A rare case report of ascending colon perforation secondary to acute pancreatitis

IntroductionSevere acute pancreatitis is associated with high morbidity and mortality. This is a result of the development of pancreatic and extra-pancreatic necrosis with subsequent infection which can lead to multiorgan failure. Complications include localized ileus, abscess formation, mechanical obstruction, rupture and perforation into the gastrointestinal tract and fistula formation (Aldridge et al., 1989; Bassi et al., 2001 [1,2]).Case presentationA 72 year old man attended the emergency department with acute epigastric pain.Biochemistry results were reviewed with a lipase of 1680 U/L (ref range <60 U/L). He was treated conservatively. He had a labile course throughout his admission and on day 7 he had significant deterioration.Abdominal CT scan demonstrated marked mechanical large bowel obstruction at the level of the sigmoid colon, caecum dilated with features suggestive of ischaemia in the caecal wall and backflow dilatation of the small bowel loops.The patient was transferred to a tertiary centre for subsequent laparotomy and bowel resection.DiscussionColonic complications of acute pancreatitis are uncommon. An analysis of pooled data reports the incidence of colonic complications from acute pancreatitis to be 3.3% and those from severe acute pancreatitis 15% (Bassi et al., 2001 [2]).Knowledge about colonic perforation from acute pancreatitis has been limited to few case reports, thus diagnostic and management dilemmas continue to persist.ConclusionsWe report a rare case of ascending colon perforation in severe acute pancreatitis. This is particularly unusual given the anatomical propensity for splenic flexure involvement or transverse colon involvement being noted in literature. This highlights the high index of suspicion required for colonic complications given the varied, non-specific and often delayed presentation of complications.     

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目的 探讨胰腺假性囊肿(PPC)的治疗方法和其基础疾病的关系。方法 收集浙江大学医学院附属第一医院1992～2003年收治的73例PPC的临床资料，根据D’Egidio分型方法分型，前瞻性分析其基础疾病、主胰管解剖和治疗成功率的相关关系。结果 37例D’EgidioⅠ型PPC中16例进行手术引流，8例发生并发症或复发，治疗成功率为50％(8／16)；另11例行经皮穿刺引流，治疗成功率82％(9／11)。24例Ⅱ型PPC中9例行经皮穿刺或手术外引流，5例发生并发症或复发，治疗成功率为44％(4／9)；另12例经手术内引流或切除治疗，治疗成功率为92％(11／12)，12例Ⅲ型PPC，10例经手术内引流或切除治疗，2例复发，治疗成功率为80％(8／10)。结论 对胰腺假性囊肿基础疾病的分型可以指导其治疗。了解胰腺假性囊肿的基础疾病，对Ⅱ型、Ⅲ型PPC行ERCP明确胰管解剖，有利于正确选择治疗方案，降低并发症发生率和复发率。     

Outcomes of delayed endoscopic retrograde cholangiopancreatography in patients with acute biliary pancreatitis with cholangitis

ObjectiveThe recommended treatment for acute biliary pancreatitis(ABP) with cholangitis is urgent endoscopic retrograde cholangiopancreatography(ERCP). However, tight schedules in the endoscopy room mean that urgent ERCP may not always be performed. This study aimed to compare the outcomes of early (≤72 h) and delayed(>72 h) ERCP in patients with ABP with cholangitis.MethodsNinety-five patients diagnosed with ABP with cholangitis who underwent ERCP between May 2012 and April 2018 were retrospectively reviewed.ResultsSixty-seven patients(70.5%) were classified in the early ERCP and 28(29.5%) in the delayed ERCP groups. There was no significant difference in pancreatitis severity between the groups. Total bilirubin was higher in the early compared with the late ERCP group (5.7 ± 5.2 versus 3.5 ± 2.3 mg/dL, p = 0.03). Fewer patients in the early group had end-stage renal disease (0 versus 3, p = 0.006) and relatively fewer patients in the early group took aspirin (15(22.4%) versus 12(42.9%), p = 0.04). There were no significant differences between the early and delayed ERCP groups in terms of mortality (2(3.0%) versus 0), disease-related complications(11 (16.4%) versus 5(17.9%), p = 0.86), or ERCP-related complications(5(7.5%) versus 3(10.7%), p = 0.60). The total length of stay(LoS) was shorter in the early group(6.3 ± 4.4 versus 9.8 ± 6.1 days, p = 0.002). The rate of complete stone removal was lower in the early compared with the delayed ERCP group(32/42(76.2%) versus 18/18(100%), p = 0.02).ConclusionDelayed ERCP can be performed in selected patients with ABP with cholangitis, with similar complication rates but longer LoS compared with early ERCP.     

