Utility of endoscopic ultrasound in pancreatitis： A review

The close proximity of the endoscopic ultrasound probe to the pancreas results in superior spatial resolution compared to CT scan and MRI. In addition, endoscopic ultrasound （EUS） is a minimally invasive procedure that does not share the relatively high complication rate of ERCP. Due to these advantages, EUS has evolved into an important technique to assess pancreatobiliary disease. This review will discuss the role of EUS in patients with pancreatitis. The indications can be divided into acute pancreatitis and chronic pancreatitis. In acute pancreatitis, EUS is used to determine the etiology; in suspected chronic pancreatitis it is helpful to establish the diagnosis. Lastly, this review will discuss biliary pancreatitis with suspicion for persistent choledocholithiasis.     

Role of endoscopic ultrasonography in patients with first episode of idiopathic acute pancreatitis

Background/Aims

Acute pancreatitis (AP) evades an etiological diagnosis in up to 10 % to 30 % of patients. This group, ie. idiopathic acute pancreatitis (IAP) is prone to a high recurrence (up to 70 %). Endoscopic ultrasound (EUS) is promising, but there is limited data on elucidating the cause of IAP, from India. This observational study was designed to study the role of EUS after the first episode of IAP.

Methods

All patients diagnosed to have first episode of IAP were included in the study and taken up for EUS examination after 6 weeks. Patients with conditions known to predispose or precipitate AP, like alcohol binge, drugs, metabolic or autoimmune conditions, or even a positive family history, were excluded from the study.

Result

A total of 51 patients were included. EUS positivity was found in 29 (56.9 %) patients. It included common bile duct (CBD) calculus in 5 (9.8 %), CBD sludge in 4 (7.8 %), gallbladder calculus in 2 (3.9 %), gallbladder sludge in 2 (3.9 %), and chronic pancreatitis (CP) in 16 (31.4 %) patients. Fourteen patients had a normal study and eight patients had indeterminate CP.

Conclusions

EUS is safe and has a reasonable diagnostic yield in patients with first episode of IAP. CP and biliary lithiasis are the most frequent positive findings on EUS. EUS should be included in the diagnostic protocol after the first episode of IAP, rather than waiting for recurrent episodes.     

Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis

One of the most frequent and serious complications of endoscopic retrograde cholangiopancreatography (ERCP) is acute pancreatitis. The aim of this study was to evaluate the preventive effect of low-dose heparin (unfractionated or low-molecular-weight heparin) on post-ERCP pancreatitis (PEP) and its side-effects by a systematic review and meta-analysis of clinical trials. Searching PubMed and EMBASE, up to August 2011, two independent reviewers systematically identified prospective clinical trials detecting the effect of prophylactic low-dose heparin on the incidence of PEP, severe PEP, and post-ERCP hemorrhage complications. Four clinical trials fulfilled our selection criteria, with three prospective randomized and one nonrandomized. A meta-analysis of these clinical trials was then performed. A total of 1438 patients were included. Meta-analysis of these trials indicated that there was no significant association between the use of heparin and the reduction of PEP [relative risk (RR) 0.67, 95% confidence interval (CI): 0.44-1.03, P=0.07] and severe PEP (RR 0.62, 95% CI: 0.15-2.60, P=0.51). However, low-dose heparin did not increase the incidence of post-ERCP hemorrhage complications (RR 0.84, 95% CI: 0.34-2.03, P=0.69). This meta-analysis did not demonstrate a statistically significant benefit of prophylactic heparin use for the prevention of post-ERCP pancreatitis. More multicenter trials involving a larger number of patients are needed to show a possible prevention effect of PEP from heparin and its related compounds.     

The role of endoscopic ultrasonography in the etiological evaluation of idiopathic acute pancreatitis]

Up to 30% of patients with acute pancreatitis are diagnosed of idiopathic acute pancreatitis after an initial evaluation including a complete clinical history, physical examination, analysis with calcium and triglycerides determination, and at least one transabdominal ultrasonography. Unexplained pancreatitis represents a diagnostic challenge, although after different explorations a cause is found in the majority of these patients. During the last years endosonography has proved to be a low morbidity exploration very useful in the evaluation of patients with this entity. In this article we review the role of endosonography in the etiologic study of patients with idiopathic acute pancreatitis.     

