First Episode Of Pancreatitis Research Articles

FRI055 LYNC-LD: Prospective Multicenter Natural History Study Of Lipodystrophy Syndromes To Determine Prevalence, Incidence And Predictors Of Diabetes And Severe Hypertriglyceridemia, And Their Complications

Abstract Disclosure: M.C. Foss de Freitas: Advisory Board Member; Self; PTC Therapeutics. D.S. Rosenberg: None. M. Celik Guler: None. M. Yosef: None. S. Khalatbari: None. R. Carman: None. A. DillGomes: None. M. Ashmus: None. C. Spino: None. B. Akinci: Advisory Board Member; Self; Aegerion Pharmaceuticals, Regeneron Pharmaceuticals. Consulting Fee; Self; Aegerion Pharmaceuticals, Regeneron Pharmaceuticals, AstraZeneca, Lilly USA, LLC, Merck & Co., Novartis Pharmaceuticals, Novo Nordisk, Boehringer Ingelheim, Sanofi, Servier. R.J. Brown: Grant Recipient; Self; Regeneron Pharmaceuticals. E.A. Oral: Consulting Fee; Self; Regeneron Pharmaceuticals, Aegerion Pharmaceuticals, Ionis Pharmaceuticals Inc., Third Rock Ventures, Rejuvenate Inc. Grant Recipient; Self; Regeneron Pharmaceuticals, Aegerion Pharmaceuticals, Ionis Pharmaceuticals Inc., Novo Nordisk, Rhythm pharmaceuticals, Fractyl Laboratories, GID Dynamics. Other; Self; Aegerion Pharmaceuticals. Background: Lipodystrophy syndromes are rare disorders characterized by selective deficiency of adipose tissue leading to insulin resistance, diabetes mellitus, dyslipidemia and hepatic steatosis. We are conducting a comprehensive, multicenter and international observational registry study to document the natural history and prevalence of lipodystrophy syndromes in the contemporary era. Methods: All participants clinically diagnosed with a lipodystrophy syndrome, excluding HIV-associated lipodystrophy, at the participating centers may be enrolled. Once enrolled, demographic information and detailed medical history are obtained by the study team and from the participant. Patients are followed with reevaluations every 12 months. Participant questionnaires include the Patient Health Questionnaire (PHQ-9), the generalized anxiety disorder 7-item scale (GAD-7), the RAND SF-36 quality of life questionnaire, and a brief pain inventory (BPI). Univariable and multivariable repeated measure analyses were performed. Results: 148 individuals were enrolled from March 2018 to March 2022 (data-cut) with baseline age: 42 ± 15 years, 82% female, and BMI: 27.6 ± 6.5 kg/m2. Familial partial lipodystrophy is the most prevalent diagnosis (n=93, 65%), followed by congenital generalized lipodystrophy (n=13, 9.1%). There was a high prevalence of diabetes mellitus (77%), hypertriglyceridemia (82%), and hepatic steatosis (69%). 25% had at least one pancreatitis episode reported, with first episode of pancreatitis reported at age 30 ± 13 years. Cirrhosis was observed in 10% of the participants, with age of onset 39 ± 13 years. We observed a high incidence of depression and anxiety (47 and 45%) from medical history evaluation. The pain severity score (PSS) calculated from the BPI was positively associated with depression (PHQ9; p<0.0001) and anxiety (GAD-7; p=0.0003) adjusted for follow-up time. Patients with mild/moderate pain (PSS ≤4) showed a significant positive association with several Quality of Life (QoL) scores, such as physical functioning, limitation to physical health, limitation with emotional problems, and lack of energy/fatigue, social functioning, and general health (p<0.001 for all associations). During follow-up, we observed a decrease in triglyceride levels (from 585 ± 802 at baseline to 480 ± 486 mg/dL at year 3 (n=28)), while HbA1c increased from 7.4 ± 1.9 at baseline to 8.2 ± 2.1 % at year 3 (n=28). We observed 6 (4%) deaths during the 4-year follow-up. Conclusion: Our data may help clinicians, scientists, and patients with medical evaluation and decision-making in the clinical environment and provide insight into natural history as regulators evaluate new drugs. Presentation: Friday, June 16, 2023

