Factors and outcomes associated with pancreatic duct disruption in patients with acute necrotizing pancreatitis

Background and aimsAcute necrotizing pancreatitis (ANP) can affect main pancreatic duct (MPD) as well as parenchyma. However, the incidence and outcomes of MPD disruption has not been well studied in the setting of ANP.MethodsThis retrospective study investigated 84 of 465 patients with ANP who underwent magnetic resonance cholangiopancreatography and/or endoscopic retrograde cholangiopancreatography. The MPD disruption group was subclassified into complete and partial disruption.ResultsMPD disruption was documented in 38% (32/84) of the ANP patients. Extensive necrosis, enlarging/refractory pancreatic fluid collections (PFCs), persistence of amylase-rich output from percutaneous drainage, and amylase-rich ascites/pleural effusion were more frequently associated with MPD disruption. Hospital stay was prolonged (mean 55 vs. 29 days) and recurrence of PFCs (41% vs. 14%) was more frequent in the MPD disruption group, although mortality did not differ between ANP patients with and without MPD disruption. Subgroup analysis between complete disruption (n = 14) and partial disruption (n = 18) revealed a more frequent association of extensive necrosis and full-thickness glandular necrosis with complete disruption. The success rate of endoscopic transpapillary pancreatic stenting across the stricture site was lower in complete disruption (20% vs. 92%). Patients with complete MPD disruption also showed a high rate of PFC recurrence (71% vs. 17%) and required surgery more often (43% vs. 6%).ConclusionsMPD disruption is not uncommon in patients with ANP with clinical suspicion on ductal disruption. Associated MPD disruption may influence morbidity, but not mortality of patients with ANP. Complete MPD disruption is often treated by surgery, whereas partial MPD disruption can be managed successfully with endoscopic transpapillary stenting and/or transmural drainage. Further prospective studies are needed to study these items.     

Prevention of post-ERCP pancreatitis

Post-procedure pancreatitis is the most common complication of endoscopic retrograde cholangio pan-creatography(ERCP) and carries a high morbidity and mortality occurring in at least 3%-5% of all procedures. We reviewed the available literature searching for "ERCP" and "pancreatitis" and "post-ERCP pancreatitis". in PubMed and Medline. This review looks at the diag-nosis, risk factors, causes and methods of preventing post-procedure pancreatitis. These include the evidence for patient selection, endoscopic techniques and phar-macological prophylaxis of ERCP induced pancreatitis. Selecting the right patient for the procedure by a risk benefits assessment is the best way of avoiding unnec-essary ERCPs. Risk is particularly high in young women with sphincter of Oddi dysfunction(SOD). Many of the trials reviewed have rather few numbers of subjects and hence difficult to appraise. Meta-analyses have helped screen for promising modalities of prophylaxis. At present, evidence is emerging that pancreatic stent-ing of patients with SOD and rectally administered non-steroidal anti-inflammatory drugs in a large unselected trial reduce the risk of post-procedure pancreatitis. A recent meta-analysis have demonstrated that rectally administered indomethecin, just before or after ERCP isassociated with significantly lower rate of pancreatitis compared with placebo [OR = 0.49(0.34-0.71); P = 0.0002]. Number needed to treat was 20. It is likely that one of these prophylactic measures will begin to be increasingly practised in high risk groups.     

