%) females with mean age 51±6.58 years, There were 100(37%) patientsin group II; 65(65%) males and 35(35%) females with mean age 53±8.96 years (p>0.05). Amylase, lipase, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, Creactive protein and helicobacter pylori values were significantly different between the groups (p<0.05). Elevation of pancreatic enzymes with a level less than three-fold in patients with abdominal pain reflected mucosal injury of the gastrointestinal tract and may raise the necessity for diagnostic upper endoscopy.

The Frequency of Pancreatic Enzyme Elevations and Effect on Disease Severity in COVID-19

Aim: In this study, we aimed to evaluate the frequency of pancreatic enzyme elevations in COVID-19-infected patients and to examine the effect on disease severity.&#x0D; Material and Methods: A total of 1249 patients who hospitalized with COVID-19 infection were included. The frequency of pancreatic enzyme elevations and the effect on disease severity in patients infected with COVID-19 were investigated.&#x0D; Results: The pancreatic enzyme elevations (amylase/lipase or both) were detected in 32 of 1249 patients (incidence 2.96%). 32 cases with a mean age of 64.97±5.63 years were included in this study. 30 (93.75%) of the cases were men’s gender. 31 (96.87%) of them had elevated amylase levels, 26 (81.25%) had elevated lipase levels and 25 (78.12%) of them had elevated both amylase and lipase levels. Only 10 (31.25%) of them tested radiological for acute pancreatitis (AP) and there was no radiological finding compatible with AP in any of the limited numbers of abdominal computerized tomography scans performed. 18 (56.25%) of the patients were transferred to the intensive care unit due to clinical worsening and mortality developed in 13 (40.62%) patients. The mean age of the deceased cases was 66.4±6.6 years and there was no statistically significant difference between deceased and survived COVID-19 patients (&gt;0.05).&#x0D; Conclusion: The median lymphocyte count was lower, and the median AST, ALT, and lipase levels were higher in the deceased group. Perhaps close clinical follow-up of patients with pathological findings in these values and radiological imaging, if necessary, may be beneficial in the method of the disease.&#x0D; Keywords: COVID-19; disease severity; pancreatic enzyme elevations.

The Effectiveness of the Combination of Arterial Infusion Chemotherapy and Radiotherapy for Biliary Tract Cancer: A Prospective Pilot Study.

The standard treatment of unresectable biliary tract cancer (BTC) has shown an insufficient response rate (RR). Our retrospective setting revealed that a combination therapy consisting of intra-arterial chemotherapy plus radiation therapy (IAC + RT) provided a high RR and long-term survival benefits in unresectable BTC. This prospective study aimed to test the effectiveness and safety of IAC + RT as the first-line therapy. The regimen included one-shot IAC with cisplatin, 3-6 months of reservoir IAC (5-FU and cisplatin, q/week), and 50.4 Gy of external radiation. The primary endpoints include the RR, disease control rate, and adverse event rate. This study included seven patients with unresectable BTC without distant metastasis, with five cases classified as stage 4. RT was completed in all cases, and the median number of reservoir IAC sessions was 16. The RR was 57.1% for imaging and 71.4% for clinical assessment, and the disease control rate was 100%, indicating a high antitumor efficacy, which allowed two cases to be transferred to surgery. Five cases of leukopenia and neutropenia; four cases of thrombocytopenia; and two cases of hemoglobin depletion, pancreatic enzyme elevation, and cholangitis were observed, but with no treatment-related deaths. This study revealed a very high antitumor effect with IAC + RT for some unresectable BTC, and it could be useful for conversion therapy.

Brigatinib-associated autoimmune hepatitis: A case report

Brigatinib is a next-generation anaplastic lymphoma kinase (ALK) inhibitor that targets a wide variety of ALK mutations and ROS1 rearrangements. While pancreatic enzyme elevations due to brigatinib are well known, we wanted to present a case that caused liver toxicity. ALK and ROS1 translocations were detected in a 58-year-old patient diagnosed with metastatic lung adenocarcinoma. In the patient who had a good response with brigatinib, more than 5-fold elevation was detected in liver enzymes at the fifth month of treatment. After excluding other hepatitis factors, the patient was thought to have autoimmune hepatitis, and methylprednisolone was started and liver enzymes were decreased. Increased creatine kinase and lipase levels are common side effects associated with brigatinib, while liver toxicity is rare. Autoimmune hepatitis due to brigatinib was considered because of hepatic toxicity that developed in the fifth month of treatment and responded well to steroids.

