Acute pancreatitis following antilymphocyte globulin therapy in a renal transplant recipient

Acute pancreatitis is a rare complication following OKT3 therapy, which to our knowledge has never been reported in patients treated with antilymphocyte globulin (ALG). We herein report a case of a kidney transplantation patient who developed acute pancreatitis 2 days after treatment with ALG for grade IIb acute rejection. The symptoms subsided after discontinuing this drug. Resumption of ALG therapy triggered another episode of acute pancreatitis. Therefore, the clinical course strongly suggests that ALG was the etiological factor of acute pancreatitis in this particular patient.     

Acute pancreatitis following kidney transplantation - role of viral infections

Acute pancreatitis following renal transplantation is an unusual complication that carries a high mortality. Over the last 10 yr, five of 185 patients at our center developed acute pancreatitis. All had live related donors and were on conventional triple drug immunosuppression. Pancreatitis was classified according to the computed tomography scan based on Atlanta Classification. All five patients who developed acute pancreatitis had evidence of symptomatic or serologically active viral infection (chicken pox in two, cytomegalovirus infection in two, hepatitis E virus in one) and no patient without viral infection developed pancreatitis. Overall, 45 patients developed symptomatic or serologically active viral infection. There was a significant association between viral infection and pancreatitis (chi-square test, p < 0.001). Three patients with severe acute pancreatitis died while both patients with mild pancreatitis survived. An active search for viral infections should be made in all patients with acute pancreatitis. Specific antiviral measures may help reduce the mortality of acute pancreatitis in these patients. Consideration must be given to varicella immunization in patients with renal failure.     

Treatment of metastatic seminoma by chemotherapy.: an experience

PURPOSE: To describe the outcome of chemotherapy using cisplatin-based regimen, and experimental combination with carboplatin and ifosfamide to treat advanced seminoma. METHODS: From 1981 to Jan. 1999, 15 patients with Stage IIA, IIB, IIIA or IIIC metastatic seminoma and one patient with lung disease, who suffered a relapse of his primary mediastinal lesion were treated. Three of these patients had relapsed, following surveillance for Stage I testicular cancer, and another had received prophylactic radiotherapy to the retroperitoneal lymph nodes in advance. The first patient's regimen consisted of cisplatin and cyclophosphamide. Since 1983, cases have been treated with the same regimen as that used to treat non-seminomatous germ-cell tumors; cisplatin/vinblastine/bleomycin (PVB); cisplatin/vinblastine/actinomycin D/cyclophosphamide/bleomycin (VAB-6); cisplatin/etoposide/bleomycin (BEP). From 1993, six patients with non-bulky metastatic seminoma participated in a trial involving 3 courses of carboplatin (400 mg/m2) and ifosfamide (2,000 mg/m2, 3 days). RESULTS: Of the entire group, 10 patients (62.5%) achieved a CR after chemotherapy alone. Four cases who received radiation, following chemotherapy, produced CR. Surgical resection of residual tumors were performed on 2 patients. Resected tumors were fibrous and no evidence of malignancy. All those individuals who participated in this study, are alive and disease-free today, from 11 months to 18 years. Carboplatin and ifosfamide demonstrated only mild toxicity, during a 4-week cycle, with subjects being treated on an outpatient basis. CONCLUSION: As expected, the type of chemotherapy we used, to treat non-seminomatous germ-cell tumors proved to be highly effective for seminomatous types, as well. Carboplatin and ifosfamide performed well and safe, in the treatment of non-bulky metastatic seminoma. Comparative studies of long-term treatment results and QOL, using either radiotherapy or low-toxicity chemotherapy for Stage IIA disease should be undertaken.     

