Recurrent Attacks Of Pancreatitis Research Articles

Diabetes mellitus as a consequence of acute severe pancreatitis: Unraveling the mystery.

The occurrence of diabetes mellitus (DM) in pancreatitis is being increasingly recognized lately. Diabetes can develop not only with chronic pancreatitis but even after the first episode of acute pancreatitis (AP). The incidence of diabetes after AP varies from 18% to 23% in 3 years and reaches up to 40% over 5 years. The exact pathogenesis of diabetes after AP is poorly understood and various mechanisms proposed include loss of islet cell mass, AP-induced autoimmunity, and alterations in the insulin incretin axis. Risk factors associated with increased risk of diabetes includes male sex, recurrent attacks of pancreatitis, presence of pancreatic exocrine insufficiency and level of pancreatitic necrosis. Diagnosis of post-pancreatitis DM (PPDM) is often excluded. Treatment includes a trial of oral antidiabetic drugs in mild diabetes. Often, insulin is required in uncontrolled diabetes. Given the lack of awareness of this metabolic disorder after AP, this review will evaluate current information on epidemiology, risk factors, diagnosis and management of PPDM and identify the knowledge gaps.

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.

A case of early-onset idiopathic chronic pancreatitis associated with a loss-of-function TRPV6 p.R483Q variant successfully treated by pancreatic duct stenting.

Several pancreatitis-related genetic variants have been identified. Recently, the association of loss-of-function variants in the transient receptor potential cation channel subfamily V member 6 (TRPV6) gene and early-onset non-alcoholic chronic pancreatitis (CP) has been reported. However, detailed clinical presentation of the cases carrying TRPV6 variants remains largely unknown. We report a case of early CP carrying a TRPV6 variant in which recurrent attacks of pancreatitis were successfully managed by pancreatic duct stenting. A 12-year-old boy with CP was referred to our hospital for further investigation. He had experienced recurrent pancreatitis attacks since he was 11years old. Pancreatic ductal anomalies were not identified on magnetic resonance cholangiopancreatography. Genetic analysis revealed that the patient had a loss-of-function TRPV6 c.1448G > A (p.R483Q) variant in a heterozygous form. Conservative treatments were not effective; thus, we placed pancreatic duct stent by endoscopic intervention, and the frequency of relapses have dramatically decreased. We present the first pediatric report of early CP associated with the TRPV6 variant that was successfully treated with pancreatic duct stenting. This case suggests that pancreatic duct stenting is effective in preventing the relapse of pancreatitis related to the TRPV6 variant.

DIAGNOSIS OF ENDOCRINE DISEASE: Post-pancreatitis diabetes mellitus: prime time for secondary disease.

While most people with diabetes have type 2 disease, a non-negligible minority develops a secondary diabetes. Post-pancreatitis diabetes mellitus (PPDM) is an exemplar secondary diabetes that represents a sequela of pancreatitis - the most common disease of the exocrine pancreas. Although this type of diabetes has been known as a clinical entity since the late 19th century, early 21st century high-quality epidemiological, clinical, and translational studies from around the world have amassed a sizeable body of knowledge that have led to a renewed understanding of PPDM. People have at least two-fold higher lifetime risk of developing diabetes after an attack of pancreatitis than those in the general population without a history of diseases of the exocrine pancreas. PPDM is caused by acute pancreatitis (including non-necrotising pancreatitis, which constitutes the majority of acute pancreatitis) in four-fifth of cases and chronic pancreatitis in one-fifth of cases. Moreover, the frequency of incident diabetes is not considerably lower after acute pancreatitis than after chronic pancreatitis. Recurrent attacks of pancreatitis and exocrine pancreatic dysfunction portend high risk for PPDM, but are not mandatory for its development. Further, young- or middle-aged non-obese men have an increased risk of developing PPDM. In comparison with type 2 diabetes, PPDM is characterised by poorer glycaemic control, higher risk of developing cancer (in particular, pancreatic cancer), younger age at death, and a higher risk of mortality. Metformin monotherapy is recommended as the first-line therapy for PPDM. Appropriate screening of individuals after an attack of pancreatitis, correct identification of PPDM, and apposite management is crucial with a view to improving the outcomes of this secondary but not inappreciable disease.