Treatment options in painful chronic pancreatitis: a systematic review

Background

Longlasting and unbearable pain is the most common and striking symptom of chronic pancreatitis. Accordingly, pain relief and improvement in patients'' quality of life are the primary goals in the treatment of this disease. This systematic review aims to summarize the available data on treatment options.

Methods

A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement for reporting systematic reviews and meta-analysis. The search was limited to randomized controlled trials and meta-analyses. Reference lists were then hand-searched for additional relevant titles. The results obtained were examined individually by two independent investigators for further selection and data extraction.

Results

A total of 416 abstracts were reviewed, of which 367 were excluded because they were obviously irrelevant or represented overlapping studies. Consequently, 49 full-text articles were systematically reviewed.

Conclusions

First-line medical options include the provision of pain medication, adjunctive agents and pancreatic enzymes, and abstinence from alcohol and tobacco. If medical treatment fails, endoscopic treatment offers pain relief in the majority of patients in the short term. However, current data suggest that surgical treatment seems to be superior to endoscopic intervention because it is significantly more effective and, especially, lasts longer.     

Physical activity for chronic pancreatitis: a systematic review

BackgroundChronic pancreatitis (CP) is a progressive inflammatory disorder of the pancreas. Sarcopenia is a degenerative loss of skeletal muscle mass, quality, and strength and is commonly associated with chronic pancreatitis. Regular physical activity and adequate functional fitness have been found to ameliorate the risk and effects of sarcopenia in other chronic diseases. The objective of this systematic review was to collate all the published evidence which has examined any type of physical activity as an intervention in the chronic pancreatitis patient population.MethodsThis systematic review was conducted in accordance with the PRISMA guidelines. The search strategy was designed by the medical librarian (DM) for Embase and then modified for the other search platforms. Two of the researchers (BM) and (AM) then performed the literature search using the databases Embase, Medline, CINAHL, and Web of Science.ResultsAn electronic identified a total of 571 references imported to Covidence as 420 when the duplicates (151) were removed. 420 titles were screened and 390 were removed as not relevant from their titles. 30 full text papers were selected and from these, only one full text paper was deemed suitable for inclusion.ConclusionsThere is currently insufficient evidence to advise physical activity in the chronic pancreatitis population. However, given the evidence to support physical activity in many other chronic diseases this review highlights the need for urgent investigation of physical activity as an intervention on this specific patient population.     

Biliary pancreatitis: a review. Emphasizing appropriate endoscopic intervention

Gallstones are a common cause of acute pancreatitis. This article reviews acute biliary pancreatitis and includes natural history, noting the serious nature of some cases; pathogenesis, identifying transient obstruction as the primary pathogenetic event; diagnosis, including biochemical parameters and imaging; assessment of severity, underlining the importance of early prognostic signs, organ failure, and local complications; and management. Management is reviewed in detail, giving a historical perspective to the role of surgery, highlighting the role of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy and paying particular attention to the four prospective randomized clinical trials in suggesting which patients are most likely to benefit from early endoscopic evaluation and therapy. Also discussed are additional clinical situations related to biliary pancreatitis in which endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy play a role. Finally, a suggested endoscopic approach to acute biliary pancreatitis is presented along with an algorithm incorporating severity stratification, principles of endoscopic intervention, and concepts of sterile and infected pancreatic necrosis.     

Acute exacerbation of idiopathic pulmonary fibrosis: a systematic review

Acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is a clinical entity defined by rapid deterioration of IPF during the course of the disease that is not due to infections, pulmonary embolism, or heart failure. The condition needs to be differentiated from acute interstitial pneumonia (or Hamman-Rich syndrome), which occurs in patients with no underlying lung disease. The exact etiology and pathogenesis remain unknown, but the condition is characterized by diffuse alveolar damage (on a background of IPF) that probably occurs as a result of a massive lung injury due to some unknown etiologic agent. High-resolution computed tomography can help in prognostication and management of this condition. Once infections and other causes of worsening have been excluded, treatment involves enhanced immunosuppression with pulse doses of methylprednisolone and cytotoxic agents. Our systematic review shows that the outcome, however, is poor, with 1-month and 3-month mortality around 60% and 67%, respectively. Few studies have shown beneficial effects of cyclosporine, pirfenidone, and anticoagulants in the management and prevention of AE-IPF. The etiology, risk factors, pathogenesis, therapy, prognosis, and predictors need to be studied and the potential role of newer agents in the management and prevention of AE-IPF needs to be further clarified.     