Pancreatitis Following Heart Transplantation: Report of a Case

Serious complications involving the alimentary tract following cardiac transplantations are commonly reported, and may be associated with significant morbidity and mortality. One of the most serious gastrointestinal complications in such patients is acute pancreatitis. There is still little known concerning its pathogenesis, early diagnosis, and the most appropriate treatment for this clinical condition. Many authors have reported a high mortality caused by difficulties in making an accurate diagnosis resulting in the use of inappropriate therapy for so called crypto-symptomatic acute pancreatitis. The factor suspected to be responsible for the increased frequency of the gastroenterological diseases and for their masked onset seems to be immunosuppression, especially by corticosteroids. The case of a 46-year-old male patient with cardiac transplant, who, 3 years after the transplantation, developed mild acute pancreatitis, is presented. The immunosuppressive regimen he followed was based on cyclosporine. The acute pancreatitis was treated conservatively with a satisfactory outcome. In the course of the illness the patient developed a pancreatic pseudocyst that was managed successfully by percutaneous drainage. The patient is currently being followed up, and both his medical ailments and health-related quality of life are being monitored, while he continues to show mild symptoms of chronic pancreatitis.     

Acute gallstone pancreatitis in childhood.

Acute pancreatitis is rarely considered in the diagnosis of paediatric abdominal pain and can be misdiagnosed. Gallstones are uncommon in children and are a rare cause of pancreatitis. Trauma, infections and idiopathic causes are the commonest aetiological factors. Three cases of gallstone-induced acute pancreatitis with jaundice in children are reported which resolved with conservative treatment. The gallstones were managed by laparoscopic cholecystectomy with or without endoscopic retrograde cholangiopancreatography (ERCP). The three children had presented previously to a doctor with symptoms of gallstone disease but the diagnosis was missed. It is concluded that acute pancreatitis should be considered in children presenting as an emergency with abdominal pain. Children with recurrent attacks of upper abdominal pain should be investigated for gallstone disease so that the diagnosis is made before the development of potentially serious complications such as acute pancreatitis and jaundice.     

Clinical challenges in drug induced pancreatitis: Presentation of two cases and review of the literature

INTRODUCTIONA wide variety of drugs have been reported to cause pancreatitis. Although the incidence of drug induced acute pancreatitis is low, the disease is associated with substantial morbidity and mortality, which makes timely identification of the causative agent important.PRESENTATION OF CASEHerein, we report two patients with clinical, biochemical, and radiological evidence of acute pancreatitis. There were no etiologic factors except their prescribed drugs.DISCUSSIONThe majority of patients with acute pancreatitis recover uneventfully, but there remains an uncontrollable risk of mortality. It is prudent to withdraw a medication with a known association with acute pancreatitis. Necessity of multi-drug regimens especially in oncological patients however, presents a challenge.CONCLUSIONCorticosteroid pulse therapy was easily detectable as the causative agent in our first case, but combined anti-neoplastic drug therapy and additional multi-drug regimen presented great difficulties in identifying single causative agent in our second patient.     

妊娠合并急性胰腺炎16例诊治经验

【摘要】〓目的〓增加对妊娠合并急性胰腺炎的认识,探讨其临床特点、治疗原则、预防措施以及其对孕产妇和胎儿的影响结果。方法〓回顾性分析16例妊娠合并急性胰腺炎的临床特点、治疗方法及结局。结果〓13例轻型胰腺炎患者采用保守治疗,无一例因胰腺炎行剖宫产术,母婴均安全出院,3例重症胰腺炎患者保守治疗加用连续肾脏替代治疗后病情无明显好转,及时行剖宫产术,孕妇均治愈。结论〓妊娠合并急性胰腺炎的主要诱因是胆管疾病和高脂血症;诊断主要依据影像学检查;治疗轻型胰腺炎可以行保守治疗;重症胰腺炎在保守治疗基础上应果断终止妊娠并进行胰周引流术。     

