Setting Of Acute Pancreatitis Research Articles

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis.

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

Catheter-directed thrombolysis versus systemic anticoagulation in the treatment of symptomatic splanchnic venous thrombosis secondary to acute pancreatitis: a retrospective cohort study

BackgroundCatheter-directed thrombolysis (CDT) has been an important therapy and seems effective in patients with splanchnic venous thrombosis (SVT) secondary to some diseases, but this intervention hasn’t been formally evaluated in the setting of acute pancreatitis (AP).MethodsThis was a retrospective study enrolled patients between January 2013 and December 2018. AP patients who developed SVT-induced symptoms, including intractable ascites and/or enteral nutrition intolerance, were included. Demographics, SVT associated parameters, clinical features and outcomes, long-term quality of life evaluated by using SF-36 questionnaire were compared between CDT group and systemic anticoagulation (SAC) group.Results6 patients underwent CDT and 17 received SAC. Patients in CDT group had a higher recanalization rate (100% versus 35.3%; p = 0.014) and shorter time to symptoms resolution (median 8 days versus. 31.5 days, p = 0.004). Mortality and length of hospital stay were comparable between two groups. The association analysis indicated that CDT use exerted a significantly beneficial effect on recanalization rate (risk ratio, 2.833; 95% CI, 1.489 to 5.393; p = 0.002) and time to symptoms resolution (mean difference, -33.333; 95% CI, -64.612 to -2.055; p = 0.038). No SVT-related symptoms recurrence was recorded in survivors at six-month follow-up. There was no statistical difference in either item of SF-36 questionnaire between two groups.ConclusionsCompared with SAC, CDT may facilitate vascular recanalization and shorten symptom resolution for symptomatic SVT.

S1689 Isolated Thrombosis Within a Superior Mesenteric Vein Aneurysm in the Setting of Acute Pancreatitis

S1689 Isolated Thrombosis Within a Superior Mesenteric Vein Aneurysm in the Setting of Acute Pancreatitis

S2825 Endoscopic Management of an Obstructing Duodenal Wall Hematoma in the Setting of Acute Pancreatitis

Introduction: Spontaneous duodenal wall hematoma is a rare condition which can be associated with acute and chronic pancreatitis. It is often complicated by small bowel obstruction. When conservative management fails, options are limited. Here we describe a case of small bowel obstruction secondary to pancreatitis-associated duodenal wall hematoma which was successfully managed endoscopically through cystduodenostomy. Case Description/Methods: A 69-year-old male with HIV and normal CD4 count presented with acute abdominal pain and non-bloody emesis with elevated lipase of 374 U/L (ULN 82). Computed tomography revealed a 5.8 cm multilobulated pancreatic pseudocyst with associated inflammation and coarse calcifications and a 10 cm circumferential submucosal mass within the duodenum with significant luminal narrowing and compression of the adjacent inferior vena cava (a). Endoscopic ultrasound confirmed a homogenous, hypoechoic subepithelial lesion obstructing the second portion of the duodenum consistent with a hematoma (b). A nasogastric-jejunal tube was placed for feeding and decompression. Due to persistent obstruction and IVC compression, on hospital day 10 endoscopic drainage of the duodenal hematoma was performed via cystduodenostomy with a 15x10 mm electrocautery-enhanced lumen-apposing metal stent (LAMS) (AXIOS, Boston Scientific, Marlborough, MA, USA) (c). The LAMS was immediately removed after near-complete evacuation of the hematoma cavity to minimize the risk of bleeding complications. A plastic double-pigtail stent was left in place to facilitate complete drainage. The duodenum was then dilated with a 12-13.5-15mm hydrostatic balloon dilator. The pigtail stent was removed 3 days later with clinical, radiographic, and endoscopic resolution of the duodenal obstruction (d). Discussion: Duodenal hematoma is a previously described rare complication of pancreatitis. Endoscopic evacuation was a safe and effective means of relieving the duodenal obstruction in this patient. This minimally invasive option resulted in immediate resolution and can be considered when conservative management fails.Figure 1.: 10 cm duodenal wall hematoma on CT scan (a) and endoscopy (b). Endoscopic drainage via cystduodenostomy with a lumen-apposing metal stent (c). Resolution of the duodenal wall hematoma (d).

