Issues in hyperlipidemic pancreatitis

Hypertriglyceridemia (HTG) is a rare cause of pancreatitis. Pancreatitis secondary to HTG, presents typically as an episode of acute pancreatitis (AP) or recurrent AP, rarely as chronic pancreatitis. A serum triglyceride (TG) level of more than 1,000 to 2,000 mg/dL in patients with type I, IV, or V hyperlipidemia (Fredrickson's classification) is an identifiable risk factor. The typical clinical profile of hyperlipidemic pancreatitis (HLP) is a patient with a preexisting lipid abnormality along with the presence of a secondary factor (e.g., poorly controlled diabetes, alcohol use, or a medication) that can induce HTG. Less commonly, a patient with isolated hyperlipidemia (type V or I) without a precipitating factor presents with pancreatitis. Interestingly, serum pancreatic enzymes may be normal or only minimally elevated, even in the presence of severe pancreatitis diagnosed by imaging studies. The clinical course in HLP is not different from that of pancreatitis of other causes. Routine management of AP caused by hyperlipidemia should be similar to that of other causes. A thorough family history of lipid abnormalities should be obtained, and an attempt to identify secondary causes should be made. Reduction of TG levels to well below 1,000 mg/dL effectively prevents further episodes of pancreatitis. The mainstay of treatment includes dietary restriction of fat and lipid-lowering medications (mainly fibric acid derivatives). Experiences with plasmapheresis, lipid pheresis, and extracorporeal lipid elimination are limited.     

How we treat Waldenström's macroglobulinemia

Waldenstr?m's macroglobulinemia (WM) is a lymphoplasmacytic lymphoma which produces monoclonal immunoglobulin M (IgM). Over the last decade, new treatment modalites have been developed for the management of this disorder. Our objective is to provide treatment recommendations for WM. A review of published reports was facilitated by a MEDLINE computer search and by a manual search of Index Medicus. Other sources included abstracts and conference proceedings. Most patients with WM who are diagnosed by chance without symptoms should not be treated. Initiation of treatment should not be based on level of serum monoclonal protein per se. The presence of cytopenia, significant adenopathy or organomegaly, symptomatic hyperviscosity, severe neuropathy or cryoglobulinemia indicates the need for treatment. The main choices for primary treatment of symptomatic patients with WM include alkylating agents, the nucleoside analogs fludarabine or cladribine and the monoclonal antibody rituximab or combinations of these programs. There are no data from prospective randomized studies to recommend the use of one program over another. Nevertheless, the need for rapid disease control may favor the use of nucleoside analogs, whereas the presence of significant cytopenia may favor rituximab. High dose therapy with autologous stem cell transplantation may induce responses even in patients with resistance to all three class of agents. It may be prudent to avoid nucleoside analogs in patients who are candidates for high dose therapy. Despite the lack of randomized trials, a rational approach to the treatment of patients with WM is possible. Several factors, including the presence of cytopenias, need for rapid disease control, candidacy for autologous stem cell transplantation, age and co-morbid conditions, should be taken into consideration when choosing the most appropriate primary treatment.     

Plasmapheresis in the management of acute severe hyperlipidemic pancreatitis: report of 5 cases.

BACKGROUND/AIM: Hyperlipidemic pancreatitis is an acute and potentially life-threatening complication of hypertriglyceridemia that can be provoked when triglyceride levels (TGL) exceed 11.3 mmol/l (1,000 mg/dl). Except for standard symptomatic treatment, plasmapheresis has been performed to rapidly reduce TGL and chylomicron levels in the blood. In 5 patients with hyperlipidemic pancreatitis, treatment with plasmapheresis was evaluated. METHODS: Five male patients who suffered from acute pancreatitis with severe primary hyperlipidemia were studied. In addition to the standard treatment, they were treated with plasmapheresis. RESULTS: Plasma exchange lowered the lipid level and TGLs in all cases. It also improved abdominal pain, the clinical state of the patients, and signs and symptoms of the disease. Complications of treatment were not encountered, none of the patients died and only 1 patient underwent surgery. Follow-up of the patients lasted 4-28 months, and recurrence of pancreatitis was not noted. CONCLUSION: Our study showed that plasmapheresis was successfully applied in patients with hyperlipidemic pancreatitis, especially to improve the acute phase of the disease.     