S3347 Proximal Migration of Pancreatic Stent in Pancreatic Divisum: Challenges in Retrieval and Review of Literature

INTRODUCTION: Pancreatic divisum is the commonest congenital malformation of pancreas. When patients get symptomatic with recurrent attacks of pancreatitis, they undergo ERCP with sphincterotomy and stent placement. Proximal migration of pancreatic stent in Pancreatic divisum is rare and is challenging to manage. We describe an interesting case of proximal migration of pancreatic stent in Pancreatic divisum and perform review of literature. CASE DESCRIPTION/METHODS: A 55-year-old female with past medical history of Pancreas Divisum, Recurrent Pancreatitis presented with sharp epigastric pain radiating to her back associated with nausea and vomiting. On physical exam, she appeared stable with moderate epigastric tenderness. Imaging revealed stones in the main pancreatic duct (PD) with Pancreas Divisum. ERCP was performed, which revealed stenosed minor papilla, which was selectively cannulated and sphincterotomy was performed, ductal stone was removed, and an 8.5 Fr x 9 cm straight plastic stent was placed (Figure 1). During repeat ERCP 3 weeks later, stent was found to have migrated deep into the main PD (Figure 2). The PD was explored endoscopically using SpyGlass Direct Visualization System (Boston Scientific, Natick, Massachusetts, USA). Proximally migrated PD stent was seen which was successfully retrieved using a SpyGlass Retrieval Snare and multiple PD stents were removed. A 5 Fr x 9 cm pigtail PD stent was placed to ensure adequate pancreatic drainage after intraductal intervention. DISCUSSION: Pancreatic stents can migrate both distally as well as proximally into the PD. Migrated stent can cause recurrent pancreatitis, infection, perforation as swell as stenosis of the duct. Incidence of stent migration has been reported at about 1.5% in medical literature.(1) Retrieval of migrated stent is challenging, especially in pancreatic divisum due to anatomical location of main pancreatic duct and the acute angle at which endoscope must be maneuvered. Use of SpyGlass Direct Visualization System enables direct and fluoroscopic visualization of the pancreatic duct. If endoscopic retrieval is not possible, surgical retrieval may be necessary. Risk factors for proximal migration of stent include cholangiocarcinoma, malignant strictures, longer stent use.(1,2).Figure 1.: Cannulation of minor papilla and stone in PD (as pointed by arrow), stent placement.Figure 2.: Migrated PD stent.

Etiology, clinical presentation and management of pancreatic pseudocyst

Background: The clinical presentation of pseudocyst is varied among individuals and so does the spectrum of management ranging from resolution to open or minimal access/ endoscopic drainage procedures. This study aims to review the various etiological factors, mode of clinical presentation of pseudocyst in relation to age and sex, and to study various modalities of investigation & management of pseudocysts.Methods: In this prospective study, 31 diagnosed patients of pseudocyst of pancreas were included who underwent different biochemical and radiological investigations. The study duration was 2 years from November 2016 to October 2018 carried out at a tertiary care hospital and the management and outcome of these patients were studied.Results: Males (93.54%) were the predominating gender suffering from pseudocyst and alcohol consumption (70.96%) was the most common etiological factor. 67.74% of patients had pseudocyst formation after recurrent attacks of pancreatitis. 20 patients (64.51%) patients were managed conservatively with complete resolution of pseudocyst in 10 patients. In rest of the 11 patients, 7 patients underwent open internal drainage, 2 patients underwent endoscopic internal drainage and pancreatic duct stenting; in one patient, external drainage was performed and another patient distal pancreatic resection was done.Conclusions: Pseudocyst of pancreas is predominantly seen in males with alcohol consumption being the commonest etiological factor. Spontaneous resolution of pseudocyst occurs in most of the patients and symptomatic patients can be managed by intervention by open/endoscopic internal drainage with or without pancreatic stenting and external drainage should be reserved for infected pseudocysts.

Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group.

Wide variations exist in how physicians manage the nutritional aspects of children affected by acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic (CP) pancreatitis. Better consensus for optimal management is needed. This consensus statement on nutrition in pediatric pancreatic diseases was developed through a joint ESPGHAN-NASPGHAN working group that performed an evidence-based search of the literature on nutrition in AP, ARP, and CP with a focus on pediatrics. The literature was summarized, quality of evidence reviewed, and expert recommendations developed. The authorship met to discuss the evidence and statements. Voting on recommendations occurred over 2 rounds based on feedback. A consensus of at least 75% was required to approve a recommendation. Areas requiring further research were identified. The literature on nutrition in pediatric pancreatitis is limited. Children with mild AP benefit from starting an early nutritional regimen in the course of the attack. Early nutrition should be attempted in severe AP when possible; enteral nutrition is preferred over parenteral nutrition. Children with ARP are likely to tolerate and benefit from a regular diet. Children with CP need ongoing assessment for growth and nutritional deficiencies, exocrine and endocrine insufficiencies. This document presents the first authoritative recommendations on nutritional considerations in pediatric pancreatitis. Future research should address the gaps in knowledge particularly relating to optimal nutrition for AP in children, role of diet or dietary supplements on recurrent attacks of pancreatitis and pain episodes, monitoring practices to detect early growth and nutritional deficiencies in CP and identifying risk factors that predispose children to these deficiencies.

Laparoscopic cholecystectomy role in the management of acute biliary pancreatitis

Objective The aim of this paper was to evaluate the role of laparoscopic cholecystectomy (LC) in the management of acute biliary pancreatitis before patient discharge from the point of view of availability, advantages, and disadvantages. Background In patients with mild gallstone pancreatitis, cholecystectomy during the same hospital admission might reduce the risk of recurrent gallstone-related complications, compared with the more commonly used strategy of interval cholecystectomy. However, evidence to support same-admission cholecystectomy is poor, and concerns exist about an increased risk of cholecystectomy-related complications with this approach. In this study, we aimed to compare same-admission and interval cholecystectomy, with the hypothesis that same-admission cholecystectomy would reduce the risk of recurrent gallstone-related complications without increasing the difficulty of surgery. Patients and methods This is a prospective study carried on 20 consecutive patients in Menoufia University, Faculty of Medicine and Alexandria University, Faculty of Medicine; all of them presented with symptoms of acute biliary pancreatitis from April 2015 to September 2016. Overall, 20 cases were included because of limited number of patient who presented to our hospital in this period of time and fulfilled the inclusion criteria. Computed tomography severity index is the main method for choosing patients in the study then assess operative time and difficulty and postoperative pain and hospital stay and recurrence of attacks. Results A total of 20 cases underwent LC at the same time of admission in the hospital, and none of them (0%) were converted to open technique; operative time and difficulty was average, and all of them (100%) had no recurrent attacks of pancreatitis in postoperative follow-up. Conclusion LC in mild acute biliary pancreatitis is safe and should be done during the same hospital admission to prevent further attacks of pancreatitis.

Primary Hyperparathyroidism due to Parathyroid adenoma presenting as recurrent acute pancreatitis

Primary hyperparathyroidism (PHPT) due to parathyroid adenoma presenting as recurrent acute pancreatitis is a rare entity. A 17-year-old male presented with recurrent attacks of pancreatitis and was found to have elevated serum calcium and Parathyroid hormone levels, 11.9mg/dL (8.5-10.2 mg/dL) and 396 pg/ml (10-65pg/ml) respectively. USG neck showed a 1.1 x 0.9 cm hypoechoic nodule in the superior aspect of left thyroid lobe. Parathyroid scintigraphy findings were consistent with parathyroid adenoma. After recovery of pancreatitis, surgical excision of the adenoma was done and the histopathological findings confirmed parathyroid adenoma. There were no further recurrence of pancreatitis following the excision.Asian Journal of Medical Sciences Vol.8(1) 2017 98-100

