Pancreatic Rest Research Articles

Effect of endogenous cholecystokinin on the course of acute pancreatitis in rats.

To examine the effects of pancreatic rest, stimulation and rest/stimulation on the natural course of recovery after acute pancreatitis. Acute hemorrhagic pancreatitis (AP) was induced in male rats by intraductal infusion of 40 μL/100 g body weight of 3% sodium taurocholate. All rats took food ad libitum. At 24 h after induction of AP, rats were divided into four groups: control (AP-C), pancreas rest (AP-R), stimulation (AP-S), and rest/stimulation (AP-R/S). Rats in the AP-C, AP-R and AP-S groups received oral administration of 2 mL/kg body weight saline, cholecystokinin (CCK)-1 receptor antagonist, and endogenous CCK release stimulant, respectively, twice daily for 10 d, while those in the AP-R/S group received twice daily CCK-1 receptor antagonist for the first 5 d followed by twice daily CCK release stimulant for 5 d. Rats without any treatment were used as control group (Control). Biochemical and histological changes in the pancreas, and secretory function were evaluated on day 12 at 24 h after the last treatment. Feeding ad libitum (AP-C) delayed biochemical, histological and functional recovery from AP. In AP-C rats, bombesin-stimulated pancreatic secretory function and HOMA-β-cell score were significantly lower than those in other groups of rats. In AP-R rats, protein per DNA ratio and pancreatic exocrine secretory function were significantly low compared with those in Control rats. In AP-S and AP-R/S rats, the above parameters recovered to the Control levels. Bombesin-stimulated pancreatic exocrine response in AP-R/S rats was higher than in AP-S rats and almost returned to control levels. In the pancreas of AP-C rats, destruction of pancreatic acini, marked infiltration of inflammatory cells, and strong expression of α-smooth muscle actin, tumor necrosis factor-α and interleukin-1β were seen. Pancreatic rest reversed these histological alterations, but not atrophy of pancreatic acini and mild infiltration of inflammatory cells. In AP-S and AP-R/S rats, the pancreas showed almost normal architecture. The favorable treatment strategy for AP is to keep the pancreas at rest during an early stage followed by pancreatic stimulation by promoting endogenous CCK release.

Intraductal papillary mucinous neoplasm causing recurrent acute pancreatitis, necrotizing pancreatitis, and multifocal adenocarcinoma

A 58-year-old woman presented for evaluation of recurrent acute pancreatitis after routine etiologies were excluded. Initial EUS revealed a small (1.0 × 0.7 cm) cystic lesion in the uncinate process of the pancreas consistent with side-branch intraductal papillary mucinous neoplasm (bIPMN). Fifteen months later, the patient developed another episode of acute pancreatitis, and a repeat magnetic resonance imaging (MRI) study showed a stable IPMN (A). Unfortunately, 5 months later the patient developed necrotizing pancreatitis involving most of the pancreas and requiring prolonged pancreatic rest with nasojejunal tube feeding and ultimately endoscopic cystgastrostomy for walled-off pancreatic necrosis (B).

Combined Endoscopic and Surgical Treatment of an Intramural Gastric Abscess Secondary to a Large Pancreatic Rest