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Purpose - to analyze modern approaches to understanding classification, etiopathogenesis, principles of diagnosis of pancreatitis in children. The pancreas has an important role in the processes of adequate digestion and assimilation of nutrients, as it ensures the fermentation of proteins, fats, and carbohydrates. The problem of pancreatitis in pediatrics worries not only domestic specialists, it is extremely important for study by the medical community in the world. Experts of the European Pancreatic Club focused on the fact that the incidence of acute pancreatitis has increased over the last 10-15 years and is 3.6-13.3 cases per 100,000 children. Taking into account such statistics, acute pancreatitis leaves the rubric of rare diseases, as it approaches the frequency in adults. It is important to understand the leading etiological factors of pancreatitis in childhood, as they are not identical to those in adult patients. However, the etiological factors in children are not of the same type according to the data of various studies. For example, according to the results of a twelve-year research in the USA, the dominant causes of pancreatitis in children were biliary tract problems (36.2%) and drug use (25.6%). Among sick children living in India, the causes were mostly injuries (21%) and biliary pathology. One of the latest data obtained in the study of children in the USA shows the structure of etiological factors: idiopathic (31%) and the influence of medications (23%). Analysis of the clinical course of the first episode of pancreatitis in children revealed that age, male gender, pancreatic necrosis and a higher body mass index were associated with the formation of a recurrent course. However, it is necessary to take into account possible anatomical anomalies of the biliary tract, hyperlipidemia and genetic factors. Modern guidelines and clinical recommendations for the diagnosis of pancreatitis in children mostly coincide and suggest taking into account the existing clinical symptoms and their consistency with the data of additional research methods. No conflict of interests was declared by the author.

Primary and Secondary Factors in Hypertriglyceridemia Induced Acute Pancreatitis: A Case-Based Focus Review

Hypertriglyceridemia (HTG) is a known cause of pancreatitis. We described a case of severe hypertriglyceridemia (likely familial) causing the first episode of pancreatitis in this patient. A 21-year-old female known for hypertriglyceridemia and DM type 2 came to the emergency room with severe epigastric pain along with nausea and vomiting. Physical exam revealed epigastric tenderness, diminished bowel sounds, and signs of dehydration. Initial blood work was mostly unremarkable mildly elevated lipase 83.

Ascaris “Download” as a cause of acute recurrent pancreatitis in a child

Introduction. Infestation with the roundworm Ascaris lumbricoides is one of the most prevalent helminthic diseases belonging to the soil-transmitted helminths class. Infections are especially affecting children in tropical countries and low and middle-income countries but also may occur in developing countries where sanitation and hygiene are poor. We aim to present a case report to sound the alarm on this widespread pathology. Case presentation. We report the case of a 9-year-old boy with Down syndrome and duodenal stenosis admitted to our hospital with recurrent bouts of pancreatitis secondary to ascariasis. Child is living in poor sanitation conditions. The first episode of pancreatitis was at the age of seven. The abdominal ultrasound shows enlargement and heterogeneity of the head and body of the pancreas, and multiple images of "the strip sign" in the duodenum, suggesting the presence of Ascaris lumbricoides. Live worms were expelled several times. During the next two years, this child was admitted for similar episodes suggesting re-infection with the soil-transmitted helminths, repeated courses of albendazole were administered to the patient and to his close relatives contact. Conclusions. Ascaris lumbricoides infection is rarely a direct cause of mortality, but it contributes to overwhelming morbidity. Periodically repeated de-worming treatment and additional preventive measures such as improvements to water, sanitation and hygiene (WASH) could ensure high rates of eradication.

