Severe acute pancreatitis： Clinical course and management

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (> 50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis- Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.     

Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm

Chronic pancreatitis is an ongoing disease characterized by persistent inflammation of pancreatic tissues.With disease progression,patients with chronic pancreatitis may develop troublesome complications in addition to exocrine and endocrine pancreatic functional loss.Among them,a pseudoaneurysm,mainly induced by digestive enzyme erosion of vessels in proximity to the pancreas,is a rare and life-threatening complication if bleeding of the pseudoaneurysm occurs.At present,no prospective randomized trials have investigated the therapeutic strategy for this rare but critical situation.The role of arterial embolization,the timing of surgical intervention and even surgical procedures are still controversial.In this review,we suggest that dynamic abdominal computed tomography and angiography should be performed first to localize the bleedersand to evaluate the associated complications such as pseudocyst formation,followed by arterial embolization to stop the bleeding and to achieve early stabilization of the patient’s condition.With advances and improvements in endoscopic devices and techniques,therapeutic endoscopy for pancreatic pseudocysts is technically feasible,safe and effective.Surgical intervention is recommended for a bleeding pseudoaneurysm in patients with chronic pancreatitis who are in an unstable condition,for those in whom arterial embolization of the bleeding pseudoaneurysm fails,and when endoscopic management of the pseudocyst is unsuccessful.If a bleeding pseudoaneurysm is located over the tail of the pancreas,resection is a preferential procedure,whereas if the lesion is situated over the head or body of the pancreas,relatively conservative surgical procedures are recommended.     

Acute necrotizing pancreatitis as fi rst manifestation of primary hyperparathyroidism

We report the case of a female patient with severe acute necrotizing pancreatitis associated with hypercalcemia as first manifestation of primary hyperparathyroidism caused by a benign parathyroid adenoma.Initially the acute pancreatitis was treated conservatively.The patient subsequently underwent surgical resection of the parathyroid adenoma and surgical clearance of a large infected pancreatic pseudocyst.Although the association of parathyroid adenoma-induced hypercalcemia and acute pancreatitis is a kno...     

Hemosuccus pancreaticus： Problems and pitfalls in diagnosis and treatment

Hemosuccus pancreaticus is a rare cause of intermittent upper gastrointestinal bleeding. We report two cases of hemosuccus pancreaticus with multiple episodes of upper gastrointestinal bleeding. The causes of hemorrhage were rupture of pseudoaneurysm of the splenic artery and bleeding from the wall of pancreatic pseudocyst. Interventional radiology is the first modality for early diagnosis and possible treatment of hemosuccus pancreaticus. When angiography shows no abnormal findings or interventional radiological therapy can not be successful, surgery should be considered without delay. Our patients herein underwent surgery without recurrence or sequelae. Intraoperative ultrasonography and pancreatoscopy were helpful modalities for confirming the source of hemorrhage and determining the cutting line of the pancreas. When we encounter intermittent upper gastrointestinal bleeding with an obscure source, hemosuccus pancreaticus should be included in differential diagnoses especially in patients with chronic pancreatitis, which would lead to a prompt and proper treatment.     

Magnetic resonance imaging for local complications of acute pancreatitis: A pictorial review

Acute pancreatitis is a common disease characterized by sudden upper abdominal pain and vomiting. Alcoholism and choledocholithiasis are the most common factors for this disease. The choice of treatment for acute pancreatitis might be affected by local complications, such as local hemorrhage in or around the pancreas, and peripancreatic infection or pseudoaneurysm. Diagnostic imaging modalities for acute pancreatitis have a significant role in confirming the diagnosis of the disease, helping detect the exte...     

Acute pancreatitis induced by transarterial chemoembolization：a single-center experience of over 1500 cases

