Recurrent Pancreatitis In Patients Research Articles

Prospective multicentre study of indications for surgery in patients with idiopathic acute pancreatitis following endoscopic ultrasonography (PICUS).

Cholecystectomy in patients with idiopathic acute pancreatitis (IAP) is controversial. A randomized trial found cholecystectomy to reduce the recurrence rate of IAP but did not include preoperative endoscopic ultrasonography (EUS). As EUS is effective in detecting gallstone disease, cholecystectomy may be indicated only in patients with gallstone disease. This study aimed to determine the diagnostic value of EUS in patients with IAP, and the rate of recurrent pancreatitis in patients in whom EUS could not determine the aetiology (EUS-negative IAP). This prospective multicentre cohort study included patients with a first episode of IAP who underwent outpatient EUS. The primary outcome was detection of aetiology by EUS. Secondary outcomes included adverse events after EUS, recurrence of pancreatitis, and quality of life during 1-year follow-up. After screening 957 consecutive patients with acute pancreatitis from 24 centres, 105 patients with IAP were included and underwent EUS. In 34 patients (32 per cent), EUS detected an aetiology: (micro)lithiasis and biliary sludge (23.8 per cent), chronic pancreatitis (6.7 per cent), and neoplasms (2.9 per cent); 2 of the latter patients underwent pancreatoduodenectomy. During 1-year follow-up, the pancreatitis recurrence rate was 17 per cent (12 of 71) among patients with EUS-negative IAP versus 6 per cent (2 of 34) among those with positive EUS. Recurrent pancreatitis was associated with poorer quality of life. EUS detected an aetiology in a one-third of patients with a first episode of IAP, requiring mostly cholecystectomy or pancreatoduodenectomy. The role of cholecystectomy in patients with EUS-negative IAP remains uncertain and warrants further study.

Incidence of acute recurrent pancreatitis in patients with Gilbert’s syndrome

Incidence of acute recurrent pancreatitis in patients with Gilbert’s syndrome

1324 Recurrent Pancreatitis Associated With Pancreas Divisum and Rare Solid Pseudopapillary Neoplasm of the Pancreas

INTRODUCTION: Pancreas Divisum (PD) is a benign congenital anomaly found in approximately 4-10% of general population. Rare cases of acute pancreatitis associated with PD and pancreatic tumors have been described. While most common causes of pancreatitis are gallstones and alcohol use, uncommon causes such as anatomic/genetic variants and malignancies of the pancreaticobiliary system should be investigated especially in case of recurrent cryptogenic pancreatitis. We present a case of recurrent pancreatitis in a patient with pancreas divisum and rare solid pseudopapillary neoplasm of the pancreas. CASE DESCRIPTION/METHODS: A 65-year old woman with past medical history of psoriatic arthritis on methotrexate therapy and no family history of pancreatitis was evaluated for recurrent pancreatitis. Patient had at least eight episodes of acute pancreatitis from 2011 to 2019. Patient denied any alcohol/tobacco history. Serum triglycerides/calcium were not elevated. Genetic causes were excluded. Imaging ruled out gallstones but showed presence of pancreas divisum. Endoscopic ultrasound (EUS)/Endoscopic retrograde cholangiopancreatography (ERCP) in 2016 was negative for stricture, focal mass or lesions. In April 2017, patient underwent repeat EUS/ERCP with stent placement into the minor papilla for presumed stenosis. However, that resulted in an exacerbation of her symptoms and the stent was subsequently removed. Patient continued to have recurrent acute pancreatitis and underwent repeat EUS in August 2018 which showed an 8 × 8 mm pancreatic genu mass adjacent to the Santorini duct. Biopsy was consistent with rare, slow growing solid pseudopapillary neoplasm (SPN) of the pancreas. Patient underwent pancreaticoduodenectomy in 2019. Pathology confirmed SPN. Patient has had no further episodes of pancreatitis. DISCUSSION: Pancreas Divisum (PD) results from failure of fusion of ventral and dorsal pancreatic ducts during embryogenesis. It has been controversial whether PD by itself causes recurrent pancreatitis. Clearly, in our patient, addressing the PD alone did not resolve her symptoms of recurrent pancreatitis. Sporadic hemorrhage within the SPN and intermittent compression of the Santorini duct was the likely cause of recurrent pancreatitis in our patient. Patients with cryptogenic recurrent pancreatitis should be evaluated periodically for the presence of slow growing tumors that may not be evident on initial imaging and may be the cause of recurrent pancreatitis in such patients.

