Gallstone-induced Pancreatitis Research Articles

Severity of Gallstone-, Sludge-, or Microlithiasis-Induced Pancreatitis-All of the Same?

Severity of microlithiasis- and sludge-induced pancreatitis in comparison to gallstone-induced pancreatitis has never been studied for a lack of definition. In this retrospective cohort study, 263 patients with acute biliary pancreatitis treated at a tertiary care center from 2005 to 2021 were stratified according to the recent consensus definition for microlithiasis and sludge. The gallstone-pancreatitis cohort was compared to microlithiasis, sludge, and suspected stone passage pancreatitis cohorts in terms of pancreatitis outcome, liver function, and endosonography/endoscopic retrograde cholangiopancreatography results using one-way analysis of variance and χ 2 test. Multinomial logistic regression analysis was performed to correct for bias. Microlithiasis- and sludge-induced pancreatitis, classified according to the revised Atlanta classification, did not present with a milder course than gallstone-induced pancreatitis ( P = 0.62). Microlithiasis and sludge showed an increase in bilirubin on the day of admission to hospital, which was not significantly different from gallstone-induced pancreatitis ( P = 0.36). The likelihood of detecting biliary disease on endosonography resulting in bile duct clearance was highest on the day of admission and day 1, respectively. Microlithiasis and sludge induce gallstone-equivalent impaired liver function tests and induce pancreatitis with similar severity compared with gallstone-induced acute biliary pancreatitis.

A Descriptive Study of the Demographic and Clinicopathological Characteristics of Individuals With Gallstone-Induced Pancreatitis in a Tertiary-Level Hospital in Ranchi, Jharkhand.

Gallstones are a major cause of acute pancreatitis, which is associated with high recurrence, morbidity, and mortality. Careful consideration of demographic and clinicopathological features is required to understand the association between the cause and severity of pancreatitis in various populations, and such crucial information is lacking for Jharkhand's population. Here, we sought to describe the demographic and clinicopathological features of gallstone-induced acute pancreatitis at a tertiary hospital in Ranchi. This hospital-based descriptive study was conducted at Rajendra Institute of Medical Sciences in Ranchi. The hospital records of patients admitted to the surgical unit with acute gallstone-induced pancreatitis from January 2023 to December 2023 were analyzed. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Of the 72 patients admitted with acute gallstone-induced pancreatitis (mean age: 42.5 years), 46 (64%) were males and 26 (36%) were females. All 72 patients had abdominal pain and 44 (61%) were vomiting. The severe vs. non-severe pancreatitis groups differed significantly in age (≥40) and male gender (p = 0.013 and 0.031, respectively). A total of 45 (62.5%) patients had severe gallstone-induced pancreatitis, and the most common complication was acute kidney injury, followed by pleural effusion (18 (25%) and 13 (18.1%) cases, respectively). Our study revealed that gallstone-induced pancreatitis was more common in males and that age and gender were significantly associated with severity. However, late presentation to the hospital may have influenced our study, resulting in more severe cases being reported, with the most common complication being acute kidney injury. To our knowledge, this is the first study to describe the demographic, clinicopathological, and outcome data of acute gallstone-induced pancreatitis in Ranchi. These results can guide hospital policy development to improve patient outcomes.

Can the Computed Tomography Severity Index be a Prognostic Tool in Acute Gallstone-Induced Pancreatitis?

Can the Computed Tomography Severity Index be a Prognostic Tool in Acute Gallstone-Induced Pancreatitis?

Can Organ Failure and Infected Pancreatic Necrosis be Used to Forecast Mortality in Patients with Gallstone-Induced Pancreatitis?

Can Organ Failure and Infected Pancreatic Necrosis be Used to Forecast Mortality in Patients with Gallstone-Induced Pancreatitis?

