Development of colonic stenosis following severe acute pancreatitis

BackgroundColonic necrosis after acute pancreatitis is rare. When it does occur, it is commonly due to ischaemia or inflammation and may necessitate early colonic resection.Case outlineA 72-year-old man developed colonic necrosis 6 weeks after severe acute pancreatitis. CT scan revealed a bulky mass near the left colon. Barium enema and colonoscopy revealed stenosis of the left colonic flexure, and this segment of bowel was successfully resected.DiscussionSevere acute pancreatitis must be recognised as a cause of colonic ischaemia and necrosis. The possible pathogenic mechanisms include severe local inflammation and an ischaemic process. This complication is associated with a very poor prognosis despite surgical intervention, but a timely resection may prevent further problems.     

Development of colonic necrosis following severe acute pancreatitis

We herein describe a 70-year-old male patient who developed colonic necrosis following severe acute pancreatitis. He was referred to our hospital with a diagnosis of acute pancreatitis. In the course of the disease, he developed sudden and massive hematochezia and died. The autopsy findings revealed large bowel ischemia with transmural infarction. The possible pathogenic mechanisms of colonic ischemia are also discussed.     

Duodenal obstruction following acute pancreatitis caused by a large duodenal diverticular bezoar

Bezoars are concretions of indigestible materials in the gastrointestinal tract. It generally develops in patients with previous gastric surgery or patients with delayed gastric emptying. Cases of periampullary duodenal divericular bezoar are rare. Clinical manifestations by a bezoar vary from no symptom to acute abdominal syndrome depending on the location of the bezoar. Biliary obstruction or acute pancreatitis caused by a bezoar has been rarely reported. Small bowel obstruction by a bezoar is also rare, but it is a complication that requires surgery. This is a case of acute pancreatitis and subsequent duodenal obstruction caused by a large duodenal bezoar migrating from a periampullary diverticulum to the duodenal lumen, which mimicked pancreatic abscess or microperforation on abdominal computerized tomography. The patient underwent surgical removal of the bezoar and recovered completely.     

Timing of mortality in severe acute pancreatitis： Experience from 643 patients

AIM： To determine the timing of mortality after onset of severe acute pancreatitis （SAP） and the course of the disease in a large series of patients. METHODS： From July 1996 to June 2005, all patients diagnosed with acute pancreatitis at Chang Gung Memorial Hospital, Taipei, Taiwan were retrospectively studied. Three thousand two hundred and fifty episodes of acute pancreatitis were recorded in 2248 patients （1431 males and 817 females; median age, 55.6 years; range, 18-97 years）. Mortality was divided into two groups： early death （≤ 14 d after admission）, and late death （〉 14 d after admission）. The clinical features of patients in these two groups were compared. RESULTS： Although the overall mortality rate of acute pancreatitis was 3.8% （123/3250）, mortality rate of SAP was as high as 16.3% （105/643）. Of those 105 SAP mortalities, 44 （41.9%） deaths occurred within the first 14 d after admission and 61 （58.1%） occurred after14 d. Incidence of early death did not significantly differ from that of late death. The co-morbidities did not contribute to the timing of death. Early deaths mainly resulted from multiple organ failure. Late deaths were mainly caused by secondary complication of infected necrosis. Intraabdominal bleeding significantly caused higher mortality in late death. CONCLUSION： Approximately half （42%） of SAP deaths occur within 14 d and most were due to multiple organ failure. The late deaths of SAP were mostly due to infected necrosis.     

One-stop outpatient cardiology clinics: 10 years' experience

A one-stop outpatient cardiology clinic was set up at the Vic General Hospital in Spain in 1996. The aims were to provide patients with a rapid response, and to ensure that, on the same day, they saw a specialist and were referred for any relevant investigations required, primarily echocardiography, exercise testing, and Holter monitoring. We report experience from 10 years of follow-up, involving 19,515 consultations. The mean waiting time for a consultation was 3 days. We analyzed the reasons for the consultations, the investigations carried out, and the reductions in follow-up visits and hospital admissions. Primary care physicians' level of satisfaction was increased by this approach. The one-stop clinic proved feasible in clinical practice and proved robust during the follow-up period. This clinical model was beneficial for patients, was highly acceptable to primary care physicians, reduced the need for patients to contact the hospital, and, possibly, reduced hospital admissions.     