Prevention of post-ERCP pancreatitis简

Post-procedure pancreatitis is the most common complication of endoscopic retrograde cholangio pancreatography (ERCP) and carries a high morbidity and mortality occurring in at least 3%-5% of all procedures. We reviewed the available literature searching for “ERCP” and “pancreatitis” and “post-ERCP pancreatitis”. in PubMed and Medline. This review looks at the diagnosis, risk factors, causes and methods of preventing post-procedure pancreatitis. These include the evidence for patient selection, endoscopic techniques and pharmacological prophylaxis of ERCP induced pancreatitis. Selecting the right patient for the procedure by a risk benefits assessment is the best way of avoiding unnecessary ERCPs. Risk is particularly high in young women with sphincter of Oddi dysfunction (SOD). Many of the trials reviewed have rather few numbers of subjects and hence difficult to appraise. Meta-analyses have helped screen for promising modalities of prophylaxis. At present, evidence is emerging that pancreatic stenting of patients with SOD and rectally administered nonsteroidal anti-inflammatory drugs in a large unselected trial reduce the risk of post-procedure pancreatitis. A recent meta-analysis have demonstrated that rectally administered indomethecin, just before or after ERCP is associated with significantly lower rate of pancreatitis compared with placebo [OR = 0.49 (0.34-0.71); P = 0.0002]. Number needed to treat was 20. It is likely that one of these prophylactic measures will begin to be increasingly practised in high risk groups.     

Management of patients after recovering from acute severe biliary pancreatitis

Cholelithiasis is the most common cause of acute pancreatitis,accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned,the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management,including cholecystectomy,endoscopic retrograde cholangiopancreatography(ERCP) and sphincterotomy,or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process,usually not earlier than 6 wk after onset of acute pancreatitis,seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed,but if used for definitive treatment,they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques,if not therapeutic,can be used as a bridge to definitive operative treatment,which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.     

ERCP in acute biliary pancreatitis

The role of urgent endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis is for many years a subject for disagreement among physicians. Although the evidence seemed to be in favor of performing ERCP, endoscopists usually hesitate to conform to the guidelines. ERCP is an invasive procedure, with complications which can affect patients' outcome. Recent evidence suggests that we should probably modify our policy, recruiting less invasive procedures, like magnetic resonance cholangiopancreatography and endoscopic ultrasound, before conducting ERCP in patients with acute biliary pancreatitis. In this editorial the different aspects regarding the role of ERCP in acute biliary pancreatitis are discussed.     

经内镜逆行胰胆管造影在治疗妊娠合并急性胆源性胰腺炎中的作用

目的 探讨ERCP在妊娠合并急性胆源性胰腺炎(ABP)中的治疗作用.方法 选择2002年1月至2007年1月共收治的24例妊娠合并ABP患者,其中轻症14例,重症10例.在内科治疗的基础上,在无x线透视下急诊行ERCP.先行内镜鼻胆管引流术(ENBD)以减压、减黄,待患者病情稳定后,对明确有胆总管结石的患者,若早、中期妊娠则行内镜胆道塑料内支架引流术(ERBD),若晚期妊娠则在终止妊娠后再次行ERCP取石.结果 24例患者均顺利完成急诊ERCP+ENBD,有4例见壶腹部结石嵌顿,用针型刀剖开十二指肠乳头,取出结石;15例明确有胆总管结石,其中5例行ERBD,10例终止妊娠后再次行ERCP取石成功.无孕妇死亡,无转外科手术治疗,均治愈出院.重症患者中有2例胎儿死亡.结论　对妊娠合并ABP患者急诊行ERCP+ENBD,病情稳定后行ERBD或再次行ERCP取石是安全、有效的.     

Role and timing of endoscopy in acute biliary pancreatitis

The role and timing of endoscopy in the setting of acute biliary pancreatitis (ABP) is still being debated. Despite numerous randomized trials have been published, there is an obvious lack of consensus on the indications and timing of endoscopic retrograde cholangiopancreatography (ERCP) in ABP in meta-analyses and nationwide guidelines. The present editorial has been written to clarify the role of endoscopy in ABP. In clinical practice the decision to perform an ERCP is often based on biochemical and radiological criteria despite they already have been shown to be unreliable predictors of common bile duct stone presence. Endoscopic ultrasonography (EUS) is not currently a worldwide standard diagnostic procedure early in the course of acute biliary pancreatitis, but it has been shown to be accurate, safe and cost effective in diagnosing biliary obstructions compared with magnetic resonance cholangiopancreatography and ERCP and therefore in preventing unnecessary ERCP and its related complications. Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.     