Comparison of outcome of male versus female laparoscopic cholecystectomy: BMI-adjusted prospective observational study

Background. Laparoscopic cholecystectomy has become the choice of treatment for symptomatic cholelithiasis and has replaced open cholecystectomy. Numerous studies and scoring system have been developed over the past 2–3 decades which predict the rate of conversion of laparoscopic to open cholecystectomy. Recently, few scoring systems have been developed which incorporates various intraoperative findings to predict this conversion. No studies are available in literature to assess gender-specific and body weight complications in laparoscopic cholecystectomy. The purpose of this study was to compare the outcome of laparoscopic cholecystectomy between male and female patients in terms of preoperative factors, intraoperative difficulties and rate of conversion to open cholecystectomy and common postoperative complications. Materials and methods. This non-randomized, prospective, observational study was conducted at a tertiary care hospital in Northern India from June 2019 to May 2021. Various preoperative data was collected from the patients like age, the American Society of Anesthesiologists (ASA) class, comorbidity, indication for surgery, preoperative ultrasonography findings and any previous surgery. Surgeries in all patients were started with laparoscopic cholecystectomy under general anaesthesia. The outcomes were measured in terms of time taken to complete surgery, whether laparoscopic cholecystectomy was converted to open cholecystectomy, common bile duct/cystic duct injury during surgery, common postoperative complications and average length of hospital stay in days. Results. A total of 300 patients were included in the study: 222 females and 78 males. Mean age of presentation in women was (46.45±11.55) years ranging from 21 to 71 years and in men (51.78±11.49) years ranging from 36 years to 76 years. This difference was statistically significant (p=0.001). The other significant preoperative differences between males and females were comorbidity (p=0.001) and previous surgeries (p=0.001). However, the ASA class under which the patients were operated was not significant (p=0.998). The various indications for surgery to include chronic cholecystitis, resolved acute cholecystitis, gallstone-induced pancreatitis and common bile duct stone had no statistical difference between men and women (p=0.072). Conclusions. This study concludes that intraoperative difficulties were more often in male patients as compared to females. The average operating time, conversion of laparoscopic to open cholecystectomy and postoperative hospital stay were significantly higher in men than in women.

COMPARATIVE STUDY OF DISEASE SEVERITY, COURSE, COMPLICATIONS, AND CLINICAL OUTCOME BETWEEN ALCOHOL-INDUCED PANCREATITIS AND GALL STONE-INDUCED PANCREATITIS

Objective:To assess whether the etiological factors of alcohol and gall stones affect the disease severity, course, disease-associated complications, and clinical outcome in terms of length of hospital stay, infection/organ failure rates, intervention rates, and mortality. Materials and Method: We conducted a hospital-based prospective study in the Department of Radio-Diagnosis, Assam Medical College, where 75 cases with acute pancreatitis were screened and subdivided into three etiological groups: (i) alcoholism (33 cases), (ii) cholelithiasis (23 cases), and (iii) other causes (19 cases), out of which 56 cases with etiology of alcoholism and gall stones were included in our study. The severity was scored using the Modified CT Severity Index. Clinical follow-up was done for both alcohol-induced Pancreatitis and Gall stone-induced pancreatitis groups to assess the disease course, disease-associated complications& clinical outcome. Statistical analysis: We analyzed data using the computer program Statistical Package for Social Sciences (SPSS for Windows, version 21.0. Chicago, SPSS Inc.) and Microsoft Excel 2010. Results: In a total of 75 cases screened for our study, alcohol-induced pancreatitis was the leading cause of acute pancreatitis (33 cases), followed by gall stone-induced pancreatitis (23 cases). Together, they accounted for 56 cases and constituted our study population. The majority of cases in our study were categorized under Moderate acute Pancreatitis in both alcohol-induced acute pancreatitis and gall stone-induced Pancreatitis as per the Modified CT Severity Index. The occurrence of ascites was more in alcohol-induced A.P. No significant difference was noted between the two groups in parameters such as peripancreatic or pancreatic fluid collection, necrosis, pleural effusion, extrapancreatic parenchymal abnormality, vascular complications & G.I. complications. There was no statistically significant difference in clinical outcome between the two groups regarding the length of hospital stay, infection/organ failure evidence, need for intervention, and mortality. Conclusion: Our study found no significant difference between the two etiological groups regarding disease severity, course & complications, and clinical outcome except for the increased occurrence of ascites in alcohol-induced pancreatitis.

