Management Of Acute Pancreatitis Research Articles

WTP3.7 Are we using antibiotics appropriately in acute pancreatitis?

Abstract Aim To re-evaluate antibiotic use in the management of acute pancreatitis at our hospital. Method This retrospective closed loop audit incorporated patients with acute pancreatitis admitted to our hospital between 01/04/22 and 30/06/22. The initial audit was conducted in 2020. The gold standard was guidelines published by the World Society of Emergency Surgery (2019). Data sources included patient paper notes, and clinical results and prescribing software. Results 44 patients presented with acute pancreatitis during the re-audit period; 80 patients were included in the initial audit. 22 of the re-audit patients (50%) received antibiotics, compared with 47 patients (59.1%) in the initial audit. Co-amoxiclav was the most used antibiotic (10 re-audit patients, 46.2%). 19 of the re-audit patients (86.3%) receiving antibiotics had mild or moderate acute pancreatitis (on Modified Glasgow Score); whereas most patients (29, 61%) in the initial audit had severe pancreatitis. Procalcitonin was not measured prior to commencing antibiotics in either audit. Also, no re-audit patient had CT-confirmed evidence of infected pancreatic necrosis. 5 re-audit patients (21.4%) were treated appropriately with antibiotics for extra-pancreatic infection, including acute cholecystitis and hospital-acquired pneumonia. Conclusion Decisions to commence antibiotics in acute pancreatitis have generally been inattentive to guideline recommendations, with greater focus on clinical impression of patient condition and inflammatory markers, such as C reactive protein. However, inappropriate antibiotic use may not bring patient benefit and negatively affect clinical care, for example yielding Clostridium Difficile infection and antimicrobial resistance. Hence, we will now change practice and measure procalcitonin to inform decision-making about antibiotics in acute pancreatitis.

492 Raising the standards: management of acute pancreatitis in a district general hospital

Abstract Introduction Pancreatitis is a common condition seen in General Surgery which may cause significant morbidity and mortality. Current guidelines include fluid resuscitation, ABG and Glasgow-Imrie scoring every 48 hours. The aim of this study is to assess how well the current guidelines are being adhered to at NGH, identify the problems affecting patient care, and plan a sustainable solution. Methods 57 of 102 admissions coded as pancreatitis between Jan-July 2022 fit the inclusion criteria. Information regarding adequate fluid prescription, usage of antibiotics, type of pancreatitis, Glasgow scoring and the type of pancreatitis was collected from patients’ paper and electronic records. Results Average length of stay was 8.3 days. 5 patients (8.8%) were necrotising and 13(22.8%) had concurrent cholecystitis. ABG was done in 14 (24.6%) patients. 17 (29.8%) had a Glasgow-Imrie score planned and 10 (17.5%) had a documented score. 55 (96.5%) patients were fluid resuscitated and all received adequate analgesia. 5 (8.8%) were admitted to ITU, 2 (3.5%) had critical care review. 3/5 (60%) of patients were scored prior to ITU admission. 13 (22.8%) had recurrent pancreatitis and 6 (10.5%) died. Conclusion The current management of pancreatitis at NGH could be improved. Scoring for pancreatitis severity helps early management of patient in need of ITU. We propose creating a pancreatitis pro-forma with scoring to be placed inside every patient's notes with a checklist for pancreatitis management and scoring.

ThTP1.13 Improving Practice in Acute Pancreatitis Management at University Hospital Wishaw

Abstract Acute pancreatitis has an incidence of 150 to 420 cases per million population in the UK and appropriate management is essential given its high early mortality rate. This clinical audit aimed to improve the initial management of acute pancreatitis in patients presenting to UHW between June 2021 and August 2022. Retrospective analysis was performed for all acute pancreatitis patients discharged between 01/06/21 and 01/12/21. Management was compared against NICE, BSG and RCS audit standards which encompassed risk stratification, investigations, non-operative and operative management. Initial results were presented at the surgical monthly meeting in April 2022 to raise awareness of standardising care. An acute pancreatitis sticker was implemented to drive change. To assess the intervention impact, prospective data collection was performed from May to August 2022. Results revealed an improvement in nine out of ten of the audit standards. Suitable investigation into pancreatitis aetiology improved from 25% to 50%, with a notable 83% reduction in clinicians assuming alcohol induced pancreatitis without prior investigation of cause. Initial risk stratification of patients improved from 36% to 52% and severity assessment was bettered from 4% to 36%. The provision of nutritional support to relevant patients rose from 11% to 46%. Comparison of sub-cohorts revealed that adherence with the pancreatitis sticker showed measurably better compliance with standards. Raising awareness through departmental teaching and a pancreatitis sticker have demonstrated an improvement in standardisation of care, benefiting patient outcomes. Use of a visual aid has been shown to better standards therefore, future cycles should focus on compliance with sticker implementation.

