Gallstone-related Acute Pancreatitis Research Articles

Body mass index and the risk of acute pancreatitis by etiology: A prospective analysis of Korean National Screening Cohort.

It is unclear whether obesity increases the incidence of acute pancreatitis (AP) in the general population. Further, no study has prospectively examined the associations of the risk of AP by etiology with measured body mass index (BMI) values. A total of 512928 Korean participants in routine health examinations during 2002-2003 were followed up until 2013 via linkage to national hospital discharge records to assess AP incidence. Multivariable-adjusted hazard ratios were calculated using BMI measurements. During 10.5 mean years of follow-up, 1656 persons developed AP (337 gallstone related and 1319 non-gallstone related). Nonlinear associations were found: U-curves for total and non-gallstone-related AP and a reverse L-curve for gallstone-related AP. Each 5kg/m2 increment in BMI increased gallstone-related AP by 123% (95% confidence interval=48-234%) and non-gallstone-related AP by 42% (9-84%) in the range ≥25kg/m2 (Pheterogeneity =0.068). Obese persons had a doubled risk of gallstone-related AP compared with normal-weight persons. In the range <25kg/m2 , BMI had inverse association with non-gallstone-related AP but no association with gallstone-related AP (Pheterogeneity <0.001). In subgroup analyses, for non-gallstone-related AP, hazard ratios per each 5kg/m2 BMI increment were 0.50 (men), 0.73 (women), 0.46 (alcohol drinkers), 0.69 (alcohol non-drinkers), 0.43 (ever smokers), and 0.73 (never smokers). Gallstone-related AP and non-gallstone-related AP have different nonlinear associations with BMI. Higher BMI increases the risk of both gallstone-related AP and non-gallstone-related AP but more strongly for gallstone-related AP. For non-gallstone-related AP, in the range <25kg/m2 , BMI has inverse associations that were stronger in men, current alcohol drinkers, and ever smokers than in their counterparts.

Acute Small Bowel Obstruction Secondary to a Pancreatic Pseudocyst

Pancreatic pseudocysts are one of the most frequent complications after acute pancreatitis occurring in up to 20% of cases. Majority of the pseudocysts less than 4 cm resolve in 6–8 weeks. Large pseudocysts in the pancreatic head can cause biliary or duodenal obstruction. However, acute jejunal obstruction due to pancreatic pseudocyst has been rarely reported. We present a case of gallstone-related acute pancreatitis resulting in pseudocyst formation causing acute jejunal obstruction. The patient was successfully treated by surgery.

Cholecystectomy Reduces Recurrent Pancreatitis and Improves Survival After Endoscopic Sphincterotomy

BackgroundThe aim of this study was to assess whether cholecystectomy can decrease the recurrent pancreatitis in the elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) and successful clearance of bile duct (BD) stones after gallstone-related acute pancreatitis. MethodsWe analyzed data from National Health Insurance Research Database of Taiwan. Elderly patients (age ≧70 years old) who had gallstone-related acute pancreatitis and underwent successful EST with BD stones clearance were eligible for enrollment. This nationwide, population-based, propensity score (PS)-matched cohort study involved two cohorts: (1) patients who underwent cholecystectomy after ERCP with BD stone clearance as study group and (2) those who adopted wait-and-see strategy (without cholecystectomy) after ERCP with BD stone clearance as control group. The primary and secondary endpoints were recurrent acute pancreatitis and all-cause mortality, respectively. ResultsDuring the study period, a total of 670 elderly patients (male 291, female 379) with a mean age of 79.1 was enrolled for analysis after PS matching. The incidence rate of recurrent acute pancreatitis was 12.39 per 1000 person-years in the cholecystectomy cohort and 23.94 per 1000 person-years in the PS-matched control cohort. The risk of recurrent acute pancreatitis was significantly lower in the cholecystectomy cohort (HR, 0.56; 95 % confidence interval [CI], 0.34–0.91; P = 0.021). The HR for all-cause mortality among the cholecystectomy cohort was 0.75 (95 % CI, 0.59–0.95; P = 0.016) compared with the control cohort. ConclusionsCholecystectomy decreased the subsequent recurrent acute pancreatitis and the all-cause mortality in elderly patients with EST and clearance of BD stones after gallstone-related acute pancreatitis.

