Serum Pancreatic Enzyme Levels Research Articles

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Position statement on the definition, incidence, diagnosis and outcome of acute on chronic pancreatitis

BackgroundAcute on chronic pancreatitis (ACP) is a relatively common condition, but there are significant gaps in our knowledge on the definition, incidence, diagnosis, treatment and prognosis. MethodsA systematic review that followed PICO (Population; Intervention; Comparator; Outcome) recommendation for quantitative questions and PICo (Population, Phenomenon of Interest, Context) for qualitative research was done to answer 10 of the most relevant questions about ACP. Quality of evidence was judged by the GRADE criteria (Grades of Recommendation, Assessment, Development and Evaluation). The manuscript was sent for review to 12 international experts from various disciplines and continents using a Delphi process. ResultsThe quality of evidence, for most statements, was low to very low, which means that the recommendations in general are only conditional. Despite that, it was possible to reach strong levels of agreement by the expert panel for all 10 questions. A new consensus definition of ACP was reached. Although common, the real incidence of ACP is not known, with alcohol as a major risk factor. Although pain dominates, other non-specific symptoms and signs can be present. Serum levels of pancreatic enzymes may be less than 3 times the upper limit of normal and cross-sectional imaging is considered more accurate for the diagnosis in many cases. It appears that it is less severe and with a lower mortality risk than acute pancreatitis. ConclusionsAlthough the evidence base is poor, this position statement provides a foundation from which to advance management of ACP.

Spontaneous regression in solid pseudopapillary neoplasm of pancreas.

A solid pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm that mainly occurs in young women. We herein report the case of spontaneous regression in SPN of the pancreas. A 48-years-old female was found to have a mass in the head of the pancreas on examination for her back pain and referred to our hospital in 20XX. Laboratory data showed no abnormalities in serum levels of pancreatic enzymes and tumor markers. A contrast CT scan of upper abdomen showed a slightly enhanced lesion (23 × 19mm in diameter) without cystic component or fibrous capsule in the head of the pancreas. An MRI scan showed the mass as low-intensity in T1-WI and high-intensity in T2-WI. She admitted to our hospital for further examination of a pancreatic mass by EUS-FNA in 20XX + 4. EUS showed a slightly hypoechoic mass (30 × 19mm in diameter) compared with the neighboring normal pancreas. Tumor margin was relatively clear and the internal echo image was homogenous. Histological findings revealed a solid and pseudopapillary proliferation of eosinophilic polygonal cells with oval nuclei. The tumor cells were positive for vimentin and CD10 in the cytoplasm and β-catenin in the nuclei, which led to the diagnosis of SPN. We recommended this patient to undergo surgical resection, however, the patient chose follow-up examinations. Follow-up study after 1 year using MRI scan showed spontaneous regression, which was coincided with her menopause. These findings suggest that the natural regression of SPN may occur and female sex hormone changes may regulate the growth of SPN.