Introduction: Pancreatic rest (PR) is a well-described entity. Intramural gastric abscess has been reported in association with gastric tumors. We present a case of a large previously asymptomatic intramuscular PR becoming symptomatic secondary to abscess formation. A 39-year-old female presented with 3 days of fever, chills, and epigastric pain. Her past medical history was unremarkable. On exam her temperature was 99.1 F, BP 107/64, and pulse 111. Abdominal exam revealed epigastric tenderness. hemoglobin was 13.4, and white blood cells 25. CT scan of the abdomen with IV contrast revealed a 5-cm mass in gastric wall along the lesser curvature partially enhancing but centrally hypodense (Figure 1). An EGD revealed an 8-cm submucosal lesion with central ulceration partially obstructing the antrum, consistent with a submucosal tumor. The abscess was unroofed using the “well” biopsy technique resulting in drainage of thick white exudate. The mucosal defect was dilated to 8-mm using a CRE balloon to facilitate drainage. Aspirates revealed Strep oralis. Post-procedure the abdominal pain resolved, white blood cells returned to normal, and fever resolved. The patient completed 10 days of antibiotics. Echocardiogram was negative for endocarditis. Subsequent EUS revealed an intramural, sub-epithelial 4 x 3 cm hypoechoic mass arising from the muscularis propria (MP). Biopsies showed fragments of smooth muscle tissue with negative C-KIT and CD-34, suggestive of a leiomyoma. Due to its location deep in the MP, treatment required surgical wedge resection. Histopathological exam revealed a large PR within the MP. Pancreatic rest arises during rotation of the foregut where fragments of the pancreas separate from its main body and deposit into ectopic sites. PR is typically small and asymptomatic, found in 2-15% of autopsies, often in the antrum. Previous case reports of large intragastric PR describe bleeding, obstruction, and malignant transformation. Our case was unusual in that a large PR presented as a gastric abscess. Intramural gastric abscess has been reported with gastric tumors, foreign body ingestion, gastric surgery, and by contiguous spread. This is a novel case of a large previously asymptomatic intramuscular PR becoming symptomatic secondary to abscess formation which was drained endoscopically prior to definitive surgery.Figure 1

Natural Orifice Endoscopic Surgery (NOTES) Techniques for Full Thickness R0 Endoscopic Resection of Deep Seated Subepithelial Tumors (SETs): First U.S. Cases

Introduction: Most UGI SETs are GISTs, potentially malignant tumors. Many guidelines recommend surgery for suspected GISTs ≥2 cm and endoscopic surveillance of those <2 cm. This approach creates a large burden of surgery and endoscopy for small SETs the majority of which are low-risk. This situation motivated endoscopists, mostly from Asia, to use ESD to “enucleate” muscularis propria (MP) based SETs. However, such enucleation may leave microscopic residual tumor within the MP. Recently, pioneering Asian centers reported two endoscopic techniques that achieve R0 en bloc resection of MP-based SETs: submucosal tunnel endoscopic resection (STER)- an offshoot of peroral endoscopic myotomy utilizing the submucosal tunnel method to ensure secure closure of the full-thickness defect in the wall of the GI tract, and endoscopic full-thickness resection (EFTR)-direct full thickness resection with closure of the defect with clips or sutures. We report possibly the first series of EFTR and STER in the U.S. Methods: Procedures were performed from 4/2012-6/2014. Data were retrieved from a prospectively maintained database. 33 resections (26 EFTR, 7 STER) were performed by a gastroenterologist with extensive ESD/POEM experience. Results: Mean age 58 (18-84). ASA Class I 12%, II 70%, III 18%. Anesthesia: General 45%, propofol 55%. SET location: 6 esophagus, 22 stomach, 2 colon, 3 rectum. 17 GISTs, 8 leiomyomas, 2 pancreatic rests, 1 schwannoma, 1 leiomyosarcoma and 4 other. Mean size 22 mm (10- 55). Mean resection time 72 minutes (21-220). Closure: endoclips 30%, endoscopic suturing 49%, both 21%. Most patients admitted mainly for observation. Complete en bloc resection achieved in 91%. Piecemeal resection in 3 patients (2 pancreatic rests, 1 5cm GIST). Adverse events: 2 needle decompression of capnoperitoneum, 3 bleeding requiring prolonged endoscopic hemostasis with 2 requiring transfusion, 3 patients 12-24 hour ICU observation, 2 patients required laparoscopic “standby” for immediate assistance that was not needed, 1 patient required laparoscopic conversion due to left gastric artery abutting tumor and 1 balloon dilation of stricture at tunnel closure site. Mean LOS 1.5 days (1-3). Conclusion: Unlike traditional ESD, EFTR and STER achieve en bloc R0 resection of MP-based SETs and represent a NOTES alternative to laparoscopic wedge resection. The excellent outcomes probably reflect our extensive experience with POEM, advanced closure techniques, and ESD for SETs. Advantages include: 1. Incision-less approach 2. “Wedge” resection of SETs at locations where laparoscopic “wedge” resection is challenging or impossible such as the GE junction, esophagus and gastric cardia 3. Definitive diagnosis and complete resection obviating any further endoscopic surveillance for low risk lesions. Disclosure - Stavros Stavropoulos: Boston Scientific Consultant.

