A prospective audit against national standards of the presentation and management of acute pancreatitis in the South of England

BACKGROUND: The incidence of acute pancreatitis shows regional variations in the UK. AIMS: To document the incidence and presentation of acute pancreatitis in hospitals in Wessex, and to audit the process and outcome of management of patients against the UK guidelines. METHODS: A prospective survey was carried out of all patients with acute pancreatitis in a one year period, in eight geographically adjacent acute hospitals in the Wessex region. RESULTS: 186 patients with acute pancreatitis were identified, an incidence of 152 per million in the adult population. Aetiology was: gallstones 33%, alcohol 20%, idiopathic 32%, other 15%. There were 60 severe cases with 17 deaths. Age and APACHE-II score had significant relations to outcome, but delay to admission, serum amylase level, aetiology, and sex did not. The mortality rate (9.1%) was within the audit standard of 10%. Some management goals were not met: in mild cases, only one third of patients with gallstone pancreatitis had definitive treatment within four weeks. In severe cases, there was poor use of objective severity stratification (19%), low admission rates to a high dependency unit or intensive care unit (67%), and only 33% of patients had computed tomography. Only seven of 17 patients with severe gallstone pancreatitis had an urgent endoscopic retrograde cholangiopancreatography. CONCLUSIONS: The incidence of clinically diagnosed acute pancreatitis in England continues to rise. Current management of acute pancreatitis is suboptimal when compared with evidence based UK guidelines but the mortality rate was within the guideline standard.     

胆囊结石形态与胆源性胰腺炎关系的临床分析

目的探讨胆囊结石形态与急性胰腺炎的关系。方法收集2011年2月至2013年2月收治的110例胆源性胰腺炎患者作为胰腺炎组,110例胆囊结石患者作为非胰腺炎组。分析比较两组患者胆囊结石大小、数量、形状及质地与胰腺炎的关系。率的比较采用卡方检验。结果胰腺炎组与非胰腺炎组结石大小、数量、形状相比较差异具有统计学意义(χ2=41.146、27.150、13.839,P均0.01);两组结石质地的比较差异有统计学意义(χ2=8.000,P0.05);轻型和重型急性胰腺炎患者中结石3 mm者分别为66.36%和86.67%,3~10 mm分别为17.89%和13.33%。结论相比较其他类型的结石,患者微小多发性、质软易碎的结石发生胰腺炎的几率增高;且结石越小,胰腺炎严重程度有增高的趋势。     

Proposal of the term “gallstone cholangiopancreatitis” to specify gallstone pancreatitis that needs urgent endoscopic retrograde cholangiopancreatography

Opie's "pancreatic duct obstruction" and "common channel" theories are generally accepted as explanations of the mechanisms involved in gallstone acute pancreatitis(AP). Common channel elucidates the mechanism of necrotizing pancreatitis due to gallstones. For pancreatic duct obstruction, the clinical picture of most patients with ampullary stone impaction accompanied by biliopancreatic obstruction is dominated by life-threatening acute cholangitis rather than by AP, which clouds the understanding of the severity of gallstone AP. According to the revised Atlanta classification, it is difficult to consider these clinical features as indications of severe pancreatitis. Hence, the term "gallstone cholangiopancreatitis" is suggested to define severe disease complicated by acute cholangitis due to persistent ampullary stone impaction. It incorporates the terms "cholangitis" and "gallstone pancreatitis." "Cholangitis" refers to acute cholangitis due to cholangiovenous reflux through the foci of extensive hepatocyte necrosis reflexed by marked elevation in transaminase levels caused by persistent ampullary obstruction. "Gallstone pancreatitis" refers to elevated pancreatic enzyme levels consequent to pancreatic duct obstruction. This pancreatic lesion is characterized by minimal or mild inflammation. Gallstone cholangiopancreatitis may be valuable in clinical practice for specifying gallstone AP that needs urgent endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy.     