Influence of Ambulatory Triglyceride Levels on Risk of Recurrence in Patients with Hypertriglyceridemic Pancreatitis.

To evaluate impact of ambulatory triglyceride levels on risk of recurrent pancreatitis in patients with hypertriglyceridemic pancreatitis. We conducted a longitudinal retrospective cohort study of patients with serum triglyceride level ≥ 500mg/dL during index hospitalization for acute pancreatitis within a regional integrated healthcare system between 2006 and 2013 (follow-up through 2015). Cases were identified based on combination of diagnosis codes and serum amylase/lipase. We used multivariable robust Poisson regression to determine independent effect of baseline (first outpatient) triglyceride measurement on risk of recurrent pancreatitis. Ambulatory triglyceride levels were categorized as normal (0-200mg/dL), moderately elevated (201-500mg/dL), and highly elevated (> 500mg/dL). We further assessed factors related to likelihood of normalization of serum triglycerides (< 200mg/dL) in the outpatient setting. One hundred and fifty-one patients met study inclusion criteria with median follow-up of 3years. Overall, 45 (29.8%) patients experienced at least 1 recurrent attack with 25 (16.6%) experiencing multiple episodes. In multivariable analysis, patients that continued to have moderately elevated ((adjusted rate ratio RR 5.47 (95% CL 1.80, 16.65)) as well as highly elevated (RR 8.45 (2.55, 27.96)) triglycerides were at increased risk of disease recurrence compared to patients that achieved normalization. Patients with triglyceride measurement performed within 30days from discharge were more likely to achieve normalization, 40 versus 26%, p = 0.03. For patients with hypertriglyceridemic pancreatitis, even modest elevation in subsequent triglyceride levels was associated with increased risk of recurrence. Future efforts should focus on ensuring timely care in the outpatient setting with a goal of normalizing triglycerides.

Recurrent Pancreatitis Related to Significantly Elevated Serum Triglyceride Level

Although gall stones and alcohol are the most common causes of pancreatitis, however one of the rare but well known metabolic cause of pancreatitis is hypertriglyceridemia. Hypertriglyceridemia is considered to significantly increase the risk for pancreatitis when levels are more than 1000 mg/dL (11.2 mmol/L). The presentation may vary from moderate to severe acute pancreatitis or recurrent acute pancreatitis. The mainstay of management is to reduce the triglyceride levels during acute attack of pancreatitis along with the usual management of pancreatitis and in order to prevent the future attacks to be compliant to dietary restriction of fats, pharmacological therapy, and avoiding aggravating factors. We discuss case of a 40-year-old medically free lady presenting with recurrent episodes of acute pancreatitis with significantly elevated serum triglyceride level reaching up to 5700 mg/dl (64.57 mmol/L) during one of the acute attacks. Our patient had three attacks of pancreatitis each time after stopping her anti hyperlipidemia medications. In 2006 patient presented for the first time with acute pancreatitis with serum triglyceride level of 1975 mg/dl (22.26 mmol/L). During second attack of pancreatitis in 2009 the patient presented with triglyceride level of 5700 mg/dl (64.57 mmol/L) requiring plasmapheresis and upon discharge was continued on oral anti hyperlipidemia medications. But the patient was not compliant to her medications. Again she presented in 2013 with acute attack having triglyceride level of 2470 mg/dl (27.96 mmol/L) requiring plasmapheresis again. Patient improved biochemically and clinically after the plasmapheresis. High level of serum triglyceride reaching up to 5700 mg/dl (64.57 mmol/L) as seen during one of the attacks of pancreatitis in our patient is rarely reported in the literature. During the acute attack of hypertriglyceridemia induced pancreatitis specific triglyceride reducing therapy like plasmapheresis is extremely helpful. It is necessary to be compliant to the anti hyperlipidemia medications and to avoid aggravating factors in order to prevent recurrent pancreatitis in patients with hypertriglyceridemia.Figure 1

Indicators of endothelial function and some cytokines blood levels during chronic recurrent pancreatitis in patients with chronic obstructive pulmonary disease

Indicators of endothelial function and some cytokines blood levels during chronic recurrent pancreatitis in patients with chronic obstructive pulmonary disease

Nocturnal Hydration—An Effective Modality to Reduce Recurrent Abdominal Pain and Recurrent Pancreatitis in Patients with Adult-Onset Cystic Fibrosis