Dietary Factors Reduce Risk of Acute Pancreatitis in a Large Multiethnic Cohort.

Pancreatitis is a source of substantial morbidity and health cost in the United States. Little is known about how diet might contribute to its pathogenesis. To characterize dietary factors that are associated with risk of pancreatitis by disease subtype, we conducted a prospective analysis of 145,886 African Americans, Native Hawaiians, Japanese Americans, Latinos, and whites in the Multiethnic Cohort. In the Multiethnic Cohort (age at baseline, 45-75 y), we identified cases of pancreatitis using hospitalization claim files from 1993 through 2012. Patients were categorized as having gallstone-related acute pancreatitis (AP) (n= 1210), AP not related to gallstones (n= 1222), or recurrent AP or suspected chronic pancreatitis (n= 378). Diet information was obtained from a questionnaire administered when the study began. Associations were estimated by hazard ratios and 95% confidence intervals using Cox proportional hazard models adjusted for confounders. Dietary intakes of saturated fat (P trend= .0011) and cholesterol (P trend= .0008) and their food sources, including red meat (P trend < .0001) and eggs (P trend= .0052), were associated positively with gallstone-related AP. Fiber intake, however, was associated inversely with gallstone-related AP (P trend= .0005) and AP not related to gallstones (P trend= .0035). Vitamin D, mainly from milk, was associated inversely with gallstone-related AP (Ptrend=.0015), whereas coffee consumption protected against AP not related to gallstones (P trend<.0001). With the exception of red meat, no other dietary factors were associated with recurrent acute or suspected chronic pancreatitis. Associations between dietary factors and pancreatitis were observed mainly for gallstone-related AP. Interestingly, dietary fiber protected against AP related and unrelated to gallstones. Coffee drinking protected against AP not associated with gallstones. Further studies are warranted to confirm our findings.

Prospective Study of Alcohol Drinking, Smoking, and Pancreatitis

We conducted a prospective analysis of 145,886 participants in the multiethnic cohort to examine the relationship of alcohol drinking and smoking with pancreatitis. Pancreatitis cases were categorized as gallstone-related acute pancreatitis (GSAP) (N = 1,065), non-GSAP (N = 1,222), and recurrent acute (RAP)/chronic pancreatitis (CP) (N = 523). We used the baseline questionnaire to identify alcohol intake and smoking history. Associations were estimated by hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox models. Cigarette smoking was associated with non-GSAP and RAP/CP. Moderate alcohol intake was inversely associated with all types of pancreatitis in women (HRs, 0.66 to 0.81 for <1 drink per day), and with RAP/CP in men (HR, 0.57; 95% CI, 0.41-0.79 for <2 drinks per day). The risk of non-GS pancreatitis associated with current smoking was highest among men who consumed more than 4 drinks per day (HR, 2.06; 95% CI, 1.28-3.30), whereas among never smokers, moderate drinking was associated with a reduced risk (HR, 0.70; 95% CI, 0.51-0.96). In women, drinking less than 2 drinks per day was associated with a reduced risk of GSAP among never smokers (HR, 0.61; 95% CI, 0.46-0.80). Smoking is a risk factor for non-GS pancreatitis. Moderate alcohol intake is protective against all types of pancreatitis in women and against RAP/CP in men.