Marked Hyperlipidemia and Pancreatitis Associated with Isotretinoin Therapy

Isotretinoin, a retinoid derivative, is in wide use as a treatment for severe acne and other dermatologic conditions. Its effects on serum lipids, most notably the induction of hypertriglyceridemia, have been well documented. We present a case of a young woman with a previous history of gestational hyperlipidemia who developed hypertriglyceridemia and pancreatitis after initiation of isotretinoin therapy. A history of gestational hyperlipidemia may serve as a marker to help identify patients who are at increased risk for developing severe hypertriglyceridemia while receiving isotretinoin. Her case emphasizes the need to consider the possibility of pancreatitis in patients who develop abdominal pain while receiving this drug.     

Fundamental and intensive care of acute pancreatitis

Patients who have been diagnosed as having acute pancreatitis should be, on principle, hospitalized. Crucial fundamental management is required soon after a diagnosis of acute pancreatitis has been made and includes monitoring of the conscious state, the respiratory and cardiovascular system, the urinary output, adequate fluid replacement and pain control. Along with such management, etiologic diagnosis and severity assessment should be conducted. Patients with a diagnosis of severe acute pancreatitis should be transferred to a medical facility where intensive respiratory and cardiovascular management as well as interventional treatment, blood purification therapy and nutritional support are available. The disease condition in acute pancreatitis changes every moment and even symptoms that are mild at the time of diagnosis may become severe later. Therefore, severity assessment should be conducted repeatedly at least within 48 h following diagnosis. An adequate dose of fluid replacement is essential to stabilize cardiovascular dynamics and the dose should be adjusted while assessing circulatory dynamics constantly. A large dose of fluid replacement is usually required in patients with severe acute pancreatitis. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with severe acute pancreatitis. Although the efficacy of intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional continuous regional arterial infusion and blood purification therapy.     

Evaluation and treatment of hypertriglyceridemia: an endocrine society clinical practice guideline

Objective: The aim was to develop clinical practice guidelines on hypertriglyceridemia. Participants: The Task Force included a chair selected by The Endocrine Society Clinical Guidelines Subcommittee (CGS), five additional experts in the field, and a methodologist. The authors received no corporate funding or remuneration. Consensus Process: Consensus was guided by systematic reviews of evidence, e-mail discussion, conference calls, and one in-person meeting. The guidelines were reviewed and approved sequentially by The Endocrine Society's CGS and Clinical Affairs Core Committee, members responding to a web posting, and The Endocrine Society Council. At each stage, the Task Force incorporated changes in response to written comments. Conclusions: The Task Force recommends that the diagnosis of hypertriglyceridemia be based on fasting levels, that mild and moderate hypertriglyceridemia (triglycerides of 150-999 mg/dl) be diagnosed to aid in the evaluation of cardiovascular risk, and that severe and very severe hypertriglyceridemia (triglycerides of > 1000 mg/dl) be considered a risk for pancreatitis. The Task Force also recommends that patients with hypertriglyceridemia be evaluated for secondary causes of hyperlipidemia and that subjects with primary hypertriglyceridemia be evaluated for family history of dyslipidemia and cardiovascular disease. The Task Force recommends that the treatment goal in patients with moderate hypertriglyceridemia be a non-high-density lipoprotein cholesterol level in agreement with National Cholesterol Education Program Adult Treatment Panel guidelines. The initial treatment should be lifestyle therapy; a combination of diet modification and drug therapy may also be considered. In patients with severe or very severe hypertriglyceridemia, a fibrate should be used as a first-line agent.     