Recurrent abdominal pain and recurrent pancreatitis are common problems associated with some patients with cystic fibrosis (CF). There is no known effective method to prevent recurrent abdominal pain and recurrent pancreatitis in such patients. The objective of this study was to determine whether nocturnal hydration (NH) prevents recurrent abdominal pain and recurrent acute pancreatitis in patients with adult-onset CF. Adult CF patients who were referred to our Pancreatic Diseases Clinic for recurrent abdominal pain and pancreatitis were enrolled in the study. Each patient was encouraged to drink plenty of water during the night and established a 6-month diary (3 months before and 3 months after NH was initiated), recording the frequency and severity of their abdominal pain, the amount of pain medication taken, and the volume of their water intake. We also reviewed the number of doctor's clinic visits, emergency room visits, and hospitalizations for about 1 year before and 1 year after the initiation of the NH. The frequency and the severity of abdominal pain in this group of patients were significantly reduced. The amount of pain medication and the number of emergency room visits and hospitalizations for abdominal pain and acute pancreatitis were reduced. NH is a simple and cost-effective method to prevent recurrent abdominal pain and pancreatitis in patients with adult-onset CF.

Pancreatic duct strictures are a common cause of recurrent pancreatitis after successful management of pancreatic necrosis

Successful surgical management of pancreatic necrosis can result in structural changes that cause recurrent pancreatitis. The purpose of this study is to review our clinical experience managing recurrent pancreatitis in patients after successful pancreatic debridement. We retrospectively reviewed 98 patients with pancreatic necrosis treated by debridement who made a complete recovery at our institution over an 8-year period (January 1995 to January 2003). Fourteen patients (14%) developed recurrent pancreatitis 5 to 39 months (median, 15 months) after recovery. Five patients (36%) had pancreatic pseudocysts and 9 (64%) had radiologic evidence of obstructive pancreatitis. All patients had either a high-grade pancreatic duct stricture (N=7) or complete duct cutoff (N=7), localized to the pancreatic neck (N=10) or proximal pancreatic body (N=4) identified by either endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. Two patients failed endoscopic stent therapy. All patients required re-operative treatment: 6 distal pancreatectomy, 6 pancreatico-jejunostomy Roux-en-Y, and 2 cystojejunostomy Roux-en-Y with no recurrence of pancreatitis after a median follow-up of 22 months. Recurrent pancreatitis occurs in 14% of patients after successful pancreatic debridement. Pancreatic duct obstruction in the neck or proximal body is the primary etiologic factor. Re-operation directed at alleviating this ductal obstruction by resection or drainage is effective.

Long-term risk of recurrent pancreatitis in patients with acute billary pancreatitis treated by endoscopic sphinclerotomy alone

Long-term risk of recurrent pancreatitis in patients with acute billary pancreatitis treated by endoscopic sphinclerotomy alone

Long-term risk of recurrent pancreatitis in patients with acute billary pancreatitis treated by endoscopic sphinclerotomy alone

Long-term risk of recurrent pancreatitis in patients with acute billary pancreatitis treated by endoscopic sphinclerotomy alone

Endoscopic botulinum toxin injection into the minor papilla for treatment of idiopathic recurrent pancreatitis in patients with pancreas divisum

Background: In some patients with pancreas divisum, obstruction to the flow of pancreatic juice into the duodenum is the presumptive cause of acute recurrent pancreatitis. However, identification of those patients who may benefit from minor papilla sphincterotomy or stent placement is difficult. Methods: Five patients with acute recurrent pancreatitis and pancreas divisum were therefore treated by endoscopic injection of 50 units of botulinum toxin into the minor papilla in an outpatient setting. Results: Botulinum toxin injection was successfully performed on six occasions in 5 patients and no adverse effects were noted. Two patients relapsed after 9 and 10 months, respectively, but had definite relief of symptoms after needle-knife sphincterotomy. One patient relapsed 7 months after botulinum toxin injection but became symptom free again after a second botulinum toxin injection. Another patient is still in clinical remission 4 months after botulinum toxin administration, and 1 patient did not respond to either botulinum toxin administration or to sphincterotomy and stent placement. Conclusions: Endoscopic injection of botulinum toxin into the minor papilla in patients with pancreas divisum and acute recurrent pancreatitis is a safe procedure that is easy to perform and provides short-term relief in some patients. Response to botulinum toxin injection may predict whether patients with pancreas divisum and acute recurrent pancreatitis will benefit from other forms of endoscopic therapy.