A CASE OF RECURRENT PANCREATITIS DUE TO HYPERTRIGLYCERIDEMIA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hypertriglyceridemia (HTG) accounts for 10% of all cases of acute pancreatitis (AP). It can present as acute or recurrent episodes of AP typically in the presence of coexistent conditions, such as inadequately controlled diabetes (DM), excess alcohol consumption or medication use. We present a case of recurrent pancreatitis in a patient with history of HTG and non-compliance with medication. CASE PRESENTATION: A 39-years-old female with history of HTG, DM and alcohol dependance disorder presented to the ED with 1-day history of severe epigastric pain radiating to her back, associated with nausea and non-bilious vomiting. On examination she was hemodynamically stable. There was marked tenderness to palpation in the epigastric region. Her initial laboratory findings were significant for fasting serum glucose (FSG) of 323 mg/dL, severe hyponatremia 118mEq/L, Calc Osmolality 249mOsm/L, total cholesterol 794 mg/dL and triglycerides 6088 mg /dl. Computed tomogram of the abdomen showed moderate fluid and diffuse peripancreatic inflammatory stranding. The patient was managed for AP with intravenous fluids (IV D5-NS), fixed rate insulin infusion and narcotics for pain control. She was also commenced on Atorvastatin 40mg and Gemfibrozil 600mg, twice daily. Once the patient's condition stabilized, she was discharged with subcutaneous insulin, Metformin and lipid lowering agents. DISCUSSION: Hypertriglyceridemia is a rare but well-known cause of acute pancreatitis. Although the precise mechanism is not known, it is proposed that HTG causes an excess of free fatty acids (FFAs) and elevated chylomicrons leading to rise in plasma viscosity, which may induce ischemia in pancreatic tissue and trigger organ inflammation.[1] The clinical presentation includes epigastric pain, increased serum levels of pancreatic enzymes and typical AP findings on imaging.[2] Serum triglyceride levels rapidly decrease within the first 48 hours of onset of acute AP, therefore earliest possible determination of serum triglyceride levels is crucial [3].Multiple treatment modalities including Insulin and/or heparin, plasmapheresis and oral lipid lowering agents have been evaluated. Fibrates have been proven effective in lowering triglyceride levels and raising HDL levels, and are generally considered to be first-choice drugs for the treatment of HTG [4,5]. Our patient showed good response to treatment with Insulin infusion and fibrates. She refused plasmapheresis trial. CONCLUSIONS: We suggest routine testing of triglyceride levels in patients presenting with signs and symptoms suggestive of acute pancreatitis especially in those with pre-existing medical co-morbidities. REFERENCE #1: 1.Nicolò de Pretis, Antonio Amodio, Luca Frulloni Hypertriglyceridemic pancreatitis: Epidemiology, pathophysiology and clinical managementUnited European Gastroenterol J. 2018 Jun; 6(5): 649–655. REFERENCE #2: 2. Scherer J, Singh VP, Pitchumoni CS, Yadav D Issues in hypertriglyceridemic pancreatitis: an update.J Clin Gastroenterol. 2014 Mar; 48(3):195-203. REFERENCE #3: 3. Maki KC, Bays HE, Dicklin MR. Treatment options for the management of hypertriglyceridemia: strategies based on the best-available evidence. J. Clin. Lipidol. 6(5), 413–426 (2012) DISCLOSURES: no disclosure on file for Moses Bachan; no disclosure on file for Zinobia Khan; No relevant relationships by Dileep Kumar, source=Web Response No relevant relationships by Ambreen Shahzadi, source=Web Response

Serum amylase and lipase levels in healthy volunteers assessed by multiple commercial analyzers: Variability with established reference values

Background/Aims: Although serum pancreatic enzyme measurements for amylase and lipase are the most widely used biochemical tests for the diagnosis of pancreatitis, limitations for their interpretation of pancreatic disease do exist. An international reference method or an evidence-based cut-off value of serum pancreatic enzyme levels has not been established to facilitate standardization. Therefore, different analytic methods for serum pancreatic enzyme levels have verified their own Reference Ranges (RR) as normal values. The aim of this study is to evaluate the frequency of serum pancreatic enzyme values outside of the RR in healthy volunteers, using 5 different pancreatic enzyme analyzers to determine variability of values between analyzers. Methods: Healthy volunteers were screened to exclude a history of pancreatic disease or pancreatic surgery, severe gastrointestinal disease, excess alcohol intake, tobacco use, amongst other conditions. Volunteers were prospectively enrolled and blood samples from a single draw were analyzed for serum pancreatic enzyme levels on five different automated chemistry analyzer platforms. Whether or not the results were within each analyzer's institutional RR was evaluated. Results: Among screened healthy volunteers, 180 participants were enrolled who met the inclusion criteria. Serum amylase results were outside the RR in 8 (4.4%), 11 (7.2%), 19 (10.5%), 6 (3.3%) and 7 (3.9%) subjects, respectively, based on the 5 separate analyzers. Serum lipase results were not within the RR in 3 (1.7%), 20 (13.2%), 13 (7.2%), 1 (0.6%) and 2 (1.1%) subjects, respectively. Among all 22 (12.2%) subjects that were outliers of the serum amylase level, 10 (5.6%) of those subjects were outside of the RR for two or more analyzers. In contrast, among all 32 (17.8%) subjects who were outliers of serum lipase level, only four subjects (2.2%) were outside of the RR for two or more analyzers. Conclusion: Although there was slight variability in test results for serum amylase and lipase between different commonly available testing systems in healthy subjects, no values exceeded three times the upper limit of normal. There was a small group of healthy volunteers that fell outside of the reference range on two or more analyzers. If there is clinical ambiguity due to an abnormal serum pancreatic enzyme, further diagnostic testing can be pursued. Standardization amongst pancreas enzyme analyzers with a unified reference methodology and standard would be beneficial.