Management of dyslipidemia in primary care

BACKGROUND: Cardiovascular disease remains the leading cause of mortality in Canada. The link between hyperlipidemia and coronary heart disease has been clearly established. There is overwhelming evidence for reductions in coronary events and cardiovascular mortality with lowering of low-density lipoprotein cholesterol (LDL-C). Despite the evidence, hyperlipidemia treatment remains suboptimal. OBJECTIVE: To evaluate compliance with published dyslipidemia guidelines in a primary care setting. The primary outcome measure was target LDL-C level. METHODS: Retrospective chart review of a random selection of 300 patients diagnosed with hyperlipidemia in a large academic family medicine clinic. The primary outcome measure was a target LDL-C level of less than 2.5 mmol/L for patients with diabetes or coronary heart disease. For patients without diabetes or coronary heart disease, Framingham risk assessment tables were used to determine ideal target LDL-C levels. RESULTS: Overall, 53% of patients achieved target LDL-C. Target LDL-C levels were achieved in 48% of patients with diabetes or coronary heart disease. Males were twice as likely to be prescribed lipid lowering therapy than females. Males on lipid lowering therapy were twice as likely as females on lipid lowering therapy to achieve target LDL-C levels. Males with diabetes or coronary heart disease were twice as likely as females with diabetes or coronary heart disease to achieve target LDL-C levels. Only 44% of patients with diabetes or coronary heart disease were prescribed lipid lowering therapy. CONCLUSION: Results from an academic family medicine clinic indicate suboptimal compliance with current dyslipidemia management guidelines. Primary care physicians need to continue to take an aggressive stance on lipid lowering strategies, especially in high-risk patients and females.     

Pain Management in chronic pancreatitis

Opinion statement Painful chronic pancreatitis is difficult to manage. We believe a multidisciplinary approach is the best means of evaluating this complex syndrome. In our opinion, the initial evaluation should aim at firmly establishing the diagnosis of chronic pan-creatitis: calcifications on imaging; duct morphologic changes on pancreatography; parenchymal changes on ultrasound; or evidence of pancreatic dysfunction on secre-tin/ cholecystokinin stimulation tests. In addition, psychological assessment and qual-ity-of-life measurements are recommended. Once the diagnosis of chronic pancreatitis has been made, characterization of the chronic pain syndrome (visceral, non-visceral) with a diagnostic differential nerve block (DNB) is performed. Unlike celiac plexus block, which interrupts visceral afferent impulses traveling through the celiac plexus, a DNB is a meticulous, diagnostic tempo-rary block that localizes the origin of chronic abdominal pain. This pain can be classi-fied as visceral, psychologic/central, somatosensory, or mixed when more than one pain pathway is involved. Treatment modalities are different for these different types of pain syndromes. Chronic pancreatic pain should be visceral in origin if pain is stemming from an inflamed/scarred gland [1]. There is evidence that DNB may be helpful in characterizing abdominal pain in chronic pancreatitis [1]. Furthermore, it allows better selection of patients for treatment of chronic pancreatic pain [2]. Initial treatment in all patients should include pancreatic enzyme therapy, abstinence from alcohol, non-narcotic analgesics, and a low-fat diet. Patients who fail initial therapy should be considered for surgery or enrollment in medical treatment trials. Those identified by DNB as having visceral-type pain should be directed to med-ical and surgical therapy based on pancreatic duct morphology. Visceral-pain patients with dilated ducts or focal disease should undergo pancreatic duct drainage, or surgi-cal resection procedures. Patients with nonciliated ducts should undergo further medi-cal therapy, including celiac plexus blocks, enrollment into treatment trials of endoscopic therapy, or drug trials with new agents such as tramadol, gabapentin, or octreotide, or nutritional supplementation. Finally, those patients with visceral pain unresponsive to all medical therapy and who are not surgical candidates should be enrolled in a trial of thorascopic splanchnicectomy for intractable pain (Fig. 1). Patients identified by DNB as having a non-visceral type of chronic abdominal pain should undergo initial medical therapy as above ( enzymes, cessation of alcohol, diet modifications, analgesics).     

Pancreaticoduodenectomy for the Treatment of Groove Pancreatitis

Background and Aim

Groove pancreatitis is a segmental form of chronic pancreatitis that can be treated with pancreaticoduodenectomy (PD), although outcome studies for this approach are lacking. We performed an assessment of pain symptoms, need for opioids, and weight gain following PD for symptomatic groove pancreatitis.