A STUDY ON RESPIRATORY COMPLICATIONS AND ITS OUTCOME IN ACUTE PANCREATITIS

Background: Respiratory complications are frequent in acute pancreatitis, and respiratory dysfunction, presenting as Acute lung injury (ALI) or Acute Respiratory Distress Syndrome (ARDS), is a major component of multiple organ dysfunction syndrome (MODS), with a frequent need for ventilator support, which contributes to early death in severe acute pancreatitis. The current study was done with the objective of assessing the morbidity and mortality of acute pancreatitis cases with respiratory complications and to find out whether there is any association between the aetiology of acute pancreatitis and respiratory complications.
 Methodology: It was a prospective observational study conducted in a tertiary care centre in Kerala. All participants admitted with symptoms suggestive of acute pancreatitis were screened for potential enrolment. The inclusion criteria employed were that the patients should be aged above 18 years, and presenting with the first episode of pancreatitis, irrespective of aetiology. All the patients who were admitted were monitored daily for the worsening of any respiratory complications and provided with adequate respiratory supports.
 Results: Out of the 101 participants recruited, males were 84.2%. Mean (SD) age was 42.1 (11.4) years. Majority of cases (61%) had alcoholic aetiology. Fourteen patients required high flow nasal oxygen support, four patients were given face mask support, five patients required ventilator support and three patients required tracheostomy support. Respiratory complications and requirement of support were found to be associated with higher morbidity as well as mortality. Respiratory complications were higher in those with alcoholic etiology but this was not significant in univariate analysis.
 Conclusion: Respiratory complications pose challenges in clinical course of acute pancreatitis in terms of morbidity as well as mortality. Aetiology did not seem to play a major role in development of respiratory complications.

Biliary sphincterotomy reduces the risk of acute gallstone pancreatitis recurrence in non-candidates for cholecystectomy

BackgroundPopulation aging and comorbidity are leading to an increase in patients unfit for cholecystectomy. AimsTo evaluate whether endoscopic biliary sphincterotomy after a first episode of acute gallstone pancreatitis reduces the risk of pancreatitis recurrence and gallstone-related events in non-surgical candidates. MethodsRetrospective study of patients admitted for a first episode of acute gallstone pancreatitis rejected for cholecystectomy between 2013–2018. The role of endoscopic sphincterotomy was evaluated by adjusting for age, severity of pancreatitis, and presence of choledocholithiasis. ResultsWe included 247 patients (mean age 80 ± 12 years; Charlson index: 5; severity of pancreatitis: 72% mild). Sphincterotomy was performed in 23.9%. Recurrence of pancreatitis occurred in 17.4% patients (median follow-up: 426 days). The one-year cumulative incidence of a new episode of pancreatitis was 1.8% (95% confidence interval [CI]: 0.2–12%) and 23% (95% CI: 17–31%) in patients with and without sphincterotomy, respectively (p = 0.006). In multivariate analysis, sphincterotomy showed a protective role for recurrence of pancreatitis (adjusted hazard ratio [HR]: 0.29, 95% CI: 0.08–0.92, p = 0.037) and for any gallstone-related event (HR 0.46, 95% CI: 0.21–0.98, p = 0.043). ConclusionsEndoscopic biliary sphincterotomy reduced the risk of gallstone pancreatitis recurrence and other biliary-related disorders in patients with a first episode of pancreatitis non-candidates for cholecystectomy.

Endoscopic Therapy for Recurrent Acute Pancreatitis

Recurrent acute pancreatitis (RAP) is a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of a normal anatomical and functional gland, however, a chronic disease at early stage may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The etiology of RAP can be identified in up to 70% of cases; for the remaining cases the term “idiopathic” is used. Most common causes include bile duct stone disease, sphincter of Oddi dysfunction, anatomical ductal variants interfering with pancreatic juice outflow, genetic mutations, any obstruction of the main pancreatic duct or pancreatico-biliary junction, and alcohol consumption. Patients with RAP have few treatment options available to them to manage their symptoms or prevent progression to chronic pancreatitis. Endoscopic therapy has been found effective in those cases in whom a mechanical obstruction is found. The efficacy of endoscopic therapy in patients with a history of RAP depends on two main factors: whether or not the bouts of acute pancreatitis occur in a normal pancreas or in a setting of chronic pancreatitis, and whether or not a cause can be identified and removed. Because occult bile stone disease and sphincter of Oddi dysfunction account for the majority of cases, cholecystectomy, and eventually endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. However, in the last years concerns the efficacy of endotherapy in sphincter of Oddi dysfunction have been raised. Pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis caused by pancreatic ductal obstruction, independently from the cause of obstruction, in symptomatic pancreas divisum and in some cases of genetic mutations.

