Enalapril-induced acute recurrent pancreatitis

Enalapril, an angiotensin-converting enzyme inhibitor, has several adverse effects, but acute pancreatitis is uncommon. The case of a patient with enalapril-induced pancreatitis is described. Development of severe, necrotizing pancreatitis after inadvertent rechallenge confirmed the causal relationship between enalapril and acute pancreatitis.     

Progression to recurrent acute pancreatitis after a first attack of acute pancreatitis in adults

PurposePatients with a first attack of acute pancreatitis (AP) can develop recurrent acute pancreatitis (RAP). Hence, this study aimed to investigate the clinical features of the disease and the risk factors for RAP.MethodsWe performed a retrospective study of 522 patients from Jan 1 to Dec 31, 2006. All patients with AP were followed for 36 months. The primary end point was the rate of RAP. The secondary end points were the risk factors that were evaluated by Cox regression analysis. The cumulative risk of RAP was assessed using Kaplan-Meier analysis.Results56 of the 522 patients (10.7%) developed RAP. Among those RAP patients, 37 (7.1%) experienced one relapse, 10 (1.9%) experienced two relapses, and 9 (1.7%) experienced three or more relapses. Univariate analysis indicated that age (p = 0.016), male sex, etiology of AP (p = 0.001), local complications (p = 0.001) and Length of stay (LOS) (p = 0.007) were associated with RAP. Multivariate analysis with the Cox proportional hazards model showed that male sex (HR = 2.486, 95% CI, 0.169–0.960, p = 0.04), HTG-associated etiology (HR = 5.690, 95% CI, 2.138–15.146, p = 0.001), alcohol-associated etiology (HR = 5.867, 95% CI, 1.446–23.803, p = 0.013) and current local complications at index admission (HR = 8.917, 95% CI, 3.650–21.789, p = 0.001) were significant independent risk factors for RAP.ConclusionsA first attack of AP led to RAP in 10.7% of patients within 3 years. Male sex was significantly associated with RAP. The etiologies of alcohol and HTG and local complications were the strongest risk factors for recurrent disease. Patients with these characteristics should be given special attention and followed-up closely.     

Role of genetic disorders in acute recurrent pancreatitis

There was remarkable progress in the understanding of the role genetic risk factors in chronic pancreatitis. These factors seem to be much more important than thought in the past. The rare autosomal-dominant mutations N29I and R122H of PRSS1 （cationic trypsinogen） as well as the variant N34S of SPINK1 （pancreatic secretory trypsin inhibitor） are associated to a disease onset in childhood or youth. Compared to chronic alcoholic pancreatitis the progression is slow so that for a long time only signs of acute-recurrent pancreatitis are found. Only at later time points （more than 10-15 years） there is evidence for chronic pancreatitis in the majority of patients. Acute recurrent pancreatitis may therefore be regarded as a transition state until definite signs of chronic pancreatitis are detectable.     

Ampullary adenomyoma presenting as acute recurrent pancreatitis

Adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. Despite its benign nature,ampullary adenomyoma is usually presented as biliary obstruction. Most cases are misdiagnosed as carcinoma or adenoma by preoperative endoscopic or radiologic procedure. Therefore,it is frequently treated with extensive surgery. To our knowledge,this is the first reported case in English literature of adenomyoma located in the peripancreatic orifice resulting in intermittent pancreatic duct obstruction and recurrent pancreatitis diagnosed by the endoscopic piecemeal resection.     

Risk factors of recurrent pancreatitis after first acute pancreatitis attack: a retrospective cohort study

Abstract

Background and aims: Few studies have been conducted in Asia on the recurrence of acute pancreatitis (AP). This study was designed to investigate characteristics of the disease to predict recurrence.

Methods: We retrospectively analyzed 617 patients that experienced a first AP attack between January 2009 and December 2014. Based on reviews of clinical and follow-up data, we attempted to identify risk factors of recurrence using Cox regression analysis.