Gastric Feeding and “Gut Rousing” in Acute Pancreatitis

The "pancreatic rest" concept is entrenched in the management of acute pancreatitis. As a result, "nonstimulatory" feeding has been widely advocated in patients with this disease, being parenteral nutrition 2-3 decades ago and jejunal tube feeding in the past decade. However, accumulating clinical evidence from the fields of acute pancreatitis and critical care medicine suggests that gastric feeding is as safe and effective as jejunal feeding in most patients. This has paved the way for a new conceptual framework called "gut rousing." Acute pancreatitis management now requires consideration of gut function. Enteral nutrition is a gut-directed therapy, and avoiding stimulation of the pancreas in patients with acute pancreatitis need not overshadow the main goal of maintaining or restoring gut function.

Jejunal Feeding in Patients With Pancreatitis

Patients with severe acute pancreatitis complicated by organ failure and/or pancreatic necrosis or fluid collections should have placement of a double-lumen nasogastric-jejunal tube to be used for both gastric decompression and jejunal feeding. These patients are at risk for gastric outlet obstruction, which may be treated so that complications such as aspiration and reflux are avoided. Furthermore, early enteral feeding can prevent ileus, suppress further organ failure, and ultimately restore gut function if continued in an uninterrupted manner. Ultimately, this patient population will benefit from pancreatic rest and jejunal feeding specifically when compared with patients using nasogastric feeding tubes.

Hypertriglyceridemia Induced Pancreatitis (Chylomicronemia Syndrome) Treated with Supportive Care

Hypertriglyceridemia is a rare cause of pancreatitis. In treatment pancreatic rest, lifestyle changes, medications (fibrates, n-3 polyunsaturated fatty acids, and nicotinic acid) are essential. Many experimental treatment modalities have been reported as insulin and heparin infusion and plasmapheresis. In this study we present the hypertriglyceridemia-induced pancreatitis treated with supportive care.

Endoscopic approach to subepithelial lesions.

Endoscopy and endoscopic ultrasound (EUS) play a critical role in the detection and management of subepithelial lesions of the gastrointestinal tract. The most common subepithelial lesions detected by endoscopists are gastrointestinal stromal tumors (GISTs), leiomyomas, lipomas, granular cell tumors (GCTs), pancreatic rests and carcinoid tumors. These lesions can be classified based on unique histochemical staining and the gastrointestinal layer of origin. While the majority of the lesions are considered benign, some tumors such as GISTs and carcinoids have a strong propensity for malignant transformation. Therefore, appropriate endoscopic versus surgical management based on size and location is crucial in the prevention of malignant transformation and metastasis. In this review, we provide a systematic approach to the diagnosis, management and treatment of commonly encountered subepithelial lesions.