Eluxadoline-induced Recurrent Pancreatitis in a Young Female without a Gallbladder: A Case Report and Literature Review

Eluxadoline is a mixed opioid receptor agonist and antagonist approved for the treatment of diarrhea-predominant irritable bowel syndrome (IBS). It is believed to decrease visceral hypersensitivity without completely inhibiting intestinal motility. Pooled safety data from two phase three randomized trials have reported few cases of pancreatitis especially in patients with sphincter of Oddi (SO) dysfunction and cholecystectomy patients. We present a rare case of eluxadoline-induced recurrent pancreatitis in a 31-year-old female without a gallbladder. Her medical history was significant for irritable bowel syndrome with diarrhea (IBS-D), cholecystectomy, and depression. She was started on 75 mg of eluxadoline (the recommended dose for IBS-D patients without a gallbladder) three weeks prior to the first episode of pancreatitis. She had a recurrent episode of pancreatitis after few weeks and her symptoms and lipase levels improved significantly two days after stopping eluxadoline. The exact mechanism of eluxadoline to cause pancreatitis is unknown but it is believed to increase SO contractions. The absence of gallbladder prevents cholecystokinin mediated relaxation of the SO thus contributing more to spasms with eluxadoline. Few cases of severe pancreatitis and death have been reported even with the reduced dose of eluxadoline recommended for cholecystectomy patients. This case highlights the importance of considering drug-induced pancreatitis and avoidance of eluxadoline even in reduced doses in patients without a gallbladder.

Management of Gallstone-Induced Acute Pancreatitis in Pregnancy: A Tertiary-Center Experience.

Objectives:Gallbladder stones are the most frequently reported etiology of acute pancreatitis in pregnancy and are often diagnosed in the third trimester. This condition is associated with both mother and infant morbidity and mortality, and its treatment remains controversial.Methods:Relevant patient data between September 2010 and April 2017 from the Kanuni Sultan Suleyman Training and Research Hospital were analyzed regarding etiology (of gallstone pancreatitis), trimester of pregnancy, diagnostic tools, pancreatitis stage, clinical status, medical treatment, surgical interventions, and pregnancy status.Results:We included 68 patients recorded with acute pancreatitis due to biliary gallstones. Pancreatitis symptoms developed in most (n=38) (55.8%) patients during the third trimester. Of 24 patients who had their first episode of pancreatitis in the first trimester of pregnancy, 12 (50%) were readmitted due to recurrence. Seven (11.3%) patients whose Ranson scale score was 3 underwent computed tomography evaluation. The number of patients with acute cholecystitis with pancreatitis was 5 (7.3%), whereas the number of patients with choledocholithiasis was 4 (5.8%). Sphincterotomy with endoscopic retrograde cholangiopancreatography was performed in 2 (2.9%) patients. Laparoscopic cholecystectomy was performed in 9 (13.2%) patients during pregnancy. No fetal and maternal morbidity and mortality was found in all periods.Conclusion:Developments in supportive care, wide-spread use of imaging methods, and a multidisciplinary approach with better antenatal care of pregnant patients with acute pancreatitis can help prevent fetal and maternal morbidity and mortality in such cases. Early laparoscopic cholecystectomy should be considered especially in pregnant patients with acute pancreatitis due to gallstones in the first trimester.

Acute recurrent pancreatitis: Etiopathogenesis, diagnosis and treatment.

Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term "idiopathic" is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches.

Risk Factors For Acute Pancreatitis In Patients With Acute Lymphoblastic Leukemia