Emergent Management of Gastric Variceal Bleed in the Setting of Acute Pancreatitis-Related Sinistral Hypertension With Partial Splenic Embolization: A Series of Two Cases

Sinistral portal hypertension in the setting of acute pancreatitis is a known complication owing to splenic vein thrombosis. It can lead to upper gastrointestinal bleeding due to the development of fundal gastric varices due to the shunting of blood via short gastric veins. However, in the setting of acute pancreatitis, surgical procedures can have high post-operative morbidity. Emergent management of cases with absent gastro-renal shunt can be done by partial splenic arterial embolization, as it is minimally invasive and can provide similar results. Herein, we report a case series of two cases of acute pancreatitis complicated with splenic vein thrombosis and gastric varices, which were managed by partial splenic artery embolization.

Hypertriglyceridemia-Induced Acute Pancreatitis During Pregnancy: A Case Report

Hypertriglyceridemia-induced acute pancreatitis is a rare and serious condition that places both the mother and the fetus at severe risk for morbidity and mortality. The goal of this case report is to describe the management of a pregnant patient with severely elevated triglycerides in the setting of acute pancreatitis. A 28-year-old female G2P1001 at 29 weeks of gestational age presented with epigastric abdominal pain. A computed tomography scan of the abdomen and pelvis with contrast demonstrated acute interstitial edematous pancreatitis. A lipid panel was performed, revealing a serum triglyceride level of 3,949 mg/dL. Insulin and maternal bowel rest reduced her serum triglyceride levels; however, additional medical therapy including fibrate and statin drugs were initiated to achieve goal levels of triglycerides and improve patient symptoms. The patient ultimately recovered and remained on treatment until delivery. Initial management addresses acute pancreatitis and involves fluid resuscitation, pain control, and bowel rest. Triglyceride-lowering drug therapies are rarely used during pregnancy due to the potential for fetal teratogenicity; however, given the severity of hypertriglyceridemia fenofibrate and atorvastatin were prescribed. Additional medical treatment included insulin, omega-3, and ethyl eicosapentaenoic acid.

Spontaneous jejunal perforation in the setting of acute pancreatitis

Spontaneous jejunal perforation is uncommonly seen in the pediatric population. Many etiologies are implicated, including the rare instance of acute pancreatitis. The digestive pancreatic enzymes cause inflammation, ischemia and necrosis which may lead to small bowel perforation. Early diagnosis of the condition, as well as emergent medical and surgical management lead to a better patient outcome. We present a case of a 3 year old male patient with acute pancreatitis and small bowel perforation, requiring exploratory celiotomy, primary repair and subsequent medical management with complete recovery.

Clinical and Imaging Predictors of Pancreatic Cancer in Patients Hospitalized for Acute Pancreatitis.

Identifying factors associated with increased short-term risk of pancreatic cancer in the setting of acute pancreatitis (AP) can inform clinical care decisions and expedite cancer diagnosis. A retrospective cohort study of patients hospitalized for AP between 2007 and 2017 in an integrated health-care system in Southern California. AP cases were identified by diagnosis code with laboratory confirmation. Multivariable Cox proportional hazards regression model was used to assess risk of pancreatic cancer within 3 years of AP, adjusting for patient demographics, clinical parameters (body mass index, AP etiology, chronic pancreatitis, diabetes) and radiographic imaging features. Among 9,490 patients hospitalized with AP, the mean (standard deviation) age was 55.8 (17.8) years, 55% were women, and 42% were Hispanic. Majority of AP cases were biliary (64%), 12% were alcohol-related, 5% were hypertriglyceridemia-induced, and 19% were other/unknown etiology. Ninety-five (1%) patients were diagnosed with pancreatic cancer within 3 years of AP (4.2 cases/1000 person-years). Risk factors for pancreatic cancer were age ≥65 years (hazard risk [HR]: 2.5, 95% confidence interval [CI]: 1.2-5.3), male sex (HR: 1.9, 95% CI: 1.2-2.8), Asian/Pacific Islander race (HR: 2.0, 95% CI: 1.1-3.6), and underweight body mass index (HR: 2.6, 95% CI:1.1-6.5). In addition, other/unknown AP etiology (HR: 2.0, 95%CI: 1.3-3.1) and dilatation of the main pancreatic duct(HR: 6.6, 95% CI: 4.2-10.5) were independently associated with increased risk of pancreatic cancer. Inaddition to older age, the lack of well-established etiology,underweight body habitus, and main pancreatic duct dilatation were independently associated with increased short-term riskof pancreatic cancer among patients hospitalized forAP.

