History Of Pancreatic Disease Research Articles

1191 Novel Biomarkers for the Diagnosis of Chronic Pancreatitis: An Exploratory Case-Control Study

Abstract Aim Chronic pancreatitis is a complex inflammatory syndrome with manifestations including abdominal pain, malnutrition, and diabetes. Early recognition is necessary for optimal management; however this remains clinically challenging and there are no established biomarkers for diagnosis. This exploratory study aims to determine the expression of a set of fibrosis-related serum biomarkers in patients with chronic pancreatitis relative to controls. Method Participants were recruited from specialist outpatient clinics at a single centre. Ethical approval was granted via the institutional biobank. Cases were defined as adult patients with a radiological and/or histological diagnosis of chronic pancreatitis. Controls were adult patients with no history of pancreatic disease. Blood samples were collected from each participant and the serum concentrations of candidate biomarkers measured in duplicate by enzyme-linked immunosorbent assays. Results In cases (n = 17; median age 53 years) compared to controls (n = 4; median age 54 years), the mean serum concentration of osteoactivin was 39.32 ng/ml vs. 18.70 ng/ml (2.1 fold); fibronectin was 512.33 μg/ml vs. 328.83 μg/ml (1.6 fold), osteopontin was 8.19 ng/ml vs. 7.47 ng/ml (1.1 fold), vimentin was 637.94 ng/ml vs. 562.14 ng/ml (1.1 fold), TIMP1 was 0.25 μg/ml vs. 0.23 μg/ml (1.0 fold) and osteonectin was 3.8 μg/ml vs. 4.71 μg/ml (0.8 fold). Conclusions This pilot study demonstrated differential expression of several fibrosis-related serum biomarkers in patients with chronic pancreatitis compared to controls. An expanded study will aim to establish the utility of these biomarkers for the early diagnosis of this condition.

Risk factors for pancreatitis occurrence after gallstone treatment using endoscopic retrograde cholangiopancreatography.

Patients with gallstones are prone to pancreatitis after treatment using endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to explore the risk factors for pancreatitis occurrence after gallstone treatment using ERCP. A total of 193 patients treated from October 2017 to October 2020 were assigned into pancreatitis group (n=55) and non-pancreatitis group (n=138). Multivariate logistic regression analysis was utilized to analyse the risk factors for post-ERCP pancreatitis. The discrimination and accuracy of an established nomogram model were evaluated using receiver operating characteristic and calibration curves, respectively. The incidence rate of pancreatitis was 28.50% (55/193). Young age, long course of disease, gallbladder wall thickness >3 mm, sand-like stones, history of pancreatic disease, number of intubation ≥2 and absence of pancreatic duct stenting were risk factors for post-ERCP pancreatitis (P<0.05). The established model had high discrimination and accuracy. The incidence rates of pancreatitis in patients with and without pancreatic duct stenting were 11.84% (9/76) and 39.31% (46/117), respectively. The patients undergoing pancreatic duct stenting had lower serum amylase levels 6, 12 and 24 h after ERCP than those of patients who did not. Patients with gallstones have a higher risk of developing pancreatitis. Young age, long course of disease, gallbladder wall thickness >3 mm, sand-like stones, history of pancreatic disease, pancreatic duct visualization and number of intubation ≥2 are risk factors for post-ERCP pancreatitis.