Methods

The study was a retrospective case series describing all patients with groove pancreatitis who underwent PD at our medical center. The primary outcome was the change in pain level and opioid use following PD.

Results

Five patients underwent PD for treatment of groove pancreatitis. Patients’ perception of pain, using a 10-point visual analog scale, improved after surgery from 5.0 to 0.2. Opioid analgesics, as measured by oral morphine equivalents, dropped from 77.6 to 0 mg daily, with all five patients being completely free of opioids post-operatively. Weight loss ceased in all five patients, with an overall mean weight gain of 15.4 pounds post-operatively.

Conclusions

PD reduces pain and opioid analgesic use in groove pancreatitis. This intervention should be considered for patients with this condition.     

The effectiveness of anxiety treatment on alcohol-dependent patients with a comorbid phobic disorder: a randomized controlled trial

OBJECTIVE: Evidence has emerged which indicates that the post-treatment relapse rate for alcohol-dependent patients with a comorbid anxiety disorder is higher than for alcohol-dependent patients without a comorbid anxiety disorder. The question raised by this evidence is whether the relapse rate in these dually diagnosed patients could be reduced if they were given additional treatment for the comorbid anxiety disorder. We attempted to answer this question by conducting a trial among patients with a double diagnosis of alcohol dependence and agoraphobia or social phobia. METHOD: We conducted a 32-week randomized controlled trial among 96 abstinent patients with a primary diagnosis of alcohol dependence and a comorbid anxiety disorder involving agoraphobia or social phobia. The patients were randomly assigned to an intensive psychosocial relapse-prevention program on its own (n = 49) or in combination with an anxiety treatment program comprising cognitive behavioral therapy (CBT) and optional pharmacotherapy consisting of an SSRI (n = 47). The primary outcome measure was the percentage of patients who suffered an alcohol relapse during a 32-week period. The secondary outcome measures were total abstinence, a reduction in the days of heavy drinking, and less severe anxiety symptoms. RESULTS: Although the additional therapy clearly reduced the anxiety symptoms, it had no significant effect on the alcohol relapse rates. CONCLUSION: Anxiety treatment for alcohol-dependent patients with a comorbid anxiety disorder can alleviate anxiety symptoms, but it has no significant effect on the outcome of alcohol treatment programs.     

复发性胆源性胰腺炎的临床特点及诱发因素分析

目的探讨复发性胆源性胰腺炎的临床特点及诱发因素。方法选取江北区人民医院2008年1月-2014年12月收治的272例胆源性胰腺炎患者,其中复发性胆源性胰腺炎56例(复发组),初发性胆源性胰腺炎216例(初发组)。比较2组患者的临床特点和诱因。计量资料组间比较采用t检验,计数资料组间比较采用χ2检验。结果 2组患者的年龄、病死率比较,差异均无统计学意义(P值均0.05)。与初发组比较,复发组中男性所占比例、APACHE-Ⅱ评分、中重度胰腺炎、胆总管结石发生率、合并胆总管开口狭窄率、合并高脂血症率、手术治疗率均显著升高(P值均0.05)。复发组复发2次者与复发2次以上者的胰腺炎分型比较,差异亦有统计学意义(P=0.040)。复发组有明确诱因者明显高于初发组(80.36%vs 58.33%,P=0.002)。复发组中高脂饮食、饮酒率明显高于初发组(P值均0.05),但是2组胆道感染、口服药物率的差异无统计学意义(P值均0.05)。结论复发性胰腺炎在男性中多见,相对较重,常合并胆总管结石、胆总管开口狭窄、高脂血症,手术治疗率高。高脂饮食和饮酒是复发性胆源性胰腺炎的重要诱因。     

Acute pancreatitis following hematopoietic stem cell transplantation: prevalence and cause of pancreatic amylasemia