BACKGROUND: Acute pancreatitis is a relatively rare but po-tentially lethal complication after transarterial chemotherapy. This study aimed to review the complications such as acute pancreatitis after transarterial chemotherapy with or without embolization for hepatocellular carcinoma.
METHODS: A total of 1632 patients with hepatocellular car-cinoma who had undergone transarterial chemoembolization from January 2000 to February 2014 in a single-center were reviewed retrospectively. We investigated the potential com-plications of transarterial chemoembolization, such as acute pancreatitis and acute pancreatitis-related complications.
RESULTS: Of the 1632 patients with hepatocellular carcinoma who had undergone 5434 transarterial chemoembolizations, 1328 were male and 304 female. The median age of these pa-tients was 61 years. Most (79.6%) of the patients suffered from HBV-related hepatocellular carcinoma. The median tumor size was 5.2 cm. Of the 1632 patients, 145 patients underwent transarterial chemoembolization with doxorubicin elut-ing bead, making up a total of 538 episodes. The remaining patients underwent transarterial chemoembolization with cisplatin. Seven (0.4%) patients suffered from acute pancre-atitis post-chemoembolization. Six patients had chemoembo-lization with doxorubicin and one had chemoembolization with cisplatin. Patients who received doxorubicin eluting bead had a higher risk of acute pancreatitis [6/145 (4.1%) vs 1/1487 (0.1%), P<0.0001]. Two patients had anatomical arte-rial variations. Four patients developed acute pancreatitis-related complications including necrotizing pancreatitis (n=3) and pseudocyst formation (n=1). All of the 4 patients resolved after the use of antibiotics and other conservative treatment. Three patients had further transarterial chemoembolization without any complication.
CONCLUSIONS: Acute pancreatitis after transarterial chemo-embolization could result in serious complications, especially after treatment with doxorubicin eluting bead. Continuation of current treatment with transarterial chemoembolization after acute pancreatitis is feasible providing the initial attack is completely resolved.     

Stent placement is effective on both postoperative hepatic arterial pseudoaneurysm and subsequent portal veinstricture： A case report

To treat postoperative bleeding after hepato-pancreato-biliary surgery, interventional radiology has become essential. We report a case of coincidental pseudoan-eurysm and jejunal varices that were both successfully treated by stent-grafts. After a pancreaticoduodenec-tomy, the patient developed a pseudoaneurysm in the hepatic artery and a stenosis in its periphery. After establishing hepatic arterial flow by placing stent-grafts over both the pseudoaneurysm and the stenosis, the pseudoaneurysm was embolized with microcoils. Nine months later, the patient developed jejunal varices caused by a severe stricture in the main trunk of the portal vein. Percutaneous transhepatic portography was performed and stent-grafts were placed over the stenotic segment. A venoplasty using stent-grafts nor-malized the portal blood flow and the jejunal varices vanished. Although stenosis occurred due to scarred tissues from leakage after pancreaticoduodenectomy, stent-grafts were useful for managing jejunal bleeding post-operatively.     

An autopsy case of acute pancreatitis with a high serum IgG4 complicated by amyloidosis and rheumatoid arthritis

We report an autopsy case of acute pancreatitis with a high serum IgG4 concentration complicated by systemic amyloid A amyloidosis and rheumatoid arthritis (RA). The patient was a 42-year-old Japanese female with a 22-year history of rheumatoid arthritis. She was diagnosed with myasthenia gravis when she was 31-year old. At the onset of pancreatitis, the patient was anti-nudear antibody-positive, and had high serum gamma globulin and IgG4 levels. Dexamethasone and conventional therapy induced clinical remission and significantly decreased the serum IgG4 and gamma globulin. However, despite the decreased disease parameters, the patient developed a bleeding pseudocyst and died of cardiac failure. In the autopsy examination, it was determined that pancreatitis was probably caused by ischemia due to vascular obstruction caused by amyloid deposition in the pancreas. Even though acute pancreatitis is a rare complication in RA patients, we speculate that an autoimmune pancreatitis-related mechanism and ischemia due to vascular obstruction by amyloid deposition might be attributable to a single source that leads to acute pancreatitis in our particular case.     

Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed?

In 1886,Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis.Since then,necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis(NP).No published report has successfully questioned the role of necrosectomy.Recently,however,increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy.The literature concerning NP published primarily after 2000 was reviewed;it demonstrates the feasibility of a paradigm shift.The majority(75%)of minimally invasive necrosectomies show higher completion rates:between 80%and 100%.Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent.Related morbidities range from 40%to 92%.Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy,but not with video-assisted retroperitoneal necrosectomy series.Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments.Most series have reached higher success rates of 79%-93%,and even 100%,using transcystic multiple drainage methods.It is becoming evident that transluminal endoscopic drainage treatment of walledoff NP without a necrosectomy is feasible.With further refinement of the drainage procedures,a paradigm shift from necrosectomy to drainage is inevitable.     