Protein expression in exocrine pancreatic diseases. Focus on VMP1 mediated autophagy.

The exocrine pancreas produces enzymes involved in the digestive process whereas endocrine pancreas mainly regulates glucose metabolism. Diseases of the exocrine pancreas are characterized by high morbidity and mortality. Acute pancreatitis is a painful disease in which pancreatic secretory proteins are prematurely activated causing the digestion of the gland. Pancreatic adenocarcinoma is one of the most malignant cancers due to its resistance to treatment, its late diagnosis and high capacity for metastasis. Autophagy is a catabolic process that aims at degrading cytoplasmic contents and damaged organelles, to preserve cell viability and homeostasis. VMP1 is a transmembrane protein that plays a key role in triggering autophagy and being part of the autophagosome membrane. A specific type of selective autophagy pathway called zymophagy protects the pancreas against self-digestion in the setting of acute pancreatitis by sequestering intracellularly activated zymogen granules. Mitophagy is also responsible for maintaining pancreatitis as a mild disease by preserving mitochondrial function. Dysregulation of these selective autophagic processes by pancreatitis itself constitutes a risk factor for development of severe disease. In pancreatic adenocarcinoma, VMP1 mediated autophagy promotes cancer cell survival and resistance to chemotherapy. Therefore, it is relevant to highlight a role for controlling VMP1 expression and targeting VMP1 molecular pathways to improve exocrine pancreatic diseases prognosis.

Haemolytic uraemic syndrome associated with pancreatitis: report of four cases and review of the literature.

BackgroundThe incidence of acute kidney injury (AKI) in patients with acute pancreatitis ranges from 15% to 40% and is associated with poor prognosis. Haemolytic uraemic syndrome (HUS) in the setting of acute pancreatitis is an uncommon association with fewer than 30 cases reported in the literature.MethodsA retrospective review of the clinical records at our institution between January 1981 and December 2019 was carried out to identify patients with acute pancreatitis and HUS. Additionally, a literature review was conducted on this topic. The aims of the study were to describe the clinical course and outcomes of patients affected by this condition.ResultsFour cases of HUS following an acute pancreatitis were identified. The mean (±SD) age of the study group was 30 ± 6 years, all of which were males. Excessive alcohol consumption was the main cause of acute pancreatitis in all four patients. HUS with progressive AKI developed in a median interval of 2 days from the onset of pancreatitis (range 1–3 days). All patients required kidney replacement therapy during the course of follow-up. A kidney biopsy was performed in two patients, showing typical thrombotic microangiopathic features. One case was treated with eculizumab, whereas the rest were treated with supportive care and/or plasma exchange. A normalization of haematological parameters and complete recovery of kidney function were observed in all patients at last follow-up, although this improvement was significantly faster in the patient treated with eculizumab.ConclusionsHUS may infrequently develop in patients with acute pancreatitis. An early identification of this complication is mandatory, and complement blockade with eculizumab may be associated with a faster kidney function recovery.

Prophylaxis Against Venous Thromboembolism in Patients with Necrotizing Pancreatitis: Can We Do Better?