Acute pancreatitis is a life-threatening complication of acute lymphoblastic leukemia (ALL) treatment. Previous studies have reported that intensive chemotherapy (especially asparaginase) and older age may predispose patients to pancreatitis (Samarasinghe et al. Br J Haematol 2013, Kearney et al. Pediatr Blood Cancer 2009;53:162 and Knoderer et al. Pediatr Blood Cancer 2007;49:634); however only a few large trials and case series have been reported. We studied 5185 ALL patients (age 0 to 30 years) enrolled between 1994 and 2012 on six front-line protocols for childhood ALL (St. Jude Total XIIIB and Total XV; COG P9904/P9905/P9906 and AALL0232) at St. Jude Children's Research Hospital and in the Children's Oncology Group. Pancreatitis was diagnosed in 117 (2.3%) patients by clinical symptoms, elevation in the serum amylase or lipase levels and abnormal radiographic or surgical findings according to NCI CTCAE version 2.0 (grade 3-4) or 3.0 (grade 2-4). The first episode of pancreatitis developed during remission induction in 24 of 117 (20.5%) patients and during the first year of therapy (including remission induction) in 104 of 117 (88.9%) patients.We investigated whether age, gender, race, immunophenotype, cumulative asparaginase dose and formulation (native E. coli-asparaginase [Elspar] vs PEG-asparaginase [Oncaspar]) were associated with the development of pancreatitis. Race was categorized as white, black, Hispanic, Asian and other based on inferred genetic ancestry (European, African, Native American and Asian) using STRUCTURE (Yang et al. Nat Genet 2011;43:237-241). Patients with pancreatitis were significantly older than those without the complication (median age, 11.7 years vs 7.3 years; P = 2.2 × 10-9). Hispanics (46 of 1177, 3.9%) and blacks (11 of 350, 3.1%) had a higher risk of pancreatitis than did whites (46 of 3069, 1.5%) and Asians (1 of 99, 1.0%; P = 1.6 × 10-5). Patients treated on protocols featuring higher cumulative dose of asparaginase (Total XV, COG P9906 and AALL0232) developed more pancreatitis than those on the protocols with lower dose of asparaginase (Total XIIIB and COG P9904/P9905) (103 of 3358, 3.1% vs 14 of 1827, 0.8%; P = 1.2 × 10-8; Figure 1). Gender, immunophenotype and asparaginase formulation were not associated with the development of pancreatitis. In a multivariate model, Native American ancestry (hazard ratio = 1.20 for every 10% increase; P = 8.4 × 10-8), older age (hazard ratio = 1.08 for every 1 year increase; P = 1.2 × 10-5) and higher cumulative dose of asparaginase (hazard ratio = 3.27 for those receiving native E.coli-asparaginase [or PEG-asparaginase equivalent] ≥ 240,000 U/m2 vs< 240,000 U/m2; P = 1.1 × 10-4) remained independent risk factors for pancreatitis, while African ancestry was only marginally significant (hazard ratio = 1.08 for every 10% increase; P = 0.053). In summary, older age, Native American ancestry and higher asparaginase exposure independently predict the development of pancreatitis in children treated for ALL. [Display omitted] Disclosures:Evans:St. Jude: In accordance with institutional policy, St. Jude allocates a portion of the income it receives from licensing inventions and tangible research materials to those researchers responsible for creating this intellectual property., In accordance with institutional policy, St. Jude allocates a portion of the income it receives from licensing inventions and tangible research materials to those researchers responsible for creating this intellectual property. Patents & Royalties, Under this policy, I and/or my spouse have in the past received a portion of the income St. Jude receives from licensing patent rights related to TPMT polymorphisms as clinical diagnostics. Other. Hunger:Jazz Pharmaceuticals: I receive funding for investigator-initiated research of asparaginase from Jazz Pharmaceuticals., I receive funding for investigator-initiated research of asparaginase from Jazz Pharmaceuticals. Other; Sigma-Tau Pharmaceuticals: I receive funding for investigator-initiated research of asparaginase from Sigma-Tau Pharmaceuticals. Other. Relling:Sigma-Tau Pharmaceuticals: I receive funding for investigator-initiated research on the pharmacology of asparaginase from Sigma-Tau Pharmaceuticals., I receive funding for investigator-initiated research on the pharmacology of asparaginase from Sigma-Tau Pharmaceuticals. Other; St. Jude Children's Research Hospital : I have in the past received a portion of the income St. Jude receives from licensing patent rights related to TPMT polymorphisms as clinical diagnostics., I have in the past received a portion of the income St. Jude receives from licensing patent rights related to TPMT polymorphisms as clinical diagnostics. Patents & Royalties.