内镜治疗急性胆源性胰腺炎的系统评价

目的:评价内镜治疗急性胆源性胰腺炎的临床疗效和安全性.方法:通过计算机检索全面收集全世界关于内镜治疗急性胆源性胰腺炎的随机对照试验/或半随机对照试验,并辅手工检索和其他检索.按照纳入排除标准纳入文献,由两名研究者独立筛选并提取资料,采用Handbook5.0推荐的质量评价标准评价纳入研究的方法学质量,采用RevMan5.0软件进行统计学处理.结果:最终纳入4个研究,包括317例患者.Meta分析结果显示内镜组治疗组与传统治疗组相比,在腹痛缓解时间(OR=-2.98,95%CI:-4.98,0.97)、白细胞复常时间(OR=-4.63,95%CI:-5.29,-3.97)、血淀粉酶复常时间(OR=-3.85,95%CI:-4.49,-3.21)、并发症发生率(OR=0.34,95%CI:0.18,0.66)和住院时间(OR=-7.51,95%CI:-9.89,-5.13)方面存在统计学差异.结论:当前研究显示,与传统治疗组相比,内镜治疗组能显著减少急性胆源性胰腺炎的腹痛缓解时间、白细胞及血淀粉酶复常时间,降低并发症的发生,缩短住院时间.     

奥曲肽预防内镜下逆行胰胆管造影术后胰腺炎疗效的系统评价

目的系统评价奥曲肽能否有效、安全地预防内镜下逆行胰胆管造影(ERCP)术后胰腺炎(PEP).方法通过计算机和人工检索资料(语种不限),应用Jadad评分量表进行评分(由两人独立整理资料),利用Cochrane协作网提供的RevMan 4.2软件进行统计学分析.结果 (1)奥曲肽预防对降低PEP发病率的影响:P<0.00...     

Current controversies in fluid resuscitation in acute pancreatitis: a systematic review

Acute pancreatitis (AP) is a common inflammatory disorder of the pancreas resulting in considerable morbidity and mortality. Aggressive intravenous fluid resuscitation generally is recommended in all patients with AP and remains the cornerstone of management of these patients. However, the optimal rate, type, and the goal of resuscitation remain unclear. The purpose of this review was to give an insight about the pathophysiologic alterations in the pancreatic microcirculation that occur in AP, the markers for early recognition of severity of pancreatitis, the optimal fluid, and timing and extent of fluid resuscitation. An early elevated hematocrit, blood urea nitrogen, or creatinine should prompt clinicians to institute more intensive early resuscitation measures. Crystalloids are the currently recommended fluids for management of these patients. Current studies are underway to determine the optimal end points of fluid resuscitation that determine outcome.     

复发性特发性胰腺炎内镜治疗的临床分析

目的 探讨复发性特发性胰腺炎(RIP)的病因及其内镜治疗的疗效.方法 回顾性分析2005年4月至2011年4月诊断为RIP的58例患者资料.所有患者均行ERCP,术前怀疑Oddi括约肌功能障碍者行Oddi括约肌测压.根据临床表现和ERCP结果判断病因并制订个体化的内镜治疗措施,术后随访观察腹痛及胰腺炎发作情况.结果 58例患者中男性29例,女性29例,胰腺炎发作次数为3 ～ 10余次.病因为胆管微结石29例,Oddi括约肌功能障碍19例(胰腺型16例,混合型3例),胰胆管汇流异常4例,ERCP无明显异常者6例.行单纯胆管括约肌切开33例,胰胆管括约肌共同切开8例,单纯胰管括约肌切开17例,括约肌切开后同时胰管支架置入术24例.58例患者获得随访41例,随访时间3～67个月(平均33个月).随访期间9例(22.0％)患者胰腺炎复发.内镜治疗RIP有效率为78％(32/41).结论 胆管微结石和Oddi括约肌功能障碍是RIP的主要病因,饮酒是其主要诱因.ERCP及其介入治疗疗效确切.     