Wernicke’s Encephalopathy Complicating Hypermesis Gravidarum: a Rare Case Report

Introduction: Wernicke’s Encephalopathy (WE) is an uncommon neurological disorder due to thiamine deficiency. Its clinical findings are variable steering its high incidence postmortem. Seldom, thiamine deficiency is present in a clinical triad consisting of cognitive disorder, ocular abnormalities and gait ataxia. Most commonly, the clinical picture is not specific leading to late or misdiagnosis. In pregnant woman with Hyperemesis Gravidarum, incoercible vomiting and poor intake paves the path to thiamine deficiency by depleting B1 storage affecting cerebral energy homeostasis. Ergo, HG leads to neurological complications affecting maternal mortality and morbidity. Case Report: We hereby present the uncommon case of WE complicate HG in 18 weeks’ gestation primigravidae. Diagnosis relied on clinical findings as the clinical picture was typical: confusion, disorientation and memory impairment besides static and kinetic cerebellar syndrome and ophthalmological abnormalities such as unequal pupils and horizontal nystagmus. Biological findings were out of normal range as it showed electrolytes imbalance, dehydration and elevated liver and pancreatic enzymes. Imaging investigations were normal. Treatment was based on intravenous thiamine supplementation and vomiting management. Conclusion: We are a preventable neurological disorder. Prompt treatment and correct dosage in light of the appropriate guidelines enlighten the prognosis and may even lead to remission. Whereas late or non-diagnosis leads to dramatic complications such as Korsakoff’s syndrome. This article aims to raise clinician’s suspicion of WE and emphasizes the importance of preventive thiamine supplementation during pregnancies and prophylactic intravenous thiamine administration in pregnancy with Hyperemesis Gravidarum.

Hyperamylasemia is not Associated with Dipeptidyl Peptidase 4 Inhibitors in South Indian Adults with Type 2 Diabetes Mellitus.

Although not definitive, there is small increased risk of acute pancreatitis with the use of dipeptidyl peptidase 4 inhibitors (DPP4i). Hence, there is an interest in the elevation of pancreatic enzymes among type 2 diabetes mellitus (T2DM) patients using DPP4i. However, the studies regarding their association are limited and provide conflicting results. Moreover, there are no such studies among South Indian T2DM patients. Hence, we evaluated the prevalence of hyperamylasemia among South Indian T2DM patients and its association with DPP4i use. This cross-sectional study was conducted at a tertiary health care center from South India. Adult T2DM patients on stable doses of antidiabetic medications for at least previous 3 months were included in the study. Patients with other types of diabetes mellitus, gall stones, diabetic ketoacidosis, acute illness, chronic kidney disease and untreated hypothyroidism were excluded from the study. All participants were evaluated with glycemic parameters, serum creatinine and serum amylase. Hyperamylasemia was defined as serum amylase ≥220 U/L. A total of 200 participants were included in the study among whom 93 patients were not on DPP4i whereas 107 were on DPP4i including 41 (38.32%) each on teneligliptin and sitagliptin. Baseline characteristics including glycemic measures were comparable between DPP4i users and nonusers. A total of 14 patients (7%) had hyperamylasemia but the prevalence of hyperamylasemia did not differ between DPP4i users and nonuser (6/107 vs. 8/93, P = 0.42). Asymptomatic hyperamylasemia is not uncommon in South Indian T2DM patients but is not associated with the use of DPP4i.

EMPHYSEMATOUS PANCREATITIS: A RARE COMPLICATION OF ACUTE PANCREATITIS

Abstract Introduction Emphysematous pancreatitis (EP) is a serious and rare complication within the spectrum of acute pancreatitis (AP). The diagnosis is based on clinical and radiological data, that presents intraparenchymal pancreatic air in the setting of necrotizing infection. This clinical and radiological manifestation of infected pancreatic necrosis has mortality rates of over 40%. Clinical case A 71-year-old male came to the emergency department due to epigastric pain of 48h duration associated with hypotension, bradycardia with elevated pancreatic enzymes, requiring admission to the Intensive Care Unit. Initial resuscitation treatment was established, and a CT scan was performed which showed abundant air in the retroperitoneum, associated with signs of inflammation of the pancreatic gland as well as obstructive choledocholithiasis and without being able to radiologically rule out an intestinal perforation. After fluid resuscitation and stabilization of the patient, urgent surgery was performed, which showed necrosis of the entire pancreatic gland with abscessed peripancreatic collections. Wide open necrosectomy, exploration of the bile duct with extraction of lithiasis, and cholecystectomy were performed. The patient had a slow and prolonged postoperative period, progressively improving until he was discharged home. Discussion Therapeutic options for EP range from conservative management to surgery. Surgery, in these patients, is the last therapeutic step, after endoscopic or percutaneous drainage. The video-assisted retroperitoneal approach is the better procedure to be considered, since it entails less morbidity and mortality than open necrosectomy.