经内镜治疗急性胆源性胰腺炎的临床价值

目的探讨治疗性ERCP在急性胆源性胰腺炎（acute biliary pancreatitis，ABP）治疗及减少复发中的临床价值。方法将ABP患者依据其治疗方式，分为内镜组行ERCP治疗和对照组行常规治疗，比较其腹痛缓解时间及血、尿淀粉酶降至正常时间及肝功能恢复时间和住院天数。随访所有ABP患者，比较两组患者复发率。结果117例ABP患者中急性轻症胆源性胰腺炎患者99例（84．6％），急性重症胆源性胰腺炎患者18例（15．4％）。内镜组和对照组总例数分别为49例和68例。内镜组与对照组比较，急性轻症胆源性胰腺炎和急性重症胆源性胰腺炎的腹痛缓解时间、肝功能恢复时间、住院天数均明显缩短（P〈0．05或P〈0．01）。血、尿淀粉酶恢复时间两组比较差异无统计学意义。内镜组无明显内镜治疗相关并发症发生。所有患者平均随访时间20个月（5—37个月）；7例失访，随访率94．0％。内镜组的复发率0（0／46）明显低于对照组46．8％（29／62）（P〈0．01）。结论与常规治疗比较，ERCP治疗ABP是较好方法之一，不仅疗效好、恢复较快，而且安全，并能减少胆源性胰腺炎的复发。     

Endoscopic sphincterotomy in acute biliary pancreatitis: A question of anesthesiological risk

Two consecutive surveys of acute pancreatitis in Italy, based on more than 1000 patients with acute pancreatitis, reported that the etiology of the disease indicates biliary origin in about 60% of the cases. The United Kingdom guidelines report that severe gallstone pancreatitis in the presence of increasingly deranged liver function tests and signs of cholangitis (fever, rigors, and positive blood cultures) requires an immediate and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). These guidelines also recommend that patients with gallstone pancreatitis should undergo prompt cholecystectomy, possibly during the same hospitalization. However, a certain percentage of patients are unfit for cholecystectomy because advanced age and presence of comorbidity. We evaluated the early and long-term results of endoscopic intervention in relation to the anesthesiological risk for 87 patients with acute biliary pancreatitis. All patients underwent ERCP and were evaluated according to the American Society of Anesthesiology (ASA) criteria immediately before the operative procedure. The severity of acute pancreatitis was positively related to the anesthesiological grade. There was no significant relationship between the frequency of biliopancreatic complications during the follow-up and the ASA grade. The frequency of cholecystectomy was inversely related to the ASA grade and multivariate analysis showed that the ASA grade and age were significantly related to survival. Finally, endoscopic treatment also appeared to be safe and effective in patients at high anesthesiological risk with acute pancreatitis. These results further support the hypothesis that endoscopic sphincterotomy might be considered a definitive treatment for patients with acute biliary pancreatitis and an elevated ASA grade.     

急性胆源性胰腺炎内镜治疗的临床对比研究

目的:通过对比观察给予不同治疗方案的3组急性胆源性胰腺炎(ABP)患者,探讨ABP经内镜治疗的优劣.方法:将119例ABP(包括SABP)患者分为内镜组(40例)、药物组(42例)、手术组(37例).对比观察3组患者治疗后症状、实验室指标恢复情况、并发症发生率、死亡率以及住院天数.结果:内镜组总并发症发生率12.5%(5/40),死亡率5.0%(2/40).手术组并发症发生率29.7%(11/37),死亡率5.4%(2/37);保守组并发症发生率23.8%(10/42),死亡率7.1%(3/42).在3组SABP中,内镜组患者在症状恢复时间、实验室指标恢复时间、及住院天数方面较手术组及保守组均明显缩短、并发症发生率较手术组及保守组均降低(P<0.05).结论:内镜治疗ABP(尤其SABP)是一项较安全、有效、经济简便、并发症少、可重复操作的治疗措施,值得临床大力推广.     