急性胆源性胰腺炎41例外科治疗临床体会

目的探讨急性胆源性胰腺炎(acute biliary pancreatitis ABP)外科治疗的时机与方法。方法 41例ABP患者均采用外科手术治疗。结果本组41例患者均获治愈。结论对ABP的治疗应根据其病情与类型而定,对伴有胆总管下端梗阻或胆道感染的重症ABP应急诊或早期(72 h)手术,对不伴胆道完全梗阻、胆管炎的重症ABP患者,早期采取保守治疗,手术尽量延至病情稳定后。对急性水肿性ABP可经保守治疗,病情稳定后2～4周行胆道手术,但保守治疗期间若出现胆管炎、胆囊坏疽或穿孔应急诊手术。     

Treatment of acute pancreatitis with 5-fluorouracil]

The authors developed an outline for the treatment of acute pancreatitis with 5-fluorouracil which consists in a single or double injection of 250 mg of the drug. The method was used in 54 acute pancreatitis cases. A single intravenous injection of 250 mg of the drug proved to be sufficient for arresting the acute process in edematous and edemo-hemorrhagic pancreatitis. This method helps to shorten the treatment period. Clinical data were confirmed by experimental findings in 12 dogs.     

The unusual presentation of pancreatitis in infancy.

Two infants with acute pancreatitis are described. It appears that acute pancreatitis in infancy presents in one of two ways: part of a severe generalized illness, or as ascites. The outlook for the former depends on the prognosis of the generalized illness. If pancreatitis can be recognized as the cause of the ascites, then adequate treatment will result in survival. Although the cause in some infants is said to be idiopathic, exploration should be performed, the lesser sac investigated and if the child is in reasonable condition, appropriate study of the biliary tree and pancreatic ductile system should be considered. If a pseudocyst is present, adequate drainage is mandatory. Early diagnosis and appropriate treatment will be possible only if this rare disorder is suspected. The eventual prognosis is excellent and the chance of recurrent attacks is minimal.     

梗阻型急性胆源性胰腺炎的治疗方式及手术时机的选择

目的 探讨梗阻型急性胆源性胰腺炎的治疗方式及手术时机的选择.方法 回顾分析广州医学院第三附属医院2000年至2010年76例梗阻型急性胆源性胰腺炎的临床资料.结果 全组手术治疗36例,两周内手术20例,延期手术16例,死亡1例,术后随访无复发.内镜治疗15例,其中ERCP/EST 11例,ERCP/ENBD 1例,ERCP 3例,均获痊愈,随访1例复发.非手术治疗25例,死亡1例,随访6例复发.结论 外科手术在胆源性胰腺炎治疗中具有重要地位.对梗阻型急性胆源性胰腺炎患者应在经短期积极的非手术治疗后早期手术或内镜治疗解除胆道梗阻.

Abstract：

Objective To investigate the management and timing of operation in obstructive acute biliary pancreatifis.Methods A etrospective review was performed of seventy-six consecutive patients who presented to a single tertiary care institution from 2000 to 2010 with obstructive acute biliary pancreatitis.Results Of the seventy-six patients,thirty-six patients underwent operations,with early(after onset within 2 weeks)operations in twenty cases,delayed operationsin sixteen cases and one case dead,no one experienced recurrent pancreatitis during follow-up.Fifteen patients were treated by endoscopy,ERCP/EST in eleven cases,ERCP/ENBD in one case and ERCP only in three case.All patients were cured,only one patient experienced recurrent pancreatitis.Twenty-five patients received conservative treatment,one patient died,six patients experienced recurrent panereatitis.Conclusions Surgery is essential in the management of acute biliary pancreatitis.In cases of obstructive acute biliary pancreatitis,early operation or endoscopic therapy should be performed to remove biliopancreatic obstruction after aggressive conservative treatment.     

论重症急性胰腺炎治疗观念的转变

In 1989, Fitz defined and classified severe acute pancreatitis (SAP) and he thought that surgical treatment of SAP is feasible. Since then, the strategy of treating SAP was a controversial issue over past decades. Currently, relevant literatures reported that medical or minimally invasive treatments are superior to surgical treatment, while it is too early to make the final conclusion because of the complexity of SAP. From 1989 to 2008, 1852 patients with acute pancreatitis were treated at the General Hospital of PLA, and the clinical data of 18 patients who died of SAP were retrospectively analyzed. Based on the analysis, we concluded that medical conservative therapy and surgical operative therapy should not be opposed to each other. Selecting ideal timing and appropriate operation on the basis of pathological changes of retroperitoneum and pancreatitis should be considered seriously, and the new concept of "miniaturization of trauma" should also be introduced in treating SAP.     