Pancreatic Morphological Changes in Long-Term Follow-Up after Initial Episode of Acute Alcoholic Pancreatitis

ObjectiveThe long-term morphological changes induced by a single episode of alcoholic pancreatitis are not known. Our aim was to study these morphological changes in secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) after the first episode of alcohol-associated acute pancreatitis and to evaluate the risk factors and possible protective factors potentially associated with later chronic findings. We have previously reported 2-year follow-up results in pancreatic morphology. This study extends the follow-up to 9 years. Patients and MethodsIn this prospective follow-up study, S-MRCP imaging was performed for 44 (41 M, 3 F; mean age, 46 (25–68) years) patients after their first episode of alcohol-associated pancreatitis. Pancreatic morphology was evaluated at 3 months and at 2, 7, and 9 years after hospitalization. Recurrent attacks of pancreatitis were studied and pancreatic function was monitored by laboratory tests. Patients’ alcohol consumption was evaluated with questionnaires, laboratory markers, and self-estimated alcohol consumption via interview. Smoking and body mass index were annually recorded. ResultsAt 3 months, 32 % of the patients had normal findings in S-MRCP, 52 % had acute, and 16 % had chronic changes. At 7 years, S-MRCP was performed on 36 patients with normal findings in 53 %, the rest (47 %) having chronic findings. Pancreatic cyst was present in 36 %, parenchymal changes in 28 %, and atrophy in 28 % of the cases. There were no new changes in the pancreas in the attending patients between 7 and 9 years (18 patients). Of the patients with only acute findings at 3 months, 60 % resolved to normal in 7 years, but the rest (40 %) showed chronic changes later on. The initial attack was mild in 65 %, moderate in 25 %, and severe in 10 % of the patients. Patients with mild first attack had fewer chronic changes at 7 years compared to patients with moderate or moderate and severe together (p = 0.03, p = 0.01). Of the patients in the seventh year of S-MRCP, 22 % had suffered a recurrent episode of acute pancreatitis (mean, 22 (2–60) months) and 11 % had a clinical diagnosis of chronic pancreatitis. At 7 years, 88 % of the patients with recurrences had chronic findings in S-MRCP versus 36 % with nonrecurrent pancreatitis (p = 0.02). Six (17 %) patients abstained from alcohol throughout follow-up (mean, 8.7 (7–9.1) years), but even one of these developed pancreatic atrophy. Out of the non-abstinent patients who did not suffer recurrences, 4/22 (18 %) had developed new findings during at follow-up S-MRCP (NS). In univariate analysis, heavy smoking showed no correlation with increased chronic changes compared to nonsmoking. ConclusionsMorphological pancreatic changes increase with recurrent episodes of acute pancreatitis. Patients with mild first attack have fewer chronic changes in the pancreas in the long term. However, even a single episode of acute alcoholic pancreatitis may induce chronic morphological changes in long-term follow-up.

Sonographic diagnosis of choledochocele

We present a case of a 48-year-old female with a history of cholecystectomy and recurrent attacks of pancreatitis whose initial abdominal sonography (US) revealed multiple conglomerated stones in the descending part of the duodenum. Abdominal CT, MRI, and magnetic resonance cholangiopancreatography showed the same findings. The distended sacciform distal intramural segment of the common bile duct was protruding into the duodenum. The imaging findings explained the etiology of the patient's recurrent attacks of pancreatitis and led to surgical excision of the choledococele.

Survival from cancer of the pancreas in England and Wales up to 2001.

Survival from cancer of the pancreas in England and Wales up to 2001.