Surgeons provide definitive care to patients with gallstone pancreatitis

Background

The optimal management of patients with gallstone pancreatitis (GP) remains a matter of debate. There are wide variations in the use of diagnostic testing and same-stay cholecystectomy. We hypothesize that a general surgery service (SURG) will deliver more efficient, definitive care for patients with GP.

Methods

A retrospective cohort study of consecutive GP patients in an urban hospital from 2006 to 2009. Differences between groups were assessed by the two-tailed Student t test for continuous variables and the Fisher exact test for ordinal data.

Results

One hundred twenty-four patients with GP were admitted, 79 to medicine (MED) and 45 to surgery (SURG). In the MED group, 21 patients (27%) underwent same-stay cholecystectomy, and 7 patients (9%) returned with recurrent biliary pancreatitis. In the SURG group, 44 patients had definitive surgery, and none returned with recurrent disease (P < .01 and .09, respectively). The SURG group had fewer laboratory tests, antibiotics, and consultations.

Conclusions

For patients with GP, admission to surgery results in definitive treatment with same-stay cholecystectomy. This is a more efficient approach with fewer readmissions for the same disease process.     

The application of immobilized polymyxin B fiber in the treatment of septic shock associated with severe acute pancreatitis: Report of two cases

(Received for publication on Sept. 2, 1998; accepted on May 28, 1999)     

内镜逆行胰胆管造影术治疗急性胆源性胰腺炎的临床疗效观察

目的观察内镜逆行胰胆管造影术(ERCP)治疗急性胆源性胰腺炎的效果。方法选取2016-02—2019-02间新蔡县人民医院收治的100例急性胆源性胰腺炎患者,按照随机数字表法分为2组,各50例。对照组采用药物治疗,观察组采用ERCP术治疗。比较2组治疗前后的血清炎症因子(CRP、TNF-α、IL-6、IL-8)水平、肝功能指标(AST、ALT、GGT、TBiL)、生化指标,以及临床症状改善效果。结果治疗后观察组患者的血清炎症因子水平、肝功能指标,以及体温、肝功能、淀粉酶、白细胞计数、胃肠道功能恢复正常时间,和恶心、呕吐消失及腹痛缓解时间等指标比较,均明显优于对照组,差异均有统计学意义(P<0.05)。结论采用ERCP术治疗急性胆源性胰腺炎,能有效抑制炎症因子释放,有利于改善患者的症状和促进肝功能及生化指标的恢复,是处理急性胆源性胰腺炎的重要治疗方式。     

JPN Guidelines for the management of acute pancreatitis: surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.     

Does endoscopic retrograde cholangiopancreatography reduce the risk of local pancreatic complications in acute pancreatitis? A systematic review and metaanalysis

Background  Recent studies have added to the controversy regarding the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of patients with acute biliary pancreatitis. This debate is due in part to a marked difference between the trials regarding the definition of “complication” as an outcome. This study sought to determine the effect of early ERCP versus conservative treatment on local pancreatic complications (defined by the current classification) experienced by patients with acute biliary pancreatitis. Methods  Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, Science Citation Index) and conference proceedings were searched for relevant randomized controlled trials up to December 2007. The effect of both treatment strategies on local pancreatic complications was calculated with random-effects models. Results  Five trials involving 717 patients were included in this systematic review. Pooled analysis of all the patients with acute pancreatitis did not demonstrate a statistically significant difference between the two treatment strategies (relative risk [RR], 0.94; 95% confidence interval [CI], 0.63–1.40; p = 0.62). Similar results were observed after subgroup analysis based on the severity of disease as follows: mild acute pancreatitis (RR, 0.79; 95% CI, 0.26–2.47; p = 0.69); severe acute pancreatitis (RR, 0.77; 95% CI, 0.30–1.98; p = 0.59). Conclusion  The early use of ERCP did not result in a significantly reduced risk of local pancreatic complications for either patients with mild acute pancreatitis or those with severe form of the disease.     