A 53-year-old Man Presented with Skin Rash on Swollen Right Calf

&lt;p&gt;胰臟炎、脂膜炎與多發性關節炎症候群（pancreatitis, panniculitis, and polyarthritis, PPP）是胰臟疾病患者罕見發生於肢體的合併症。雖然PPP症候群罕見，當延遲診斷或缺乏胰臟炎治療時會導致高死亡率。本個案為53歲男性胰臟炎史，此次因右小腿長期反復發紅性皮疹腫脹和復發性雙膝關節炎，經相關檢查後診斷為右小腿膿瘍與多發性膝關節炎住院，於施行右小腿手術中發現與組織病理報告皆有脂膜炎病徵之異常呈現；雖然個案無腹部不適主訴，但回溯先前腹部電腦斷層有滲出性胰臟炎發現，因此於治療後期診斷為PPP症候群，持續給予適當抗生素和抗胰臟炎藥物治療使症狀獲得改善。因此當臨床遇見中年男性胰臟病史患者、伴隨反復性下肢腫脹、發紅性皮疹和復發性膝關節炎症狀，則胰臟炎、脂膜炎與多發性關節炎症候群就必須列入考慮，以避免錯失治療先機。&lt;/p&gt;&lt;p&gt;The pancreatitis, panniculitis, and polyarthritis (PPP) syndrome is a complication that rarely occur inthe limbs of patients with pancreatic diseases. Although PPP syndrome is rare, the mortality rate is high due to late diagnosis, or the lack of pancreatitis treatment. The case is about a 53-year-old man with a history of pancreatitis. This time the patient was hospitalized due to long-term recurrent skin rashes, swelling of the right calf, and bilateral knee arthritis. After necessary examinations, he was initially diagnosed with right lower leg abscess and knee polyarthritis. However, there were abnormal signs of panniculitis from operative findings and histopathological reports. Although the patient had no complaint of abdominal discomfort, but exudative pancreatitis was discovered through backtrack-ing the computer tomography. Therefore, he was diagnosed with PPP syndrome at the later stage of the treatment and continued to undergo appropriate antibiotics and anti-pancreatitis medications until the symptoms were improved. Consequently, when a middle-aged man with a history of pancreatic disease is encountered clinically, accompanied with repetitive lower limb swelling, skin rashes and recurrent knee arthritis, the PPP syndrome must be considered to quire early treatment opportunity.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Pancreas ultrasound two-dimensional shear wave elastography in healthy children.

Pancreas shear wave speed might be a biomarker of pancreatic disease in children. This study aimed to measure pancreas shear wave speed by two-dimensional (2-D) ultrasound shear wave elastography (SWE) in a balanced cohort of presumed healthy children. This was a prospective study of 120 children (<18years of age) without a known history of pancreatic disease, who underwent ultrasound 2-D SWE of the pancreas. Five shear wave speed measurements in the pancreas body and/or tail were obtained for each participant using a Canon Aplio i800 system, i8CX1 transducer. The Mann-Whitney U test or Kruskal-Wallis test were used to compare continuous distributions. Spearman's correlation was used to assess univariate relationships between continuous variables. Multivariable regression with stepwise selection was used to evaluate independent predictors of pancreas shear wave speed. The median age for the study population was 5.0years (range: 7days to 17.8years) and 61 (50.8%) of the participants were female. The median depth of shear wave speed measurement was 4.7cm (interquartile range [IQR]: 4.2-5.3). The median pancreas shear wave speed was 1.31m/s (IQR: 1.21-1.40). On multivariable analysis, female biological sex (P=0.051), the number of hours nil per os (P=0.097), the median depth of measurement (P=0.001) and the median liver shear wave speed (P=0.020) were positively associated with pancreas shear wave speed. We report pancreas shear wave speed in a large, balanced cohort of children without a known history of pancreatic disease, providing reference values for normal.

Validation of threshold values for pancreas thickness and T1-weighted signal intensity ratio in the pediatric pancreas.

Pancreas atrophy and the loss of T1-weighted signal intensity by magnetic resonance imaging (MRI) are findings of chronic pancreatitis. The purpose of this study was to test published normal values and cutoffs for pancreas thickness and the pancreas:spleen T1-weighted signal intensity ratio in children without pancreatic disease. This was a secondary analysis of prospectively collected MRI data for 50 children (range: 6.3-15.9years; 27 female) with no history of pancreatic disease. Two observers (R1, R2) measured linear pancreas thickness on axial T1-weighted, fat-saturated gradient recalled echo images and placed regions of interest in the pancreas and spleen to calculate the T1-weighted signal intensity ratio. Measurements were compared to published pediatric normal values (computed tomography [CT], ultrasound [US]) and adult cutoffs (CT, MRI). Compared to published pediatric values for CT, 68% (R1: 34/50) or 40% (R2: 22/50) of participants had ≥1 pancreas segment with thickness below the normal range. No participant had a thickness value below the normal range published for US. Compared to cutoff values in adults, 84% (R1: 42/50) or 80% (R2: 40/50) of participants met the criteria for pancreas atrophy. Mean T1-weighted signal intensity ratio was 1.33±0.15 (R1) and 1.32±0.16 (R2). Twelve (R1: 24.5% of 49) or 11/49 (R2: 22.4%) participants had a T1-weighted signal intensity ratio below the threshold associated with exocrine insufficiency in adults. Previously defined thresholds for pancreas thickness and pancreas:spleen T1-weighted signal intensity ratio appear too restrictive for a pediatric population. Further study is needed to define optimal quantitative metrics for findings of chronic pancreatitis in children.