Rare Case of Duplication Cyst was Misdiagnosed as Pancreatic Pseudocyst

A 7-year-old boy presents with a history of recurrent pancreatitis. His abdominal pain started in 2007, but his first episode of pancreatitis was in January 2010. Since that time has had at least five known episodes of pancreatitis with mild elevation of his amylase and lipase (range: 200 - 300). There is no history of abdominal trauma and he had negative genetic testing for the hereditary pancreatitis (CFTR, PRSS1, and SPINK1 gene mutations). He had numerous imaging studies revealing a persistent cystic lesion near the pancreatic head, since his first episode of pancreatitis. Computed tomography of the abdomen showed thick-walled U-shaped cystic structure lying between the head of the pancreas, the inferior gastric antrum and the proximal descending duodenum. An abdominal US demonstrated a bi-lobed thick-walled cystic mass with a positive rim sign. Recurrent pancreatitis is uncommon in pediatric patients. Causes of recurrent pancreatitis in pediatrics are different than those in adults. While hereditary pancreatitis is one of the causes, the genetic testing was negative and there was no sign of pancreatic injury or inflammation in any of the images. Pancreatic pseudocyst is a complication of acute pancreatitis and usually has a thin wall instead of a thick wall, and it’s unlikely to be present during the first episode of pancreatitis. Foregut duplication cyst is a rare (about 1 in 4,500) congenital anomaly that can happen anywhere throughout the GI tract. The US finding of a rim sign is a typical appearance of a duplication cyst and usually is managed by surgical resection. Even though foregut duplication is a rare congenital anomaly, it should always be considered in the differential diagnosis of cases of chronic pancreatis, especially with the presence of thick walled cystic formation on imaging studies. J Med Cases. 2013;4(5):316-317 doi: https://doi.org/10.4021/jmc1181w

Chronic pancreatitis as presentation of Crohn’s disease in a child

It is reported that a pancreatic disease may precede the diagnosis of inflammatory bowel disease (IBD) both in children and in adults. Idiopathic chronic pancreatitis, however, occasionally co-exists with the IBD, mainly at pediatric age. We report a case of a patient who progressively developed the features of a chronic pancreatitis, before the diagnosis of Crohn's Disease (CD). Ten months after the onset of the first episode of pancreatitis the patient developed bloody diarrhea, mucus stools and biochemical findings of inflammation. The colonoscopy revealed a diffuse colitis without involvement of the last loop and the gastroscopy showed inflammation of the iuxta-papillary area. The histological findings confirmed the diagnosis of CD that involved the colon and the duodenum. In conclusion, in children the idiopathic chronic pancreatitis may be an unusual presentation of CD. Thus, if other known cause of chronic pancreatitis are not found, a not invasive work up to exclude the IBD should be warranted. An early coincidental diagnosis of the IBD may delay the progression of the pancreatic disease.

A case of intraductal papillary mucinous neoplasms after recurrent acute pancreatitis.

We report a case of main pancreatic duct (MPD)-type intraductal papillary mucinous neoplasms of the pancreas (IPMNs), in whom diagnostic imaging modalities showed abnormal findings after 4 episodes of acute pancreatitis. The patient was 51years old at his first admission for acute pancreatitis. He experienced two more episodes of acute pancreatitis, though repeated computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) showed no abnormality to explain the cause of the pancreatitis. After 3½ years from his first episode of pancreatitis, CT and endoscopic ultrasonography revealed pancreatic duct dilation of the pancreas head. Seven years after the first admission, a second ERCP and intraductal ultrasonography revealed a partially dilated MPD with papillary tumors. He underwent pancreaticoduodenectomy, and the pathological diagnosis was intraductal papillary mucinous adenoma with moderate atypia. This case suggests that acute pancreatitis can precede visualized IPMNs. Therefore, acute recurrent pancreatitis with unknown etiology should be followed up for the possibility of IPMNs, in order to detect neoplastic changes in the early stage to provide a better prognosis for the patient.

Utilidad de la ecoendoscopia en el diagnóstico etiológico de los pacientes con pancreatitis aguda idiopática