中药高位保留灌肠预防内镜逆行胰胆管造影术后胰腺炎的Meta分析

目的：系统评价中药高位保留灌肠预防内镜逆行胰胆管造影术后胰腺炎（PEP）的疗效和安全性。方法：计算机检索PubMed、The Cochrane Library、EMbase、中国知网、维普数据库、万方数据库、中国生物医学文献服务系统数据库,搜集关于中药高位保留灌肠预防PEP疗效和安全性的随机对照试验（RCT）,检索时限均从建库至2022年12月9日。由2名研究者独立进行文献的筛选、资料的提取及偏倚风险的评估,通过Stata 15软件进行数据分析。结果：纳入的6项RCTs共包含样本量579例。Meta分析显示,与西医常规治疗相比,中药高位保留灌肠可以降低PEP发生率（OR=0.27,95%CI[0.13,0.54],P <0.001）、内镜逆行胰胆管造影术后高淀粉酶血症(PEH)发生率（OR=0.29,95%CI[0.19,0.44],P <0.001）,降低术后3 h(SMD=-0.51,95%CI[-0.85,-0.17],P=0.003)、6 h(SMD=-1.15,95%CI[-1.72,-0.59],P <0.001)、12 h(SMD=-0.69,95%CI...     

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目的 探讨内镜在重症急性胆管炎（ACST）急诊治疗中的应用价值。方法 自1997年1月至2002年5月应用十二指肠镜急诊治疗重症急性胆管炎。对于乳头部结石嵌顿用针型刀切开乳头、插管困难者先行乳头括约肌切开术。选择直径＜1.2cm的1－2颗胆总管结石行经内镜括约肌切开术（EST），网篮取石放置鼻胆引流管（ENBD），其余直接行鼻胆引流管引流。结果 156例ACST中148例ENBD治疗成功，内镜治疗成功率94．9％。125例ENBD治疗后24小时内症状减轻。所有良性病变（胆总管结石、胆管良性狭窄）均得到有效引流，5例胆道恶性肿瘤由于胆管的多处狭窄引流失败。平均引流时间为7.3天（1－25天）。无一例消化道穿孔和死亡，术后5例出现急性轻型胰腺炎，3例乳头出血，总的并发症发生率5．1％。结论 急诊内镜治疗ACST操作简便，安全有效，尤其适用于高龄、一般情况较差、肝硬化凝血功能障碍和多次胆道手术病人。     

重症急性胰腺炎术后并发结肠瘘治疗的经验总结

目的 探讨重症急性胰腺炎(severe acute pancreatitis,SAP)术后并发结肠瘘的原因和诊治经验.方法 统计2008年1月至2014年12月我院收治的SAP术后并发结肠瘘的病人相关情况,了解其发生原因、危险因素、常见部位、发生时间,并针对诊断、治疗方法进行总结分析.结果 125例经手术治疗的SAP病人共11例发生结肠瘘(8.8％),6例经应用抗生素、全肠外营养、充分确切引流等非手术治疗后治愈,4例经手术治愈,1例因并发多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)死亡.结论 SAP术后并发结肠瘘与多因素有关,通过积极的非手术治疗措施多可治愈,少数病例需采取手术方式解决.     

重症急性胰腺炎并发肠瘘的诊断和治疗

目的探讨重症急性胰腺炎(SAP)术后并发肠瘘的诊断和治疗。方法对2000年7月至2007年7月手术治疗的107例SAP进行回顾性分析,并对可能导致肠瘘发生的危险因素及其诊断治疗进行总结。结果治疗的SAP发生肠瘘21例,其中结肠瘘17例,十二指肠瘘4例,均出现在术后两周内,有胰腺感染的较无感染的发生率高(P<0.05);早期手术较后期手术发生率高(P<0.05);蝶形引流术较经后上腰引流术发生率高(P<0.05)。结论SAP术后的肠瘘与胰外炎性浸润,手术创伤以及手术时机的选择和手术方式有关。肠瘘的治疗应充分考虑原发病的状况,并根据肠瘘的位置、局部炎症的情况,早期通过加强营养支持,保持瘘口周围引流通畅,多数肠瘘可自行愈合,后期少数不愈合肠瘘可考虑手术治疗。     