Elevated amylase and lipase levels in patients with DKA followed in the pediatric intensive care unit.

Diabetic ketoacidosis (DKA) is a life-threatening acute metabolic decompensation condition due to insulin deficiency and elevation of pancreatic enzymes is common. The goal of this study was to determine the laboratory findings and biochemical characteristics associated with pancreatic enzyme elevation during DKA. The files of patients hospitalized in the pediatric intensive care unit with the diagnosis of DKA between March 2020 and 2022 were reviewed retrospectively. Demographic data, length of stay at hospital, initial biochemistry, hemogram, blood gas values, amylase, and lipase in the first 24h were noted. Those with elevated amylase and/or lipase values were grouped. Patients were grouped according to the severity of DKA. These groups were analyzed statistically. Amylase and/or lipase were found to be elevated in 21 (28%) of diagnosed with DKA. pH and HCO3 were significantly lower, length of stay in the intensive care unit, and triglyceride levels were significantly higher in patients with high amylase and/or lipase when compared with the control group (p<0.05). Although lipase values have a negative correlation with blood gas parameters and a positive correlation with TG and cholesterol values, correlation degree was found to be weak (p<0.05). Lipase was significantly higher in the severe diabetic ketoacidosis group than the moderate group (p<0.001). Elevations in amylase and lipase values can be encountered frequently in patients with DKA. Considering that the metabolic deterioration due to DKA may have an effect on this, we recommend that the patient should be followed closely and the enzyme level should be monitored intermittently.

Elevated pancreatic enzymes during immunotherapy for malignant pleural mesothelioma: a case report

We report a patient with malignant pleural mesothelioma who developed pancreatic enzyme elevations and pancreatitis during immune checkpoint inhibitor treatment. A male in his eighties visited his family clinic because of respiratory distress on exertion and was pointed out a left pleural effusion. A thoracoscopic pleural biopsy gave a diagnosis of desmoplastic pleural mesothelioma. The patient was started a combination immunotherapy of ipilimumab and nivolumab. At a routine visit of 32 days after the start of the treatment, blood tests revealed elevated amylase and lipase. The patient had no subjective symptoms such as abdominal or back pain or loss of appetite. Contrast-enhanced computed tomography imaging revealed decreased contrast uptake in the pancreas, and magnetic resonance imaging revealed edematous changes in the pancreas. These findings led us to the diagnosis of asymptomatic immune mediated acute pancreatitis. Extracellular fluid replacement and steroid treatment were initiated. Both amylase and lipase quickly decreased close to normal range but began to rise again when the prednisolone dose was reduced. Infliximab was administered, then amylase and lipase decreased again. Follow-up magnetic resonance imaging demonstrated that the edematous changes in the pancreas had resolved. During the treatment of pancreatitis, mesothelioma demonstrated no exacerbation. There is no established treatment strategy for immune mediated pancreatitis. Appropriated management of asymptomatic elevation of pancreatic enzymes during ICI treatment should be established.

Mediastinal Pseudocyst in a Case of Chronic Pancreatitis: A Rare Presentation

Pancreatic pseudocysts are collections of fluid localised within the pancreas or in the peripancreatic space, which can occur following acute pancreatitis or in patients with a history of acute pancreatitis and chronic pancreatitis. They are well-known complications of pancreatitis. The pathogenesis of pancreatitis depends on its etiology, where enzyme-rich fluid and products of autoregulation accumulate in acute pancreatitis, and cysts are formed due to obstructed ducts in chronic pancreatitis. The development of pancreatic pseudocysts is more commonly associated with chronic pancreatitis than acute pancreatitis. Unless ruptured, pancreatic pseudocysts are usually not hazardous. Diagnosis of pseudocysts has become easier with advanced diagnostic techniques such as ultrasound and Computed Tomography (CT) scans. Patients presenting with abdominal pain and elevated pancreatic enzymes should be suspected of having pseudocysts. Approximately one-third of these cases resolve spontaneously. In the past, surgery was the only management method, but recently, with newer techniques such as percutaneous drainage and endoscopic cyst enterostomy, management has become easier. Percutaneous drainage, performed under local anaesthesia, is a cost-effective procedure with very low complications. The recurrence rate is higher with single-needle treatment, so catheters are used to decrease recurrence. Drainage should be the first choice of management, but with advancing technology and endoscopic techniques, it may become more useful in the future with skilled practitioners. In this case report, we will examine the case of a 30-year-old male who presented with symptoms of pain in the epigastric region and was diagnosed with a pancreatic pseudocyst. This case demonstrates a rare presentation where the pseudocyst extends into the mediastinum and thorax.