A novel complex deletion–insertion mutation mediated by Alu repetitive elements leads to lipoprotein lipase deficiency

Lipoprotein lipase (LPL) deficiency is a rare autosomal recessive inherited disorder, characterized by marked hypertriglyceridemia, eruptive xanthoma, hepatosplenomegaly, recurrent attacks of pancreatitis, and markedly low or absent LPL activity in postheparin plasma. A majority of LPL deficient patients have been reported to have point mutations in the LPL gene; however, we find a complex deletion–insertion mutation by Alu elements, mobile retrotransposons, in a patient with LPL deficiency. This patient suffered from acute pancreatitis, showed chylomicronemia and lacked detectable LPL activity or mass in her postheparin plasma. Southern blot analysis and long-range PCR of the patient’s DNA demonstrated a 2.2-kb deletion encompassing exon 2. Sequence analysis revealed (1) a 2.3-kb deletion between an AT-rich region adjacent to an Alu element in intron 1 and another Alu element in intron 2; (2) an insertion of approximately 150 bp 5′-truncated Alu sequence with a poly (A) tail at the deletion point. The inserted sequence belongs to Alu Yb9, the youngest subfamily of Alu elements. The deletion occurred at the consensus cleavage site (3′-A|TTTT-5′) without target site duplication. These findings indicated that Alu retrotransposition caused the complex deletion–insertion. The patient was homozygous for this complex mutation, which eliminates exon 2 and leads to LPL deficiency. To our knowledge, the patient is the first case with LPL deficiency due to a complex deletion–insertion mediated by Alu repetitive elements.

Diacylglycerol oil for apolipoprotein C-II deficiency

Sir, Apolipoprotein C-II is a cofactor of lipoprotein lipase (LPL), which hydrolyses triglycerides of chylomicrons and very low-density lipoproteins (VLDLs).1 We report our therapeutic experience with diacylglycerol (DAG) oil, a natural edible oil, in a patient with apolipoprotein C-II deficiency, a rare, autosomal, recessively-inherited disease. A 43-year-old Japanese man presented with hypertriglyceridaemia, chylomicronaemia, hepatosplenomegaly, postprandial epigastric pain, and recurrent attacks of pancreatitis. Fasting serum triglyceride fluctuated from 545 to 2252 mg/dl, even on treatment with fibrate and ethyl icosapentate, indicating refractory hypertriglyceridaemia. On admission, levels of fasting serum total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, plasma glucose, and haemoglobin A1c were 317, 33, 28, 2252, 107 mg/dl and 5.0%, respectively. Serum apolipoprotein …

A case of intraductal papillary mucinous tumour following recurrent attacks of pancreatitis lasting 26 years

We report an interesting case of a patient with neither family nor personal history for pancreatic diseases that was admitted to our department in 1982, at the age of 25 years. At that time, medical history, absence of alcohol abuse, and radiological imaging suggested a diagnosis of idiopathic chronic pancreatitis. The patient underwent a left-pancreatectomy, with histological confirmation of chronic pancreatitis. He was asymptomatic until 1988, when episodes of pain arose, requiring a pancreatico-jejunostomy. No further problems ensued until 2004 when radiological investigation following pain-related symptoms revealed enormous dilation of the pancreatic duct. A pylorus-preserving pancreaticoduodenectomy resulting in total pancreatectomy was performed. Histological examination revealed an intraductal papillary mucinous non-invasive carcinoma. Review of the previously resected specimen revealed former misdiagnosis. This tumour usually affects an elderly population and nowadays is recognised as a possible cause of chronic obstructive pancreatitis. This report represents a slippery case of misdiagnosis and demonstrates that follow-up is always mandatory following a diagnosis of idiopathic chronic pancreatitis.

A case of hereditary pancreatitis with a N29I mutation in the cationic trypsinogen gene

Hereditary pancreatitis is an autosomal dominant disease characterized by recurrent episodes of pancreatitis, often beginning in childhood, with a positive family history involving at least two other affected family members with no known other precipitating factors. Most forms of hereditary pancreatitis are caused by one of two common mutations, i.e., R122H in exon 3 and N29I in exon 2 of the cationic trypsinogen (CT) (PRSS1) gene, located on chromosome 7. The authors describe the case of a 15-year-old boy who had suffered from recurrent attacks of pancreatitis since age three. His mother and grandmother had chronic pancreatitis and diabetes mellitus. Mutation analysis was performed on the family due to the suspicion of hereditary pancreatitis. The CT gene was analyzed in DNA samples extracted from the peripheral blood of three family members, the mother, the proband, and the proband's sister. Two members of the family, the mother and the proband, were found to have a N29I mutation in the CT gene. The authors document the first family with hereditary pancreatitis associated with the N29I mutation in Korea