To clarify the frequency and cause of acute pancreatitis following hematopoietic stem cell transplantation (SCT), we examined retrospectively 57 patients who underwent hematopoietic SCT in our institute from 1984 to 2000. Twelve (21%) of the patients showed an elevated level of serum pancreatic amylase following SCT. However, only 3 patients were clinically diagnosed as having acute pancreatitis. Among these 12 patients, 11 had undergone allogeneic transplantation. Furthermore, patients who had undergone unrelated transplantation (7/16; 44%) tended to show a higher incidence of increased amylase than those who had undergone related transplantation (4/24; 17%). Six patients were at an advanced stage of acute GVHD (grade III or IV) and all showed an elevated level of serum amylase, whereas only four patients showed an elevated serum amylase level among 34 with mild acute GVHD (grade I or II) or without GVHD. Furthermore, five out of 12 patients who showed an increased amylase level were concurrently diagnosed as having viral infection such as cytomegalovirus, adenovirus, or varicella zoster virus. We conclude that pancreatitis following SCT occurs more often than realized, and is mostly subclinical. This is closely associated with severe acute GVHD, and possibly viral infection.     

Acute pancreatitis: is there a need for surgery?

The treatment of acute pancreatitis is primarily non-surgical. An interdisciplinary approach as well as timely and aggressive intensive care has led to a significant improvement of the prognosis in severe necrotising pancreatitis. Early surgical procedures were associated with high morbidity and mortality and therefore were abandoned and replaced with forceful conservative treatment. However, there are still specific indications for surgery during the course of acute pancreatitis. These include cholecystectomy for biliary pancreatitis, surgical debridement of infected necrosis in septic patients and emergency operations for gastrointestinal perforations or haemorrhage. The following article focuses on surgical indications, optimal timing of surgery and competing surgical and non-surgical concepts like laparoscopic or endoscopic management. All mentioned procedures demand the cooperation of an experienced team of gastroenterologists, surgeons, radiologists and intensive care specialists, who are able to manage the potentially life-threatening complications of this disease. All patients with severe necrotising pancreatitis should be transferred to a specialised centre for interdisciplinary therapy.     

Hyperlipidemia in acute pancreatitis

Whether hyperlipidemia is a pre-existing metabolic disorder or a consequence of acute pancreatitis is still debated. Mild to moderate elevation of serum triglyceride levels are likely to be an epiphenomenon of the pancreatic disease. A marked hyperchylomicronemia and hypertrygliceridemia would be needed to trigger acute pancreatitis; a relevant defect in the lipid catabolism and clearance should therefore pre-exist. The aim of the present study was to investigate whether patients with acute pancreatitis and marked hyperlipidemia have an impaired clearance capacity of exogenous lipids, which would define the hyperlipidemia as a preexistent abnormality and therefore a potential cause of the pancreatic disease. With this aim, the kinetics of the removal of exogenous triglycerides from the circulation have been analyzed. Twenty patients with acute pancreatitis have been studied. Ten of them suffered from an episode of acute pancreatitis with marked hyperlipidemia (serum triglyceride levels>20mmol/L). Four to six months after recovery from the pancreatitis, a two-stage infusion of Intralipid 20% was carried out and the fractional removal rate (K₂) and the maximal clearance capacity (K₁) of exogenous triglycerides were calculated. At low infusion rates a first order kinetics for removal was observed, whereas at high infusion rates a zero order kinetics was operating. All patients with a previous attack of normolipidemic acute pancreatitis had normal K₂ and K₁ values. Five patients with previous hyperlipidemic acute pancreatitis had an abnormally low clearance capacity of exogenous triglycerides, whereas the remaining five had normal removal values. The present study provides new information in the association between hyperlipidemia and acute pancreatitis by showing that even a marked elevation of serum lipid levels should not be invariably considered as the etiological factor of the pancreatic disease, even if other potential causes are not evident.     