The aim of this study was to evaluate the utility of endoscopic ultrasonography in the etiological diagnosis of patients initially diagnosed with acute idiopathic pancreatitis and to determine the clinical and laboratory factors related to the results of this technique. We studied 73 patients initially diagnosed with acute idiopathic pancreatitis and referred to our service for biliopancreatic endoscopic ultrasonography. A positive result was considered to be identification of at least one possible cause of pancreatitis, excluding patients in whom the only echoendoscopic finding was chronic pancreatitis. The clinical characteristics and clinical course of these patients were compared with the results of the technique. Endoscopic ultrasonography diagnosed at least one possible cause of acute pancreatitis in 32 patients (44%). The most frequent diagnoses were cholelithiasis (16%) and biliary sludge (20%). The diagnostic yield of endoscopic ultrasonography was lower in patients with prior cholecystectomy (16% vs. 49%; p=0.037) while a positive result was more likely in patients with elevated glutamyl oxaloacetic transaminase (GOT) or glutamyl pyruvic transaminase (GPT) levels at diagnosis of acute pancreatitis (GOT: 68 vs. 31%; p=0.002; GPT: 63 vs. 26%; p=0.001). No differences were found in diagnostic yield according to whether endoscopic ultrasonography was performed during the first episode of pancreatitis (48%) or in recurrent episodes (37%) (p=0.40). Over a mean follow-up period of 28 months, recurrence of new episodes of pancreatitis was significantly lower in patients with an etiological diagnosis (3 vs. 22%; p=0.02). Endoscopic ultrasonography is a useful technique in the etiological diagnosis of acute pancreatitis of unknown origin, especially in patients with elevated transaminase levels and/or without cholecystectomy. This technique should be used in the first episode of acute idiopathic pancreatitis.

Sphincter of Oddi dysfunction and bile duct microlithiasis in acute idiopathic pancreatitis

Although there are numerous causes of acute panc-reatitis, an etiology cannot always be found. Two potential etiologies, microlithiasis and sphincter of Oddi dysfunction, are discussed in this review. Gallbladder microlithiasis, missed on transcutaneous ultrasound, is reported as the cause of idiopathic acute pancreatitis in a wide frequency range of 6%-80%. The best diagnostic technique for gallbladder microlithiasis is endoscopic ultrasound although biliary crystal analysis and empiric cholecystectomy remain as reasonable options. In contrast, in patients who are post-cholecystectomy, bile duct microlithiasis does not appear to have a role in the pathogenesis of acute pancreatitis. Sphincter of Oddi dysfunction is present in 30%-65% of patients with idiopathic acute recurrent pancreatitis in whom other diagnoses have been excluded. It is unclear if this sphincter dysfunction was the original etiology of the first episode of pancreatitis although it appears to have a causative role in recurring episodes since sphincter ablation decreases the frequency of recurrent attacks. Unfortunately, this conclusion is primarily based on small retrospective case series; larger prospective studies of the outcome of pancreatic sphincterotomy for SOD-associated acute pancreatitis are sorely needed. Another problem with this diagnosis and its treatment is the concern over potential procedure related complications from endoscopic retrograde cholangiopancreatography (ERCP), manometry and pancreatic sphincterotomy. For these reasons, patients should have recurrent acute pancreatitis, not a single episode, and have a careful informed consent before assessment of the sphincter of Oddi is undertaken.

Recurrent idiopathic pancreatitis in familial adenomatous polyposis: Report of a case-series and review of the literature

Familial adenomatous polyposis (FAP) is characterized by the development of multiple adenomatous polyps predominantly in the colon but also in the duodenum. Scattered case reports indicate that there is a risk for pancreatitis in FAP. The most likely cause of pancreatitis in FAP is obstructing ampullary adenomas. We describe 7 FAP patients who experienced one or more episodes of pancreatitis. Two patients experienced pancreatitis after endoscopic treatment of ampullary adenoma. The cause of the pancreatitis in 5 of 7 patients could not be determined, as none of the patients had obstruction of the ampulla. Furthermore, other risk factors for pancreatitis such as pancreatic serine protease inhibitor Kazal type I (SPINK1) gene mutations were ruled out. A review of literature identified 20 FAP patients who developed the first episode of pancreatitis at a mean age of 45 years (range 23-72 years). Some 55% had recurrent episodes of pancreatitis. Eight patients had (peri) ampullary adenomas or carcinomas. In most cases, the course of pancreatitis was mild with an uneventful outcome, but one patient died after an episode of acute pancreatitis.