Anomalous pancreaticobiliary junction (APBJ) with the drainage of the uncinate process into the minor papilla: demonstration by MRI

We report a case of a 30-year-old patient with anomalous pancreaticobiliary junction (APBJ) that has not been described before. The patient had a clinical history of recurrent attacks of pancreatitis, cholangitis and cholecystitis that were confirmed by abnormal laboratory values. Endoscopic retrograde cholangiopancreatography revealed a 20 mm long junction of choledoc and pancreatic duct, and uncinate process draining into the minor papilla. On MR cholangiopancreatography, strictures at the junction of hepatic duct, increased gallbladder wall thickness and intraductal stone in the pancreatic duct were demonstrated as complementary findings. Other MRI findings included decreased signal intensity of the pancreas consistent with fibrosis from past pancreatitis attacks and atrophy of the left liver lobe.

Adenovirus-mediated Rescue of Lipoprotein Lipase-deficient Mice: LIPOLYSIS OF TRIGLYCERIDE-RICH LIPOPROTEINS IS ESSENTIAL FOR HIGH DENSITY LIPOPROTEIN MATURATION IN MICE

Lipoprotein lipase (LPL) is the rate-limiting enzyme for the hydrolysis of triglycerides and the subsequent uptake of free fatty acids in extrahepatic tissues. Deficiency of LPL in humans (Type I hyperlipoproteinemia) is associated with massive chylomicronemia, low high density lipoprotein (HDL) cholesterol levels, and recurrent attacks of pancreatitis when not controlled by a strict diet. In contrast to humans, homozygous LPL knock-out mice (L0) do not survive suckling and die between 18 and 24 h after birth. In this study, an adenovirus-based protocol was utilized for the transient expression of LPL during the suckling period in an effort to rescue L0 mice. After a single intraperitoneal injection of 5x10(9) plaque-forming units of LPL-expressing virus immediately after birth, more than 90% of L0 mice survived the first days of life. 3% of L0 mice survived the entire suckling period and lived for up to 20 months, although LPL activity in mouse tissues and postheparin plasma was undetectable in all animals after 6 weeks of age. Adult LPL-deficient mice were smaller than their littermates until 2-3 months of age and exhibited very high triglyceride levels in the fed (4997 +/- 1102 versus 113.4 +/- 18.7 mg/dl) and fasted state (2007 +/- 375 versus 65.5 +/- 7.4 mg/dl). Plasma total cholesterol levels, free fatty acids, and ketone bodies were elevated in L0 mice, whereas plasma glucose was normal. Most strikingly, L0 mice lacked apoA-I-containing prebeta-HDL particles as well as mature HDL resulting in undetectable HDL cholesterol and HDL-apoA-I levels. HDL deficiency in plasma was evident despite normal apoA-I mRNA levels in the liver and normal apoA-I protein levels in plasma, which were predominantly found in the chylomicron fraction. The absence of prebeta-HDL and mature HDL particles supports the concept that the lipolysis of triglyceride-rich lipoproteins is an essential step for HDL maturation.

