Pharmacological approach to acute pancreatitis

The aim of the present review is to summarize the current knowledge regarding pharmacological prevention and treatment of acute pancreatitis （AP） based on experimental animal models and clinical trials. Somatostatin （SS） and octreotide inhibit the exocrine production of pancreatic enzymes and may be useful as prophylaxis against Post Endoscopic retrograde cholangiopancreatography Pancreatitis （PEP）. The protease inhibitor Gabexate mesilate （GM） is used routinely as treatment to AP in some countries, but randomized clinical trials and a meta-analysis do not support this practice. Nitroglycerin （NGL） is a nitrogen oxide （NO） donor, which relaxes the sphincter of Oddi. Studies show conflicting results when applied prior to ERCP and a large multicenter randomized study is warranted. Steroids administered as prophylaxis against PEP has been validated without effect in several randomized trials. The non-steroidal anti-inflammatory drugs （NSAID） indomethacin and diclofenac have in randomized studies showed potential as prophylaxis against PEP. Interleukin 10 （IL-10） is a cytokine with anti-inflammatory properties but two trials testing IL-10 as prophylaxis to PEP have returned conflicting results. Antibodies against tumor necrosis factor-alpha （TNF-α） have a potential as rescue therapy but no clinical trials are currently being conducted. The antibiotics beta- lactams and quinolones reduce mortality when necrosis is present in pancreas and may also reduce incidence of infected necrosis. Evidence based pharmacological treatment of AP is limited and studies on the effect of potent anti-inflammatory drugs are warranted.     

Endoscopic approach for diagnosing autoimmune pancreatitis

It is of utmost importance to differentiate autoimmune pancreatitis (AIP) from pancreatic cancer (PC). Segmental AIP cases are sometimes difficult to differentiate from PC. On endoscopic retrograde cholangiopancreatography, long or skipped irregular narrowing of the main pancreatic duct (MPD), less upstream dilatation of the distal MPD, side branches derived from the narrowed portion of the MPD, absence of obstruction of the MPD, and stenosis of the intrahepatic bile duct suggest AIP rather than PC. Abundant infiltration of IgG4-positive plasma cells is frequently and rather specifically detected in the major duodenal papilla of AIP patients. IgG4-immunostaining of biopsy specimens obtained from the major duodenal papilla is useful for supporting a diagnosis of AIP with pancreatic head involvement. On endoscopic ultrasonography (EUS), hyperechoic spots in the hypoechoic mass and the duct-penetrating sign suggest AIP rather than PC. EUS and intraductal ultrasonography sometimes show wall thickening of the common bile duct even in the segment in which abnormalities are not clearly observed with cholangiography in AIP patients. EUS-guided fine needle aspiration, especially EUS-guided Tru-Cut biopsy, is useful to diagnose AIP, as well as to exclude PC.     

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.     

Endoscopic ultrasound in idiopathic acute pancreatitis

OBJECTIVE: The aim of this study was to determine the utility of endoscopic ultrasound (EUS) in patients with unexplained acute pancreatitis, and whether endoscopic retrograde cholangiopancreatography (ERCP) is subsequently needed. METHODS: Subjects who underwent EUS for assessment of idiopathic acute pancreatitis were identified, their medical records were reviewed, and they were contacted for a follow-up telephone interview. EUS diagnosis was compared with the final diagnosis and outcome. RESULTS: EUS revealed a cause of pancreatitis in 21 of the 31 subjects (68%), including microlithiasis in five (16%), chronic pancreatitis in 14 (45%), pancreas divisum in two (6.5%), pancreatic cancer in one (3.2%), and was not diagnostic in 10 (32%). During a mean follow-up period of 16 months, diagnosis changed in four subjects (13%), and nine subjects (29%) had ERCP because of persistent symptoms or recurrent pancreatitis. CONCLUSION: EUS, a less invasive test than ERCP, demonstrated an etiology in two-thirds of patients with idiopathic acute pancreatitis. Most patients did not require ERCP during the follow-up period. EUS can be an alternative to ERCP in patients with unexplained acute pancreatitis.     

Endoscopic therapy in acute recurrent pancreatitis

Endoscopic retrograde cholangiopancreatography （ERCP） has evolved from a largely diagnostic to a largely therapeutic modality. Cross-sectional imaging, such as computed tomography （CT） and magnetic resonance imaging （MRI）, and less invasive endoscopy, especially endoscopic ultrasound （EUS）, have largely taken over from ERCP for diagnosis. However, ERCP remains the ＂first line＂ therapeutic tool in the management of mechanical causes of acute recurrent pancreatitis, including bile duct stones （choledocholithiasis）, ampullary masses （benign and malignant）, congenital variants of biliary and pancreatic anatomy （e.g. pancreas divisum, choledochoceles）, sphincter of Oddi dysfunction （SOD）, pancreatic stones and strictures, and parasitic disorders involving the biliary tree and/or pancreatic duct （e.g Ascariasis, Clonorchiasis）.     