Use of morphine in experimental acute pancreatitis increases severity and delays regeneration

Obesity and type 2 diabetes—diseases linked to glucose intolerance and insulin resistance—have been positively associated with the risk of acute pancreatitis. However, it is unclear whether consumption of foods that increase postprandial glycemia and insulinemia have similar associations. We examined the association between dietary glycemic load and risk of non–gallstone-related acute pancreatitis.We performed a prospective study of 44,791 men and 36,309 women (aged 45–84 years), without a history of acute pancreatitis, from the Cohort of Swedish Men and the Swedish Mammography Cohort. Glycemic loads were calculated from food frequency questionnaire data collected in 1997, and participants were followed for the development of non–gallstone-related acute pancreatitis through 2010 via linkage to the Swedish National Patient Register. Hazard ratios (HRs) were estimated using Cox proportional hazard models.During a total follow-up of 967,568 person-years, there were 364 cases of incident non–gallstone-related acute pancreatitis (236 in men and 128 in women). Incidence rates, standardized for age and sex, were 49 cases per 100,000 person-years in the highest quartile of glycemic load and 33 cases per 100,000 person-years in the lowest. The multivariate-adjusted HR of non–gallstone-related acute pancreatitis was 1.60 (95% confidence interval [CI], 1.17–2.18) for the highest compared with the lowest quartile. Every 50-unit increase in glycemic load per day (∼3 servings of white bread) had an HR of 1.38 in men (95% CI, 1.11–1.72) and women (95% CI, 1.02–1.86).Based on a large, prospective cohort study, diets with high glycemic load are associated with an increased risk of non–gallstone-related acute pancreatitis.

Fish consumption and risk of non–gallstone-related acute pancreatitis: a prospective cohort study

Epidemiologic data on the role of diet in acute pancreatitis are sparse. We examined the association of total fish consumption, as well as of consumption of fatty fish and lean fish separately, with risk of non-gallstone-related acute pancreatitis. We used data from 2 prospective cohorts, the Cohort of Swedish Men and the Swedish Mammography Cohort, that included 39,267 men and 32,191 women who were aged 45-84 y at the start of a 13-y follow-up period (1998-2010). Fish consumption was assessed by using a food-frequency questionnaire at baseline, and cases of incident non-gallstone-related acute pancreatitis were identified by linkage to the Swedish National Patient Register. HRs were estimated by using Cox proportional hazard models. During a total follow-up of 860,176 person-years, 320 cases (209 cases in men and 111 cases in women) of incident non-gallstone-related acute pancreatitis were identified. We observed that total fish consumption ≤2.0-3.0 servings/wk was associated with a significantly decreased risk of the disease (P-nonlinearity = 0.017). In comparison with 0.9 servings/wk, multivariable-adjusted HRs were 0.86 (95% CI: 0.76, 0.96), 0.77 (95% CI: 0.62, 0.96), and 0.85 (95% CI: 0.65, 1.10) for 1.4, 2.4, and 3.5 servings/wk, respectively. In the analysis of fatty fish and lean fish, we observed that the consumption of each subtype had a similarly shaped association with risk of non-gallstone-related acute pancreatitis as that observed for total fish consumption, although neither was significant. Multivariable-adjusted HRs were 0.83 for fatty fish (95% CI: 0.65, 1.04) and 0.87 for lean fish (95% CI: 0.69, 1.11) when 0.6-2.0 servings/wk was compared with ≤0.5 servings/wk. Our data suggest that the consumption of total fish (fatty fish and lean fish combined) may be associated with decreased risk of non-gallstone-related acute pancreatitis.

Acute Pancreatitis (AP) in Post-bariatric Surgery (BRS) Status: Analysis of National Trends, Complications, and Outcomes 2007-2011: ACG Obesity Award