Secretin Improves Visualization of Nondilated Pancreatic Ducts in Children Undergoing MRCP.

OBJECTIVE. The objective of our study was to assess whether secretin improves visualization of a nondilated pancreatic duct and whether it increases identification of variant duct anatomy on MRCP in pediatric patients. MATERIALS AND METHODS. This study is a delayed retrospective review of MRCP images that were prospectively obtained of 50 volunteers without a history of pancreatic disease who ranged in age from 6 to 15 years old. MRCP images (coronal 3D fast recovery fast spin-echo [FSE] and coronal single-shot FSE fat-saturated sequences) obtained before and after secretin administration were separated for review by three radiologists (reviewers 1-3). The reviewers were blinded to the purpose of the study and to secretin administration. Reviewers ranked subjective image quality (Likert scale, 1-5 points) and reported pancreaticobiliary duct anatomy and duct visibility (yes or no). Paired t tests were used for comparison of means, and the chi-square test or Fisher exact test was used for comparison of frequencies. Sensitivity and specificity of MRCP images obtained before secretin administration were judged against MRCP images obtained after secretin administration as the reference standard. RESULTS. The frequency of image quality scores of 4 or greater assigned to 3D MRCP images was statistically significantly greater after secretin administration for reviewer 2 (p < 0.0001) and reviewer 3 (p = 0.005) and approached statistical significance for reviewer 1 (p = 0.052). Mean number of visible pancreatic duct segments (head and uncinate, body, tail) was significantly greater on the MRCP images obtained after secretin administration than on those obtained before secretin administration for all reviewers (reviewer 1, 1.9 vs 1.3; reviewer 2, 1.9 vs 1.2; reviewer 3, 1.4 vs 0.8; all, p < 0.01). For all three reviewers, the sensitivity of MRCP images obtained before secretin administration was poor for variant pancreatic ductal anatomy (reviewer 1, 37.5%; reviewer 2, 50.0%; reviewer 3, 40.0%). CONCLUSION. Secretin administration improved subjective MRCP image quality, improved subjective visualization of the pancreatic duct, and provided greater sensitivity for anatomic variants such as pancreas divisum in a cohort of children with nondilated pancreatic ducts.

Pancreatic endosonographic findings and clinical correlation in Crohn's disease

OBJECTIVES:We aimed to evaluate the incidence of pancreatic alterations in Crohn's disease using endoscopic ultrasound (EUS) and to correlate the number of alterations with current clinical data.METHODS:Patients diagnosed with Crohn's disease (n=51) were examined using EUS, and 11 variables were analyzed. A control group consisted of patients with no history of pancreatic disease or Crohn's disease. Patients presenting with three or more alterations underwent magnetic resonance imaging (MRI). Pancreatic function was determined using a fecal elastase assay.RESULTS:Two of the 51 patients (3.9%) presented with four EUS alterations, 3 (5.9%) presented with three, 11 (21.5%) presented with two, and 13 (25.5%) presented with one; in the control group, only 16% presented with one EUS alteration (p<0.001). Parenchymal abnormalities accounted for 39 of the EUS findings, and ductal abnormalities accounted for 11. Pancreatic lesions were not detected by MRI. Low fecal elastase levels were observed in 4 patients, none of whom presented with significant pancreatic alterations after undergoing EUS. Ileal involvement was predictive of the number of EUS alterations.CONCLUSION:A higher incidence of pancreatic abnormalities was found in patients with Crohn's disease than in individuals in the control group. The majority of these abnormalities are related to parenchymal alterations. In this group of patients, future studies should be conducted to determine whether such morphological abnormalities could evolve to induce exocrine or endocrine pancreatic insufficiency and, if so, identify the risk factors and determine which patients should undergo EUS.