胆囊结石与急性胰腺炎的关系

目的 探讨胆囊结石患者发生急性胰腺炎（AP）的影响因素.方法 选取武汉大学人民医院消化内科收治的诊断为胆囊结石的患者118例,通过影像学检查,测量胆囊大小、胆囊结石大小及数量,判断是否伴有胆总管结石.根据有无并发AP进行分组,比较各相关因素对AP发生率的影响.结果 118例胆囊结石患者中并发AP 61例.74例的胆囊大小正常,其中49例（66.2％）发生AP;44例胆囊增大或缩小,其中12例（27.3％）发生AP.31例为单发结石,其中11例（35.5％）发生AP;87例为多发结石,其中50例（57.5％）发生AP.发生AP的11例单发结石患者,其中8例（72.7％）结石≥10mm;50例多发结石患者中41例（82.0％）结石＜10 mm.19例伴有胆总管结石,其中17例（89.5％）发生AP;99例无胆总管结石,其中44例（44.4％）发生AP.各因素的两组间差异均有统计学意义（Х^2=16.758,P=0.000;Х^2 =4.425,P=0.029;Х^2=13.434,P=0.001;Х^2 =12.994,P=0.000）.结论 急性胆源性胰腺炎的发生与胆囊结石相关,胆囊是否正常、胆囊结石大小及数量、是否伴有胆总管结石均是影响AP发生的相关因素.     

Relation between the risk of gallstone pancreatitis and characteristics of gallstone in Korea

BACKGROUND/AIMS: Pancreatitis is a serious complication of patients with gallstones. However, risk factors of gallstone pancreatitis were unpredictable until recently. In Korea, characteristics of gallstones are different from Western countries. The present study was designed to determine differences in the risk of gallstone pancreatitis and characteristics of gallstones in Korean patients. METHODOLOGY: Clinical data were collected on patients undergoing laparoscopic cholecystectomy. The physical characteristics of gallstones recovered at surgery were also recorded. Patients with gallstone pancreatitis were compared with patients who had uncomplicated biliary pain. RESULTS: In a logistic regression model, acute gallstone pancreatitis was associated with a stone diameter of less than 5 mm (odds ratio: 3.3695; P = 0.0352) and with stone number of more than 20 (odds ratio: 3.8686; P = 0.0361). No other variable, including pigment stone, age, and sex, remained statistically significant in the adjusted analysis (P > 0.05). CONCLUSIONS: Patients with at least 1 gallstone smaller than 5 mm in diameter and stone number more than 20 each have a more than 3-fold increased risk of presenting with acute gallstone pancreatitis. The composition of gallstones, especially pigment stones, was not an important risk factor in gallstone pancreatitis in Korean patients with stones having a different composition than those from Western countries.     

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES: Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy. METHODS: Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations. RESULTS: Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (相似文献   

Pathological Pancreatic Exocrine Function and Duct Morphology in Patients with Cholelithiasis

Most authors claim alcohol consumption to be the only relevant reason for chronic pancreatitis. However, gallstones might cause this disease, as they do cause acute pancreatitis. In this study 91 gallstone patients and 94 age-matched controls were investigated concerning exocrine pancreatic function (fecal elastase-1 concentrations). Furthermore x-rays of 100 consecutive ERCP patients were evaluated for differences concerning pancreatic duct changes between patients with and without evidence of cholelithiasis. Pathological elastase 1 levels were more frequent in gallstone patients (30,8%) as compared to age-matched controls (19%). Symptoms such as upper abdominal pain, bloating, and fat intolerance were reported more often in gallstone patients. In ERCP of gallstone patients (N = 60), 77% were found to have chronic pancreatitis according to the Cambridge classification, while in nongallstone-patients (N = 32) 47% had chronic pancreatitis. In conclusion, according to these data a pathophysiological connection between gallstones and chronic pancreatitis appears to be probable.     

Should urgent ERCP be performed in patients with acute biliary pancreatitis without acute cholangitis?

Endoscopists who perform endoscopic retrograde cholangiopancreatography (ERCP) are frequently pressured to perform urgent (usually night or weekend) ERCP in patients with acute biliary pancreatitis in the belief that this procedure reduces morbidity and mortality. However, with the exception of those patients with concurrent acute cholangitis, data that urgent ERCP with biliary compression is helpful in all patients with acute gallstone pancreatitis are lacking. In this Practice Point commentary, I discuss the findings and limitations of a meta-analysis conducted by Petrov et al. that pooled data from three randomized, controlled trials that included 450 patients in total. Four other randomized, controlled trials on this topic were excluded from the analysis because of methodologic problems. The authors concluded that early ERCP was not associated with a significant reduction in complications or mortality in patients with predicted mild or severe acute biliary pancreatitis.     