Endoscopic ultrasonography and idiopathic acute pancreatitis

Idiopathic acute pancreatitis is a diagnostic challenge for gastroenterologists. The possibility of finding a cause for pancreatitis usually relies on how far the diagnostic study is taken. Endoscopic explorations such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography can help to determine the cause of pancreatitis. Furthermore, microscopic bile examination and magnetic resonance cholangiopancreatography can also be helpful in the work up of these patients. In this article an approximation to the diagnostic approach to patients with idiopathic acute pancreatitis is made, taking into account the reported evidence with which to choose between the different available explorations.     

Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis

Endoscopic retrograde cholangiopancreatography （ERCP） is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound （EUS） and magnetic retrograde cholangiopancreatography （MRCP）, ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.     

Role of endoscopic ultrasound during hospitalization for acute pancreatitis

Endoscopic ultrasound(EUS)is often used to detect the cause of acute pancreatitis(AP)after the acute attack has subsided.The limited data on its role during hospitalization for AP are reviewed here.The ability of EUS to visualize the pancreas and bile duct,the sonographic appearance of the pancreas,correlation of such appearance to clinical outcomes and the impact on AP management are analyzed from studies.The most important indication for EUS appears to be for detection of suspected common bile duct and/or gall bladder stones and microlithiasis.Such an approach might avoid diagnostic endoscopic retrograde cholangio-pancreatography with its known complications.The use of EUS during hospitalization for AP still appears to be infrequent but may become more frequent in future.     

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study

AIM: To investigate the clinical usefulness of early endoscopic ultrasonography(EUS) in the management of acute biliary pancreatitis(ABP).METHODS: All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low,moderate,or high probability of common bile duct(CBD) stones,according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated:(1) clinical: age,sex,fever;(2) radiological: dilated CBD; and(3) biochemical: bilirubin,AST,ALT,g GT,ALP,amylase,lipasis,PCR. Association between presence of CBD stone at EUS and the individual predictors wereassessed by univariate logistic regression. Predictors significantly associated with CBD stones(P 0.05) were entered in a multivariate logistic regression model.RESULTS: A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients(38 females,53.5%,mean age 58 ± 20.12 years,range 27-89 years; 33 males,46.5%,mean age 65 ± 11.86 years,range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases(29%),moderate in 26(37%),and high in the remaining 24(34%). The 71 patients included in the study underwent EUS,which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min(range 9-34 min),without any notable complications.The overall CBD stone frequency was 44%(31 of 71),with a significant increase from the group at low pretest probability to that at moderate(OR = 5.79,P = 0.01) and high(OR = 4.25,P = 0.03) pretest probability.CONCLUSION: Early EUS in ABP allows,if appropriate,immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.     

老年急性重症胆源性胰腺炎的早期内镜治疗

目的探讨早期急诊内镜治疗对老年急性重症胆源性胰腺炎的临床价值。方法确诊为急性重症胆源性胰腺炎的92例高龄患者,分成内镜组（n=43）和对照组（n=49）,对其血清肿瘤坏死因子（TNF）-α、白细胞介素（IL）-6、IL-8以及淀粉酶恢复正常时间、腹痛缓解时间、住院天数,还有并发症发生率和死亡率等指标进行比较分析。结果治疗7d后内镜组患者血清TNF-α、IL-6、IL-8和对照组比较下降更明显,差异有统计学意义[（45．16±13．48）μg／L比（176．89±47．35）μg／L、（31．76±13．85）μg／L比（68．48±24．87）μg／L、（113．39±63．78）μg／L比（309．86±117．13）μg／L,P均〈0．05];内镜组患者腹痛缓解时间、淀粉酶恢复正常时间、住院时间明显短于对照组[（10．2±1．7）d比（13．2±2．4）d、（3．3±1．0）d比（5．5±1．2）d、（15±1．6）d比（20±3．0）d,P均〈0．05];并发症发生率也低于对照组（5％比22％,P〈0．05）。结论早期内镜介入治疗老年急性重症胆源性胰腺炎具有微创、安全、有效的优点,能明显缓解病情的进一步发展。     