Pancreatic stiffness values using a point shear wave elastography technique in patients with healthy pancreas

Background In the current literature, there is only a small number of studies that have evaluated the utility of point share wave elastography for pancreatic assessment. Objective To assess the feasibility of Virtual Touch Quantification (VTQ) elastography for pancreas assessment, as well as the mean pancreatic stiffness values in healthy subjects. Material and Method We included 70 subjects (52.8% women, 47.2% men, average BMI = 25.9 ± 4.9 kg/m2, average age 46.8 ± 18.4 years) with a normal pancreatic ultrasound aspect and with no history of pancreatic disease or diabetes, in whom elastography measurements were performed with a Siemens Acuson S2000 Virtual Touch ultrasound system (Siemens AG, Erlangen, Germany) using a 4CI transducer. For each patient, 10 valid VTQ measurements of the pancreatic parenchyma were performed under fasting conditions. Reliable measurements were defined as a median value of ten pancreas stiffness measurements with a success rate ≥ 60% and an interquartile range interval Results Out of 70 subjects, reliable measurements were acquired in 61 subjects (87.1%) by means of VTQ elastography. The mean pancreas stiffness values in healthy subjects was 1.26 m/s ± 0.1 m/s, CI 95% (1.24-1.28). There were no significant differences between the mean pancreas stiffness in men vs. women 1.25 m/s ± 0.09 m/s, CI 95% (1.21-1.28) vs. 1.28 m/s ± 0.1 m/s CI 95% (1.25-1.31) (p = 0.103). Conclusion VTQ can be a useful tool for pancreas quantification characterized by a good feasibility (87.1%) in healthy subjects. The mean pancreas stiffness values in healthy individuals was 1.26 m/s ± 0.1m/s.

Impaired Exocrine Pancreatic Function Associates With Changes in Intestinal Microbiota Composition and Diversity

Changes in intestinal microbiome composition are associated with inflammatory, metabolic, and malignant disorders. We studied how exocrine pancreatic function affects intestinal microbiota. We performed 16S ribosomal RNA gene sequencing analysis of stool samples from 1795 volunteers from the population-based Study of Health in Pomerania who had no history of pancreatic disease. We also measured fecal pancreatic elastase by enzyme-linked immunosorbent assay and performed quantitative imaging of secretin-stimulated pancreatic fluid secretion. Associations of exocrine pancreatic function with microbial diversity or individual genera were calculated by permutational analysis of variance or linear regression, respectively. Differences in pancreatic elastase levels associated with significantly (P < .0001) greater changes in microbiota diversity than with participant age, body mass index, sex, smoking, alcohol consumption, or dietary factors. Significant changes in the abundance of 30 taxa, such as an increase in Prevotella (q < .0001) and a decrease of Bacteroides (q < .0001), indicated a shift from a type-1 to a type-2 enterotype. Changes in pancreatic fluid secretion alone were also associated with changes in microbial diversity (P= .0002), although to a lesser degree. In an analysis of fecal samples from 1795 volunteers, pancreatic acinar cell, rather than duct cell, function is presently the single most significant host factor to be associated with changes in intestinal microbiota composition.

Can diffusion-weighted MRI replace conventional contrast enhanced MRI in the differentiation between benign and malignant pancreatic masses?

PurposeTo evaluate the role of diffusion weighted MRI (DW MRI) in the differentiating between benign and malignant pancreatic masses. Patients and MethodsSixty patients (36 men, mean age, 62 years; range, 48–72 years], 24 women (mean age, 64 years; range, 54–69 years] suspected to have solid pancreatic masses were examined by conventional and DWI. None of our patients had a history of pancreatic disease. DWI of the pancreas was performed in addition to the routine liver MR. Final diagnosis was obtained by diagnostic biopsy, lab. data and follow up. Results38 patients had a benign lesion and 22 patients had a malignant lesion. Using DWI, 36 cases were diagnosed to have benign lesions and 24 cases were diagnosed to have malignant lesions. There were two false positive cases due to low ADC value. The mean ADC values of malignant lesions were lower compared with benign lesion. The mean ADC value for malignant lesions was 1.1 +/− 0.201 × 10−3 mm2/sec, and for benign lesions it was 1.6 + l − 0.121 × 10−3 mm2/sec. ConclusionDWI and ADC values can help differentiate between benign and malignant pancreatic masses. Also DWI can be used for investigating patients for whom contrast-enhanced CT or MRI studies are contraindicated.