Peritonitis: 10 years' experience in a single surgical unit.

BACKGROUND: Peritonitis secondary to gut perforation is still one of the commonest surgical emergencies in India and is associated with high morbidity and mortality. The present study examines the aetiology and outcome of peritonitis cases operated on in our surgical unit, and compares our findings with those of previous studies performed between 1981 and 1991. METHOD: A retrospective study of 260 peritonitis patients operated on in a single surgical unit from 1995 to 2006 was done and data involving clinical presentation, operative findings and post-operative course were studied and analysed. RESULTS: Causes of peritonitis were small bowel perforation (96 ileal, 17 jejunal), peptic perforation (45 duodenal, 16 gastric), appendicular perforation (36), primary peritonitis (8), and others (42). The incidence of major complications was 25% (burst-11%, leak-5%, intraabdominal abscess-5%, multi-organ failure-6.5%). The overall mortality was 10%. High mortality was observed in jejunal, gall bladder and liver abscess perforation cases (> 20%). Histopathological evaluation (143 specimens) revealed tuberculosis in 42 (mostly small bowel), malignancy in 8, and inflammation in the rest. Comparisons with a similar study carried out in the same unit and published in 1995 revealed similar demographic features and mortality, but a change in the most common cause (peptic ulcer perforation to small bowel perforation), and an increased performance of enterostomy compared with primary repair in small bowel perforation and a decrease in the leak rate (13% to 4%). CONCLUSION: Small bowel perforation is the commonest form of perforation and the mortality rate associated with peritonitis remains unchanged.     

Predictors of severe and critical acute pancreatitis: A systematic review

BackgroundPersistent organ failure and infected pancreatic necrosis are major determinants of mortality in acute pancreatitis, but there is a gap in the literature assessing the best available predictors of these two determinants. The purpose of this review was to investigate the utility of predictors of persistent organ failure and infected pancreatic necrosis in patients with acute pancreatitis, both alone and in combination.MethodsWe performed a systematic search of the literature in 3 databases for prospective studies evaluating predictors of persistent organ failure, infected pancreatic necrosis, or both, with strict eligibility criteria.ResultsThe best predictors of persistent organ failure were the Japanese Severity Score and Bedside Index of Severity in Acute Pancreatitis when the evaluation was performed within 48 h of admission, and blood urea nitrogen and Japanese Severity Score after 48 h of admission. Systemic Inflammation Response Syndrome was a poor predictor of persistent organ failure. The best predictor of infected pancreatic necrosis was procalcitonin.ConclusionsBased on the best available data, it is justifiable to use blood urea nitrogen for prediction of persistent organ failure after 48 h of admission and procalcitonin for prediction of infected pancreatic necrosis in patients with confirmed pancreatic necrosis. There is no predictor of persistent organ failure that can be justifiably used in clinical practice within 48 h of admission.     

Galactose elimination capacity as a prognostic marker in patients with severe acetaminophen-induced hepatotoxicity: 10 years' experience.