Is It a Bird? Is It a Plane? It's a Tumour – Operative Transcystic Choledochoscopy for Differentiation of Biliary Duct Filling Defect and New Early Diagnosis of Insidious Pancreatic Adenocarcinoma

Background: Operative Transcystic Choledochoscopy (OTC) during Laparoscopic Cholecystectomy (LC) is a one-procedure solution for clearance of Common Bile Duct (CBD) calculi under vision and allows identification and biopsy of biliary neoplasms. Success and complication rates in high-volume centres are similar or superior to Endoscopic Retrograde Cholangiopancreatography (ERCP). Preference for ‘minimally-invasive’ techniques like ERCP has led to infrequent use and resultant deskilling. Its ongoing role is therefore currently unclear. Case: A well 65-year-old male with epigastric pain and raised lipase, and Computed Tomography (CT) showing cholelithiasis and ‘focal pancreatitis involving the uncinate process’, underwent LC for gallstone-induced pancreatitis 6 days after presentation. Pre-operative bilirubin was normal and ALKP (133 U/L) and GGT (270 U/L) newly raised. An oedematous stone-containing gallbladder and a distal CBD filling defect on Intraoperative Cholangiogram were found. OTC demonstrated a CBD wall growth but biopsy equipment was unavailable. No peritoneal or liver metastases were seen. Ca19.9 (588 kU/L) was elevated. Pancreas-protocol CT/MRI showed a 14x14mm ‘indeterminate abnormality’ in the head/uncinate process without vascular involvement, and staging CT was negative for metastases. Endoscopic Ultrasound-guided biopsy diagnosed pancreatic adenocarcinoma following non-diagnostic ERCP. A Whipple’s procedure was planned but later abandoned as liver metastases were confirmed on frozen section at staging laparoscopy. Discussion: Despite recent movement away from OT during LC, this study highlights its utility in early identification of insidious biliary neoplasmswith the first case of preliminary pancreatic adenocarcinoma diagnosed with OTC during LC in a non-obstructed patient.

Comparison of clinical characteristics and outcomes between alcohol-induced and gallstone-induced acute pancreatitis: An Australian retrospective observational study.

Objectives:To compare the characteristics and outcomes of patients presenting to hospital with alcohol-induced and gallstone-induced acute pancreatitis.Methods:Retrospective study of all patients with alcohol-induced or gallstone-induced pancreatitis during the period 1 June 2012 to 31 May 2016. The primary outcome measure was hospital mortality. Secondary outcome measures included hospital length of stay, requirements for intensive care unit admission, intensive care unit mortality, mechanical ventilation, renal replacement therapy, requirement of inotropes and total parenteral nutrition.Results:A total of 642 consecutive patients (49% alcohol; 51% gallstone) were included. No statistically significant differences were found between alcohol-induced and gallstone-induced acute pancreatitis with respect to hospital mortality, requirement for intensive care unit admission, intensive care unit mortality and requirement for mechanical ventilation, renal replacement therapy, inotropes or total parenteral nutrition. There was significant difference in hospital length of stay (3.07 versus 4.84; p < 0.0001). On multivariable regression analysis, Bedside Index of Severity in Acute Pancreatitis score (estimate: 0.393; standard error: 0.058; p < 0.0001) and admission haematocrit (estimate: 0.025; standard error: 0.008; p = 0.002) were found to be independently associated with prolonged hospital length of stay.Conclusion:Hospital mortality did not differ between patients with alcohol-induced and gallstone-induced acute pancreatitis. The duration of hospital stay was longer with gallstone-induced pancreatitis. Bedside Index of Severity in Acute Pancreatitis score and admission haematocrit were independently associated with hospital length of stay.