Results: During a median follow-up of 3.2?years (range 3–72?months), 100(16.2%) of the 617 study subjects experienced one or more episodes of recurrent acute pancreatitis (RAP). Of these 100 patients, 75(75%) experienced one relapse, 12(12%) two relapses, and 13(13%) three or more relapses. The etiologies of RAP were an alcohol (48%), gallstone (31%), idiopathic (14%), and others (7%). Univariate analysis showed that an age of <60?years, male gender, smoking, an alcohol-associated etiology, and a local complication at index admission were significant risk factors of RAP. Cox regression analysis showed that an age of <60?years (HR = 1.602, 95% CI: 1.029–2.493), male gender (HR = 1.927, 95% CI: 1.127–3.295), and the presence of a local complication (HR = 3.334, 95% CI: 2.211–5.026) were significant risk factors of RAP development.

Conclusion: A local complication at index admission was found to be the strongest risk factor of RAP, and a male gender and an age of <60?years were significantly associated with RAP. Special attention and close follow-up should be afforded to patients with a local complication at index admission or male patients <60?years old.     

复发性急性胰腺炎42例临床分析

目的探讨复发性急性胰腺炎的病因及诊治。方法回顾性分析42例复发性急性胰腺炎的病因及诊治情况。结果 42例复发病例中,胆源性25例,特发性9例,乙醇性6例,高脂血症、胰腺肿瘤各1例。42例均先行内科保守治疗,其中中转手术治疗14例(均治愈,愈后无复发);28例坚持内科治疗,愈后再次复发9例。本组死亡4例(手术、非手术各2例)。结论急性胰腺炎愈后复发的病因复杂,与疾病及多种药物使用有关,最常见的病因为胆石症、酗酒和暴饮暴食及特发性胰腺炎等有关。明确病因,积极恰当治疗,可减少复发性急性胰腺炎的发生。     

Idiopathic recurrent pancreatitis

The cause of recurrent acute pancreatitis can be identified in the majority of patients. A small group of patients in whom an etiological association is not obvious is characterized as idiopathic recurrent pancreatitis (IRP). During the last seven years, we used endoscopic retrograde cholangiopancreatography (ERCP) and sphincter of Oddi (SO) manometric pressure studies to investigate 116 patients initially diagnosed as IRP. Forty-four of the 116 patients were found to have a demonstrable cause of their pancreatitis. Appropriate therapeutic intervention was carried out in 43 of these patients with a favorable outcome in the majority of patients noted during long-term follow-up.     

Analysis of the clinical features of recurrent acute pancreatitis in China

Background Since few systematic studies have focused on recurrent acute pancreatitis in China, we sought to investigate its clinical features, including etiological factors and relative frequency. Methods Patients were selected from a total 1471 patients with acute pancreatitis in ten cities of China. All had been admitted to a hospital with an attack of acute pancreatitis between January 1992 and December 2002. Data for each patient was recorded on a standardized form. Results Of the 1471 patients with acute pancreatitis, 157 (10.7%) had recurrent acute pancreatitis. The majority (63%) were male, with a mean age of 41 years (range, 13–82 years). Regarding the etiology, alcohol (20.4%) and cholelithiasis (20.4%) were the most frequent causes, followed by diet (13.4%), hypertriglyceridemia (8.3%), biliary tract infection (5.7%), other (5.1%), and idiopathic factors (26.8%). Alcohol was most frequent in male patients (30.3%), whereas cholelithiasis was most frequent (34.5%) in female patients. The majority of patients (79.6%) presented with their second attack of pancreatitis. Complications of recurrent acute pancreatitis in order of frequency were pancreatic pseudocyst, multiple organ failure, diabetes mellitus type 2, and shock. Conclusions Recurrent acute pancreatitis remains a frequent disease, with cholelithiasis and alcohol being the most usual etiological factors. Alcohol is the primary etiological factor in male patients. In about 26.8% of cases, the etiology remains unknown.     

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）.     