WTP7.4 Is there a role for ambulatory management of acute pancreatitis in selected cases?

Abstract Aim Pancreatitis is a common general surgical condition that presents with variable severity. The usual management involves a hospital admission for observation, lasting a median of five days. However, there may be a role for ambulatory management. We aimed to determine which patients presenting with acute pancreatitis may be suitably managed in the community. Method This prospective, multicentre cohort study at 113 UK sites included adult patients diagnosed with pancreatitis. Potential for ambulatory management was defined as the presence of mild pancreatitis, tolerating oral fluids, and oral analgesic requirement only. Multilevel logistic regression models determined relationships, accounting for the clustering of patients within hospitals. Results Of 2580 patients included, only 13 (0.5%) patients were managed without admission and 150 (6.1%) patients were admitted a single night only. Overall 1836 (71%) of patients had mild pancreatitis, of which 928 (50.5%) were potentially suitable for ambulatory care. After accounting for median CRP peak at 48 hours, a CRP of <150 at 48 hours was associated with a lower risk of all complications (OR 0.35, 95% CI 0.30-0.42; P<0.001) and CT-confirmed collection and/or necrosis (0.18, 0.15-0.22; P<0.001). Patients were also twice as likely to be suitable for ambulation (OR 2.07, 1.75-2.44; P<0.001). Conclusion Just over a third of patients with pancreatitis could potentially be managed ambulatory. CRP at 48 hours is a strong predictor of pancreatitis-associated complications and may help direct further follow up.

ThTP8.8 Ambulatory management of acute pancreatitis

Abstract Aim Acute pancreatitis is a common pathology with a spectrum of disease from mild to life-threatening. It is standard practice for all patients to be admitted due the inability to accurately predict severity. However, both considering the wellbeing of patients and pressures on acute hospitals, it may be the time to consider the role of ambulatory care. We retrospectively reviewed patients with pancreatitis managed ambulatorily, and assessed for trends in their presentation. Methods Retrospective review of a prospectively maintained database between 2019-2022 identifying patients with acute pancreatitis with initial ambulatory management. Results There were 19 cases of pancreatitis with planned ambulatory management, with only one representing and requiring admission for 36 hours for symptom control. Of those who had successful ambulatory management, 12 were male (67%). Median age was 55 (range 24-81). Median duration of symptoms at time of review was 5 days (range 1-21). Median number of comorbidities was 1 (0-6), with only a third (6/18) reporting no comorbidities. Median CRP was 11 (<1-153) and WCC 9 (3-25); no patients had acute kidney injury. All patients had a NEWS<2. All but two patients (with a background of pancreatitis) had imaging performed in an ambulatory setting; five had CT scans. Conclusion Patients successfully managed ambulatory were a very heterogeneous group. Our data would support that trial of ambulatory management can be considered in the absence of organ failure (renal function, or physiological instability). This should be supported by adequate safety netting, and plans for further review as appropriate.

Acute Pancreatitis Review.

Acute pancreatitis, a prevalent illness with devastating consequences, poses a grave threat to those affected. There has been a steady increase in the occurrence of acute pancreatitis at about 3% per year from 1961 to 2016. There are 3 main guidelines on acute pancreatitis, including the American College of Gastroenterology, the International Association of Pancreatology/American Pancreatic Association guideline in 2013, and the American Gastroenterological Association guideline in 2018. However, several milestone studies have been published since then. We hereby reviewed the current acute pancreatitis guidelines with an update on clinical practicechanging literature. The aggressive or moderate fluid resuscitation in acute pancreatitis (WATERFALL) trial recommended fluid resuscitation with lactated Ringer's solution at a moderate aggressive rate. All guidelines did not recommend prophylactic antibiotics use. Early enteral feeding reduces morbidity. A clear liquid diet is no longer recommended. Nutrition with nasogastric or nasojejunal feeding does not have a difference. The upcoming high vs. low-energy administration in the early phase of acute pancreatitis (GOULASH) trial will provide more information on the impact of calorie intake. Pain management should be individualized based on the degree of pain and severity of pancreatitis. In patients with moderate to severe and severe acute pancreatitis, a step-down approach with epidural analgesia can be considered for moderate to severe pain. The management of acute pancreatitis has evolved. New research on the impact of electrolytes, pharmacologic agents, the role of anticoagulants, and nutrition support will provide scientific and clinical evidence to improve patient care and decrease morbidity and mortality.