Introduction: Rates of BRS are increasing, and post-BRS patients have a high incidence of gallstones for which biliary intervention (ERCP) can be difficult. There are no studies addressing rates and outcome of AP in patients with BRS. Methods: The Nationwide Inpatient Sample (2007-2011) was reviewed for all adult patients (≥18 years) with primary diagnosis of AP. All patients with history of BRS admitted with AP (BRS-AP) were identified. BRS patients with pregnancy were excluded. ICD-9-CM codes were used to identify patients with AP (577.0) and history of BRS (V45.86). Univariate analysis was performed for demographics, hospital factors, and etiologies of AP. A multivariate analysis correcting for variables with p<0.05 was utilized to compare outcomes of complications, mortality, length of stay (LOS), and total hospitalization charges. Results: There were 1,349,842 admissions for AP, and patients with BRS accounted for 1.07% (n=14,386) of all admissions. There was a significant increase in prevalence of BRS among patients admitted with AP (0.73% to 1.39% over 5 years; p<0.001; Cochran-Armitage test). Univariate analysis comparing BRS-AP to non-BRS AP revealed differences in demographics, hospital factors, and etiologies. BRS-AP was more frequently observed in women (82.5% vs. 47.5%; p<0.01), gallstone-related AP (24.8% vs. 22.4%; p<0.01), and in those with obesity (BMI >30 kg/m2, 37.5% vs. 9.8%; p<0.01), while non-BRS AP was more frequent with alcohol related etiology (20.9% vs. 17.1%; p<0.01). Due to post-BRS anatomical changes, BRS-AP patients underwent fewer ERCPs (4.2% vs 7.7%; p<0.01) albeit more cholecystectomies (14.1% vs. 11.9%; p<0.01). After adjusting for patient, hospital, and etiological factors, complications of AP inclusive of pseudocyst (5.8% vs 3.2%; OR 1.61; 95% CI 1.23, 2.08), respiratory failure (3.4% vs. 1.3%; OR 2.70; 95% CI 1.85, 3.85) and acute kidney failure (7.8% vs. 3.9%; OR 1.41; 95% CI 1.14, 1.72) were all associated with non-BRS AP. The mortality rate although lower for BRS-AP did not reach significance (0.22% vs 0.96%; OR 0.5; 95% CI 0.23, 1.16). However, adjusted LOS (4.4 vs. 6.3 days; p <0.01) and total hospital charges ($28,200 vs. $ 31,600; p<0.01) were significantly lower in BRS-AP patients. Conclusion: Gallstone-related AP was more common in patients with BRS. Although rates of admissions for BRS-AP are increasing and ERCP is challenging, these patients have shorter length of stay, lower hospital charges, and lower AP-related morbidities compared to non-BRS patients.

Morbid Obesity (MO) Is Associated With Increased Healthcare Utilization and Is an Independent Predictor of Mortality of Acute Pancreatitis (AP)

Introduction: Obesity rates are increasing and MO (BMI≥40) adversely influences the prognosis of many gastrointestinal disorders including AP. There are no population-based studies assessing impact of MO on the outcome of acute pancreatitis (AP). The objective of this study was to evaluate the association of MO with health care resources and outcomes of AP. Methods: The nationwide inpatient sample, which is the largest inpatient care database in the United States was analyzed to identify all adult patients (≥18 years of age) hospitalized with principal diagnosis of AP (ICD-9-CM: 577.0) from 2007 to 2011. Patients with a history of bariatric surgery were excluded. ICD-9-CM codes to define MO (BMI ≥40) were: 278.01, V85.40 to V85.44. Outcomes [mortality, procedures, length of stay (LOS), and total charges] of AP were analyzed after adjusting for demographic [age, gender, race, income, insurance type, Charlson comorbidity index (CCI)], hospital (teaching status, location, region, size), and etiological differences. Results: A total of 1,337,431 inpatients with AP were identified. MO was associated with 52,659 (3.94%) of all AP admissions (MO-AP). Overall in-hospital mortality for MO-AP was significantly greater than non-MO AP (1.17% vs. 0.95%; p=0.04). Univariate analysis comparing MO-AP to non-MO AP revealed differences in all of the demographic and hospital factors. MO-AP was more frequently observed in gallstone related AP (35.5% vs. 21.5%; p<0.001), and in those with higher comorbidities (CCI ≥3, 9.6% vs. 6.8%; p<0.001) while non-MO AP was more common with alcohol related etiology (21.43% vs. 7.01%; p<0.001) and history of chronic pancreatitis (14.1% vs. 7.4%; p<0.001). Consequently, MO-AP patients underwent more cholecystectomies (21.05% vs. 11.54%; p<0.001) and ERCPs (10.6% vs. 7.9%; p <0.001). Notably, acute kidney failure (11.0% vs. 7.6%; p<0.001), respiratory failure (5.4% vs. 3.3%; p<0.001), LOS (5.9 vs. 5.1 days; p<0.001), and total hospital charges ($40,000 vs. $31,000; p<0.001) were all higher in MO-AP. Multivariate analysis revealed that MO was an independent predictor of mortality (odds ratio 1.62; 95% confidence interval 1.31, 2.01) in AP. Additionally, MO-AP patients had a higher LOS (by 0.8 days; p<0.001) and total hospitalization charges (by $7,948; p<0.001). Conclusion: Morbid obesity is an independent predictor of mortality in AP and negatively impacts inpatient hospitalization and healthcare resource utilization. With increasing rates of MO, future research should consider and evaluate its role in risk stratification scores for AP.