65例急性梗阻型胆源性胰腺炎外科治疗分析

目的 探讨急性梗阻型胆源性胰腺炎(AOGP)外科治疗的有关问题.方法 对65例梗阻型AGP患者的临床资料进行回顾性分析,轻症急性梗阻型胆源性胰腺炎(MAOGP)42例,保守治疗38例,急诊后期手术4例;重症急性梗阻性胆源性胰腺炎(SAOGP)23例,均行早期或急诊手术.结果 本组病例痊愈64例, 1例因伴心脏病、糖尿病、多器官功能衰竭及腹腔感染术后2周内死亡.结论 对伴有化脓性胆管炎的AOGP者早期宜行急诊手术,轻型梗阻性AGP早期积极非手术治疗,胰腺炎治愈后2～4周内择期手术治疗胆石病,可以降低复发率、并发症发生率和病死率.     

A prospective study of the aetiology, severity and outcome of acute pancreatitis in Eastern India.

BACKGROUND: Acute pancreatitis is a common cause of hospital admission. The aim of this study was to evaluate the aetiology, severity and outcome of acute pancreatitis in our tertiary referral center. METHODS: Between August 2002 and December 2003, 45 cases of acute pancreatitis were admitted to the hospital. Diagnosis was ascertained by clinical examination and investigations (hyperamylasaemia). The severity was assessed by the Acute Physiology and Chronic Health Evaluation scoring system and contrast enhanced computed tomography scan. The patients were treated according to a designed protocol. The data related to aetiology, severity and outcome were noted for subsequent analysis. RESULTS: Of the 45 patients, 33 were male and 12 were female. The mean age was 30 years. Of the 45 patients, 34 patients had mild pancreatitis and 11 had severe pancreatitis. The aetiology spectrum of mild pancreatitis included the following: alcoholism in 14 (41.1%), gallstones in 8 (23.5%), trauma in 6 (17.6%), idiopathic in 4 (11.7%) and post-endoscopic retrograde cholangiopancreatography in 2 (5.8%). The causes of severe acute pancreatitis came under the following headers: trauma in 3 (27.2%), idiopathic in 2 (18.1%), gallstones in 2 (18.1%), alcoholism in 2 (18.1%) and post-endoscopic retrograde cholangiopancreatography in 2(18.1%). Mild pancreatitis led on to the following: pancreatic abscess in 1, pseudocyst in 3 and readmission for pain relapse within 6 months in 10 patients. The remainder had uneventful recoveries. There was no mortality in this group. Severe acute pancreatitis led on to the following: symptomatic sterile pancreatic necrosis in 2, infected pancreatic necrosis in 2, pancreatic abscess in 2 and presentation 8 months later with colonic stricture in 1 patient. There were 2 deaths in this group due to multi-organ failure. CONCLUSION: Although gallstones have largely been implicated as a common cause of acute pancreatitis our study found alcoholism as the main aetiological factor. Blunt abdominal trauma was also seen as a common cause of acute severe pancreatitis, particularly severe acute pancreatitits, as seen in our series. The outcome in mild pancreatitis was good, severe acute pancreatitis leads to more complications and greater mortality, thus requiring careful medical and surgical management.     

Etiology of acute pancreatitis--a multi-center study in Taiwan

BACKGROUND/AIMS: Little is known about the etiology of acute pancreatitis in Taiwan. The aim of this study was to evaluate the current etiology of acute pancreatitis in Taiwan by a multi-center cooperative study. METHODOLOGY: Patients with acute pancreatitis were collected from 8 major leading hospitals located at northern, southern, middle and eastern Taiwan from July 1, 1998 to June 30, 2000. The diagnosis of acute pancreatitis was based on characteristic clinical signs and symptoms and three-fold elevation of serum amylase/lipase level or positive evidence in imaging studies. The etiology was attributed to alcohol, gallstones, hypertriglyceridemia, miscellaneous causes, and idiopathic causes. RESULTS: In total 1,193 patients with acute pancreatitis were identified. There were 852 (71.4%) men and 341 (28.6%) women with a mean age of 52.5 years, ranging from 9 to 100 years. Etiology was identified as alcohol in 423 (33.6%), gallstones in 407 (34.1%), hypertriglyceridemia in 147 (12.3%), miscellaneous causes in 109 (9.1%), and idiopathic causes in 107 (9.0%). Patients with alcohol-related acute pancreatitis were the youngest (mean age: 41.5 years), while those with gallstone pancreatitis were the eldest (mean age: 64.1 years) (p < 0.001). The predominant cause of acute pancreatitis in women is gallstones, while alcohol is the leading cause of acute pancreatitis in Taiwanese males. In northern Taiwan, gallstone is the major cause of acute pancreatitis, while alcohol is the predominant etiology in middle, southern, and eastern Taiwan. CONCLUSIONS: Alcohol has become the predominant cause of acute pancreatitis in Taiwan recently. Ecological and gender differences play important roles in the etiology of acute pancreatitis in Taiwan.     

JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis

Gallstones, along with alcohol, are one of the primary etiological factors of acute pancreatitis, and knowledge of the etiology as well as the diagnosis and management of gallstones, is crucial for managing acute pancreatitis. Because of this, evidence regarding the management of gallstone-induced pancreatitis in Japan was collected, and recommendation levels were established by comparing current clinical practices with optimal clinical practices. The JPN Guidelines for managing gallstone-induced acute pancreatitis recommend two procedures: (1) an urgent endoscopic procedure should be performed in patients in whom biliary duct obstruction is suspected and in patients complicated by cholangitis (Recommendation A); and (2) after the attack of gallstone pancreatitis has subsided, a laparoscopic cholecystectomy should be performed during the same hospital stay (Recommendation B).     

高血糖与胆石症40例临床报告

目的 分析胆石症和糖尿病发病率之间的关系。讨论糖尿病合并无症状胆石症时是应该手术治疗以及糖尿病病人胆道手术的围手术期处理。方法 对４０例合并高血糖的胆石症病人进行回顾性分析。结果 外科胆石症 ６９３例,其中４０例合并高血糖。男性１４例,女性２６例,平均年龄６０．１岁。确认糖尿病１５例,可疑糖尿病１１例,应激性高血糖１４例。手术治疗３３例,胆囊切除１４例,胆囊切除、胆总管探查１６例,胆肠内引流２例,     

Gallstone pancreatitis: When is endoscopic retrograde cholangiopancreatography truly necessary?

Acute pancreatitis is an inflammation of the pancreas that can, in a minority of patients, lead to local complications, multiorgan failure, and death. Gallstones are the most common cause of acute pancreatitis in Western countries. The majority of patients with acute gallstone pancreatitis have mild disease and recover within 3 to 5 days with bed rest and intravenous fluid replacement. In up to 20% of patients, severe pancreatitis develops and can involve pancreatic tissue necrosis and multiorgan failure. Recent advances in the care of patients with gallstone-induced pancreatitis include better severity stratification on hospital admission, more aggressive fluid resuscitation in the early disease course, early use of antibiotics in patients with pancreatic necrosis, a shift from parenteral to enteral feeding regimens, a better defined and less aggressive approach to pancreatic surgery, and the possibility to remove impacted gallstones endoscopically. Urgent endoscopic retrograde cholangiopancreatography and sphincterotomy are recommended in patients with signs of cholangitis or jaundice, ultrasound evidence of dilated common bile duct, or evidence of severe disease.     

Gallstone disease and its complications

Gallstone disease is one of the most common disorders of the gastrointestinal tract, and more cholecystectomies are performed each year in the United States than any other elective abdominal operation. As such, clinicians need a fundamental knowledge of gallstone disease and the common complications that are associated with this disease. Overall, the prevalence of gallstones in the United States is approximately 10% to 15%, of which, approximately 80% are without symptoms. Symptoms will occur in approximately 20% of those with gallstones, and this subgroup is at the highest risk for developing serious complications from their gallstone disease. These complications can range from simple recurrent biliary colic to severe, life-threatening ascending cholangitis and/or pancreatitis. This review will outline the basis for gallstone formation, the underlying mechanisms that result in gallstone-induced symptoms and a rational approach to individuals who present with symptoms consistent with gallstone disease. Current diagnostic and treatment modalities will be discussed, with a particular emphasis on acute cholecystitis and acute biliary pancreatitis.     