Groove Pancreatitis: A Rare Cause of Abdominal Pain

Purpose: A 54 year-old man was referred to our outpatient gastroenterology clinic for several weeks of upper abdominal pain. He had a history of acid reflux and Barrett's esophagus, but his symptoms were well-controlled on a proton pump inhibitor. For 3 weeks prior to presentation, he experienced dull epigastric abdominal pain that was at times severe. The pain did not radiate to the back and had no definite relation to food. His weight was stable, and he had not experienced similar symptoms in the past. There was no change in bowel habits. History revealed that he consumed 3-4 alcoholic drinks per night. Physical exam was notable for a well-appearing man with a benign abdomen. There was no epigastric tenderness to palpation, scleral icterus, hepatosplenomegaly, or jaundice. Blood studies, including liver function tests, were normal except for a minimally elevated lipase of 59 U/L. Abdominal ultrasound revealed fatty infiltration of the liver. An esophagogastroduodenoscopy (EGD) was then performed and notable for erythema and edema of the duodenal bulb. The remainder of the examination was unremarkable. A subsequent computed tomography (CT) scan of the abdomen displayed inflammation of the pancreaticoduodenal groove with associated ill-defined appearance of the head of the pancreas. The patient's abdominal pain was attributed to groove pancreatitis. His symptoms improved with conservative management and cessation of alcohol use. First described in Germany in 1973, groove pancreatitis is a chronic pancreatitis that affects the region between the pancreatic head, duodenum, and common bile duct (CBD), also known as the groove area. The exact incidence of this condition is unknown, but most patients with groove pancreatitis are men aged between 40-50 years with a history of alcohol abuse. The pathogenesis is also unclear, but it has been postulated that duodenal stenosis, obstruction of the minor papilla, and Brunner's gland hypertrophy may play a role. Clinical presentation and laboratory findings are similar to chronic pancreatitis, but nausea, vomiting, and weight loss are often more severe in groove pancreatitis. Prognosis varies widely. Conservative measures such as cessation of alcohol, initiation of pain control, and pancreatic rest can lead to resolution of symptoms. Surgery, however, may be required in the set of patients who fail to improve. Additionally, distinguishing between groove pancreatitis and adenocarcinoma of the head of the pancreas or autoimmune pancreatitis may be problematic. Clinicians must thus be aware of this disease entity since surgery can be curative. In patients who do not undergo surgical resection, close follow-up is necessary.

Nutritional management of acute pancreatitis

Enteral nutrition has emerged as one of the most effective treatments in the early management of patients with acute pancreatitis. The original rationale for nutrition in acute pancreatitis, dating back to the mid-20th century, was to provide full nutritional requirements but avoid stimulating exocrine pancreatic secretion. The purpose of this article is to review the recent clinical studies of enteral nutrition in acute pancreatitis to revise the rationale and develop a contemporary conceptual framework for nutritional management of this disease. Several recent randomized controlled trials dispel the outdated concept of 'pancreatic rest', which equates with gut neglect, and offer 'gut rousing' as a preferred concept. The new concept postulates that gastrointestinal (dys)function has a discernible impact on the outcomes of patients with acute pancreatitis. Further, timely administration of appropriate intraluminal modalities prevents or mitigates the gastrointestinal dysfunction. Nutritional management in acute pancreatitis should aim primarily at maintaining the gastrointestinal function. Providing full nutritional requirements and avoiding pancreatic exocrine stimulation should be considered as secondary aims.

Moving beyond the 'pancreatic rest' in severe and critical acute pancreatitis

Nasojejunal tube feeding is considered the current standard of care in patients with severe and critical acute pancreatitis. However, it is not known whether enteral nutrition is best delivered into the jejunum. This Commentary discusses recent clinical studies that have shown that tube feeding into the stomach is safe and well tolerated in the vast majority of patients with acute pancreatitis, thus overthrowing the notion of putting the pancreas at rest. Development of a new conceptual framework is warranted to further advance nutritional management of patients with acute pancreatitis.

Pancreatic adenocarcinoma arising in intrahepatic pancreatic heterotopia

Pancreatic heterotopia, also known as ectopic pancreas, accessory pancreas, or pancreatic rest, is defined as pancreatic tissue occurring in anatomic locations lacking geographic and vascular connections with the eutopic pancreas. Any physiologic process that occurs in normal pancreatic tissue may occur in pancreatic heterotopia, including, although rarely, malignant transformation. For this reason, any significant change in a lesion with imaging should prompt further investigation including obtaining tissue for pathologic evaluation. Histomorphologic criteria are essential in diagnosing malignancy arising in pancreatic heterotopia and include location of the tumour within or near the ectopic pancreatic tissue; the heterotopia must consist of acinar, epithelial and ductal elements; and there must be a clear transition from heterotopic to malignant tissue, preferably, an in-situ component.