Clinical Analysis of Early-Stage Pancreatic Cancer and Proposal for a New Diagnostic Algorithm: A Multicenter Observational Study.

Early diagnosis of pancreatic ductal adenocarcinoma (PDAC) is challenging but essential for improving its poor prognosis. We established a multicenter study to clarify the clinicopathological features, and to propose new algorithm for early diagnosis of PDAC. Ninety-six patients with stage 0 and IA PDAC were enrolled from 13 high-volume centers. Overall, 70% of the patients were asymptomatic. The serum pancreatic enzyme levels were abnormal in half of the patients. The sensitivity of endoscopic ultrasonography (EUS) for detecting small PDAC was superior to computed tomography and magnetic resonance imaging (MRI) (82%, 58%, and 38%, respectively). Indirect imaging findings were useful to detect early-stage PDAC; especially, main pancreatic duct stenosis on MRI had the highest positive rate of 86% in stage 0 patients. For preoperative pathological diagnosis, the sensitivity of endoscopic retrograde cholangiopancreatography (ERCP)-associated pancreatic juice cytology was 84%. Among the stage IA patients, EUS-guided fine-needle aspiration revealed adenocarcinoma in 93% patients. For early diagnosis of PDAC, it is essential to identify asymptomatic patients and ensure close examinations of indirect imaging findings and standardization of preoperative pathological diagnosis. Therefore, a new diagnostic algorithm based on tumor size and imaging findings should be developed.

Clinical characteristics of fulminant Type 1 diabetes mellitus

To compare the differences in clinical characteristics between Type 1 diabetes mellitus (T1DM) and fulminant Type 1 diabetes mellitus (FT1DM), and to reduce the missed diagnosis, misdiagnosis, and mistreatment of FT1DM by medical staff. A total of 101 hospitalized patients with T1DM (including 8 cases of FT1DM) were enrolled in this study from Changsha Central Hospital between June 2012 and December 2018. Clinical characteristics of the 8 FT1DM patients were collected and compared with all T1DM patients. All FT1DM patients were adult with the average age of (30.25±5.28) years old, accompanied by severe diabetic ketoacidosis (DKA) occurred within 1 week after onset. Moreover, pancreatic beta cells in these patients were destroyed and the islet-related antibodies were negative, while the serum pancreatic enzyme levels were increased. Compared with classic T1DM patients, the plasma glucose levels in FT1DM patients were much higher [(41.89±12.54) mmol/L vs (22.57±9.74) mmol/L], but glycosylated hemoglobin (HbA1c) and fasting C peptide levels were significantly lower [(6.08±0.41)% vs (10.87±2.46%)%, P<0.05] and [(0.02±0.00) nmol/L vs (0.03±0.06) nmol/L, P<0.05]. The onset time of FT1DM patients is very urgent via driving DKA. These patients have higher blood glucose concentration than classic T1DM patients, accompanied by electrolyte disturbances, impaired renal function, partially impaired liver function, as well as gastrointestinal symptoms and elevated trypsin. Most FTDM patients are adolescents and adults with no gender difference, especially pregnant women who are at high risk. Lifelong insulin dependence in FT1DM patients should be paid more attention in clinical treatment.

