Acute recurrent pancreatitis: Etiopathogenesis,diagnosis and treatment

Acute recurrent pancreatitis(ARP)refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion.Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland,however,an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up.The aetiology of ARP can be identified in the majority of patients.Most common causes include common bile duct stones or sludge and bile crystals;sphincter of oddi dysfunction;anatomical ductal variants interfering with pancreatic juice outflow;obstruction of the main pancreatic duct or pancreatico-biliary junction;genetic mutations;alcohol consumption.However,despite diagnostic technologies,the aetiology of ARP still remains unknown in up to 30%of cases:in these cases the term“idiopathic”is used.Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases,cholecystectomy,and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases.Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80%of patients.Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge.In uncertain cases toxinbotulin injection may help in identifying some sphincter of oddi dysfunction,but this treatment is not widely used.In the last twenty years,pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction,independently from the cause of obstruction,and has been widely used instead of more aggressive approaches.     

Acute pancreatitis-induced thrombotic thrombocytopenic purpura with recurrent acute pancreatitis

Recent successive reports on acute pancreatitis-induced thrombotic thrombocytopenic purpura (TTP) have revealed that TTP-related microvascular damage is an aggravating factor of acute pancreatitis. Here, we report the case of a 26-year-old man diagnosed with acute pancreatitis due to high alcohol consumption. The patient was unconscious as he had taken an overdose of medication, and presented with fever and renal failure due to acute pancreatitis on admission. Although the pancreatitis subsequently improved, the symptoms were still observed; on the next day, he exhibited hemoglobinuria, anemia, and thrombocytopenia. Moreover, general blood examinations indicated the presence of schistocytes and reduced activity of ADAMTS13 (a disintegrin-like metalloproteinase with thrombospondin type 1 motif 13) to 47 %. Thus, the patient was diagnosed with TTP, and plasma exchange was performed. After the development of TTP, the acute pancreatitis recurred, but a severe pathogenesis was prevented by plasma exchange. Thus, ADAMTS13 activity may be useful for predicting a severe pathogenesis of acute pancreatitis. In ADAMTS13-deficient cases, plasma exchange may be an effective technique for preventing aggravation of acute pancreatitis.     

Acute mediastinitis arising from pancreatic mediastinal fistula in recurrent pancreatitis

Acute mediastinitis is a fatal disease that usually originates from esophageal perforation and surgical infection. Rare cases of descending necrotizing mediastinitis can occur following oral cavity and pharynx infection or can be a complication of pancreatitis. The most common thoracic complications of pancreatic disease are reactive pleural effusion and pneumonia, while rare complications include thoracic conditions, such as pancreaticopleural fistula with massive pleural effusion or hemothorax and extension of pseudocyst into the mediastinum. There have been no reports of acute mediastinitis originating from pancreatitis in South Korea. In this report, we present the case of a 50-year-old female suffering from acute mediastinitis with pleural effusion arising from recurrent pancreatitis that improved after surgical intervention.     

Acute biliary pancreatitis.

Technological innovations in the past decade suggest that their systemic utilisation in acute biliary pancreatitis may have a significant impact on diagnosis and treatment. Urgent severity assessment resulting in the use of ERCP in patients with probable gallstones is essential since early endoscopic sphincterotomy may reduce morbidity and mortality. Contrast enhanced CT scanning is indispensable to the clinical decision-making process resulting in surgical intervention for necrosectomy. A rational application of diagnostic modalities, including ERCP, duodenal bile crystal analysis and dynamic biliary scanning, can greatly increase the proportion of patients with aetiological diagnosis, thereby enabling treatment to prevent further attacks. A fundamental knowledge of the patho-biochemical and patho-physiological nature of acute pancreatitis, however, is still required for further progress.     

Acute recurrent biliary pancreatitis associated with the ABCB4 gene mutation

The ABCB4 gene codes for a protein involved in the transport of phosphatidylcholine across the canalicular membrane of the hepatocyte. ABCB4 gene defects have been associated with progressive familial intrahepatic cholestasis type 3, intrahepatic cholestasis of pregnancy, adult biliary cirrhosis and the more recently described low phospholipid associated cholelithiasis syndrome. The present paper describes 2 probands with a long history of recurrent pancreatitis and cholelithiasis and the same heterozygous, as yet undescribed del 3683>3688 within exon 28 of the ABCB4 gene resulting in a loss of function. This report shows that ABCB4 mutations may cause acute recurrent biliary pancreatitis.     