The surgical approach to severe acute pancreatitis

The indications for surgery in severe acute pancreatitis include circumstances in which the diagnosis is uncertain, persistent biliary pancreatitis, infected pancreatic necrosis, and some patients with pancreatic abscess. The controversy surrounding surgical treatment for sterile pancreatic necrosis, and situations in which the disease persists in spite of intensive medical management are also addressed. Surgical principles and the merits of open versus closed drainage are reviewed.     

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.     

经内镜治疗急性胰腺炎临床探讨

目的探讨内镜治疗急性胰腺炎（ＡＰ）的临床效果。方法采用经内镜鼻胆（胰）管引流（ＥＮＢ（Ｐ）Ｄ）及经内镜乳头括约肌切开术（ＥＳＴ）等内镜技术治疗ＡＰ５６例,其中重症急性胰腺炎（ＳＡＰ）３６例。结果治愈５３例,死亡２例,因胰腺出血致导管堵塞改行手术１例。结论内镜治疗以微小创伤达到满意外科引流效果,能够有效地降低胆胰管内压,缓解胰腺病变,起到治疗作用,不失为ＡＰ治疗手段和方法上的一个补充,具有一定的临床使用价值。     

Endoscopic treatment of pseudocysts and abscess in acute pancreatitis

We report on 4 cases of necrotic pseudocysts complicating acute pancreatitis, treated by endoscopic cystostomy (3 cystogastrostomies, 1 cystoduodenostomy). Acute pancreatitis was secondary to biliary stones in 2 cases, post-surgical in one case and post-ERCP in the last case. Endoscopic treatment was performed because of recurrence of pseudocysts after percutaneous drainage guided by ultrasonography or CT scan. In 3 cases, pseudocysts were infected (pancreatic abscesses) and in 2 patients, surgery was contraindicated (severe respiratory and multiple organ failure). The outcome was uneventful in all the 4 cases and pseudocysts disappeared in a few days or weeks in 3 patients. The fourth patient underwent a complementary surgical cystogastrostomy. Endoscopic cystostomy appears to be a safe and efficient technique when performed in pseudocysts located close to the digestive wall and responsible for bulging visible during upper GI endoscopy.     

Endoscopic retrograde cholangiopancreatography-induced acute pancreatitis often has a benign outcome

BACKGROUND: Acute pancreatitis (AP) is the commonest complication of endoscopic retrograde cholangiopancreatography (ERCP). Data regarding the clinical course and outcome of post-ERCP pancreatitis are sparse, although the available data suggest it to be a severe disease. OBJECTIVE: To examine the clinical course, disease severity, and outcome of patients with post-ERCP-AP. METHODS: All consecutive patients with post-ERCP-AP were included. They were managed according to a standard protocol. Outcome measures were severity of pancreatitis, infectious complications, need for surgery and mortality. The clinical course and outcome of patients with post-ERCP-AP were also compared with those of patients with gallstone pancreatitis (GS-AP). RESULTS: Of the 1497 de novo ERCP procedures, 57 (3.8%) patients developed AP. Their mean age was 40.2 years (13.1), 16 were males of them, 54 (95%) patients had mild pancreatitis. Only 2 patients developed organ failure. Fifty-four (95%) patients recovered with conservative management. One of the 57 patients died. As compared with patients with GS-AP (n=174), APACHE II scores at admission [3.3 (3.1) vs. 5.8 (4.8); P=0.011], occurrence of pancreatic necrosis (17.5% vs. 39.1%; P=0.020), organ failure (3.5% vs. 19.0%; P=0.015), infectious complications (8.7% vs. 24.7%; P=0.040), and mortality (1.8% vs. 13.2%; P=0.044) were significantly less among patients with post-ERCP-AP. CONCLUSION: Unlike previous belief, we found that post-ERCP AP was a mild disease with a favorable outcome in most cases.     

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.     

老年人胆源性重症急性胰腺炎急诊内镜治疗与手术治疗的比较

目的探讨急诊内镜治疗老年人胆源性重症急性胰腺炎(biliary severe acute pancreatitis, BSAP)的价值。方法25例老年人BSAP经内镜治疗(ERCP EST或ENBD),与29例老年人BSAP手术治疗组进行比较,观察急诊内镜治疗老年人胆源性重症急性胰腺炎的临床疗效与安全性。结果内镜组的体温恢复时间、腹痛消失时间、上腹压痛消失时间、白细胞恢复正常时间、血清淀粉酶恢复正常时间、手术时间、住院时间、治愈率、死亡率、并发症发生率和复发率分别为3.6±1.3 d、6.4±2.2 d、8.2±3.4 d、6.5 ±2.4 d、7.3±2.1 d、37.5±6.5min、21.4±5.0d、72.0%、8.0%、16.0%和4.0%;而手术组分别为:6.5±1.6 d、10.0±3.8 d、15.8±4.2 d、11.2±3.8 d、13.5±4.8 d、132.6±34.5 min、33.0±6.8 d、51.7%、17.3%、37.9%和10.3%,两组相比,内镜组明显优于手术组,上述指标差异均有显著性(P<0.05);而肝功能恢复正常时间却无显著性差异(P>0.05)。结论内镜治疗BSAP具有微创有效,可分期分步进行治疗,清除胆道结石等优点,是治疗老年人BASP的首选方案。     

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.     

Endoscopic approach to achalasia

Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/ or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearlyequivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.