Evaluation of serum pancreatic enzymes in type 2 diabetes mellitus and its correlation with insulin resistance

Introduction: Type 2 diabetes mellitus is due to the decreased biological response to insulin or insulin resistance. Insulin resistance develops as a consequence of defects in signal transduction by insulin. These defects may also affect the exocrine pancreatic function. The aim of this study was to determine serum pancreatic enzyme levels in diabetic patients and to correlate them with insulin resistance. Materials and Methods: In this case control study we compared fasting blood sugar, serum insulin, lipase and amylase levels and insulin resistance in diabetic and normal healthy adults. The correlation of pancreatic enzymes with insulin resistance was also studied. Results: Diabetic group showed statistically significant increase in all the parameters compared to control group. Serum amylase showed a significant negative correlation with insulin resistance (p=0.007) and serum lipase a positive correlation with insulin resistance, but it was not significant (p =0.119). Conclusion: The study showed a significant alteration in the exocrine pancreatic function in diabetic patients. There is a negative correlation between serum amylase level and insulin resistance. Keywords: Amylase, Insulin Resistance, Islet-Acinar Axis, Lipase, Type 2 Diabetes Mellitus.

A rare case of acute pancreatitis: a diagnostic conundrum and unusual complications

A 63-year-old man with a history of recurrent idiopathic acute pancreatitis (AP) was admitted to our surgical ward due to severe abdominal pain. He denied chronic excessive alcohol use. Other typical causes of AP, such as gallstones, hypertriglyceridemia, and trauma, were ruled out. After considering all possible etiologies, the most likely factor producing AP was medication that had been administered to him two weeks before the very first episode of the disease. Medication should always be considered as a possible trigger of AP, especially if the first episode occurs shortly after drug administration and the etiology is unclear. During patient’s hospitalization, laboratory reports revealed significant fluctuations in the serum levels of pancreatic enzymes, which can be attributed to recurrent bacteriemia. After the 30-day period of hospitalization and long-lasting antibiotic therapy, he was discharged in a good condition with normal levels of serum pancreatic enzymes.

A rare case of acute pancreatitis: a diagnostic conundrum and unusual complications.

A 63-year-old man with a history of recurrent idiopathic acute pancreatitis (AP) was admitted to our surgical ward due to severe abdominal pain. He denied chronic excessive alcohol use. Other typical causes of AP, such as gallstones, hypertriglyceridemia, and trauma, were ruled out. After considering all possible etiologies, the most likely factor producing AP was medication that had been administered to him two weeks before the very first episode of the disease. Medication should always be considered as a possible trigger of AP, especially if the first episode occurs shortly after drug administration and the etiology is unclear. During patient's hospitalization, laboratory reports revealed significant fluctuations in the serum levels of pancreatic enzymes, which can be attributed to recurrent bacteremia. After the 30-day period of hospitalization and long-lasting antibiotic therapy, he was discharged in a good condition with normal levels of serum pancreatic enzymes.

Dulaglutide improves glucocorticoid-induced hyperglycemia in inpatient care and reduces dose and injection frequency of insulin

BackgroundGlucocorticoid (GC)-induced hyperglycemia is characterized by elevated postprandial blood glucose, which commonly requires multiple insulin injections. We investigated whether a long-acting glucagon-like peptide-1 receptor agonist, dulaglutide (Dula), safely improved GC-induced hyperglycemia in inpatients, to reduce insulin injection frequency.MethodsThe data of hospitalized patients with GC-induced hyperglycemia treated with Dula (Dula group, n = 38) or without (non-Dula group, n = 38) were retrospectively evaluated. Baseline data were collected at the beginning of GC treatment. The primary outcome in this study was glycemic control, which was compared between the groups using the six-point blood glucose (before and 2 h after each meal) profiles at discharge. The daily injection frequency of injectable drugs at discharge were also compared between groups.ResultsNo specific trend of underlying diseases was observed between the non-Dula and Dula groups. The proportion of patients previously administered with GC pulse therapy was comparable between the two groups. No significant differences were observed between groups, in the starting maintenance GC dose, GC dose at pretreatment of Dula and discharge, and cumulative GC dose during the observation. Six-point blood glucose levels at pretreatment and discharge were comparable between the two groups. However, daily injection frequency of injectable drugs and insulin dose were significantly lower in the Dula group than that in the non-Dula group. No differences were observed in the number of hypoglycemic events, the elevation of serum pancreatic enzyme levels, or gastrointestinal adverse events.ConclusionThese findings suggest that Dula could provide glycemic control while reducing the insulin dose and injection frequency in inpatients with GC-induced hyperglycemia. The occurrence of adverse events such as gastrointestinal symptoms and hypoglycemia did not increase in the Dula-treated patients compared to those not treated, suggesting its safety.