ERCP联合胆道微结石检测对明确特发性急性胰腺炎病因的价值

目的:探讨内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)联合胆道微结石检测对特发性急性胰腺炎(idiopathic pancreatitis,IAP)病因的诊断价值.方法:以2008-01/2011-01急性胰腺炎(acute pancreatitis,AP)患者105例为研究对象,选择影像学(CT、B超、MRCP)检查后不能明确病因的特发性急性胰腺炎患者42例进行诊断性ERCP检查,同时收集胆汁5mL行胆道微结石监测.以2005-01/2008-01AP患者90例为对照组,应用SPSS13.0统计软件统计,取P<0.05差异有统计学意义.结果:对照组对AP病因确诊率为55.5%(50/90),联合检查组对AP的病因确诊率为87.5%(93/105),差异有统计学意义(P<0.05),ERCP联合胆道微结石检测对IAP病因有较高的确诊率.结论:ERCP联合胆道微结石检测对明确IAP病因有重要价值.     

急性胆源性胰腺炎早期内镜治疗价值

目的探讨急性胆源性胰腺炎早期内镜治疗的价值及其安全性。方法选择92例急性胆源性胰腺炎患者早期（72h内）行ERCP及内镜治疗（ERCP组），并与同期保守治疗40例（对照组）进行比较。结果ERCP组全部成功实施十二指肠乳头切开取石，72例胆总管结石者行网篮及气囊取石，所有92例均行鼻胆管引流，重症组10例同时行胰管支架引流。ERCP组平均腹痛消失时间、血清淀粉酶恢复时间、平均住院天数及平均费用均明显低于对照组。ERCP组重症组病死率8．3％，对照组重症组病死率33．3％。结论急性胆源性胰腺炎早期ERCP治疗是安全的，能降低患者的病死率，减少患者住院天数和费用。     

The presence of the gallbladder is associated with the severity of acute biliary pancreatitis

Summary Conclusion The presence of the gallbladder at the onset of acute biliary pancreatitis is associated with increased severity of the disease. One possible explanation is that gallbladder contraction might induce bile reflux into the pancreatic duct during the transfer of a gallstone through the ampulla. Background In clinical practice there is an impression that the presence of the gallbladder in patients with biliary pancreatitis may be associated with increased severity of the disease, compared to patients who have undergone cholecystectomy. Methods To test this hypothesis, we studied 266 cases with biliary pancreatitis. Patients were divided into two groups: (A) those who had a gallbladderin situ at the onset of biliary pancreatitis (n=234, 88%) and (B) those who had undergone previous cholecystectomy (n=32, 12%). Results Pancreatitis was more severe in group A than in group B, according to Glasgow criteria (≥3 positive, 66/210=31% vs 4/29=14%,p=0.04); development of complications (77/234=33% vs 4/32=13%,p=0.01); and mortality (40/234=17% vs 1/32=3%,p=0.03). Furthermore, serum C-reactive protein levels on admission were over 150 mg/L twice as often in group A as in group B.     

高脂血症性急性胰腺炎与胆源性胰腺炎的临床对比分析

目的对比分析高脂血症性急性胰腺炎（hyperlipidemic acute pancreatitis,HLAP）与急性胆源性胰腺炎（acute biliary pancreatitis,ABP）的临床特点。方法回顾性对比分析我院2005年8月～2010年8月间收治的28例HLAP和64例ABP患者的临床资料。结果 HLAP组BMI、重症患者比例、Ranson评分≥3、CT分级为D、E及APACHEII≥8分者均较ABP组高（P〈0.05）。HLAP组血清TG、GLU、UA均显著高于ABP组,而ALT、AKP、TBIL、DBIL及血AMY均显著低于ABP组（P〈0.05）。两组患者平均住院时间无统计学差异（P〉0.05）。HLAP组患者死亡率为14.3%）,显著高于ABP组的1.5%（P〈0.05）。结论与ABP组相比,HLAP组通常病情较重,多为SAP且常不伴有血淀粉酶的显著升高,且死亡率高。