Our surgical colleagues have provided us with a single center, prospective observational audit of the rate of clinically relevant and radiologically detected venous thromboembolism (VTE), as well as the associated efficacy of standard chemical VTE prophylaxis, in patients with necrotizing pancreatitis. 1 Maatman T.K. McGuire S.P. Lewellen K.A. et al. A prospective analysis of the mechanisms underlying ineffective deep vein thrombosis prophylaxis in necrotizing pancreatitis. J Am Coll Surg. 2021; 232: 91-100 Abstract Full Text Full Text PDF Scopus (1) Google Scholar More specifically, they prospectively screened all patients for VTE on a weekly basis, as well as used serum anti-Xa levels to determine what proportion of patients were adequately prophylaxed. This work addresses previous concerns of the underappreciated risk of VTE in patients with necrotizing pancreatitis. 2 Roch A.M. Maatman T.K. Carr R.A. et al. Venous thromboembolism in necrotizing pancreatitis: an underappreciated risk. J Gastrointest Surg. 2019; 23: 2430-2438 Crossref PubMed Scopus (11) Google Scholar Among the 85 patients followed in total (201 screening events), 65% were noted to develop VTE. Significantly more concerning, however, is not the total VTE rate, but instead, the frequency of extremity deep venous thrombosis (DVT). Thirty-eight percent of patients were screened positive with an extremity DVT at a mean of 44 days after the onset of pancreatitis. Although the need to treat mesenteric (splenic, superior mesenteric, and portal venous) VTE continues to be highly debatable in the setting of acute pancreatitis, extremity DVT clearly remains a potential threat to patient outcomes.

BLACK PLEURAL EFFUSION AS A COMPLICATION OF ACUTE PANCREATITIS

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Transient pleural effusion is a known consequence of acute pancreatitis. We report a rare case of complicated black pleural effusion in a patient with acute pancreatitis. CASE PRESENTATION: A 48 year old man with a history of alcohol abuse and chronic pancreatitis presented to the emergency department with complains of epigastric pain radiating to his back after alcohol consumption. Serum amylase and lipase were elevated. Computed tomography of chest and abdomen (CT CAP) showed evidence of acute pancreatitis with an increase of distal pancreatic pseudocyst and formation of new pseudocysts. There was also moderate ascites and large left sided pleural effusion. Paracentesis was performed and ascitic fluid analysis was consistent with bacterial peritonitis. The patient was started on broad spectrum intravenous antibiotics. The patient continued to have severe abdominal pain and developed fevers with tachycardia, hypoxia and tachypnea. The patient was transferred to intensive care unit. The patient underwent a pigtail chest tube insertion on the left side which drained a black pleural fluid. The pleural fluid analysis consistent with exudative pleural effusion. Pleural fluid amylase was grossly elevated to 3,434 U/L signifying that the black pleural effusion was secondary to acute pancreatitis. Pleural and ascitic fluid cultures were negative. The patient was transferred to an outside hospital where he underwent upper GI endoscopic ultrasound guided aspiration of pancreatic pseudocyst. The culture of the pseudocyst fluid was negative. Pleural effusion resolved and chest tube was removed. The patient improved symptomatically with intravenous antibiotics. The patient was discharged with oral antibiotics. DISCUSSION: Black pleural effusions are rare and have been reported previously in patients with metastatic melanoma, adenocarcinoma of the lung, pleuropancreatic fistula and in pleural infections caused by Aspergillus niger and Rhizopus oryzae. Accumulation of black pleural effusion in our patient was likely secondary to movement of ascitic fluid from abdomen to pleural cavity through the fenestrations in diaphragm. Grossly elevated pleural fluid amylase confirmed the pancreatic origin of the pleural effusion. Although pleuropancreatic fistula was a consideration, CT CAP negative for a pleuropancreatic fistula. The complete resolution of the pleural effusion following chest drain with no further reaccumulation of pleural effusion made pleuropancreatic fistula a less likely diagnosis. CONCLUSIONS: A black pleural effusion in the setting of acute pancreatitis with ascites is an extremely rare finding. Acute pancreatitis should be part of the differential diagnosis of black pleural effusion, especially when the pleural fluid analysis shows an elevated amylase level. Reference #1: Saraya T, Light RW, Takizawa H, et al. Black pleural effusion. Am J Med 2013; 126: 641. e1–6. Reference #2: Jayakrishnan B, Dildar B, Rizavi DM, et al. Black pleural effusion. Lancet 2015;386: e7. Reference #3: Ali T, Srinivasan N, Le V, et al. Pancreaticopleural fistula. Pancreas 2009; 38: e 26–31 DISCLOSURES: No relevant relationships by Antony Arumairaj, source=Web Response No relevant relationships by Abayomi Bamgboje, source=Web Response No relevant relationships by Fidencio Davalos, source=Web Response No relevant relationships by Imnett Habtes, source=Web Response