Initial experience of irreversible electroporation for locally advanced pancreatic cancer in a Korean population.

Locally advanced pancreatic cancer (LAPC) is one of the most aggressive malignancies. Irreversible electroporation (IRE) is a novel technique that uses a non-thermal ablation to avoid vessel or duct injury. To investigate the safety and efficacy of IRE for the management of LAPC in a Korean population. Twelve patients (median age 64 years; age range 46-73 years) treated between December 2015 and March 2017 underwent intraoperative IRE for LAPC. Technical success and clinical outcomes, including complications, serum pancreatic enzyme levels, overall survival (OS), and progression-free survival (PFS), were evaluated. Tumors were located in the pancreas head in 7 (58.3%) patients and in the body/tail in 5 (41.7%) patients. The median tumor diameter in the longest axis was 3.1 cm. Vascular invasion was observed in all patients and bowel abutment in 3 (25%) patients. Technical success was achieved in all patients. The median serum levels of amylase and lipase were 55 U/L and 31 U/L, respectively, at baseline, increased to 141.5 U/L (P = 0.008) and 53 U/L (P = 0.505), respectively, one day after IRE, and normalized after one week. The rate of 30-day mortality of unknown relation was 8.3% (one individual experienced massive hematemesis 12 days after IRE). The median OS from diagnosis and IRE was 24.5 months and 13.5 months, respectively. The median PFS from diagnosis and IRE was 19.2 months and 8.6 months, respectively. For patients with LAPC, IRE appears to be a promising treatment modality with an acceptable safety profile.

Diseases of the Pancreas

Acute pancreatitis is characterized by an acute inflamatory process of the pancreas associated with abdominal pain and elevations in serum levels of pancreatic enzymes. The acute inflammation usually completely resolves with restoration of normal pancreatic architecture and function. By contrast, chronic pancreatitis is characterized by the presence of ongoing inflammation and irreversible damage to the gland. Recurrent attacks of acute pancreatitis may lead to chronic pancreatitis over time. This chapter discusses the epidemiology, etiology, pathogenesis, diagnosis, and treatment of acute and chronic pancreatitis. Figures illustrate findings on imaging studies in patients with pancreatic disorders. This review contains 6 figures, 25 tables, and 86 references. Keywords: Acute pancreatitis, chronic pancreatitis, pseudocyst, exocrine insufficiency, endocrine insufficiency, magnetic retrograde cholangiopancreatography, endoscopic ultrasonography

Особливості харчової підтримки у хворих на легкий гострий панкреатит

Introduction. The number of patients with acute pancreatitis (AP) is increasing in the world. Approximately 85% of patients with AP have a mild course of the disease. Nutritional support is an important factor in the treatment of these patients. However, the optimal timetable for restoring oral intake is almost not studied.Aim of the study. Determine the possibility of early recovery of oral nutrition in patients with mild AP.Materials and methods. We examined 51 patients with mild acute pancreatitis. In 25 patients, an early oral refeeding (EORF) was used when patients experienced hunger, and 26 patients received routine oral refeeding (RORF) after pain disappeared and normalized pancreatic enzymes serum levels.Results. Age, sexual, etiological and laboratory parameters, the severity of the condition of patients in the two groups during hospitalization were not statistically different. Before starting the diet in the EORF group, serum concentrations of pancreatic amylase and lipase were elevated. There was a significant difference in the duration of the hunger strike after hospitalization between the EORF group and the RORF group. In addition, there was a significant decrease in the total number of days of hospitalization in the EORF group compared with the group RORF. There were no differences in the relapse of abdominal pain, abdominal distension, elevated serum levels of pancreatic enzymes, and severity of the condition of patients between these two groups. All patients who developed relapse of pain and transient abdominal distension did not require a change in nutrition regimen. The activity of inflammation at the concentration of C-reactive protein significantly earlier was leveled in patients from the group of EORF. All patients were discharged according to standardized criteria.Conclusion. In patients with mild AP, early onset of oral refeeding, which is safe, promotes a faster reduction of the inflammatory process, reduces the timing of hospitalization.