A commentary on “challenges encountered in the management of gallstone-induced pancreatitis in pregnancy” (Int J Surg 2019;71:72–8)

A commentary on “challenges encountered in the management of gallstone-induced pancreatitis in pregnancy” (Int J Surg 2019;71:72–8)

Endoscopic sphincterotoMy for delayIng choLecystectomy in mild acute biliarY pancreatitis (EMILY study): protocol of a multicentre randomised clinical trial

IntroductionAccording to the literature, early cholecystectomy is necessary to avoid complications related to gallstones after an initial episode of acute biliary pancreatitis (ABP). A randomised, controlled multicentre trial (the PONCHO...

Screening of Sera from Patients with Pancreatitis by an Apoptosis Assay of Skin-derived Cells.

An excessive inflammatory response is typical in acute pancreatitis and a significant cause of early mortality in severe acute pancreatitis. This is believed to be caused by inflammatory molecules or upregulated cytokine levels in the serum of patients. The aim of this study was to identify the serum-mediated apoptosis-inducing effects in acute pancreatitis patients. A skin tissue-derived cell line, BJ, was treated for 24 hours with the sera of 22 healthy volunteers (control) and 71 acute pancreatitis patients (22 with gallstone pancreatitis, 16 with alcoholic pancreatitis, and 11 with pancreatitis with other causes) collected at the time of hospital admission (active) and discharge (resolved). Apoptosis was analyzed by flow cytometry. The average percentage of living cells, early apoptotic cells, and late apoptotic cells ranged from 78.8% to 85.0%, 5.5% to 7.3%, and 7.7% to 13.1%, respectively. The number of live cells increased significantly using the serum from the resolved state of gallstone-induced pancreatitis. In addition, the number of early apoptotic cells increased significantly using the serum from the resolved state of pancreatitis with other causes. The number of late apoptotic cells decreased significantly with the serum from the resolved state compared to the active state of gallstone- and alcohol-induced pancreatitis. Serum samples from patients with pancreatitis induced a change in the apoptosis profiles of skin-derived cells. These results indicate changes in the serum components in patients with acute pancreatitis.

Spontaneous Choledochoduodenal Fistula with Purulent Discharge Treated Endoscopically

A 93 year-old female presented with abdominal pain, nausea and vomiting that began 2 hours after eating. She had a history of gallstone-induced pancreatitis 2 weeks earlier with unsuccessful ERCP at that time secondary to ampullary edema. Examination revealed right upper quadrant tenderness with positive murphy's sign, no generalized abdominal tenderness and no jaundice was noted. Laboratory analysis revealed WBC of 25bil/l, ALT 179U/L, AST 390U/L and ALK phos.173 U/L and total bilirubin is 2.4mg/dl with 1.4mg/dl being direct portion. Right upper quadrant abdominalultrasound showed intra and extra hepatic biliary dilatation. Intravenous antibiotics and fluids for ascending cholangitis were given. Same day ERCP revealed bulging and edematous major papilla, bile and pus extruding from an opening near the ampulla (Figure 1A, 1B) suggesting Choledochoduodenal fistula (CDF), injected contrast demonstrated dilated common bile duct and multiple filling defects (Figure 2). Sphincterotomy connecting the CDF and the major papilla with balloon dilatation was performed and the stone was extracted. Biliary enteric fistula (BEF) can occur between any segment of the biliary system and the intestine, the most common between gall bladder and duodenum (62%). Li et al. showed that 50 cases out of 1200 patients with biliary disease had CDF with incidence of 4.2%. Spontaneous BEF occur secondary to stones, malignancy, crohn's, trauma, tuberculosis or metallic biliary stent. Wu et al showed the most common presenting symptom is epigastric pain (80%), cholangitis (54%) and vomiting (10%). This case had typical presentation but subacute despite pus formation as the pus was discharging through the CDF and not from common nile duct due (CBD) to its obstruction by stone. Plain films show pneumobilia (30%), ectopic stone is diagnostic if seen (3%), ERCP is the most common and effective method for diagnosis, CT can be helpful in determining the location of the fistula, upper gastrointestinal study with barium is very specific if positive as it shows the fistulous tract and ultrasound can be helpful. Distal CDF connects any segment of the intestine with distal 2 cm of CBD can be managed endoscopically but the proximal CDF, which drains elsewhere 2 cm and above the junction of CBD to the papilla will be treated surgically only.Figure 1Figure 2Figure 3

Clinical practice guideline: management of acute pancreatitis.