Role of early endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis

Objective The aim was to evaluate the role of early endoscopic retrograde cholangiopancreatography (ERCP) in reducing mortality and morbidity of acute biliary pancreatitis with the consideration of the economic burden of this maneuver. Background A stone that obstructs the ampulla of Vater can cause biliary pancreatitis. ERCP is used to remove the stones that obstruct the ampulla. The risk-to-benefit ratio of this in the setting of acute pancreatitis is a matter of debate. In this research, we intend to overweight one of the both schools (conservative vs early ERCP). Patients and methods This prospective randomized comparative study was done at the Menoufia University Hospital between April 2015 and January 2018 which included 40 patients who were divided into two groups: groups A included 20 patients managed by early ERCP. Group B included 20 patients managed initially conservatively and they will be divided into three subgroups according to the course of jaundice. B1 subgroup: Those who will continue the conservative course due to continuous daily serial declination of their direct serum bilirubin. Group B2: those with continuous daily serial rising of the serum bilirubin (for 2 consecutive days) and they will be subjected to urgent ERCP. Group B3: those with fluctuating levels of serum bilirubin and they will be subjected to elective ERCP. Both group A and B patients will be subjected to laparoscopic cholecystectomy and were compared as regards the complications, mortality, economic burden, and hospital admission time. Results There was only one complication in group A with a percentage of 5% while there were three complications in group B and there were three with a percentage of 15%; thus, there was a significant reduction in complications in group A (P 0=0.05–0.001). Conclusion Early ERCP by a well-trained endoscopist in acute biliary pancreatitis is effective in reducing the complications and hospital admission time though it has more cost.

Purtscher-like retinopathy in the setting of acute pancreatitis (clinical case)

A clinical case of bilateral retinopathy consisting of typical zones of ischemia - Purtscher spots, hemorrhages and cotton-like retinal exudates after acute pancreatitis is presented. Typical zones of retinal ischemia and the transparency of the optical media (vitreous) were considered as Purtscher-like retinopathy.

Utility of ultrasound in acute pancreatitis.

Ultrasound plays an essential role in the initial evaluation of patients with suspected or confirmed acute pancreatitis. In addition to evaluation of the pancreatic parenchyma, ultrasound is used for assessment of the gallbladder, biliary tree, peripancreatic tissues, and regional vascular structures. While enlarged and edematous pancreas are classic sonographic features of acute pancreatitis, the pancreas may appear sonographically normal in the setting of acute pancreatitis. Nonetheless, sonographic evaluation in this setting is valuable because assessment for etiologic factors such as gallstones or evidence of biliary obstruction are best performed with ultrasound. Complications of pancreatitis such as peripancreatic fluid collections, venous thrombosis, or arterial pseudoaneurysm can be identified with careful and focused ultrasound examination. Knowledge of various scanning techniques can help to mitigate some of the commonly encountered barriers to sonographic visualization of the pancreas and right upper quadrant structures. Ultrasound can also be used for guidance of percutaneous treatment such as drainage of fluid collections or pseudoaneurysm thrombosis. Difficulty in differentiating edematous from necrotizing pancreatitis can be mitigated with the use of contrast-enhanced ultrasound to assess pancreatic parenchymal enhancement.