Enhanced proliferation of pancreatic acinar cells in MRL/MpJ mice is driven by severe acinar injury but independent of inflammation

Adult pancreatic acinar cells have the ability to re-enter the cell cycle and proliferate upon injury or tissue loss. Despite this mitotic ability, the extent of acinar proliferation is often limited and unable to completely regenerate the injured tissue or restore the initial volume of the organ, thus leading to pancreatic dysfunction. Identifying molecular determinants of enhanced proliferation is critical to overcome this issue. In this study, we discovered that Murphy Roths Large (MRL/MpJ) mice can be exploited to identify molecular effectors promoting acinar proliferation upon injury, with the ultimate goal to develop therapeutic regimens to boost pancreatic regeneration. Our results show that, upon cerulein-induced acinar injury, cell proliferation was enhanced and cell cycle components up-regulated in the pancreas of MRL/MpJ mice compared to the control strain C57BL/6. Initial damage of acinar cells was exacerbated in these mice, manifested by increased serum levels of pancreatic enzymes, intra-pancreatic trypsinogen activation and acinar cell apoptosis. In addition, MRL/MpJ pancreata presented enhanced inflammation, de-differentiation of acinar cells and acinar-to-ductal metaplasia. Manipulation of inflammatory levels and mitogenic stimulation with the thyroid hormone 5,3-L-tri-iodothyronine revealed that factors derived from initial acinar injury rather than inflammatory injury promote the replicative advantage in MRL/MpJ mice.

Combination of diclofenac and aggressive hydration for the prevention of post-ERCP pancreatitis.

To investigate whether aggressive hydration can increase the efficacy of prophylactic non-steroid anti-inflammatory drugs (NSAIDs) in prevention of post-ERCP pancreatitis. NSAIDs are recommended for the prevention of PEP; however, whether aggressive hydration can have additional benefits in this regard is not known. Patients candidate for ERCP received either pre-procedural rectal diclofenac (100 mg) alone (n = 112) or in combination with aggressive hydration by lactate ringer's (n = 107) as prophylactic method. PEP was defined based on increase in serum levels of pancreatic enzymes (from baseline to 24 hours following the procedure) accompanied with symptoms. PEP was occurred in 3 patients in the diclofenac only group and in 1 patient in the diclofenac + hydration group with no significant difference (2.7% vs. 0.9%, P = 0.622). Serum amylase levels decreased over time in the diclofenac + hydration group but not in the diclofenac only group. Also, serum lipase levels decreased more rapidly over time in the diclofenac + hydration group compared to the diclofenac only group. Combination prophylactic therapy with NSAIDs plus aggressive hydration does not seem to have additional clinically important benefits in preventing PEP. Studies with larger sample of patients are required in this regard.

Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.

Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1-18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4-66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3-13 days) and regular diet at a median of 8 days (IQR 4-20 days). Median hospitalization length was 13 days (IQR, 7-24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. Therapeutic/care management, level V (case series).

Correlation between low serum levels of pancreatic enzymes and clinical stage of chronic pancreatitis