Factors Associated with Successful Endoscopic Ultrasound-Guided Pseudocyst Drainage

Background: Endoscopic ultrasound-guided drainage of pancreatic pseudocysts via cystenterostomy is well described, although factors which determine the success of this procedure are unknown. Aim: Identify factors that influence the success of endoscopic ultrasound-guided cystenterostomy. Methods: We retrospectively reviewed all endoscopic ultrasound-guided cystenterostomy procedures performed at our medical center from January 1998–November 2004 for drainage of pancreatic pseudocysts. Patients with prior surgical or radiological-guided drainage were excluded. Charts were abstracted for demographics, pancreatitis etiology, pseudocyst size, time interval from first episode of pancreatitis to cystenterostomy, appearance of cyst fluid, echogenicity of cyst fluid, presence of septations, number of stents placed and type of drainage procedure. Procedure failure was defined as the need to subsequently undergo open surgical intervention. Results: Overall, 16 patients underwent EUS-guided cystenterostomy. The mean age was 50 years old and half were female. 12 (75%) procedures were deemed successful. The etiology of pancreatitis in five patients was idiopathic, while it was gallstone in four others – etiology was not significantly associated with procedure success (p = 0.62). Successful drainage procedures occurred a mean of 3.8 months following diagnosis of pancreatitis, while failed procedures occurred after an average of 3.0 months (p = 0.23). Total number of stents placed (mean 1.9) and type of procedure (cystgastronomy vs. cystduodenostomy) did not predict procedure success. We found no association between procedure success and cyst fluid appearance, fluid echogenicity or presence of septations. Conclusions: In our experience, we found no patient- or procedure-specific factors that influence the success of endoscopic ultrasound-guided pseudocyst drainage. This may reflect appropriate patient selection prior to the procedure. Further large-scale studies are warranted. Background: Endoscopic ultrasound-guided drainage of pancreatic pseudocysts via cystenterostomy is well described, although factors which determine the success of this procedure are unknown. Aim: Identify factors that influence the success of endoscopic ultrasound-guided cystenterostomy. Methods: We retrospectively reviewed all endoscopic ultrasound-guided cystenterostomy procedures performed at our medical center from January 1998–November 2004 for drainage of pancreatic pseudocysts. Patients with prior surgical or radiological-guided drainage were excluded. Charts were abstracted for demographics, pancreatitis etiology, pseudocyst size, time interval from first episode of pancreatitis to cystenterostomy, appearance of cyst fluid, echogenicity of cyst fluid, presence of septations, number of stents placed and type of drainage procedure. Procedure failure was defined as the need to subsequently undergo open surgical intervention. Results: Overall, 16 patients underwent EUS-guided cystenterostomy. The mean age was 50 years old and half were female. 12 (75%) procedures were deemed successful. The etiology of pancreatitis in five patients was idiopathic, while it was gallstone in four others – etiology was not significantly associated with procedure success (p = 0.62). Successful drainage procedures occurred a mean of 3.8 months following diagnosis of pancreatitis, while failed procedures occurred after an average of 3.0 months (p = 0.23). Total number of stents placed (mean 1.9) and type of procedure (cystgastronomy vs. cystduodenostomy) did not predict procedure success. We found no association between procedure success and cyst fluid appearance, fluid echogenicity or presence of septations. Conclusions: In our experience, we found no patient- or procedure-specific factors that influence the success of endoscopic ultrasound-guided pseudocyst drainage. This may reflect appropriate patient selection prior to the procedure. Further large-scale studies are warranted.

Pancreatitis Among Patients With Cystic Fibrosis: Correlation With Pancreatic Status and Genotype

Pancreatitis Among Patients With Cystic Fibrosis: Correlation With Pancreatic Status and Genotype

“Air-in a view”

A 57-year-old female was referred to Duke University Medical Center (DUMC) for investigation of recurrent pancreatitis. Her first episode of pancreatitis, which had occurred 3 years earlier, manifested as epigastric pain and a markedly elevated serum amylase level which necessitated hospital admission for 9 days. Her history was negative for relevant pancreatic risk factors including alcohol abuse, medications, family history and hyperlipidaemia. Ultrasound (US) of the gallbladder showed no gallstones. CT of the abdomen showed a swollen head of pancreas with peri-pancreatic inflammatory change and fluid, consistent with pancreatitis. The biliary tree was not dilated. She made a complete recovery and was well until 8 months later when she had recurrent epigastric pain of a similar character with elevation of the serum amylase. She was admitted to hospital for 3 days. A repeat US scan showed no cholelithiasis. Following resolution of her symptoms, she underwent endoscopic retrograde cholangiopancreatography (ERCP) to exclude choledocholithiasis or a pancreatic abnormality. The patient's pancreatogram is shown in Figures 1 and 2. The cholangiogram was reported to be normal. She developed post-ERCP pancreatitis and was referred to DUMC for further evaluation.