Frequency of SPINK1 N34S mutation in acute and recurrent acute pancreatitis.

Several studies have reported association of c.101A>G (p.N34S) mutation in SPINK1 gene with chronic pancreatitis; however, the data on its relationship with acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are limited. We studied 183 unrelated patients with AP and RAP and 168 healthy controls for p.N34S variant in SPINK1 gene using sequencing of genomic DNA. SPINK1 p.N34S mutation was found in four of 168 (2.4%; all heterozygotes) controls and 22 of 183 (12.0%; including one homozygote) patients with AP (P = 0.006). On subgroup analysis, seven of 70 (10.0%) patients with gallstone-related AP, eight of 59 (13.6%; including one homozygote) patients with idiopathic AP, and six of 44 (14.6%) patients with alcohol-related AP had the p.N34S mutation (P = 0.027, 0.002 and 0.006, respectively, compared to controls). Frequency of this mutation was similar in patients with one episode of AP and those with recurrent AP (12% each). The first attack of AP occurred earlier in patients with p.N34S mutation than in those without it (mean ± SD age: 32.0 ± 9.7 versus 39.1 ± 13.4 years; P = 0.004). No patient had any other mutation in the exon 3 of the SPINK1 gene, whereas one control had a heterozygous p.P55S mutation. The p.N34S mutation in SPINK1 gene was found more frequently in patients with AP in the Indian population, irrespective of disease etiology and whether the disease was recurrent or not, and was associated with disease onset at an earlier age. These findings suggest that p.N34S mutation lowers the threshold for occurrence of AP irrespective of the causative insult.

High Dietary Glycemic Load Increases the Risk of Non–Gallstone-Related Acute Pancreatitis: A Prospective Cohort Study

Obesity and type 2 diabetes--diseases linked to glucose intolerance and insulin resistance--have been positively associated with the risk of acute pancreatitis. However, it is unclear whether consumption of foods that increase postprandial glycemia and insulinemia have similar associations. We examined the association between dietary glycemic load and risk of non-gallstone-related acute pancreatitis. We performed a prospective study of 44,791 men and 36,309 women (aged 45-84 years), without a history of acute pancreatitis, from the Cohort of Swedish Men and the Swedish Mammography Cohort. Glycemic loads were calculated from food frequency questionnaire data collected in 1997, and participants were followed for the development of non-gallstone-related acute pancreatitis through 2010 via linkage to the Swedish National Patient Register. Hazard ratios (HRs) were estimated using Cox proportional hazard models. During a total follow-up of 967,568 person-years, there were 364 cases of incident non-gallstone-related acute pancreatitis (236 in men and 128 in women). Incidence rates, standardized for age and sex, were 49 cases per 100,000 person-years in the highest quartile of glycemic load and 33 cases per 100,000 person-years in the lowest. The multivariate-adjusted HR of non-gallstone-related acute pancreatitis was 1.60 (95% confidence interval [CI], 1.17-2.18) for the highest compared with the lowest quartile. Every 50-unit increase in glycemic load per day (∼ 3 servings of white bread) had an HR of 1.38 in men (95% CI, 1.11-1.72) and women (95% CI, 1.02-1.86). Based on a large, prospective cohort study, diets with high glycemic load are associated with an increased risk of non-gallstone-related acute pancreatitis.