Blind After a Binge: Purtscher-like Retinopathy in Acute Alcoholic Pancreatitis

ABSTRACTPurtscher-like retinopathy is an occlusive microvasculopathy that causes sudden onset vision loss of varying severity. The condition is a rare complication of acute pancreatitis and is scarcely documented in the literature. In addition, it is vision-threatening, and there are no evidence-based therapies available. We report a 37-year-old woman presenting with abdominal pain and nausea in the setting of heavy alcohol use. She was diagnosed with acute pancreatitis. During hospitalization, she developed acute visual disturbance and was found to have significantly diminished visual acuity. A dilated funduscopic examination demonstrated multiple retinal cotton wool spots bilaterally and macular edema. The patient was diagnosed with Purtscher-like retinopathy in the setting of acute pancreatitis. Although the prognosis for her vision was guarded, given the ischemic nature of the insult, she had subjective improvement in visual acuity during the remainder of the hospital course with symptomatic management.

1276 Acute Pancreatitis Causing Multiple Aortic Thrombi and Multi-Organ Infarcts

INTRODUCTION: There have not been many case reports of acute pancreatitis causing aortic thrombi. In this vignette we illustrate this rare but noteworthy clinical scenario. CASE DESCRIPTION/METHODS: A 44-year-old homeless man with a history of chronic pancreatitis and alcoholism presented with acute, sharp, diffuse abdominal pain. Vital signs were notable for hypotension and tachycardia. Abdominal examination revealed a diffusely tender abdomen with guarding and rigidity. Neurological examination revealed bilateral upper extremity weakness. White blood cell count, lipase, ESR, CRP, and D-dimer were all markedly elevated A CT abdomen revealed acute pancreatitis with diffuse acute multiple thrombi in the aorta with hepatic, splenic, bowel, and bilateral renal infarcts. There was diffuse ascites of the abdomen and pelvis with bilateral pleural effusions. Cervical MRI revealed C4-C6 cord infarct with diffusely abnormal signal. Brain MRI revealed two acute ischemic infarcts in the right occipital lobe. CTA chest revealed multiple large exophytic thrombi in the descending aorta with no evidence of pulmonary embolism. Duplex ultrasound of all extremities and echocardiogram with contrast were non-revealingHypercoagulability studies revealed mildly decreased factor II, antithrombin III, and protein C levels. Anticoagulation was started with IV heparin and later switched to a direct oral anticoagulant. Paracentesis revealed pancreatic ascites. The patient's abdominal pain resolved and he was transferred to a higher tertiary care center where he was found to have a pancreatic duct leak requiring stenting. DISCUSSION: There are only a few reports in the literature of acute pancreatitis causing aortic thrombosis. The pathophysiology remains unclear. However, there are a few hypotheses. First, proteolytic enzymes released in the setting of acute pancreatitis cause direct injury to the aortic wall, resulting in a nidus for mural thrombus formation. Second, trypsin released during acute pancreatitis causes the activation of several thrombogenic factors such as platelets and fibrinogens. Lastly, hypovolemia caused by acute pancreatitis increases the risk of vascular stasis and vasospasm. In conclusion, this is a rare case of acute pancreatitis complicated by multiple aortic thrombi and multi-organ infarcts in the setting of a mild coagulation disorder. The patient responded well to supportive measures for acute pancreatitis and direct oral anticoagulants thereafter.

Superfluous amylase/lipase testing at a tertiary care hospital: a retrospective study.