Endoscopic sphincterotomy for prevention of the recurrence of acute biliary pancreatitis in patients with gallbladder in situ: long-term follow-up of 88 patients

Background Endoscopic sphincterotomy without cholecystectomy is a therapeutic option in selected patients after acute biliary pancreatitis. We conducted a prospective evaluation of the long-term effects of sphincterotomy in terms of the need for of subsequent cholecystectomy and the recurrence of gallstone pancreatitis.Methods We studied 88 patients with acute biliary pancreatitis and an intact gallbladder who, underwent endoscopic sphincterotomy either because they were high-risk candidates for surgery or because they had refused of cholecystectomy. The median follow-up was 51 months (range, 5–86).Results Only two patients (2.2%) experienced recurrent pancreatitis. Subsequent cholecystectomy was performed in 10 patients because of acute cholecystitis in eight cases and biliary colic in two cases. Sixty-six patiens (75%) remained asymptomatic.Conclusions Endoscopic sphincterotomy is a safe and acceptable alternative to cholecystectomy for the prevention of recurring attacks of gallstone pancreatitis. As a result of this procedure, 75% of patients remained free of symptoms in the long term.     

重症急性胰腺炎合并肠瘘11例诊治分析

目的 探讨重症急性胰腺炎(severe acute pancreatitis,SAP)并发肠瘘的原因和诊治方法.方法 回顾性分析我院2010年1月至2014年6月收治的11例SAP合并肠瘘病人的临床资料,对发生肠瘘的原因、部位、时间及诊断和治疗方法进行分析.结果 11例病人中发生十二指肠瘘4例(36.4％),小肠瘘2例(18.2％),结肠瘘5例(45.4％).肠瘘发生在SAP后2～10周,均经引流管或消化道造影获得影像学证据而确诊.治愈10例(90.9％),其中非手术治疗6例,手术治疗4例;1例(9.1％)病人因感染严重,并发多器官功能衰竭而死亡.结论 SAP并发肠瘘与局部组织的坏死侵袭、合并感染、手术操作、引流管放置等多种因素有关.肠瘘部位的诊断对治疗方式的选择至关重要.经充分引流、控制感染、营养支持和维持内环境稳定等处理后多数肠瘘可自行愈合,少数长期不愈合者可考虑行手术治疗.     

急性胰腺炎并发胰性脑病26例分析

目的 探讨急性胰腺炎并发胰性脑病的发病机理，诱发因素及防治措施。方法 回顾性分析10年间收治的急性胰腺炎并发胰性脑病26例的临床资料。结果 胰性脑病出现时常伴有高热，水和电解质代谢紊乱，低氧血症，氮质血症及血糖紊乱等因素存在。结论 胰酶对大脑损害是发生该病的病理基础，多种因素是发病的诱因，抑制胰酶释放是预防此病发生的关键措施，维持生理功能正常，控制感染和营养支持是预防胰性脑病发生的重要环节。     

Pancreatitis Following Heart Transplantation: Report of a Case

Serious complications involving the alimentary tract following cardiac transplantations are commonly reported, and may be associated with significant morbidity and mortality. One of the most serious gastrointestinal complications in such patients is acute pancreatitis. There is still little known concerning its pathogenesis, early diagnosis, and the most appropriate treatment for this clinical condition. Many authors have reported a high mortality caused by difficulties in making an accurate diagnosis resulting in the use of inappropriate therapy for so called crypto-symptomatic acute pancreatitis. The factor suspected to be responsible for the increased frequency of the gastroenterological diseases and for their masked onset seems to be immunosuppression, especially by corticosteroids. The case of a 46-year-old male patient with cardiac transplant, who, 3 years after the transplantation, developed mild acute pancreatitis, is presented. The immunosuppressive regimen he followed was based on cyclosporine. The acute pancreatitis was treated conservatively with a satisfactory outcome. In the course of the illness the patient developed a pancreatic pseudocyst that was managed successfully by percutaneous drainage. The patient is currently being followed up, and both his medical ailments and health-related quality of life are being monitored, while he continues to show mild symptoms of chronic pancreatitis.