Diagnosis of epigastric pain: a case report

Epigastric pain is the most significant symptom and a major clinical challenge in chronic pancreatitis. Pancreatic pain is characteristically described as a constant, severe, dull, epigastric pain that often radiates to the back and typically worsens after high-fat meals. However, many different pain patterns have been described, ranging from no pain to recurrent episodes of pain and pain free intervals, to constant pain with clusters of severe exacerbations. A 30-years old female inpatient with complaints of abdominal pain located on epigastric since 7 days ago. Patients also complain of nausea and vomiting, decreased appetite. The patient has a history of acute pancreatitis and was treated 6 months ago and is hyperthyroid. Physical examination within normal limits. On abdominal examination, there was tenderness in the epigastric part. Abdomen ultrasound examination revealed widening of the pancreatic duct. While hospitalized the patient was treated with meropenem 1 gram IV every 8 hours, pantoprazole 40 mg IV every 12 hours, ondansetron 8 mg IV every 12 hours, Kaltrofen supp if needed, Propranolol 5 mg PO every 12 hours and thyrozol 10 mg PO every 12 hours. Acute pancreatitis is an acute, non-bacterial inflammation of the pancreas organ. Radiographic examination must be done to establish diagnose beside anamnesis and laboratorium examination. To diagnose acute pancreatitis, at least 2 of 3 criteria must be met. Management of patients with acute pancreatitis includes non-operative and surgical. Antibiotics therapy in management of acute pancreatitis in the early stages is still controversial.

Antibiotic Utilization in Acute Pancreatitis: A Narrative Review.

Acute pancreatitis is a complex inflammatory disease with significant morbidity and mortality. Despite advances in its management, the role of antibiotics in the prophylaxis and treatment of acute pancreatitis remains controversial. The aim of this comprehensive review is to analyze current evidence on the use of antibiotics in acute pancreatitis, focusing on prophylactic and therapeutic strategies. Prophylactic use aims to prevent local and systemic infections. However, recent studies have questioned the routine use of antibiotics for prophylaxis and highlighted the potential risks of antibiotic resistance and adverse effects. In selected high-risk cases, such as infected necrotizing pancreatitis, prophylactic antibiotic therapy may still be beneficial. As for therapeutic use, antibiotics are usually used to treat infected pancreatic necrosis and extrapancreatic infections. When selecting an antibiotic, the microbiologic profile and local resistance patterns should be considered. Combination therapy with broad-spectrum antibiotics is often recommended to cover both Gram-positive and Gram-negative pathogens. Recent research has highlighted the importance of individualized approaches to antibiotic use in acute pancreatitis and underscored the need for a tailored approach based on patient-specific factors. This review also highlights the potential role of new antimicrobial agents and alternative strategies, such as probiotics, in the management of acute pancreatitis.

Advances in the management of acute pancreatitis.

Advances in the management of acute pancreatitis.

Role of Neutrophil to Lymphocyte Ratio (Nlr) And C - Reactive Protein to Albumin Ratio (Car) As Early Predictors of Severity in Acute Pancreatitis