Successful management of hepatic artery pseudoaneurysm complicating chronic pancreatitis by stenting

INTRODUCTION Hepatic artery pseudoaneurysm (HAP) is a serious complication of acute or chronic surgical injury to the hepatic artery. It is also seen following blunt and penetrating abdominal injury as well as in patients with chronic pancreatitis and aft…     

Hemorrhagic pseudocyst and pseudocyst with pseudoaneurysm successfully treated by pancreatectomy: report of three cases

Hemorrhagic pseudoaneurysm of pancreatic pseudocyst is one of the serious complications of acute pancreatitis. We successfully treated three patients who had hemorrhagic pseudocyst and pseudocyst with pseudoaneurysm by pancreatectomy. Case 1 was 43-year-old Japanese man who had had several episodes of acute pancreatitis and was diagnosed with hemorrhagic pseudoaneurysm of the splenic artery in a pseudocyst in the pancreatic tail, shown on computed tomography (CT) and angiography. Transarterial embolization (TAE) yielded hemostasis of the pseudoaneurysm, but rebleeding occurred 2 weeks after the TAE. Distal pancreatectomy and splenectomy was successfully performed. Case 2 was a 64-year-old Japanese man who presented to us with several attacks of acute pancreatitis. Imagings showed bleeding pseudoaneurysm of the transverse pancreatic artery in a pseudocyst in the pancreatic body. Because of marked stenosis in the proximal portion of the transverse pancreatic artery, TAE was unsuccessful. Distal pancreatectomy and splenectomy was performed successfully. Case 3 was a 40-year-old Japanese woman who had a history of abdominal trauma. Imagings showed bleeding pseudoaneurysm of the splenic artery in a posttraumatic pseudocyst in the pancreas. TAE of the pseudoaneurysm was unsuccessful because of the proximity of the pseudoaneurysm and the splenic artery. Distal pancreatectomy and splenectomy was successfully performed and her postoperative outcome was satisfactory. Whenever interventional radiology (IVR) is not indicated or has failed, aggressive and immediate surgical intervention should be considered for early and definitive recovery in these patients.     

Case of a bleeding pseudoaneurysm of the middle colic artery complicating acute pancreatitis

Massive bleeding from a pseudoaneurysm is rare, but it can be a life-threatening complication in patients with acute pancreatitis. We present a case in which massive bleeding from a pseudoneurysm in the middle colic artery complicating acute pancreatitis was successfully treated by transcatheter embolization and by continuous regional arterial infusion of a protease inhibitor and antibiotic. We also discuss the clinical features, diagnosis and treatment of such lesions in light of the literature. We emphasize the value of computed tomography in the early diagnosis of mesenteric hematoma in cases of acute pancreatitis and the value of angiography for control of bleeding from the complicating pseudoaneurysm.     

Diagnostic evaluation and aggressive surgical approach in bleeding pseudoaneurysms associated with pancreatic pseudocysts

Hemorrhage is an uncommon but serious complication of pancreatic pseudocysts. When gastrointestinal bleeding or intra-abdominal hemorrhage is associated with a pancreatic pseudocyst and the usual sources of bleeding are not detected by endoscopy, the rupture of a pseudoaneurysm inside the pseudocyst should be suspected. We present 13 cases, 11 associated with chronic and 2 with late complications after acute necrotizing pancreatitis. On the basis of sonographic findings, bleeding site was suspected in 8 of 11 patients (73%). Computed tomography (CT) was performed on 10, and bleeding was suspected in 8 (80%). The pseudoaneurysm itself was detected by CT in one and by ultrasonography in none. Visceral angiography was performed on five patients, and the pseudoaneurysm was evident in all. External drainage with arterial ligation was done as a primary operation in five patients; four of them later underwent pancreatic resection because of rebleeding. In eight cases pancreatic resection was the initial operation; none of these patients continued to bleed or needed reoperation because of the same pseudoaneurysm. There were no intraoperative deaths, but one patient died postoperatively. Aggressive diagnostic evaluation and surgical approach are associated with a reduction in mortality and morbidity in this serious complication of pancreatic pseudocysts.     