Acute pancreatitis in childhood.

AIM: to evaluate etiological agents involved in acute pancreatitis in children, as well as clinical, laboratory and radiological findings and the illness clinical course. PATIENTS AND METHODS: we reviewed the cases of acute pancreatitis diagnosed over the last 15 years. The criteria used for cases to be included were acute abdominal pain, elevated serum amylase levels and/or ultrasound abnormalities in the pancreatic area in conscious patients, and the last two criteria in unconscious patients. RESULTS: thirty-one children were included (average age 7.9 years, range 2-15; 55% males). Infection and gallstones were the most common causes (19 and 16 %, respectively). In all, 9.7% of cases were drug-related (valproic acid, L-asparaginase, azathioprine combined with high doses of methylprednisolone); 6.5% were traumatic in origin and another 6.5% was due to systemic diseases. In 35.5 % no cause was found (idiopathic). The most frequent symptoms were abdominal pain (90%) and emesis (38%). Amylase serum levels were elevated in all patients. Abdominal ultrasound scans were abnormal in 64%, with an increase in the pancreatic area in 48% and hypoechogenicity in 51%. Seven cases required surgical treatment (22%). Seven children had acute pancreatitis, and three of them died as a result of shock unrelated to pancreatitis. Relapse of disease occurred in 19% of patients. CONCLUSIONS: acute pancreatitis should always be considered in children with abdominal pain. There are a wide variety of etiological factors and in a high percentage of patients no underlying cause is found. Prognosis is variable owing to the heterogeneity of the clinical course of this illness in children.     

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.     

急性复发性胰腺炎128例的临床及影像学分析

目的研究AP复发的基本病因、临床表现及影像学特点。方法回顾性分析128例AP复发病例(复发组)及87例初发患者(对照组)的基本病因、临床表现,以及B超、CT和ERCP检查的影像特征。结果复发组患者有慢性胆囊炎病史者占46.1%;胆囊切除术后者占21.9%;胆囊结石者占28.1%;有高脂血症者占24.2%。均较对照组显著升高。作为发作诱因,油腻饮食者在复发组占32%,较对照组显著升高。复发组发生呕吐者38.3%、黄疸29.7%,较对照组显著升高。复发组血淀粉酶为(726.7±247.5)U/L,血总胆红素为(45.7±18.4)μmol/L,血ALT为(81.3±37.5)U/L、AST为(68.9±25.4)U/L、AKP为(146.3±81.2)U/L,与对照组相比均有显著差异。影像学检查,复发组胰腺回声粗强者达35.9%,胰管扩张者达17.9%,均显著高于对照组;胆囊炎症、结石和胆总管扩张的发生率也显著高于对照组;主胰管结石、扩张、狭窄及乳头部病变发生率在复发组也明显增多。另外复发组中有部分患者为胰腺分裂和胰胆汇流异常。结论胆囊炎、胆囊结石、胆总管结石等疾病可能是AP复发的主要病因,其他病因还有CP的急性发作。     

Acute (nonprogressive) alcoholic pancreatitis: prospective longitudinal study of 144 patients with recurrent alcoholic pancreatitis