Abdominal and Total Adiposity and The Risk of Acute Pancreatitis: A Population-Based Prospective Cohort Study

Previous research has indicated that obesity may be linked to the severity of acute pancreatitis. However, the association between abdominal and total adiposity as risk factors in the development of acute pancreatitis in a general population has not been studied. A follow-up study was conducted, using the Swedish Mammography Cohort and the Cohort of Swedish Men, to examine the association between waist circumference and body mass index (BMI) and the risk of first-time acute pancreatitis. Severe acute pancreatitis was defined as hospital stay of >14 days, in-hospital death, or mortality within 30 days of discharge. Cox proportional hazards models were used to estimate rate ratios (RRs) with 95% confidence intervals (CIs), adjusted for confounders. In total, 68,158 individuals, aged 46-84 years, were studied for a median of 12 years. During this time, 424 persons developed first-time acute pancreatitis. The risk of acute pancreatitis among those with a waist circumference of >105 cm was twofold increased (RR=2.37; 95% CI: 1.50-3.74) compared with individuals with a waist circumference of 75.1-85.0 cm, when adjusted for confounders. This association was seen in patients with non-gallstone-related and gallstone-related acute pancreatitis. The results remained unchanged when stratifying the analyses with regards to sex or the severity of acute pancreatitis. There was no association between BMI and the risk of acute pancreatitis. Abdominal adiposity, but not total adiposity, is an independent risk factor for the development of acute pancreatitis.

Patients With Celiac Disease Have an Increased Risk for Pancreatitis

Patients with celiac disease have been reported to be at increased risk for pancreatitis and pancreatic insufficiency, but the risk might have been overestimated because of patient selection and limited numbers of patients for analysis. Furthermore, no distinction has been made between patients with gallstone-related and non-gallstone-related pancreatitis. We performed a nationwide study to determine the risk for any pancreatitis or subtype of pancreatitis among patients with biopsy-verified celiac disease. We analyzed data from patients in Sweden with celiac disease (n = 28,908) who were identified on the basis of small intestinal biopsy records from 28 pathology departments (those with villous atrophy, Marsh 3). Biopsies were performed from 1969 to 2008, and biopsy report data were collected from 2006 to 2008. Patients with pancreatitis were identified on the basis of diagnostic codes in the Swedish Patient Register and records of pancreatic enzyme use in the Swedish Prescribed Drug Register. Data were matched with those from 143,746 individuals in the general population; Cox regression was used to estimate hazard ratios (HRs) for pancreatitis. We identified 406 patients with celiac disease who were later diagnosed with pancreatitis (and 143 with expected pancreatitis) (HR, 2.85; 95% confidence interval [CI], 2.53-3.21). The absolute risk of any pancreatitis among patients with celiac disease was 126/100,000 person-years, with an excess risk of 81/100,000 person-years. The HR for gallstone-related acute pancreatitis was 1.59 (95% CI, 1.06-2.40), for non-gallstone-related acute pancreatitis HR was 1.86 (95% CI, 1.52-2.26), for chronic pancreatitis HR was 3.33 (95% CI, 2.33-4.76), and for supplementation with pancreatic enzymes HR was 5.34 (95% CI, 2.99-9.53). The risk of any pancreatitis within 5 years of diagnosis was 2.76 (95% CI, 2.36-3.22). Based on an analysis of medical records from Sweden, patients with celiac disease have an almost 3-fold increase in risk of developing pancreatitis, compared with the general population.