A Rare Case of B-Cell Lymphoma Presenting as a Large Solid Pancreatic Mass: A Case Report

The differential diagnosis of a pancreatic mass is categorized into cystic and solid lesions. Cystic pancreatic lesions include non-neoplastic cysts and pancreatic cystic neoplasms. Possible differential diagnoses for a solid pancreatic mass include primary exocrine pancreatic cancer, pancreatic neuroendocrine tumors, metastatic cancer, focal chronic pancreatitis, and autoimmune pancreatitis. We are presenting a rare case of B cell lymphoma presenting as a large solid pancreatic mass. A 62-year-old female with past medical history of type II diabetes and hypertension presented to University Medical Center (UMC) hospital in Las Vegas emergency room with four days of epigastric abdominal pain associated with jaundice. She reported unintentional weight loss, but no fever or night sweats. She had no history of pancreatic disease or malignancies. She denied smoking or alcohol use. Physical exam was significant for scleral icterus and a palpable epigastric mass. Initial liver function panel showed AST 189, ALT 213, ALP 140, total bilirubin 7.4 with direct bilirubin 6.2, Albumin 2.9 g/dl, Lipase 63, Lactate dehydrogenase 1,008 and CEA 12.6. Autoimmune panel was sent including antinuclear antibodies, antimitochondrial antibodies, anti-LKM antibodies, IgA, IgG and IgM levels. All were found to be unremarkable. CT of the abdomen and pelvis with IV contrast showed a 5.5 x 3.7 x 3.0 cm mass in the pancreatic tail encasing the splenic vein with splenic vein thrombosis in addition to enlarged retroperitoneal lymph nodes (figure 1). Gastroenterology was consulted and an endoscopic ultrasound with fine needle aspiration was subsequently performed. Tissue pathology revealed aggressive B cell lymphoma. A consult was made with oncology for further management. Hematologic malignancies can often manifest in extranodal locations. We present a rare case of aggressive B cell lymphoma presenting as a large pancreatic mass. Rare cases of hematologic malignancies presenting as pancreatic masses have been reported in the past. Early diagnosis is of primary importance so as to avoid unnecessary surgical resection. Clues suggesting the possibility of a primary hematologic malignancy include constitutional symptoms (weight loss, fever, and night sweats), an elevated serum lactate dehydrogenase (LDH) or beta-2 microglobulin level and a normal serum carbohydrate antigen 19-9 (CA 19-9).1429.tif Figure 1: 5.5 x 3.7 x 3.0 cm mass in the pancreatic tail encasing the splenic vein with splenic vein thrombosis in addition to enlarged retroperitoneal lymph nodes

Obesity and Pancreatic Cysts in African American Patients.

ObjectiveObesity is one of the risk factors for pancreatic cancer and a prognostic factor for acute-chronic pancreatitis.AimTo explore the relationship and association between obesity and pancreatic cysts over a 25-year period in African American patients.MethodsWe reviewed the medical records of 207 patients diagnosed with pancreatic cysts via radiology and pathology data from January 1988 to December 2012. A control group was selected from a separate group of healthy patients without a history of pancreatic disease. The patients were evaluated in five groups according to the last 20 years of diagnosis in five-year intervals.ResultsMost patients with pancreatic cyst (73%) were overweight (defined as a body mass index (BMI) ≥ 25), and 53% had a history of chronic pancreatitis compared to patients in the control group. There was a significant difference between the two groups; 79% of patients group were overweight (BMI ≥ 25) vs. 66% in control group (p = 0.02). The incidence of obese and overweight patients was significant (85%) during the 2008 to 2012 interval for the test group (p = 0.009).ConclusionGiven the increasing proportion of obese pancreatic cyst patients in recent decades compared to the proportion noted in the 1990s, obesity plays a large role in the formation of pancreatic cysts.

Normal pancreatic parenchymal thickness by CT in healthy children.

Chronic pancreatitis is increasingly recognized in the pediatric population. Atrophy is an important, but qualitative, finding of chronic pancreatitis. To transition to a quantitative measure that can specifically define atrophy requires knowledge of normal pancreatic parenchymal bulk in children. The purpose of this study was to define normal pancreatic thickness (linear measurements) at multiple anatomic locations in the pancreas of healthy children. This was an Institutional Review Board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective study. Three reviewers measured the thickness of the pancreas at four locations (head, neck, body, tail) on computed tomography (CT) examinations performed with intravenous contrast in children without a history of pancreatic disease. Measurements were made on 140 examinations, evenly distributed among 7 age groups (3-16.99years) with 10 males and 10 females in each group. Agreement and bias between reviewers were assessed by intra-class correlation coefficients (ICC) and Bland-Altman analyses. Correlation with age, height and weight were assessed with Spearman's rho (ρ). The mean (for 3 readers) thicknesses of the head, neck, body and tail were 1.3-2cm, 0.7-1cm, 0.9-1.6cm and 1-1.6cm, respectively, depending on patient age. Measurement agreement between reviewers was fair to good (ICC: 0.52-0.7). Bias between reviewers ranged from 0 to 3mm. Pancreatic thickness was weakly to moderately correlated with age (ρ=0.39-0.52), height (ρ=0.44-0.61) and weight (ρ=0.51-0.64). We have defined normal ranges for thickness of the pancreas at four locations, and have shown that these measurements depend on patient age and size. These data may be useful to more objectively define pancreatic atrophy in children with suspected pancreatic disease.