Gallstone Pancreatitis

Opinion statement The majority of patients with acute gallstone pancreatitis have a mild attack and recover without additional treatment. In about 20% of patients, the attack is severe and is associated with a mortality rate of about 20%. Patients with severe pancreatitis require management in a high-dependency or intensive care setting. These patients are best managed in a specialized unit. Antibiotic prophylaxis is advised in patients with necrosis, and imipenem and cefuroxime are recommended. In severe pancreatitis, early enteral nutrition is recommended through a nasojejunal tube. In patients with severe pancreatitis or with cholangitis, urgent endoscopic retrograde cholangiopancreatography within 72 hours is indicated, and when appropriate, a sphincterotomy and clearance of the bile duct is performed. In sterile necrosis, conservative treatment is indicated unless the patient fails to improve or deteriorates, whereupon surgery is considered. If there is infection of pancreatic necrosis or abscess (pancreatic or peripancreatic), surgery is indicated. A symptomatic and persistent pancreatic pseudocyst requires intervention with either endoscopic drainage (transpapillary pancreatic stent, cystgastrostomy, or cystduodenostomy), percutaneous drainage, or surgery. Before discharge, patients should undergo cholecystectomy, or if they are unfit for surgery, endoscopic sphincterotomy and bile duct clearance.     

Predicting a ‘difficult cholecystectomy’ after mild gallstone pancreatitis

BackgroundCholecystectomy after gallstone pancreatitis may be technically demanding. The aim of this study was to investigate risk factors for a difficult cholecystectomy after mild pancreatitis.MethodsThis was a prospective study within a randomized controlled trial on the timing of cholecystectomy after mild gallstone pancreatitis. Difficulty of cholecystectomy was scored on a 0 to 10 visual analogue scale (VAS) by the senior attending surgeon. The primary outcome ‘difficult cholecystectomy’ was defined by presence of one or more of the following features: a VAS score ≥ 8, duration of surgery > 75 minutes, conversion or subtotal cholecystectomy.Results249 patients were included in the primary analysis. A difficult cholecystectomy occurred in 82 patients (33%). In the ‘same-admission cholecystectomy’ group 29 of 112 cholecystectomies were difficult (26%) versus 49 of 127 patients (39%) who underwent surgery after 2 weeks (p = 0.037). After multivariable analysis, male sex (OR 1.80, 95% confidence interval [CI] 1.04−3.13; p = 0.037), prior sphincterotomy (OR 1.79, 95% CI 1.01−3.16; p = 0.046), and delaying cholecystectomy for at least two weeks (OR 1.81, 95% CI 1.04−3.16; p = 0.036) were independent predictors of a difficult cholecystectomy.ConclusionSurgeons should anticipate a difficult cholecystectomy after mild gallstone pancreatitis in case of male sex, prior sphincterotomy and delayed cholecystectomy.     

Acute biliary pancreatitis: staging and management

BACKGROUND/AIMS: Acute biliary pancreatitis is a clinical entity with a high morbidity rate (15-50%) and mortality rate (20-35%). Early diagnosis has a primary importance for an appropriate treatment (75% of cases of idiopathic acute pancreatitis are of biliary origin). METHODOLOGY: Diagnosis of acute biliary pancreatitis in 78 patients was based on careful clinical and instrumental assessment: ultrasonography (76.9% of cases) and laboratory tests in 23.1% of cases. In our study we used the Ranson and APACHE II scores and 24 of the cases (30.7%) were classified as severe, while 54 (69.2%) were mild. All patients with severe acute biliary pancreatitis underwent emergency endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy (within 24-48 hours) followed by laparoscopic cholecystectomy (10 days). Patients with mild acute biliary pancreatitis underwent laparoscopic cholecystectomy associated with intraoperative cholangiography, within 10 days. RESULTS: In 19 patients with severe acute biliary pancreatitis operative endoscopy was curative. Subsequent laparoscopic cholecystectomy provoked subcutaneous emphysema only in one case but did not show any other serious morbidity. In the remaining 5 cases laparotomy was required because of necrosis, with a mortality rate of 60%. In all cases of mild acute biliary pancreatitis, laparoscopic cholecystectomy was successfully performed with a morbidity rate of 7.3%. Common bile duct stones were revealed with intraoperative cholangiography in 31.4% of the mild cases and in 75% of the severe cases. CONCLUSIONS: In conclusion acute biliary pancreatitis treatment is always surgical; in almost all severe cases it is performed with minimally invasive procedures (endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy with laparoscopic cholecystectomy < or = 10 days) if surgery is carried out within 24-48 hrs, as well in the mild cases (laparoscopic cholecystectomy + intraoperative cholangiography) when surgery is performed within 10 days.     

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.