Cigarette smoking, smoking cessation and acute pancreatitis: a prospective population-based study

BackgroundSeveral studies have shown that smoking increases the risk of chronic pancreatitis. However, the impact of smoking on the development of acute pancreatitis has not been fully studied.ObjectiveTo clarify the...

Trends in the incidence and significance of presentations to the emergency department due to acute pancreatitis

Acute pancreatitis is an important cause of abdominal pain that may be associated with significant morbidity for the patient and considerable workload for the hospital. Our impression has been that it is becoming increasingly common, perhaps in tandem with increased rates of other alcohol-related disease. The medical records of all patients attending our emergency department with acute pancreatitis by Hospital Inpatient Enquiry coding over a 9-year period were examined to determine its incidence, aetiology and significance (Imrie severity of pancreatitis scoring, length of hospital stay and interventional workload). The incidence of acute pancreatitis (n=97, 40 male patients) increased approximately threefold over the study period (especially in the lattermost triennial period with 75 patients) in a fashion disproportionate to changes in our locality's population. Gallstone-related disease continues to be most prevalent although alcohol-related disease also became more common. Disease severity (length of hospital stay and Imrie score) was similar throughout with a mean length of hospital stay exceeding that of the majority of accident and emergency admissions. Seven acute complications of acute pancreatitis were noted while 34 chronic sequelae developed. Requirement for invasive intervention doubled (n=19 in first triennial period in the study vs 39 in the latter triennial period), although the relative need for endoscopic retrograde cholangiopancreaticography diminished with increased availability of magnetic resonance cholangiography imaging. Nine patients with gallstone-related acute pancreatitis suffered recurrent attacks while awaiting cholecystectomy. Acute pancreatitis is an increasingly frequent cause of hospital admission while the clinical significance of each incident remains high. The presentation of acute pancreatitis to the emergency department as an early declaration of symptomatic cholelithiasis is especially worrisome as it suggests a failing of recognition and/or effective referral of premonitory biliary complaints.

Pancreatic disease in the elderly

Pancreatic diseases occur in patients of every age. Older individuals suffer more often from gallstone related acute pancreatitis, ischaemic and idiopathic acute pancreatitis, whereas alcohol-induced acute pancreatitis occurs only in a minority of cases. Similarly, alcohol-related chronic pancreatitis in elderly people is rare and late-onset idiopathic chronic pancreatitis is the most common form of the disease. This form of chronic pancreatitis is characterized by faster progression to endocrine and exocrine pancreatic insufficiency and less severe pain compared to the clinical picture found in younger patients.Ductal pancreatic adenocarcinomas, which are responsible for more than 90% of exocrine pancreatic tumours, are typically a disease of the elderly patient. Today pancreatic resection still offers the only hope for cure and also can be performed safely in elderly patients. Age, by itself, is not a reason for withholding surgical intervention from an individual patient. Today, denial of pancreatic resection is much more likely to be based on severe co-morbidity.

Fasting Exacerbates Acute Pancreatitis by Occlusion of the Common Bile Duct in Rats

We examined the effects of fasting and non-fasting on gallstone-related acute pancreatitis by the occlusion of the common bile duct (OCD). We prepared a rat OCD-induced pancreatitis model under both fasting and non-fasting conditions, and we measured amylase activity in ascites as well as production of inflammatory cytokines and chemokines. We also examined the pathology of the pancreas, myeloperoxidase (MPO) activity in some tissues and mortality rates. In the fasted OCD group, ascites containing a large amount of amylase, interleukin 1β (IL-1β), interleukin 6 (IL-6), and cytokine-induced neutrophil chemo-attractant-1 (CINC-1) as well as marked hemorrhage and necrosis of the pancreatic acinar cells were observed. Pulmonary MPO activity increased 3.4-fold compared to the control group. In the non-fasted OCD group, there was no development of ascites. Slight necrosis of acinar cells and slight increases in pulmonary MPO activity were observed. In addition, in the fasted OCD group, the cumulative mortality rate was 50% 6 days after ligation. However, in the non-fasted OCD group, none of the animals died. These results suggest that gallstone-related severe pancreatitis depends on fasting-related structural and/or functional changes in the pancreas. Moreover, increased production of inflammatory cytokines and chemokines in ascites under fasting condition may be involved in multiple organ failure resulting from severe acute pancreatitis.