Allogeneic stem cell transplantation for chronic myeloid leukemia-status in 2007

Whereas until 2000 allo-SCT was the recommended treatment for all new patients with CML who were eligible on grounds of age and donor availability, approaches to initial therapy have changed very substantially since the introduction of imatinib mesylate. Today topical questions are (1) Should any newly diagnosed patient receive SCT as primary therapy? (2) How should imatinib failure be defined? (3) Should a patient who has failed imatinib but is still in chronic phase be offered an SCT or further treatment with a 'second-generation' TKI? (4) Would prior treatment with imatinib or concomitant delay to transplant adversely affect the subsequent results of allo-SCT? (5) Once the decision to proceed with allo-SCT is taken, how exactly should this be performed? (6) If a patient relapses after allo-SCT, how should he/she be treated? These questions will be addressed, but definitive answers may not yet be possible.     

Insulin treatment in the elderly diabetic patient

Type II diabetes mellitus may affect as many as 20% of the elderly US population. In the absence of data to support the need to maintain a specific level of glucose beyond that necessary to relieve symptoms, choice of therapy is problematic. Clearly, supervised dietary therapy for the obese type II diabetic patient represents a safe and cost-effective treatment. For those patients who fail dietary therapy because they fail to lose weight or regain lost weight, or because blood glucose levels remain high despite weight loss, further therapy must be individualized. The only rational criteria for drug treatment supportable by currently available data are (1) persistent symptoms associated with hyperglycemia, (2) ketonuria in the unstressed state, and (3) certain cases of hyperlipidemia, especially with triglyceride levels greater than 1000 mg/dl. In these clinical settings, drug therapy is necessary to eliminate symptoms, prevent development of ketoacidosis, and reduce the risk of pancreatitis, respectively. Consideration of drug therapy should also be made in the case of very elevated blood glucose levels, even in the absence of symptoms, when dehydration and risk of severe hyperosmolarity exist. The issues regarding insulin versus sulfonylureas have not been examined specifically in the elderly population. Extrapolating from published studies that generally include patients older than 65 years leads to the following conclusions: Caution regarding adverse side effects of insulin (hypoglycemia, theoretic risk of hyperinsulinemia) and sulfonylureas (hypoglycemia, drug interactions, increased risk of cardiovascular death) must be balanced against the theoretic benefit of treatment in the absence of symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pancreatic cancer after surgery for chronic pancreatitis

BACKGROUND: Chronic pancreatitis is known to be a risk factor for pancreatic cancer. AIMS: To identify patients who were diagnosed with pancreatic cancer after undergoing surgery for histologically documented chronic pancreatitis. PATIENTS/METHODS: Records of 484 consecutive patients who underwent surgery for chronic pancreatitis from 1976 to 1997 were reviewed. RESULTS: Pancreatic cancer was diagnosed after a mean of 3.4 years (range: 2 months-1 years) in 14 patients (2.9%). In four patients, pancreatic cancer became evident within 12 months of surgery for chronic pancreatitis, suggesting cancer was present at the original surgery. Cancer presented with recurrent or persistent pain, jaundice, and/or weight loss. Pancreatic resection was possible in eight patients, but in the others, the cancer was inoperable. There was one long-term survivor (alive 14 years postoperatively), but for theothers mean survival was 10 months (16 months after resection vs. 4 months for inoperable cancer). CONCLUSION: Pancreatic malignancy should be suspected in patients who have had surgery for chronic pancreatitis when symptoms (such as recurrent pain, jaundice, weight loss, or anorexia) recur. Attempts at curative pancreatic resection are indicated and can offer palliation and the potential for a cure.     