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。     

Genetic variants in acute,acute recurrent and chronic pancreatitis affect the progression of disease in children

Background/objectivesAcute pancreatitis (AP) is emerging in pediatrics. A subset of children with AP progresses to acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP). The role of extensive gene testing in the progression has not been investigated previously. We have followed children enrolled in the registry and at our center for progression to ARP and CP after the first attack.MethodsThis study utilizes an extensive gene sequencing panel as a platform to evaluate the role of genetics in first attack AP, and the progression over time, from first attack to ARP and CP in children.ResultsGenes, with corresponding variants were involved in the 3 groups studied: AP, ARP and CP. We have shown that the presence of gene variants from the eight tested genes is enriched in the CP group compared to the AP and ARP groups. The presence of more than one gene was associated with CP (p = 0.01). SPINK1 mutation(s) was significantly associated with faster progression to ARP, (p = 0.04). Having a variant from CFTR, SPINK1 or PRSS1, was associated with the faster progression from AP to CP over time (p < 0.05).ConclusionsThis study shows that genetics have a significant role in progression to ARP and CP from the first attack of pancreatitis.     

急性胰腺炎的近期研究进展

急性胰腺炎（AP）仍然是一种临床挑战。在美国,每年约有220000例患者因此而住院,在最常见的消化疾病出院诊断中占第3位,当前在消化疾病死亡原因中占第14位,总体病死率约为5％,并有多器官功能衰竭患者病死率可高达47％。本文将探讨流行病学、病因、严重程度评估和治疗有争议领域近期的显著进展。     

Groove pancreatitis with recurrent duodenal obstruction

Summary Groove pancreatitis is a rare subtype of chronic pancreatitis that is difficult to distinguish from pancreatic carcinoma. Most reported patients have undergone a Whipple procedure because pancreatic cancer was not ruled out. We report a case of groove pancreatitis in a patient who presented with recurrent duodenal obstruction without biliary stricture. The diagnosis of groove pancreatitis was based on characteristic episodes of repeated duodenal obstruction and the absence of radiographic evidence of cancer. Subsequently, our patient underwent a successful pylorus-reserving pancreaticoduodenectomy (PPPD). PPPD is a favorable alternative to the Whipple operation for duodenal obstruction resulting from this disease.     

PRSS1 and SPINK1 mutations in idiopathic chronic and recurrent acute pancreatitis

AIM: To identify gene mutations in PRSS1 and SPINK1 in individuals with early onset idiopathic chronic or recurrent acute pancreatitis.METHODS: The cationic trypsinogen gene (PRSS1; exons 2 and 3) and the serine protease inhibitor Kazal 1 gene (SPINK1; exon 3) were selectively amplified and sequenced from blood samples of 19 patients admitted to the Pancreas Clinic at our institution with chronic pancreatitis and/or idiopathic recurrent acute pancreatitis that were diagnosed or with onset before age 35. Fifty healthy volunteers served as controls. Whole blood samples were collected and gene specific sequences were amplified by polymerase chain reaction (PCR). All PCR products were subsequently sequenced in order to identify the presence of any mutations.RESULTS: Nineteen patients with pancreatitis (14 males; median age 24 years, range 15-48 years) were included in this study, of which five showed the presence of gene mutations. Direct sequencing results indicated the presence of two previously unidentified mutations in exon 2 of PRSS1 (V39E and N42S) in two patients with recurrent acute pancreatitis. Two cases had the N34S SPINK1 mutation. Analysis of the relatives of one patient homozygous for this mutation showed that five of the six family members carried the N34S SPINK1 mutation. Of these members, three were healthy heterozygous carriers and two were homozygotes (one sibling had diabetes, the other was healthy). Another patient was heterozygous for a novel SPINK1 mutation located on exon 3 (V46D). All members from this patient’s family had normal genotypes, indicating that it was a de novo mutation. No mutations in either gene were present in the control subjects.CONCLUSION: Two novel PRSS1 mutations and one novel SPINK1 mutation were identified in Mexican patients with early onset idiopathic recurrent acute pancreatitis.