Metaanalysis of randomized controlled trials of endoscopic retrograde cholangiography and endoscopic sphincterotomy for the treatment of acute biliary pancreatitis.

Endoscopic retrograde cholangiography with endoscopic sphincterotomy (ERC+ES) has been advocated for the management of acute biliary pancreatitis. However, it is also viewed as dangerous. Our objective was to review published randomized, controlled trials (RCTs) of ERC+ES in patients with acute biliary pancreatitis and, by metaanalysis, to estimate the overall efficacy and safety of this approach. We performed a fully recursive literature search for published RCTs of ERC+ES in gallstone-related acute pancreatitis. RCTs were pooled. Individual and overall mortality and complication rates were calculated, together with their 95% confidence intervals (CI), absolute risk reduction (ARR), relative risk reduction (RRR), and numbers needed to treat (NNT) for avoidance of complications or death. Four published RCTs had a numerically lower complication rate, and three had a numerically lower mortality rate, in the treated groups than in controls. After pooling, there were 460 treated patients and 374 controls. Complications occurred in 115 (25.0%) treated patients and 143 (38.2%) controls (z = 4.10; p < 0.001). Twenty-four treated patients (5.2%) and 34 controls (9.1%) died (z = 2.15; p < 0.05). ERC+ES had a 34.6% RRR for complications and a 42.9% RRR for death; ARR for complications and death was 13.2% (95% CI: 6.9-19.5%) and 3.9% (95% CI: 0.35-7.45%), respectively. The NNT for avoidance of complications and death was 7.6 and 25.6, respectively. ERC+ES reduces morbidity and mortality in patients with acute biliary pancreatitis. Treating 26 such patients with ERC+ES is predicted to save one life.

Metaanalysis of randomized controlled trials of endoscopic retrograde cholangiography and endoscopic sphincterotomy for the treatment of acute biliary pancreatitis

OBJECTIVE: Endoscopic retrograde cholangiography with endoscopic sphincterotomy (ERC+ES) has been advocated for the management of acute biliary pancreatitis. However, it is also viewed as dangerous. Our objective was to review published randomized, controlled trials (RCTs) of ERC+ES in patients with acute biliary pancreatitis and, by metaanalysis, to estimate the overall efficacy and safety of this approach. METHODS: We performed a fully recursive literature search for published RCTs of ERC+ES in gallstone-related acute pancreatitis. RCTs were pooled. Individual and overall mortality and complication rates were calculated, together with their 95% confidence intervals (CI), absolute risk reduction (ARR), relative risk reduction (RRR), and numbers needed to treat (NNT) for avoidance of complications or death. RESULTS: Four published RCTs had a numerically lower complication rate, and three had a numerically lower mortality rate, in the treated groups than in controls. After pooling, there were 460 treated patients and 374 controls. Complications occurred in 115 (25.0%) treated patients and 143 (38.2%) controls (z = 4.10; p < 0.001). Twenty-four treated patients (5.2%) and 34 controls (9.1%) died (z = 2.15; p < 0.05). ERC+ES had a 34.6% RRR for complications and a 42.9% RRR for death; ARR for complications and death was 13.2% (95% CI: 6.9–19.5%) and 3.9% (95% CI: 0.35–7.45%), respectively. The NNT for avoidance of complications and death was 7.6 and 25.6, respectively. CONCLUSIONS: ERC+ES reduces morbidity and mortality in patients with acute biliary pancreatitis. Treating 26 such patients with ERC+ES is predicted to save one life.