Background: Acute pancreatitis (AP) is a life-threatening disease caused by a variety of factors, and once it progresses to severe acute pancreatitis, the prognosis is poor. Different modalities are available for predicting severity in acute pancreatitis. A single, cheap, widely available marker with high sensitivity and specificity is yet to be identified. The present study was aimed to determine the relation of the neutrophillymphocyte ratio (NLR) and CRP-Albumin ratio (CAR) in early prediction of severity in acute pancreatitis. Methods: This cross-sectional study was conducted at the Department of Gastrointestinal, Hepatobiliary and Pancreatic Disorders (GHPD), BIRDEM General Hospital, Shahbagh, Dhaka, Bangladesh, from April, 2020 to March, 2022. Diagnosis of acute pancreatitis was made by clinical findings, serum amylase and lipase levels (>3 times the upper limit of normal values), evidences of acute pancreatitis by ultrasonography and computed tomography (CT). Severity of acute pancreatitis was classified according to the revised version of Atlanta classification. Data collection was done through a structured questionnaire. Data were analyzed by SPSS 23. Receiver operating characteristic (ROC) curve was constructed to estimate the sensitivity and specificity of NLR and CAR. Results: A total of 120 patients with acute pancreatitis were enrolled in this study. Age of the patients was 45.20±13.93 (mean ±SD) years, male predominance was observed (54.2%). Majority of the cases were mild 52.5% (n=63) compared to moderate 28.3% (n=34) and severe 19.2% (n=23). The NLR was 6.63±3.344 (Mean±SD) with a range of 1.32 to 18.75. The CAR was 3.20±2.23 (Mean ±SD) with range of 0.14-7.20. The area under the curve (AUC) of NLR and CAR were 0.865 and 0.949 for severity of AP respectively. Sensitivity, specificity, PPV, NPV and accuracy of NLR at cut-off e”5.72 were 80.7%, 76.2%, 75.4%, 81.4% & 78.3% and that of CAR at cut-off e”2.07 were 96.5%, 76.2%, 78.6%, 96.0% & 85.8%. Conclusion: This study revealed that NLR and CAR are good predictors in the assessment of severity of AP. These easily accessible and low-cost inflammatory markers can be used for the management of acute pancreatitis. J Medicine 2023; Vol. 34, No. 2(1) Supplement: 213-214

Manejo de la analgesia en la pancreatitis aguda. Resultados de una encuesta nacional

IntroductionAcute pancreatitis is one of the main reasons for digestive admissions. Adequate pain treatment is crucial in its management. However, there are hardly any descriptions of the analgesic guidelines used in our setting. MethodsOn-line survey on analgesic management in acute pancreatitis, aimed at attending physicians and residents practising in Spain. ResultsTwo hundred and nine physicians from 88 centres responded to the survey. Ninety percent were specialists in gastrointestinal medicine and 69% worked in a tertiary centre. The majority (64.4%) do not routinely use scales to measure pain. When choosing a drug, experience in its use was the most important factor. The most commonly prescribed initial treatments are: combination of paracetamol and metamizole (53.5%), paracetamol alone (19.1%) and metamizole alone (17.4%). As rescue: meperidine (54.8%), tramadol (17.8%), morphine chloride (17.8%) and metamizole (11.5%). Continuous perfusion is used in 8.2% of initial treatments. Physicians with >10 years of service use more metamizole as monotherapy (50%), while residents and attending physicians with <10 years of service prescribe it in combination with paracetamol (85%). If progression is needed, morphine chloride and meperidine are mainly used. The speciality of the respondent, the size of the work centre and the unit/service where the patients were admitted did not influence the analgesia prescribed. Satisfaction with pain management reached 7.8/10 (SD 0.98). ConclusionIn our setting, metamizole and paracetamol are the most commonly used analgesics as initial pain treatment in acute pancreatitis, and meperidine is the most commonly used rescue analgesic.

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK.

Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

Something new in the management of acute pancreatitis: brief review of recent guidelines and practical tips.

Improvement in diagnostic and therapeutic techniques has led to revision of past guidelines on the management of acute pancreatitis (AP), still not uniformly applied on the territory, partly due to the different distribution of resources to the various centers, partly due to the lack of unequivocal conduct in the approach itself. We had tried to outline most important changes emerged from the revision of recent and authoritative guidelines, focusing on what we believe are still critical points and identifying attitudes more equally shared than others. Based also on the experience of our small center, which however manages numerous cases of AP and their complications, we finally proposed a simple decision algorithm, which does not claim to be a codified recommendation, but only a small and concrete suggestion.