The Risk of Acute Pancreatitis After Initiation of Dipeptidyl Peptidase 4 Inhibitors: Testing a Hypothesis of Subgroup Differences in Older U.S. Adults.

To examine whether dipeptidyl peptidase 4 inhibitors (DPP-4I) increase acute pancreatitis risk in older patients and whether the association varies by age, sex, and history of cardiovascular disease (CVD). We conducted a cohort study of DPP-4I initiators versus thiazolidinedione (TZD) or sulfonylurea initiators using U.S. Medicare beneficiaries, 2007-2014. Eligible initiators were aged 66 years or older without history of pancreatic disease or alcohol-related diseases. Patients were followed up for hospitalization due to acute pancreatitis and censored at 90 days after treatment changes. Weighted Cox models were used to estimate the hazard ratio (HR) for acute pancreatitis. Analyses were performed overall as well as within subgroups defined by age, sex, and CVD history. We found no increased risk of acute pancreatitis comparing 49,374 DPP-4I initiators to 132,223 sulfonylurea initiators (weighted HR 1.01; 95% CI 0.83-1.24) and comparing 57,301 DPP-4I initiators to 32,612 TZD initiators (weighted HR 1.11; 95% CI 0.76-1.62). Age and sex did not modify the association. Among patients with CVD, acute pancreatitis incidence was elevated in initiators of DPP-4I and sulfonylurea (2.3 and 2.4 per 1,000 person-years, respectively) but not in TZD initiators (1.5). Among patients with CVD, higher risk of acute pancreatitis was observed with DPP-4I compared with TZD (weighted HR 1.84; 95% CI 1.02-3.35) but not compared with sulfonylurea. Our study provides evidence that DPP-4I is not associated with an increased risk of acute pancreatitis in older adults overall. The positive association observed in patients with CVD could be due to chance or bias but merits further investigation.

Pancreatic Complications After Intestinal Transplantation

Purpose: To analyze the impact of pancreatic complications on the final outcome of patients with intestinal failure following intestinal transplantation (Itx). Materials and Methods: Nine patients underwent primary isolated Itx at our hospital between 2003 and 2016. Median patient age at the time of primary Itx was 22 years (range, 10-29 years). No patients had any history of pancreatic disease before Itx. Recipients were classified into a Pancreatic group (n=3) with pancreatic complications following Itx, and a Control group (n=6) without such complications. No recipients sustained pancreatic injuries or developed acute pancreatitis as intraoperative or immediately postoperative complications of Itx. We retrospectively analyzed several clinical parameters and compared outcomes between the groups. Results: One of 3 patients in the Pancreatic group, who was associated with duodenal obstruction, developed acute severe pancreatitis 115 months following Itx. She died 2 months later. Another patient died of abdominal bleeding due to laceration of the pancreas, presumably related to extensive dilation of the duodenum without abdominal bruising 87 months after Itx, and acute pancreatitis was revealed at autopsy. The remaining patient developed refractory bleeding of the pancreas 5 months after Itx. Bleeding was well controlled conservatively and the patient remains alive with a functioning graft. The underlying disease was motility disorder (MD) in all 3 patients in the pancreatic group, but was MD in 3 cases and short bowel syndrome in 3 cases in the control group. Median follow-up was 87 months in the pancreatic group and 90 months in the control group. Overall, 1- and 5-year survival rates were 33.3%, 100% and 100%, and 83.3%, 100% and 83.3% in pancreatic and control groups, respectively. Larger hemorrhages were encountered in the pancreatic group (median, 2,866 ml) than in the control group (1,919 ml) during Itx (p=0.02). No significant differences were found in other parameters, including operative time, graft condition, and rejection rates between groups. Conclusion: We speculate that patients with MD were associated with considerably high risk of severe pancreatitis. Large hemorrhage during Itx might be another risk factor for pancreatic complications. However, the mechanisms of such complications remain unclear. We encountered lethal pancreatic complications following Itx, and special attention should be paid to patients with MD with/without dilated duodenum following Itx.