ABSTRACTBACKGROUND: Measuring both serum amylase and lipase in the setting of acute pancreatitis is not recommended and monitoring changes in amylase and lipase levels after diagnostic results is of little added value. The extent of the two types of superfluous amylase/lipase testing at our institution is unknown.OBJECTIVE: Explore the extent of superfluous amylase/lipase testing.DESIGN: Medical record review.SETTINGS: Tertiary care, teaching hospital.PATIENTS AND METHODS: We retrospectively reviewed all amylase and lipase tests performed over a recent 12-month period. Amylase tests were considered superfluous if they were ordered with lipase tests at the same time or if they were repeated after diagnostic amylase results. They were considered questionably superfluous if they were repeated alone after non-diagnostic amylase results. Lipase tests were considered superfluous if they were repeated after diagnostic lipase results and questionably superfluous if they were repeated after non-diagnostic lipase results.MAIN OUTCOME MEASURES: Number and percentage of lipase and amylase tests that were superfluous or questionably superfluous.SAMPLE SIZE: 23 950.RESULTS: Superfluous testing was identified in 30.6% of 23 950 amylase/lipase tests and questionably superfluous testing in 12.4%. Of the 7330 superfluous tests, 94.8% were due to simultaneous amylase/lipase testing and 5.2% to repeated lipase testing after diagnostic results. The rate of superfluous and questionably superfluous testing was significantly higher in the inpatient setting compared to emergency department or outpatient settings (P<.0001). Of the 6483 amylase tests obtained simultaneously with non-diagnostic lipase tests, only 36 (0.6%) showed a diagnostic result. Furthermore, only 0.7% and 3.6% of amylase tests that were repeated after normal and borderline results, respectively, were diagnostic and 1.1% and 9.3% of lipase tests that were repeated after normal and borderline results, respectively, were diagnostic.CONCLUSIONS: About one third of amylase/lipase testing appears to be superfluous, mainly due to simultaneous amylase/lipase testing. Since only 0.6% of simultaneous amylase/lipase tests showed diagnostic amylase with non-diagnostic lipase levels, quality improvement initiatives should be directed at reducing this low-value practice. Repeating amylase/lipase tests following normal results is of little value.LIMITATIONS: Clinical notes and imaging studies were not reviewed.CONFLICT OF INTEREST: None.

Sudden Death in a Patient with Undiagnosed Diabetes, Acute Pancreatitis and Acute Adrenalitis

It has been well documented that acute pancreatitis and diabetic ketoacidosis (DKA) co-occur, and both of them present either as a cause or result of the other [1] [2]. Recently, hypertriglyceridemia has been reported to co-occur as well [3] [4]; the involvement of acute adrenalitis in the setting of acute pancreatitis and DKA has not been reported. We report a case of sudden death due to diabetic ketoacidosis, acute pancreatitis and acute adrenalitis in a 37-year-old female. She was found unresponsive and breathless in bed by her mother at their residence. At the time of the autopsy, both lungs were expanded and sigmoid diverticulosis was discovered on gross examination. Histology of the pancreas and the adrenal glands revealed acute inflammation despite appearing normal upon gross examination. The postmortem toxicology report showed high levels of acetone (12 mg/dL) in the postmortem blood and extremely high levels of glucose (>500 mg/dL) in the postmortem vitreous fluid. This is the first reported case of fatal diabetic ketoacidosis co-occurring with acute pancreatitis and acute adrenalitis.

The Use of International Classification of Diseases Codes to Identify Patients with Pancreatitis: A Systematic Review and Meta-analysis of Diagnostic Accuracy Studies.

BackgroundHospital discharge codes are increasingly used in gastroenterology research, but their accuracy in the setting of acute pancreatitis (AP) and chronic pancreatitis (CP), one of the most frequent digestive diseases, has never been assessed systematically. The aim was to conduct a systematic literature review and determine accuracy of diagnostic codes for AP and CP, as well as the effect of covariates.MethodsThree databases (Pubmed, EMBASE and Scopus) were searched by two independent reviewers for relevant studies that used International Classification of Disease (ICD) codes. Summary estimates of sensitivity, specificity and positive predictive value were obtained from bivariate random-effects regression models. Sensitivity and subgroup analyses according to recurrence of AP and age of the study population were performed.ResultsA total of 24 cohorts encompassing 18,106 patients were included. The pooled estimates of sensitivity and specificity of ICD codes for AP were 0.85 and 0.96, respectively. The pooled estimates of sensitivity and specificity of ICD codes for CP were 0.75 and 0.94, respectively. The positive predictive value of ICD codes was 0.71 for either AP or CP. It increased to 0.78 when applied to incident episode of AP only. The positive predictive value decreased to 0.68 when the ICD codes were applied to paediatric patients.ConclusionNearly three out of ten patients are misidentified as having either AP or CP with the indiscriminate use of ICD codes. Limiting the use of ICD codes to adult patients with incident episode of AP may improve identification of patients with pancreatitis in administrative databases.