BACKGROUND & AIMS: Patients with acetaminophen-induced fulminant hepatic failure may have the capacity for recovery if sufficient liver cell mass remains to allow regeneration. We investigated the prognostic potential of the galactose elimination capacity (GEC) as a noninvasive measurement of functioning liver cell mass in severe acetaminophen-induced hepatotoxicity. METHODS: All patients admitted with acetaminophen poisoning during a 10-year period were studied retrospectively. A total of 220 patients who had at least one GEC performed were included in the study. RESULTS: The GEC was lower in patients with than without hepatic encephalopathy (14.5 +/- 5.6 micromol/min/kg vs. 23.2 +/- 6.7 micromol/min/kg; P < 0.0001). Among patients with hepatic encephalopathy, the GEC was significantly higher in spontaneous survivors than in nonsurvivors (16.8 +/- 5.6 micromol/min/kg vs. 12.2 +/- 4.7 micromol/min/kg; P < 0.0001). In a logistic regression analysis, GEC was associated independently with mortality (odds ratio: 1.28 per 1 micromol/min/kg decrease in GEC; 95% confidence interval: 1.14-1.45). A threshold GEC of 16.5 micromol/min/kg to identify nonsurvivors had a sensitivity of 90%, a specificity of 72%, a positive predictive value of 49%, and a negative predictive value of 96%. None of 14 patients with hepatic encephalopathy and a GEC less than 10 micromol/min/kg survived. CONCLUSIONS: The GEC was strongly associated with development of hepatic encephalopathy and death from acetaminophen-induced fulminant hepatic failure. The GEC was too unspecific to be used alone for identification of transplantation candidates, but it may be useful as a supplement to other selection criteria.     

Duodenal duplication revealed by acute pancreatitis: endoscopic treatment

We report the case of a 17 year old man who presented with several episodes of acute pancreatitis due to a duodenal duplication. This was successfully treated by an incision by sphincterotome during interventional duodenoscopy. The patient is symptom free without recurrence 20 months after endoscopic treatment.     

中药大黄辅助治疗重症急性胰腺炎的系统评价

目的:评价中药大黄辅助治疗重症急性胰腺炎的疗效.方法:检索2009-06v2前Medline、中国生物医学文献数据库(CBMdisk,1978-2009)、中国期刊全文数据库(CNKI,1994.2009)、维普数据库(1989-2009)发表的有关中药大黄辅助治疗重症急性胰腺炎疗效的随机对照临床试验并手工检索相关文献,按入选和排除标准选择试验、评价入选文献的质量,提取相关数据,采用RevMan4.2软件进行统计学分析.结果:共有10项临床试验纳入本研究,大黄辅助治疗组腹痛缓解时间(WMD=-2.14,95%CI:-2.57,-1.70;P<0.01)、并发症发生率(RR=0.49;95%CI:0.36,0.65;P<0.01)均明显低于对照组,差异有统计学意义.病死率(RR=0.54;95%CI:0.25,1.13;P=0.10)与对照组比较无统计学意义.结论:中药大黄辅助治疗SAP能显著降低患者并发症发病率,并能缩短患者腹痛持续时间,但对于降低死亡率与对照组无区别.中药大黄辅助治疗SAP值得临床推广应用.     

重症急性胰腺炎的早期处理

重症急性胰腺炎起病凶险,病死率较高。对重症急性胰腺炎的早期识别及早期治疗有助于减少器官衰竭、感染等并发症的发生,降低病死率。该文从早期病情评估、早期病情监测及早期治疗3个方面介绍重症急性胰腺炎的早期处理,以期提高临床医生对重症急性胰腺炎早期诊治的认识。     

Early nasogastric enteral nutrition for severe acute pancreatitis： A systematic review