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.     

Diagnosis and endoscopic treatment of esophageal leakage: a systematic review

When esophageal leakage is suspected, diagnostic work-up usually starts with endoscopy followed by CT of the thorax. Clinicians should consider esophageal leakage a clinical emergency as early diagnosis and treatment are associated with improved outcome. Upon diagnosis, acute therapeutic management in a specialized center with appropriate multidisciplinary infrastructure and expertise is indicated as innovative endoscopic treatment options have become reasonable alternatives to invasive surgical interventions. Promising endoscopic treatment options include esophageal stent placement, endoscopic vacuum therapy, and over-the-scope clip placement. In effort to evaluate the current literature, a systematic literature search was performed on studies reporting clinical outcome of patients treated with these endoscopic treatment options for benign esophageal perforations and anastomotic leakage. The systematic search yielded 15 studies (932 patients) discussing stent placement, 14 studies (295 patients) discussing endoscopic vacuum therapy, and 8 studies (41 patients) discussing over-the-scope clip placement. Clinical success was achieved in the majority of all patients. However, the studies predominantly consisted of small single-center retrospective case series. Careful selection of patients is therefore recommended when considering endoscopic therapy for esophageal leakage. Furthermore, clinical tools may aid in predicting patients’ prognosis and selection of patients that could benefit from endoscopic therapy. In the future, randomized studies comparing available endoscopic treatment options are needed to guide treatment choice for patients with esophageal leakage in daily clinical practice.     

Aerobic fitness in children with juvenile idiopathic arthritis: a systematic review

OBJECTIVE: To determine whether children with juvenile idiopathic arthritis (JIA) have lower physical fitness compared to healthy children, and to determine the clinical relevance of this impairment. METHODS: A systematic literature search was performed using MEDLINE, CINAHL, EMBASE and SPORTDiscus. The appropriate titles were identified and the data were extracted from these publications. The maximal oxygen consumption (VO2peak; in ml.kg-1.min-1) during a maximal exercise test until volitional exhaustion was used as the main outcome for this review. RESULTS: Nine studies were identified in the literature. Data from 5 studies (144 patients) were pooled in a metaanalysis. The VO2peak of the patients with JIA was 21.8% (95% CI 13.7, 29.9) lower than that of healthy children (p < 0.0001). CONCLUSION: The results of the metaanalysis suggest that children with JIA have moderate to heavy impairment in physical fitness as represented by maximal oxygen consumption compared to healthy children.     

Psychometric characteristics of outcome measures in juvenile idiopathic arthritis: a systematic review

Objective

To review the performance characteristics of the instruments most commonly used to measure clinical outcomes in juvenile idiopathic arthritis (JIA), including global assessments, articular indices, functional/disability assessments, and quality of life measures.

Methods

As part of an Agency for Healthcare Research and Quality comparative effectiveness review of antirheumatic drugs, we explored the characteristics of commonly used outcome measures for JIA. English‐language studies of children with JIA were identified from Medline and Embase. Two independent reviewers screened titles and abstracts, with subsequent full‐text review of studies selected based on predetermined criteria.

Results

We included 35 publications describing 34 unique studies and involving 14,831 patients. The Childhood Health Assessment Questionnaire (C‐HAQ) was the most extensively studied instrument and had high reliability, but only moderate correlations with other indices of disease activity and poor responsiveness to change in disease status. The physician global assessment of disease activity (PGA) and articular indices had the strongest association with disease activity and were the most responsive to change. Measures of psychosocial function and quality of life were moderately associated with measures of disease activity, but were less responsive to changes in disease status.

Conclusion

In children with JIA, no single instrument was superior in reliability or validity or in describing the impact of JIA. Although the C‐HAQ has been extensively evaluated, the PGA and articular indices appear to have the highest responsiveness to change and, therefore, the highest potential for detecting important differences in treatment response.