Acute pancreatitis with an emphasis on infection

Acute pancreatitis is an inflammatory disease that is mild and self-limiting in about 80% of cases. However, severe necrotizing disease still has a mortality of up to 30%. Differentiated multimodal treatment concepts are needed for these patients, including a multidisciplinary team (intensivists, gastroenterologists, interventional radiologists, and surgeons). The primary therapy is supportive. Patients with infected pancreatic necrosis who are septic undergo interventional or surgical treatment, ideally not before the fourth week after onset of symptoms. This article reviews the pathophysiologic mechanisms of acute pancreatitis and describes clinical pathways for diagnosis and management based on the current literature and guidelines.     

Interventionelle Therapieverfahren bei akuter nekrotisierender Pankreatitis

The clinical course of acute pancreatitis is variable. Severe pancreatitis is observed in up to 20% of cases and is associated with high mortality rates of up to 40%. The most serious complication is the infection of the (peri-)pancreatic necroses. The therapeutic goal is debridement of the infected material. Whereas surgical methods still represent the gold standard, minimally invasive interventional approaches are gaining importance. This article reviews the different interventional procedures, particularly percutaneous, CT-guided drainage and necrosectomy. Furthermore, an overview of published studies about interventional therapy in patients with acute necrotizing pancreatitis is given.     

Management and outcome of bleeding pseudoaneurysm associated with chronic pancreatitis

Background  

A bleeding pseudoaneurysm in patients with chronic pancreatitis is a rare and potentially lethal complication. Optimal treatment of bleeding peripancreatic pseudoaneurysm remains controversial. This study reports on experience at Chang Gung Memorial Hospital (CGMH) in managing of bleeding pseudoaneurysms associated with chronic pancreatitis.     

Risk Factors and Outcome for Massive Intra-Abdominal Bleeding Among Patients With Infected Necrotizing Pancreatitis

The incidence of acute bleeding is reported to be 13.5% in patients with acute necrotizing pancreatitis. However, of all the bleeding events, intra-abdominal bleeding was less studied in the literature and its risk factors have not been well defined yet. The purpose of the present study was to investigate the risk factors for massive intra-abdominal bleeding among the patients with infected necrotizing pancreatitis and assessed the outcome of these patients.Both univariate and multivariate logistic regression models were applied for evaluating risk factors for intra-abdominal bleeding using 33 indices, including age, sex, etiology of acute pancreatitis (AP), APACHE II score, etc. Outcome assessments such as mortality, hospital and intensive care unit (ICU) durations, and cost were also compared between patients with or without intra-abdominal bleeding.Acute kidney injury (AKI) (odds ratio [OR]: 7.54, 95% confidence interval [CI]: 2.53–22.52, P < 0.001) and number of operation (OR: 8.84, 95% CI: 2.01–38.86, P = 0.004) were 2 predictors for massive intra-abdominal bleeding in the patients with infected necrotizing pancreatitis. In addition, AP patients with intra-abdominal bleeding also showed significantly higher mortality rate, prolonged hospital and ICU durations, more complications and invasive treatments, as well as increased cost.Our study revealed that AKI and multiple operations were 2 critical factors increasing the risk of intra-abdominal bleeding among patients with infected necrotizing pancreatitis. Additionally, massive intra-abdominal bleeding was also associated with poor prognosis.     

Thrombosis of splenic artery pseudoaneurysm complicating pancreatitis.

The natural history of pseudoaneurysms complicating pancreatitis is unknown. A patient with chronic pancreatitis is described in whom thrombosis of a splenic artery pseudoaneurysm occurred. Early diagnosis and radical treatment of a bleeding pseudoaneurysm are mandatory. When elective treatment is considered, however, contrast enhanced computed tomography may be useful just before surgery as thrombosis may occur.     

Microcoils embolization of splenic artery pseudoaneurysm complicated with chronic pancreatitis

Chronic pancreatitis is known to cause vascular complications including pseudoaneurysm of peripancreatic arteries that can lead to massive gastrointestinal bleeding. We report a 30-year-old man with splenic artery pseudoaneurysm formation secondary to chronic pancreatitis. The bleeding was successfully controlled by superselective microcoils embolization of the pseudoaneurysm with splenic preservation. The patient was discharged in 2 days with complete recovery. We consider superselective transcatheter embolization as one of the safest procedures and should be considered as a therapeutic option in the management of pseudoaneurysm caused by pancreatitis.