Pancreatic Insufficiency Secondary to Tobacco Exposure: A Controlled Cross-Sectional Evaluation.

Tobacco exposure is an established risk factor for pancreatic cancer and chronic pancreatitis; however, its role in pancreatic insufficiency is not clear. This controlled, cross-sectional study examined smokers and nonsmokers with no history of pancreatic disease. Histories and validated inventories of alcohol and tobacco use were obtained, and pancreatic insufficiency was assessed using the fecal elastase-1 assay. Of 7854 patients approached, 226 were interviewed and 200 enrolled. The rates of pancreatic insufficiency [18% (18/100)] and severe pancreatic insufficiency [10% (10/100)] were significantly higher in smokers than in controls [6% (6/100), P = 0.009 and 1% (1/100), P = 0.010, respectively]. On multivariate logistic regression, the risk of pancreatic insufficiency in smokers was significantly increased [odds ratio, 4.34 (1.37-13.75); P = 0.012], controlling for alcohol use and relevant covariates. Tobacco exposure was associated with the highest odds ratio for pancreatic insufficiency. Alcohol consumption was strongly associated with tobacco exposure (P < 0.001), but not with pancreatic insufficiency by multivariate analysis (P = 0.792). This study suggests that tobacco exposure is independently associated with pancreatic exocrine insufficiency in patients without a prior diagnosis of pancreatic disease. Tobacco exposure seems to have greater detrimental effects on pancreatic function than alcohol in this population.

Haematochezia from a Splenic Artery Pseudoaneurysm Communicating with Transverse Colon: A Case Report and Literature Review.

Splenic artery aneurysms (SAA) are the third most common intra-abdominal aneurysm. Complications include invasion into surrounding structures often in association with preexisting pancreatic disease. We describe an 88-year-old female, with no history of pancreatic disease, referred with lower gastrointestinal bleeding. CT angiography showed a splenic artery pseudoaneurysm with associated collection and fistula to the transverse colon at the level of the splenic flexure. The pseudoaneurysm was embolised endovascularly with metallic microcoils. Rectal bleeding ceased. The patient recovered well and follow-up angiography revealed no persistence of the splenic artery pseudoaneurysm. SAA rupture results in 29%–50% mortality. Experienced centres report success with the endovascular approach in haemodynamically unstable patients, as a bridge to surgery, and even on a background of pancreatic disease. This case highlights the importance of prompt CT angiography, if endoscopy fails to identify a cause of gastrointestinal bleeding. Endovascular embolisation provides a safe and effective alternative to surgery, where anatomical considerations and local expertise permit.

Hemosuccus Pancreaticus: A Rare Upper Gastrointestinal Bleed

Introduction: Hemosuccus pancreaticus (HP) is rare cause of hemorrhage that stems from the pancreatic duct. Gastroenterologists should be familiar with this disease because early diagnosis can be lifesaving. Case Presentation: A 69 year-old male with a history of chronic pancreatitis secondary to ethanol abuse presented to our institution with right upper quadrant abdominal pain and an elevated lipase of 19,000 U/L. The patient was admitted and treated for acute on chronic pancreatitis. His hospital course became complicated when he developed melena and a decrease of hemoglobin from 7.8 to 3.9, for which he was transfused packed red blood cells. An upper esophagogastroduodenoscopy demonstrated retained blood within the duodenum, with no source of active bleeding. Interventional Radiology was consulted and angiography of the superior mesenteric artery was performed, which demonstrated an arteriovenous fistula (AVF) located in pancreatic bed (see figure 1). A subsequent embolization was attempted. There was no extravasation of contrast observed, indicating that the bleeding had spontaneously resolved and, therefore, embolization was canceled. The patient's hemoglobin stabilized and he remained hemodynamically stable upon discharge. Upon follow up at an outpatient gastrointestinal clinic one month later, patient's hemoglobin remained stable.Figure 1Discussion: Hemosuccus pancreaticus is defined as bleeding expelled from the pancreatic duct into the duodenum at the site of the ampulla of Vater. It is a rare cause of upper gastrointestinal bleeding (1/1500). The biggest risk factor for hemosuccus pancreaticus is chronic pancreatitis, in which the inflammation results in the formation of aneurysms or pseudoaneurysms, which can rupture. Other risk factors include trauma, pancreatic tumor, and vascular malformation. HP is a diagnostic challenge because it presents as an obscure upper gastrointestinal bleed. Endoscopy is necessary to rule out other etiologies of bleeding, but does not always help determine an etiology. Ultimately, angiography is the gold standard for diagnosis. Surgery and angiographic embolization are the recommended treatment options. Left untreated, mortality can be as high as 90%. Transcatheter embolization of the bleeding artery is attempted first, with success rates of 80-100%. If bleeding cannot be stopped, then distal pancreatectomy is performed. Conclusion: Our case demonstrates that hemosuccus pancreaticus should be on the differential for the etiology of a upper gastrointestinal bleed in a patient with a history of pancreatic disease.