AIM: To evaluate the effectiveness and safety of early nasogastric enteral nutrition (NGEN) for patients with severe acute pancreatitis (SAP). METHODS: We searched Cochrane Central Register of Controlled Trials (Issue 2, 2006), Pub-Medline (1966-2006), and references from relevant articles. We included randomized controlled trials (RCTs) only, which reported the mortality of SAP patients at least. Two reviewers assessed the quality of each trial and collected data independently. The Cochrane Collaboration’s RevMan 4.2.9 software was used for statistical analysis. RESULTS: Three RCTs were included, involving 131 patients. The baselines of each trial were comparable. Meta-analysis showed no significant differences in mortality rate of SAP patients between nasogastric and conventional routes (RR = 0.76, 95% CI = 0.37 and 1.55, P = 0.45), and in other outcomes, including time of hospital stay (weighted mean difference = -5.87, 95% CI = -20.58 and 8.84, P = 0.43), complication rate of infection (RR = 1.41, 95% CI = 0.62 and 3.23, P = 0.41) or multiple organ defi ciency syndrome (RR = 0.97, 95% CI = 0.27 and 3.47, P = 0.97), rate of admission to ICU (RR = 1.00, 95% CI = 0.48 and 2.09, P = 0.99) or conversion to surgery (RR = 0.66, 95% CI = 0.12 and 3.69, P = 0.64), as well as recurrence of re-feeding pain and adverse events associated with nutrition. CONCLUSION: Early NGEN is a breakthrough in the management of SAP. Based on current studies, early NGEN appears effective and safe. Since the available evidence is poor in quantity, it is hard to make an accurate evaluation of the role of early NGEN in SAP.Before recommendation to clinical practice, further high qualified, large scale, randomized controlled trials are needed.     

Pyogenic liver abscess：An audit of 10 years’experience

AIM: To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.METHODS: A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre, were reviewed. Amoebic and hydatid abscesses were excluded. Demographic, clinical, radiological, and microbiological characteristics, as well as surgical/radiological interventions, were recorded.RESULTS: Sixty-three patients (42 males, 21 females) aged 65 (± 14) years [mean ± (SD)] had prodromal symptoms for a median (interquartile range; IQR) of 7 (5-14) d. Only 59% of patients were febrile at presentation; however, the serum C-reactive protein was elevated in all 47 in whom it was measured. Liver function tests were non-specifically abnormal. 67% of patients had a solitary abscess, while 32% had > 3 abscesses with a median (IQR) diameter of 6.3 (4-9) cm. Causative organisms were: Streptococcus milleri 25%, Klebsiella pneumoniae 21%, and Escherichia coli 16%. A presumptive cryptogenic cause was most common (34%). Four patients died in this series: one from sepsis, two from advanced cancer, and one from acute myocardial infarction. The initial procedure was radiological aspiration ± drainage in 54 and surgery in two patients. 17% underwent surgical management during their hospitalization. Serum hypoalbuminaemia [mean (95% CI): 32 (29-35) g/L vs 28 (25-31) g/L, P = 0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis.CONCLUSION: PLA is a diagnostic challenge, because the presentation of this condition is non-specific. Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs; However, a small proportion of patients still require surgical drainage.     

Continuous veno-venous haemofiltration in the treatment of severe acute pancreatitis: 6-year experience

Background. Continuous veno-venous haemofiltration (CVVH) could be reasonable for attenuation of systemic complications in severe acute pancreatitis (SAP). The aim of the study was implementation and feasibility assessment of the CVVH in the treatment protocol of SAP. Patients and methods. CVVH was applied to 111 SAP patients during 2000–2005. APACHE II, systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), serum lipase, C-reactive protein (CRP), complication rate and main outcomes were analysed comparing two periods. Results. Overall, 39 patients corresponded to Balthazar grade E SAP and 72 patients to necrotizing SAP (NSAP), with an average APACHE II score of 7 and 8.5, respectively, on admission. CVVH was started within 48 h in 82% of patients. Duration of CVVH was significantly augmented in NSAP patients during the routine period, comprising 92 h (p=0.006). The clinical presentation of SIRS and MODS was similar in both periods, with more initial pulmonary dysfunctions in NSAP (p=0.048). Peripancreatic infection decreased in the routine period; surgical interventions were performed in 34.8% vs 72.4% of patients. Hospital stay comprised on average 15.9 days for grade E SAP and 29.4 days for NSAP in the routine period, with overall mortality of 10.26% and 30.5%, respectively. Discussion. Application of CVVH in the treatment protocol of SAP is obscure due to relative invasiveness, a poorly understood mechanism of action and scarce clinical experience. We conclude that early pre-emptive application of CVVH is safe and feasible in the treatment of SAP. Duration of the procedure seems to be essential. Randomized clinical trials are justified. Our results are in favour of clinical application of CVVH in the treatment of SAP.     