Thoracic endometriosis syndrome refers to a broad spectrum of clinical manifestations related to the presence of ectopic intrathoracic endometrial tissue. Few studies have reported on manifestations other than pneumothorax.Clinical, surgical, and pathology records of all consecutive women of reproductive age referred to our institution from September 2001 to August 2016 for clinically suspected thoracic endometriosis syndrome were retrospectively reviewed. After excluding women with pneumothorax, we enrolled 31 patients, divided into three subgroups: catamenial chest pain (n = 20), endometriosis-related diaphragmatic hernia (n = 6), and endometriosis-related pleural effusion (n = 5).Surgery was performed in 11 patients with catamenial thoracic pain (median age, 30 years; range, 23 to 42). Median pain intensity assessed on the 0 to 10 Visual Analogue Scale was 8 (range, 8 to 9) before surgery. At surgery, 8 patients had diaphragmatic endometriosis implants, which were resected with direct suture of diaphragm. At follow-up, median pain score was 3 (range, 0 to 8). In the group presenting with diaphragmatic hernia (median age, 36 years; range, 29 to 50), diaphragm was repaired by direct suture or placement of prosthesis in 4 and 2 cases, respectively. At follow-up, no sign of recurrent hernia was observed. Finally, among women with endometriosis-related pleural effusion (median age, 30 years; range, 25 to 42), surgical treatment was represented by evacuation of the pleural effusion and biopsy (n = 4) or removal (n = 1) of visible endometrial foci.Thoracic endometriosis syndrome is a poorly recognized entity responsible for various manifestations other than pneumothorax. In case of catamenial thoracic pain, diaphragmatic hernia and catamenial pleural effusion surgery should be advised in a multidisciplinary setting.

IgG4 Sclerosing Cholangitis and Post Infantile Giant Cell Hepatitis: A Case Report of an Extraordinary Co-presentation

Background: Giant cell hepatitis is rarely described in adults; referred to as post infantile giant cell hepatitis (PIGCH). Most reports have mentioned PIGCH's association with systemic lupus erythromatosis, autoimmune hepatitis, lymphoma, and leukemia. However, links with other medical disorders are still evolving. Reports of primary sclerosing cholangitis (PSC) presenting as IgG4-SC has been typically described in association with other IgG4-related disorders, most frequently autoimmune pancreatitis. However, some cases of isolated IgG4-SC have been reported. Herein; we report a case of IgG4-SC presented by PIGCH. Case description: A 29-year-old gentleman presented with two month jaundice and biochemical evidence of acute hepatitis. He reported no history of drug exposure, had no gall bladder or pancreatic disease, nor prior similar attacks. The work up revealed negative serology for viral hepatitis. Markers of autoimmune liver disease were negative except for pANCA, and serum levels of pancreatic enzymes, copper and ceruplasmin were normal, and urinary copper was normal. Results: Abdominal sonography and MRCP showed normal pancreas and biliary tract. ERCP showed that the common bile duct had a single short narrowed segment with thickened walls. Histological examination of colonoscopic biopsies taken from the terminal ileum and colon demonstrated no pathological alterations. Liver histology showed evidence of parenchymal extinction with extensive giant cell transformation, ductular proliferation, cholestasis, and positive IgG4 staining, a picture suggestive of PSC and PIGCH. Discussion: In this case, we did not test for serum levels of IgG4, and resorted to immune-staining of liver tissue, as this is the hallmark for diagnosing IgG4-SC. Histopathological features and, more definitely, the positive IgG4 immunostaining were present in the liver tissue, which were crucial in diagnosing this case as IgG4-SC (IAC). Conclusion: This case presented with both IgG4-SC and biopsy proven PIGCH, and had a favourable outcome with biliary drainage and immuno-suppression therapy

An Unexpected Etiology of Pancreatic Panniculitis: A Case Report

Background: Pancreatic panniculitis is a rare cause of subcutaneous fat necrosis secondary to elevated serum levels of pancreatic enzymes. It is most often associated with pancreatic acinar cell carcinoma, but has also been seen in patients with pancreatitis.Case report: We present a case of a 64-year-old Caucasian man without symptoms of pancreatitis, who presents with pancreatic panniculitis manifesting in multiple subcutaneous ulcerating nodules of the bilateral lower extremities, discovered to have a previously unreported etiology for this condition. He had no evidence of pancreatitis or malignancy, but instead a pancreatic-portal fistula resulting in panniculitis.Conclusion: Peripancreatic vascular lesions must also be considered in the differential diagnosis of pancreatic panniculitis. The diagnosis, pathology, and treatment of pancreatic panniculitis are reviewed herein.