New diagnostic criteria of acute pancreatitis

Practical guidelines for the diagnosis of acute pancreatitis are presented so that a rapid and adequate diagnosis can be made. When acute pancreatitis is suspected in patients with acute onset of abdominal pain and tenderness mainly in the upper abdomen, the diagnosis of acute pancreatitis is made on the basis of elevated levels of pancreatic enzymes in the blood and/or urine. Furthermore, other acute abdominal diseases are ruled out if local findings associated with pancreatitis are confirmed by diagnostic imaging. According to the diagnostic criteria established in Japan, patients who present with two of the following three manifestations are diagnosed as having acute pancreatitis: characteristic upper abdominal pain, elevated levels of pancreatic enzymes, and findings of ultrasonography (US), CT or MRI suggesting acute pancreatitis. Detection of elevated levels of blood pancreatic enzymes is crucial in the diagnosis of acute pancreatitis. Measurement of blood lipase is recommended, because it is reported to be superior to all other pancreatic enzymes in terms of sensitivity and specificity. For measurements of the blood amylase level widely used in Japan, it should be cautioned that, because of its low specificity, abnormal high values are also often obtained in diseases other than pancreatitis. The cut-off level of blood pancreatic enzymes for the diagnosis of acute pancreatitis is not able to be set because of lack of sufficient evidence and consensus to date. CT study is the most appropriate procedure to confirm image findings of acute pancreatitis. Elucidation of the etiology of acute pancreatitis should be continued after a diagnosis of acute pancreatitis. In the process of the etiologic elucidation of acute pancreatitis, judgment whether it is gallstone-induced or not is most urgent and crucial for deciding treatment policy including the assessment of whether endoscopic papillary treatment should be conducted or not. The diagnosis of gallstone-induced acute pancreatitis can be made by combining detection of elevated levels of bilirubin, transamylase (ALT, AST) and ALP detected by hematological examination and the visualization of gallstones by US.     

Pancreatitis after sphincter of Oddi manometry.

The nature, frequency, severity, and possible causes of complications after 207 sphincter of Oddi manometry measurements were studied in 146 patients. Acute pancreatitis was diagnosed in 6% (12 of 207) of the investigations and in 8% (12 of 146) of the patients examined. The pancreatitis was mild in all patients. After cannulation of the pancreatic duct, acute pancreatitis occurred in 10 of 95 (11%) patients compared with one of 93 (1%) when the manometry catheter entered the bile duct only (p less than 0.02). Seven (58%) of the patients who developed acute pancreatitis, however, were found to be suffering from chronic pancreatitis. Some 26% of all sphincter of Oddi manometry measurements on patients with this diagnosis were complicated by an acute attack of pancreatitis compared with 3% (p less than 0.001) in patients without signs of chronic pancreatitis. In all patients the pancreatitis developed within three hours of manometry. We conclude that pancreatitis may occasionally follow sphincter of Oddi manometry measurement, even in patients without pancreaticobiliary disease, and that underlying chronic pancreatitis constitutes a definite risk. Sphincter of Oddi manometry measurement in control subjects should therefore be performed only in centres where the safety of the procedure has been established, and the presence of chronic pancreatitis should be excluded beforehand. Cannulation of the pancreatic duct should be avoided. Manometry can be safely performed, however, as an outpatient procedure.     

急性胰腺炎994例病因与治疗分析

目的 探讨急性胰腺炎(AP)的病因及其治疗方法 的选择.方法 回顾性分析2003年1月至2007年1月瑞金医院胰腺普外科收治的994例AP患者资料,根据病因及治疗方式进行分类统计.结果 994例AP患者中,胆源性AP 825例(83.0%),酒精性AP 24例(2.41%),高脂血症性AP29例(2.92%),妊娠性AP16例(1.61%),特发性AP 71例(7.14%),外伤性4例(0.40%),两种病因以上的混合性AP 25例(2.52%).轻症急性胰腺炎(MAP)767例(77.2%),重症急性胰腺炎(SAP)227例(22.8%).总的治愈好转率91.2%,病亡87例,病死率8.8%,其中酒精性AP的病死率达37.5%,显著高于胆源性AP.对胆源性AP患者分别采用非手术治疗、内镜逆行胰胆管造影+乳头括约肌切开(ERCP+EST)、胆囊切除术+胆总管探查或ERCP术后腹腔镜下胆囊切除术及清创引流术.采用清创引流术的患者均为SAP患者,术后病死率高达25.0%,显著高于其他治疗方法 者(P＜0.01).其他3种治疗方法 间的SAP病例比及病死率均无显著差异.结论胆道因素仍是AP的首要病因.酒精性AP病情较危重,预后较差.对胆源性AP,多种治疗方法 的疗效无显著差异.