BISAP plus serum lactate dehydrogenase: a new scoring system for assessment of severity of acute pancreatitis

Background: Acute Pancreatitis is a process of acute inflammation of pancreas along with peripancreatic tissue and multi organ involvement. To reduce morbidity and mortality by predicting the course of the disease and do an early intervention several scoring systems have been proposed such as RANSON’S score, BISAP score, APACHE II etc. Methods: Patients are chosen with clinical diagnosis of acute pancreatitis over a period of 6 months, based on inclusion criteria, with consent. They underwent investigations base d on the scoring systems and institutional protocol. The different scoring systems were used and calculated. The effectiveness of all the scoring systems were calculated using Microsoft Excel indicating its sensitivity, specificity, accuracy, positive and negative predictive value. Results: BISAP with LDH (BISAP PLUS) shows the highest sensitivity (85.71%), Positive predictive value (70.59%), Negative predictive value (84.62%) and Accuracy (76.67%) among different scoring systems. The highest specificity was seen in APACHE II (75%) Conclusions: Use of BISAP plus serum LDH (BISAP plus) can help in daily assessment and quicker management of acute pancreatitis and should be studied further, as it is showing promise in helping in management of acute pancreatitis.

Controversies in the management of acute pancreatitis: An update.

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Wernicke-Korsakoff Syndrome in pregnancy: a preventable complication (P4-4.005)

<h3>Objective:</h3> NA <h3>Background:</h3> Wernicke’s Encephalopathy (WE) is classically a triad of encephalopathy, ophthalmoplegia and gait ataxia resulting from thiamine (B1) deficiency. MRI shows symmetric white matter hyperintensities in the mammillary bodies, bilateral thalami, tectal plate and periaqueductal gray matter. WE is commonly associated with chronic alcohol use; however it can develop in any condition that limits intake or absorption of thiamine, including pancreatitis. Although rare, a number of cases of hyperemesis gravidarum in pregnancy leading to WE have been reported, however comorbid pancreatitis and progression to Korsakoff in this population have not. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 29-year-old woman of 11-weeks gestation, with multiple prior admissions for hyperemesis gravidarum and pancreatitis, was admitted for management of acute pancreatitis with a serum lipase over one-thousand. Her family initially noted symptoms of apathy, abulia, and cognitive changes which they ascribed to possession by a djinn (demon or spirit), according to an ethnomedical belief system. She also developed ataxia, identified by her family as a biomedical symptom, for which they sought medical care. Patient and her family speak Soninke, a Gambian dialect initially unavailable on hospital translation services. These factors delayed recognition of the patient’s clinical picture. Neurology was consulted on hospital day three for altered mentation, exam was notable for direction changing nystagmus, abulia, and somnolence. MRI showed a pattern typical in WE as well as cortical hyperintensities in the perirolandic cortex. Intravenous high dose thiamine improved patient’s abulia, but she continues to have residual retrograde and anterograde amnesia consistent with Korsakoff psychosis. <h3>Conclusions:</h3> Pregnant women are uniquely vulnerable to thiamine deficiency. Prompt IV thiamine repletion should be considered in hyperemesis or acute pancreatitis. Language barriers and ethnomedical beliefs can be concurrent with biomedical beliefs and limit communication and delay clinical diagnosis resulting in poor patient outcomes. <b>Disclosure:</b> Mr. Morris has nothing to disclose. Dr. Amirkhanashvili has nothing to disclose. Dr. Bhatia has nothing to disclose. Dr. Fields has nothing to disclose. Dr. Adsule has nothing to disclose. Dr. Haut has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Nile AI. Dr. Haut has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for UCB.

Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence.

The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.