There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.

Resistin is not an appropriate biochemical marker to predict severity of acute pancreatitis: a case-controlled study.

To assess levels of serum resistin upon hospital admission as a predictor of acute pancreatitis (AP) severity. AP is both a common and serious disease, with severe cases resulting in a high mortality rate. Several predictive inflammatory markers have been used clinically to assess severity. This prospective study collected data from 102 patients who were diagnosed with an initial acute biliary pancreatitis between March 2010 and February 2013. Measurements of body mass index (BMI) and waist circumference (WC) were obtained and serum resistin levels were analyzed at the time of hospital admission using enzyme-linked immunosorbent assay. Additionally, resistin levels were measured from a control group after matching gender, BMI and age. A total of 102 patients (60 females and 42 males) were diagnosed with acute gallstone-induced pancreatitis. The mean age was 45 years, and mean BMI value was 30.5 kg/m(2) (Obese, class I). Twenty-two patients (21.6%) had severe AP, while eighty-eight patients had mild pancreatitis (78.4%). Our results showed that BMI significantly correlated with pancreatitis severity (P = 0.007). Serum resistin did not correlate with BMI, weight or WC. Furthermore, serum resistin was significantly higher in patients with AP compared to control subjects (P < 0.0001). The mean resistin values upon admission were 17.5 ng/mL in the severe acute biliary pancreatitis group and 16.82 ng/mL in the mild AP group (P = 0.188), indicating that resistin is not an appropriate predictive marker of clinical severity. We demonstrate that obesity is a risk factor for developing severe AP. Further, although there is a correlation between serum resistin levels and AP at the time of hospital admission, resistin does not adequately serve as a predictive marker of clinical severity.

Dipeptidyl Peptidase-4 Inhibitor-Induced Acute Pancreatitis: A Complication Well Documented But Under Recognized

Introduction: Dipeptidyl peptidase-4 (DPP-4) inhibitors like sitagliptin and saxagliptin are wellknown to cause acute pancreatitis. We present a case of a patient in whom this complication was initially overlooked, leading to delay in treatment. Case Report: A 45-year-old female with history of gallstone-induced pancreatitis, status post-cholecystectomy 4 years ago, presented with 1-week history of nausea and epigastric abdominal pain. Physical examination revealed severe epigastric tenderness. Laboratory results showed normal liver enzymes with an elevated serum lipase level of 525 U/L. A diagnosis of acute pancreatitis was made. She denied any alcohol usage and abdominal imaging did not reveal any gallstones. It was noted that she was started on saxagliptin for uncontrolled diabetes mellitus, 1 week prior to onset of her symptoms. She developed epigastric pain after that and was prescribed proton pump inhibitor by her primary care physician, but it did not help with her symptoms. During the hospital stay, she was treated with intravenous fluids, analgesia, and her saxagliptin was stopped. Her symptoms improved with in 3 days and lipase returned to normal at the time of discharge. Discussion: Acute pancreatitis is an important and fatal side effect of DPP-4 inhibitors. This was recognized by FDA in 2009 after 88 post-marketing cases of acute pancreatitis in patients using sitagliptin were reported. The label for these medications mention that any patient initiated on these medications should be carefully observed for signs and symptoms of pancreatitis. If pancreatitis is suspected, the drug should be discontinued immediately and appropriate management should be started. Our patient developed epigastric pain within a few days of initiation of saxagliptin and her appropriate treatment was delayed as she was initially treated for gastritis. Based on the Naranjo algorithm for assessing the causality of an adverse drug reaction, the likelihood of saxagliptin being the causal agent was graded as ‘probable' with a score of 7. She had a past history of gallstone-induced pancreatitis but this is still unknown whether patients with a past history of pancreatitis are at an increased risk of developing this adverse drug effect or not. Conclusion: DPP-4 inhibitor-induced pancreatitis is a well known but still an under recognized complication. It can be easily overlooked which may lead to delay in the treatment and even fatality in severe cases. This necessitates cognizance among physicians to recognize this complication early. Also, further research is required to know whether patients with previous history of pancreatitis are at increased risk of developing pancreatitis with DPP-4 inhibitors.