Over the last 10 years, a series of 144 consecutive patients with alcoholic recurrent pancreatitis have been studied prospectively at regular intervals with particular regard to exocrine function, calcifications, pancreatographic ductal changes, and histopathology of the pancreas. Based upon the long-term course, the patients were classified into two groups; group A (n = 95), those with chronic pancreatitis (78 of them with calcifications); and group B (n = 49), those with acute (nonprogressive) pancreatitis. The duration of disease from onset was 2-19 years (median, 9.7 and 8.3 years, respectively, in group A and B). The two groups were comparable at onset of the disease in age, sex, number of episodes of pancreatitis, and number of pseudocysts. In group A, all 95 cases fulfilled the strict diagnostic criteria of chronic pancreatitis within the period of observation (e.g., progressive exocrine insufficiency and/or typical morphological changes, particularly calcifications). In group B, the exocrine function remained normal over the entire period of observation. No histologic evidence of chronic pancreatitis was detected in five of seven large pancreatic specimens. Marked to moderate ductal changes were found in 10 of 16 patients in group B (despite normal exocrine function). Our data suggest that about one third of patients of the present series with alcoholic (recurrent) pancreatitis did not progress toward chronic (progressive) pancreatitis, although some demonstrated morphological alterations (except calcifications) in association with normally preserved exocrine function (residual scars?). The pathogenetic factor(s) responsible for progression (or nonprogression) of alcoholic (recurrent) pancreatitis to chronic pancreatitis remain(s) to be elucidated.     

Acute pancreatitis

Acute pancreatitis is an inflammatory disease of the pancreas. Acute abdominal pain is the most common symptom, and increased concentrations of serum amylase and lipase confirm the diagnosis. Pancreatic injury is mild in 80% of patients, who recover without complications. The remaining patients have a severe disease with local and systemic complications. Gallstone migration into the common bile duct and alcohol abuse are the most frequent causes of pancreatitis in adults. About 15-25% of pancreatitis episodes are of unknown origin. Treatment of mild disease is supportive, but severe episodes need management by a multidisciplinary team including gastroenterologists, interventional radiologists, intensivists, and surgeons. Improved understanding of pathophysiology and better assessments of disease severity should ameliorate the management and outcome of this complex disease.     

Acute pancreatitis after gastrointestinal endoscopy.

Acute pancreatitis is a well-recognized complication of endoscopic retrograde cholangiopancreatography but is not considered to be a complication associated with other endoscopic procedures. We present a case of acute pancreatitis that occurred after uneventful upper and lower gastrointestinal endoscopy. The temporal relationship of the endoscopic procedures and development of acute pancreatitis suggests a causal relation. Furthermore, the patient had none of the usual etiologic factors associated with pancreatitis, i.e., alcoholism, cholelithiasis, hypertriglyceridemia, hypercalcemia, or use of a drug associated with pancreatitis. The causal mechanism of acute pancreatitis is uncertain but might potentially involve local trauma to the pancreas during a procedure or release of as yet undefined inflammatory mediators. In summary, three previous reports of clinical pancreatitis associated with endoscopy, in addition to the current case, suggests that acute pancreatitis should be considered as a rare complication of routine upper endoscopy or colonoscopy.     

大鼠急性坏死性胰腺炎脂质代谢的研究

目的 察大鼠急性坏死性胰腺炎时血脂的代谢及其对炎症的影响。方法 36只SD大鼠（250g左右），随机分为对照组和急性坏死性胰腺炎（ANP）3h、6h、12h、24h、48h组，每组6只。除对照组外予胰管内逆行注射5％牛磺胆酸钠复制ANP大鼠模型，观察胰腺组织病理学和透射电镜的改变。检测各组血清淀粉酶、胆固醇、三酰甘油（TG）、游离脂肪酸（FFA）和脂蛋白脂酶（LPL）含量。Rq、-PCR检测硬脂酰基辅酶A脱氢酶（SCD）和脂肪酸转移酶（CD36）mRNA的表达。结果 清淀粉酶和胰腺病理学改变符合大鼠ANP改变特征，在12h组淀粉酶和胰腺病理学改变达峰值。电镜下ANP各组腺泡细胞粗面内质网扩张、酶原颗粒增多。ANP各组血清TG和FFA水平较对照组增高，其中ANP24h组TG为（0．81=0．35）mmol／L与对照组差异显著（P〈0．01）；ANP6h组FFA为（1．32—0．32）mmol／IL；较对照组显著升高（P〈0．05）。但ANP组LPL活性较对照组下降，胰腺组织SCDlmRNA和CD36mRNA表达升高。结论 NP大鼠出现血脂增高、脂质代谢相关酶表达异常、胰腺腺泡细胞内质网扩张等方面改变，提示ANP可诱发机体脂质代谢紊乱。