A CASE OF INTRAOPERATIVE DISCOVERY OF ABERENT SUBVESICAL BILE DUCT DURING LAPAROSCOPIC CHOLECYSTECTOMY

Introduction. Subvesical bile ducts (Lyushka ducts) are tubular aberrant anatomical anomalies of the biliary tree, in which the intrahepatic bile ducts drain into the lumen of the gallbladder at different levels.&#x0D; According to various sources, this variant of the anatomical architecture of the bile ducts occurs in 1.7 - 3% of clinical cases.&#x0D; The relevance of knowing the anatomical features of the biliary tree is due to the fact that routine preoperative methods of examination in most cases do not allow to verify them, and unnoticed damage to such courses at the stage of extraction of the bile duct can lead to intraoperative and postoperative complications.&#x0D; Therefore, knowledge of the presence of such anatomical options is a condition for safe laparoscopic cholecystectomy (LC).&#x0D; Goal. To represent a clinical case of aberrant subvesical bile duct during LC.&#x0D; Presentation of a clinical case. The 41-year-old patient was hospitalized for acute biliary pancreatitis of mild severity according to the Ranson scale against the background of gallstone disease. In cooperation with related specialists, the patient underwent complex conservative treatment according to the updated recommendations for the management of acute pancreatitis (AP). After the normalization of basic laboratory indicators, exclusion of local parapancreatic complications, the patient was prepared for LC. Intraoperatively, a subvesical aberrant bile duct with a diameter of 1 mm was found, connecting the lumen of the gallbladder with the intrahepatic ducts of the IV segment of the liver. Coagulation of the bilious source was performed. A diagnostic tubular drainage was installed. No complications were observed in the early and late postoperative period.&#x0D; Discussion. Subvesical bile ducts, or "Lyushka's ducts" - anatomical variants of biliary tracts that flow directly into the gallbladder, perforating its wall at different levels.&#x0D; The etiology of Lyushka's movements is a subject of debate. The first theory describes them as an embryological abnormality of development in the early stages of embryogenesis. In our clinical case, it is quite likely that subvesical bile ducts could have arisen according to the second theory - hypertrophy of parenchymal branches as a result of previous local inflammation against the background of chronic cholecystitis and periodic exacerbation of cryptogenic hepatitis.&#x0D; Due to their small size, these movements can go unnoticed, causing various postoperative complications. Therefore, such ducts are of great clinical importance for surgeons. Their preoperative identification is often impossible, so they can be damaged intraoperatively.&#x0D; Bile leakage due to damage to aberrant ducts usually manifests itself clinically within the first postoperative week. In severe cases, the development of biliary peritonitis with subsequent sepsis is possible.&#x0D; In our case, cholelithiasis from the subvesical course was eliminated by coagulation. In cases of postoperative complications, according to the literature, endoscopic methods are the main method of treatment. A repeat laparotomy is very rarely necessary.&#x0D; Conclusions. Aberrant subvesical bile ducts are extremely rare and may be overlooked during hepatobiliary operations. Their damage occurs at the stage of separation of the ZHM from its bed and is therefore inevitable. Knowledge of their existence, intraoperative vigilance and delicate surgical technique allow to identify and timely prevent the development of complications.

Evaluating approaches to diagnosis and management of idiopathic acute pancreatitis

IntroductionIdiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence. MethodsPatients diagnosed with IAP from 2015–21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines. ResultsA total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence. ConclusionComplete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.

A Cross-Sectional Study on Aetiology, Clinical Profile and Management of Acute Pancreatitis over a period of Six months’ in a Tertiary Medical Care Hospital, YSR Kadapa

Abstract: Background: An inflammation of the pancreas that lasts only a short time is called Acute Pancreatitis (AP). High levels of pancreatic enzymes in the blood and significant upper abdominal pain are its defining characteristics. Acute pancreatitis is typically a benign, self-limiting condition that cures itself without any problems. Objectives: The current study’s objective was to assess the prevalence of various AP etiologies, compare the variations in clinical characteristics among patients with various AP causes, assess the length of hospital stay, review the diagnostic techniques used to confirm AP, and monitor the clinical management of AP. Materials and Methods: A six-month prospective observational research study in a multifunctional tertiary hospital with 750 beds. The statistical analysis and evaluation of the acute pancreatitis clinical profile were done using SPSS (Statistical Package for Social Sciences). Results: The study included 50 patients in total. Males outnumbered females 96% to 4%, with a mean age of 34.7. Alcoholism accounted for the majority of the subjects’ 44 (88%). Abdominal pain was the most common symptom, reported by all 50 (100%) of them, followed by nausea and vomiting in 38 (76%), The majority of them were prescribed Ceftriaxone, which was given to 22 (44%) of them, followed by 13 (26%) prescriptions for Metronidazole, 10 (20%) for Meropenem, 6 (12%) for Cef-Sulbactam, and 4 (8%) for Ciprofloxacin. Pancreoflat was prescribed for 33 (66%). Proton-pump inhibitors were administered to 50 (100%) patients, followed by antacids in 22 (44%) cases, and histamine type 2 receptor blockers in 1 (2%) cases. 48 (96%) of them spent between 1 and 10 days in the hospital, 1 (2%) between 11 and 20 days, and 1 (2%) between 21 and 30 days. Conclusion: The study’s findings suggest that untreated acute pancreatitis can result in major side effects. Multicenter research involving a significant patient sample and the longer time durations is also recommended. Keywords: Acute Pancreatitis, Alcohol, Abdomen Pain, Ceftriaxone, Pancreoflat, Hospital stay.