Acute pancreatitis

Prospective and population-based studies on the incidence of acute pancreatitis (AP) are lacking. Alcohol consumption has increased considerably in Iceland during the last decade. We aimed to determine the incidence, etiology, severity, and complications of AP and compare the results with a previous study on AP in Iceland. A prospective population-based study of patients diagnosed with AP at the National University Hospital of Iceland during 1 year (2010-2011). Information on symptoms, etiology, and complications was registered. During the study period, 134 patients were diagnosed with AP, 78 men (58%), median age 57 years (interquartile range 42-71). Overall, 89/104 (86%) patients had their first attack of pancreatitis, yielding a crude incidence of 40/100 000 inhabitants/year. The major etiological groups were as follows: gallstones, 52 cases (42%); alcohol 29, (23%); postendoscopic retrograde cholangio-pancreatography in 12 (9.5%); medications in eight (6.3%); and idiopathic in 15 (12%). Alcohol was more often the cause in men (25 vs. 4, P<0.05) but the incidence of gallstone-induced pancreatitis was similar in men and women (26 vs. 27). Seven patients had severe complications, three had pancreatic necrosis, two had pseudocysts, and one developed renal failure. Another patient developed acute respiratory distress syndrome and was admitted to the ICU. No patient died of AP during the study period. The incidence of AP has not increased significantly in Iceland in the last decade. Alcohol-induced pancreatitis has not increased proportionally despite increased alcohol consumption in Iceland. In a population-based setting, the vast majority of AP is of mild severity.

Retrospective study of patients with acute pancreatitis: is serum amylase still required?

ObjectivesTo assess the role of serum amylase and lipase in the diagnosis of acute pancreatitis. Secondary aims were to perform a cost analysis of these enzyme assays in patients admitted...

Strict adherence to bsg guidelines required forcholecystectomy following pancreatitis toprevent high readmission rates

Strict adherence to bsg guidelines required forcholecystectomy following pancreatitis toprevent high readmission rates

Robotic-Assisted Laparoscopic Side-to-Side Lateral Pancreaticojejunostomy

A 58-year-old veteran was diagnosed with a gallstoneinduced chronic pancreatitis and malnutrition due to intractable abdominal pain. The patient had previously undergone laparoscopic cholecystectomy. Preoperative ERCP revealed an obstructing pancreatic duct stone in the head of the pancreas with associated upstream duct dilatation. The patient had failed multiple attempts to access and stent the pancreatic duct, including unsuccessful cannulation of the minor papilla. Pancreatic protocol CT scan demonstrated a well-developed pseudocyst in communication with the dilated pancreatic duct. The video explains in details the operative steps. He was discharged home on POD #4. There were no complications during his hospitalization and at 6 months follow-up.

Gallstone‐induced acute pancreatitis

In the care of acute pancreatitis, a prompt search for the etiologic condition of the disease should be conducted. A differentiation of gallstone-induced acute pancreatitis should be given top priority in its etiologic diagnosis because it is related to the decision of treatment policy. Examinations necessary for diagnosing gallstone-induced acute pancreatitis include blood tests and ultrasonography. Early ERCP/ES should be performed in patients with gallstone-induced acute pancreatitis if a complication of cholangitis and a prolonged passage disorder of the biliary tract are suspected. The treatment for bile duct stones with the use of ERCP/ES alone is not recommended in cases of gallstone-induced pancreatitis with gallbladder stones. Cholecystectomy for gallstone-induced acute pancreatitis should be performed using a laparoscopic procedure as the first option as soon as the disease has subsided.