Acute Pancreatitis with Rapid Clinical Improvement in a Child with Isovaleric Acidemia

Isovaleric acidemia is a rare branched-chain organic acidemia. The authors describe a 3.5-year-old girl with isovaleric acidemia and acute abdominal pain associated with bilious emesis. Elevated serum amylase and abdominal ultrasonography demonstrating an enlarged and edematous pancreas, along with the presence of peripancreatic exudates, confirmed the presence of acute pancreatitis. The patient recovered quickly with intravenous hydration, pancreatic rest, and administration of intravenous L-carnitine. Pancreatitis should be ruled out in the context of vomiting in any patient with isovaleric acidemia. Conversely, branched-chain organic acidemias should be included in the differential diagnosis of any child with pancreatitis of unknown origin.

Nutritional support in acute pancreatitis

Acute pancreatitis can present as a mild or severe disease. Most patients have a mild disease and recover without requiring nutritional support. Patients with severe acute pancreatitis may develop systemic inflammatory response syndrome and progress to multi-organ failure. These ill patients have high metabolism and protein catabolism. Hence, the nutritional management of these patients can be challenging. The aim of nutritional support is to meet the elevated metabolic demands as far as possible without stimulating pancreatic secretion and yet maintaining the gut integrity. The concept of pancreatic rest has evolved over the years. To date, there is a substantial scientific proof that enteral nutrition (EN) in comparison to parenteral nutrition significantly reduces infectious complications, surgical interventions and mortality in predicted severe acute pancreatitis. EN may be able to improve outcome in these patients if given early. In this review, we summarized the current knowledge on nutrition in acute pancreatitis and shared our local experience.

Tu1521 Determinants of EUS-FNA Diagnosis of Gastric Stromal Tumors

Gastric submucosal tumors (gSMTs) are often found incidentally on EGD, prompting further evaluation by EUS. These lesions may be suspected to be gastrointestinal stromal tumors (GISTs) and need to be differentiated from pancreatic rests, cysts, lipomas, or leiomyomas. EUS-FNA confirmation of GISTs is technically challenging, often resulting in non-diagnostic sampling.

The Significance of Small Intestinal Epithelium in Gastric Antral Biopsies in Children

Intestinal metaplasia of the gastric antrum is common in adults with chronic gastritis and occurs in Helicobacter -associated gastritis in children. This study examined the frequency and clinical correlates of intestinal epithelium in 1690 consecutive antral biopsies obtained from children over a 2-year period in a tertiary pediatric care facility. Intestinal epithelium in gastric glands not associated with overlying villi was present in 22 (1.3%) biopsies. These came from 20 patients, 2-17 years of age, none of whom had clinical or histologic evidence of Helicobacter infection or significant chronic gastritis. Eight (40%) had an antral pancreatic rest, 8 had some other localized antral abnormality, and 4 were endoscopically normal. Four additional patients with a pancreatic rest had no intestinal epithelium. Six surgically resected rests and 2 rests found at autopsy were also reviewed. Heterotopic intestinal epithelium was present in 1 of the 2 postmortem specimens but was absent from all 6 surgically resected lesions. No intestinal epithelium was present in 67 antral biopsies with Helicobacter gastritis observed during this same period. Although the intestinal epithelium in these patients could be metaplastic, it more likely represents inadvertent sampling of the gastroduodenal junction induced by a lesion in the distal antrum or a focus of heterotopic epithelium and might best be addressed in the surgical pathology report by a comment to this effect. The distinction from metaplasia is more than semantic, because a diagnosis of intestinal metaplasia can have adverse clinical implications and should be made with caution in a child.