Pancreatitis in Childhood

1. Michelle M. Pietzak, MD* 2. Dan W. Thomas, MD† 1. 2. *Assistant Professor of Clinical Pediatrics. 3. 4. †Associate Professor of Pediatrics, Division of Gastroenterology and Nutrition, Childrens Hospital Los Angeles and Keck School of Medicine at the University of Southern California, Los Angeles, CA. After completing this article, readers should be able to: 1. Describe the challenge involved in diagnosing both acute and chronic pancreatitis. 2. Identify the radiologic study of choice in acute pancreatitis. 3. Identify the most common inherited disease involving the exocrine pancreas. 4. Delineate the pancreatic condition that is an absolute surgical indication, requiring necrosectomy (surgical debridement). 5. List the most common etiologies of pancreatitis in the child. Pancreatitis in children is a disease characterized by inflammation of the pancreas in the clinical setting of epigastric abdominal pain and usually is accompanied by elevated levels of pancreatic enzymes, amylase, and lipase. Pancreatitis can be categorized as acute, chronic, necrotic, hemorrhagic, and hereditary. The types are distinguished most frequently according to clinical and radiologic criteria; material obtained from the organ rarely is analyzed histologically. Acute pancreatitis is a self-limited disorder causing nausea, vomiting, anorexia, abdominal pain, and marked elevations in enzymes. Bouts of acute pancreatitis may recur, but normal pancreatic function and morphology usually are restored between attacks. If the inflammatory process is progressive, morphologic changes may occur in the gland, leading to chronic pancreatitis, often with debilitating pain and possible irreversible loss of both exocrine and endocrine function. Protein ductal plugs may calcify in the gland, leading to chronic calcific pancreatitis, which indicates advanced disease. Relatively high mortality occurs in necrotizing hemorrhagic pancreatitis, where the inflamed gland can become infected secondarily with bacteria and sepsis can occur, often in association with subsequent multiorgan failure. Hereditary pancreatitis is an autosomal dominant condition that is characterized by recurrent attacks of pancreatitis, usually presenting during childhood within affected families. It is difficult to estimate the true incidence and prevalence of pancreatitis in children because most of the literature reports individual cases or small clusters of patients. Although pancreatitis is not seen as commonly in children as in adults, …

7182 Long-term outcome of dorsal duct stenting in patients with symptomatic pancreas divisum.

<i>Aim</i>: To evaluate the long-term outcome of endoscopic stent therapy in patients with symptomatic pancreas divisum. <i>Methods</i>: All consecutive patients with pancreas divisum from April `87 to May `99 who underwent dorsal duct stent therapy were included. Indications were recurrent attacks of pancreatitis and/or pain. Data were reviewed retrospectively. Patients were contacted and completed a written questionaire. Additional information was obtained from family members, general practitioners, and referring physicians. <i>Results</i>: During the study period a total of 29 patients (16 men and 13 women, mean age 43 years, SD 16) underwent dorsal duct stent therapy. Two groups of patients were identified. There were 13 patients with chronic pain (medium follow-up after stent removal 52 months; range 16-135). In these patients a total of 18 stents were inserted (median 1, range 1-4) which remained in situ for a median of 54 days (range 2-121). Minor papilla sphincterotomy was performed in five patients (38%). There were 16 patients with recurrent pain attacks (median follow-up after stent removal 33 months; range 5-153). In these patients a total of 33 stents were inserted (median 2, range 1-5) which remained in situ for a median of 35 days (range 1-430). Minor papilla sphincterotomy was performed in nine patients (70%). Initially, 7 patients (54%) with chronic pain and 13 patients (81%) with recurrent pain attacks responded favorably to dorsal duct stenting [95% CI -0.6 to 0.06]. Of these responders, however, 4 patients (57%) with chronic pain (after a median of 13 months, range 8-40) and 6 patients (46%) with recurrent pain attacks (after a median of 5.5 months, range 0.5-12) relapsed. Long-lasting pain relief up to the date of follow-up was achieved in 3 patients (23%) with chronic pain (follow-up 33, 39 and 60 months) and in 7 patients (44%) with recurrent pain attacks (median follow-up 62 months, range 14-153) [95% CI -0.54 to 0.13]. In none of the two groups sphincterotomy of the minor papilla was associated with a more favorable outcome. <i>Conclusions</i>: In symptomatic pancreas divisum about 55% of patients with chronic pain and 80% of patients with recurrent pain attacks respond favorably to dorsal duct stenting, but during follow-up many patients relapse. Although the difference did not reach statistical significance, there is a clearcut trend towards a more favorable long-term outcome of dorsal duct stenting in patients with recurrent pain attacks compared to patients with chronic pain.