Endoscopic retrograde cholangiopancreatography-induced severe acute pancreatitis.

BACKGROUND/AIMS: There is scant information in the literature about the outcomes of endoscopic retrograde cholangiopancreatography (ERCP)-induced severe acute pancreatitis (ESAP). Compared to other causes, higher morbidity and mortality have been reported in ERCP-induced acute pancreatitis. We undertook this study to determine the differences between ESAP and SAP due to other causes (OSAP). METHODS: We retrospectively identified all cases of SAP admitted to our institution during the years 1992-2001. We reviewed the medical records of all SAP patients to obtain information on demographics, interventions, local and systemic complications and outcomes. RESULTS: We identified 207 patients with SAP, of whom 16 (7.7%) had ESAP and 191 OSAP. There was no difference between ESAP and OSAP with regard to demographics, clinical interventions, local and systemic complications and outcomes. Both groups had a similar mortality (25 vs. 18%). CONCLUSION: ESAP has a similar morbidity and mortality compared to OSAP.     

Antibiotic prophylaxis in severe acute pancreatitis.

Severe acute pancreatitis is considered to be a subgroup of acute pancreatitis with the development of local and/or systemic complications. A significant correlation exists between the development of pancreatic necrosis, the frequency of bacterial contamination of necrosis and the evolution of systemic complications. Bacterial infection and the extent of necrosis are determinants for the outcome of severe acute pancreatitis. The late course of necrotizing pancreatitis is determined by bacterial infection of pancreatic and peripancreatic necroses. Mortality increases from 5-25% in patients with sterile necrosis to 15-28% when infection has occurred. The use of prophylactic antibiotics has been recommended in patients with necrotizing pancreatitis. Several controlled clinical trials demonstrated a significant reduction in pancreatic infections or a significant reduction of hospital mortality. However, the results of these clinical trials are controversial and not convincing. Recently, the largest randomized placebo-controlled, double-blind trial has been able to demonstrate that antibiotic prophylaxis with ciprofloxacin and metronidazole has no beneficial effects with regard to the reduction of pancreatic infection and the decrease of hospital mortality. The clinical data from this placebo-controlled trial do not support antibiotic prophylaxis in all patients with necrotizing pancreatitis, but in specific subgroups of patients with pancreatic necrosis and a complicated course.     

Changing patterns of blood culture isolates from patients with acute leukemia: a review of twenty years' experience.

During the 20-year period, 1972-1991, 286 episodes of bacteremia occurred in 200 (45%) of 445 patients with acute leukemia in a hematology ward, giving an incidence of 482 episodes per 1,000 hospital admissions. The frequency of bacteremia was almost unchanged throughout the study period. The frequency of gram-negative bacilli decreased significantly, however, from 81% of all the isolates for the first half of the study period to 50% for the latter half. Despite the common use of ceftazidime and imipenem during the last 5-year period, Pseudomonas aeruginosa increased in frequency to be the most frequent organism. This was opposite to the decreased frequencies of Escherichia coli, Klebsiella pneumoniae and Enterobacter cloacae. The isolates of P. aeruginosa obtained during this period, all of which proved sensitive to ceftazidime and/or imipenem, were almost equally distributed among five serogroups, although a temporal preponderance of a limited number of serogroups was observed during the preceding 15-year period. On the other hand, the frequency of gram-positive cocci increased from 9% in the first decade to 35% in the latter decade. Staphylococcus epidermidis, Enterococcus species and, to a lesser extent, Staphylococcus aureus were ranked as major pathogens. Among the recent isolates of S. aureus, methicillin-resistant strains virtually replaced methicillin-sensitive ones. Therefore, until more effective means for control of P. aeruginosa bacteremia in particular become available, the occurrence of this infection will continue to limit the successful treatment of acute leukemia.