Enteral Feeding Patients With Gastric Outlet Obstruction

Patients with upper gastrointestinal obstructions were previously managed with gastric decompression and parenteral feeding. The authors present their experience in 50 patients with obstructions chiefly due to complicated severe acute (n = 31) or chronic cystic pancreatitis (n = 11) using a double-lumen nasogastric decompression and jejunal feeding tube system (NGJ) held in place with a nasal bridle that passes through the obstructed gastroduodenal segments, allowing distal jejunal feeding, and at the same time decompresses the stomach to prevent vomiting and aspiration. The tip of the jejunal tube was placed approximately 40 cm down the jejunum to maintain pancreatic rest. Duration of feeding ranged from 1-145 days (median 25 days); 19 patients were discharged home with tube feeds. Only 1 patient could not tolerate feeding and needed to be converted to parenteral feeding. Average tube life was 14 days, with replacement being needed most commonly for kinking or clogging of the jejunal tube (56%) or accidental dislodgement (24%). The obstruction resolved spontaneously in 60%, allowing resumption of normal eating. Of the patients with severe acute pancreatitis or pancreatic pseudocysts, pancreatic rest resulted in resolution of the disease without surgery in 87%, and need for surgery in the remainder was put off for 31-76 days. Seven patients died predominantly of complications of acute pancreatitis between 1 and 31 days. In conclusion, NGJ feeding provides a relatively safe conservative management for critically ill patients with upper gastrointestinal obstructions, reducing the need for surgery and parenteral feeding.

Heterotopic pancreas causing duodenal obstruction in a patient previously treated for choledochal cyst

A 9-year-old boy presented with duodenal pancreatic rest causing obstruction and required surgical intervention. He had been treated at the age of 4 months for a choledochal cyst. Both choledochal cyst and heterotopic pancreas are entities that are commonly encountered in children, but the incidental presence of both the entities in the same child, albeit presenting metachronously, is extremely rare.

Pancreatic Rest Resection Using Band Ligation Snare Polypectomy

BackgroundAlthough pancreatic rests have characteristic endoscopic features, confirming a histological diagnosis may be desirable to exclude other significant pathology.AimsThe aim of this study was to assess the efficacy and safety of endoscopic band ligation snare polypectomy (EBLSP) for removal of suspected pancreatic rests and to compare the diagnostic yield to other endoscopic tissue sampling methods.MethodsAn electronic endoscopic report database was searched for patients referred for evaluation of incidentally found gastric antral subepithelial lesions. Tissue sampling technique, pathology, and complications were recorded.ResultsRemoval of suspected pancreatic rests with EBLSP was successful in all 21 cases without complications. Nineteen of 21 (90%) who underwent EBLSP had a histological diagnosis of heterotopic pancreas compared with 5 of 14 (36%) who underwent tissue sampling with biopsy and/or snare (P = 0.001). The endoscopic characteristics of the histology proven pancreatic rests were an antral subepithelial mass with central umbilication measuring 6–10 mm in diameter and located 2–6 cm from the pylorus in the 3–7 o’clock position.ConclusionsEndoscopic band ligation snare polypectomy resection of gastric antral lesions suspected to be pancreatic rests had a diagnostic yield superior to standard biopsy forceps and snare polypectomy techniques. However, because all pathologically confirmed pancreatic rests had typical endoscopic appearances of pancreatic rests, it may not be necessary to obtain histologic diagnosis for every suspected gastric antral heterotopic pancreas.

Oral refeeding in mild acute pancreatitis: An old challenge

Although the idea that pancreas rest has long been considered as a very relevant topic in acute pancreatitis (AP) therapy, the right time and type of diet to be offered to patients recovering from an acute attack are a great challenge to clinicians who treat this condition. Fortunately, the last decade was noted for several trials looking for the best answer to the question: "when and how to start oral refeeding in AP?" It is well known that 80% of patients present with mild disease characterized by usually uncomplicated clinical course are managed with pancreatic rest through nil per oral; while the use of specific nutritional intervention is an exception. Therefore, mild AP has been the most investigated form of AP and researchers have tried different kind of meals to offer calories and reduce costs by shortening hospitalization time. Usually in mild AP, the oral refeeding is introduced between the first 3 d and 7 d after hospitalization but, the type of diet and patients' tolerance have been scrutinized in detail with mixed results. Although 20% to 25% have pain recurrence requiring nutritional support and greater time of hospitalization, most patients seem to tolerate oral refeeding well. We propose analyzing the most recent investigations of this matter and their conclusions to develop a better understanding of the management of AP.