Age-related change of the secretory flow of pancreatic juice in the main pancreatic duct: evaluation with cine-dynamic MRCP using spatially selective inversion recovery pulse.

The purpose of this study is to evaluate age-related changes in the secretory flow of pancreatic juice in the main pancreatic duct noninvasively by means of nonpharmacologic cine-dynamic MRCP using spatially selective inversion recovery (IR) pulse. Fifty-three subjects without a history of pancreatic disease were included. Four-second breath-hold MRCP using spatially selective IR pulse was performed every 15 seconds during 5 minutes (acquiring a total of 20 images) in cine-dynamic fashion. The secretion grade was classified into five grades by the distance of pancreatic juice inflow within the tagged area. The mean secretion grade and the frequency of secretion in cine-dynamic MRCP were compared among three age-range groups (group 1, < 40 years; group 2, 40-70 years; and group 3, > 70 years). Statistical analysis was performed using Spearman rank correlation coefficient and Kruskal-Wallis and Mann-Whitney U tests. The secretion grade and the frequency of secretion were significantly reduced with aging (r = -0.77, p < 0.001; and r = -0.74, p < 0.001, respectively). The mean secretion grade and the frequency of secretion were significantly lower in group 3 than in group 2 (mean grade, 0.36 vs 1.48, p = 0.001; and 4.8 vs 11.9 times, p = 0.001) and were lower in group 2 than in group 1 (mean grade, 1.48 vs 2.48, p < 0.001; and 11.9 vs 16.2 times, p = 0.011). Cine-dynamic MRCP using spatially selective IR pulse was able to show the age-related decrease of the secretory flow of pancreatic juice in the main pancreatic duct visually and noninvasively.

Diffusion‐weighted magnetic resonance imaging of pancreatic adenocarcinomas: Association with histopathology and tumor grade

To evaluate the utility of diffusion-weighted magnetic resonance imaging (DWI) in pancreatic ductal adenocarcinoma with various grades of differentiation. Following Institutional Review Board (IRB) approval, 21 consecutive patients with surgical pathology-proven pancreatic adenocarcinomas were retrospectively evaluated. Histopathologic characteristics and grades of differentiation of adenocarcinomas were analyzed. Twenty-one patients without a known history of pancreatic disease were evaluated as the control group. Anatomic MR images and DW images were acquired using 1.5-T MR systems. DWI with b values of 0 and 500 sec/mm² were performed on both patients and control groups. The difference in mean apparent diffusion coefficient (ADC) values among groups of normal pancreatic parenchyma, adenocarcinomas with poor differentiation, and adenocarcinomas with well/moderate differentiation were compared using one-way analysis of variance. Mean ADCs of pancreatic adenocarcinomas (1.77 ± 0.45 × 10⁻³ mm²/sec) was not significantly lower than that of normal parenchyma (1.98 ± 0.31) (P = 0.09). When adenocarcinomas were subdivided based on grades of differentiation, however, poorly differentiated adenocarcinoma with histopathologic characteristics of limited glandular formation and dense fibrosis had significantly lower ADCs (1.46 ± 0.17) compared to those of well/moderately differentiated adenocarcinomas (2.10 ± 0.42) characterized by neoplastic tubular structures (P < 0.01). Well/moderately differentiated adenocarcinomas with dense fibrosis showed significantly lower ADC values (1.49 ± 0.19) than those with loose fibrosis (2.26 ± 0.30) (P = 0.01). Difference in ADC values using DWI between poorly and well/moderately differentiated pancreatic ductal adenocarcinoma may relate to differences in glandular formation and density of fibrosis.