早期经鼻肠内营养在急性重症胰腺炎中的应用

目的 探讨早期经鼻肠内营养（EN）在急性重症胰腺炎（ASP）中应用的安全性和有效性。方法 以近2年来的ASP26例分：EN组12例,TPN组14例。其治疗结果作对比,观察住院天数、各种并发症、病死率和费用的差异。结果 EN组平均住院天数,ARDS和其他感染性并发症均低于TPN组,病死率明显下降,治疗总费用显著减少。结论 EN在ASP中的应用是安全有效的,值得提倡。     

Challenges in diagnosing acute pancreatitis in renal transplant patients

Abstract: Acute pancreatitis is a recognized occurrence in patients with end‐stage renal disease, those on dialysis and those who have undergone renal transplantation. The incidence is significantly increased in comparison to the general population and carries significant mortality. We report two cases of acute pancreatitis that occurred in stable renal transplant recipients, and in which there was diagnostic difficulty. The etiology of the acute pancreatitis is not always identifiable in these patients. Classical symptoms and laboratory findings are often absent, which may cause diagnostic difficulty. Our experience suggests that in immunosuppressed patients with unexplained abdominal pain or abnormal liver function tests, acute pancreatitis should be considered at an early stage in order to initiate appropriate treatment and therefore minimize mortality and morbidity.     

论重症急性胰腺炎治疗观念的转变

对重症急性胰腺炎(severe acute pancreatitis,SAP) 的治疗,争议从来没有停止过;对SAP,我们从来未曾真正地了解.1989年,美国麻省总医院病理学家Fitz对SAP进行了定性、分类,并认为手术治疗是可行的.     

JPN Guidelines for the management of acute pancreatitis: diagnostic criteria for acute pancreatitis

The currently used diagnostic criteria for acute pancreatitis in Japan are presentation with at least two of the following three manifestations: (1) acute abdominal pain and tenderness in the upper abdomen; (2) elevated levels of pancreatic enzyme in the blood, urine, or ascitic fluid; and (3) abnormal imaging findings in the pancreas associated with acute pancreatitis. When a diagnosis is made on this basis, other pancreatic diseases and acute abdomen can be ruled out. The purpose of this article is to review the conventional criteria and, in particular, the various methods of diagnosis based on pancreatic enzyme values, with the aim of improving the quality of diagnosis of acute pancreatitis and formulating common internationally agreed criteria. The review considers the following recommendations: — Better even than the total blood amylase level, the blood lipase level is the best pancreatic enzyme for the diagnosis of acute pancreatitis and its differentiation from other diseases. — A pivotal factor in the diagnosis of acute pancreatitis is identifying an increase in pancreatic enzymes in the blood. — Ultrasonography (US) is also one of the procedures that should be performed in all patients with suspected acute pancreatitis. — Magnetic resonance imaging (MRI) is one of the most important imaging procedures for diagnosing acute pancreatitis and its intraperitoneal complications. — Computed tomography (CT) is also one of the most important imaging procedures for diagnosing acute pancreatitis and its intraabdominal complications. CT should be performed when a diagnosis of acute pancreatitis cannot be established on the basis of the clinical findings, results of blood and urine tests, or US, or when the etiology of the pancreatitis is unknown. — When acute pancreatitis is suspected, chest and abdominal X-ray examinations should be performed to determine whether any abnormal findings caused by acute pancreatitis are present. — Because the etiology of acute pancreatitis can have a crucial influence on both the treatment policy and severity assessment, it should be evaluated promptly and accurately. It is particularly important to differentiate between gallstone-induced acute pancreatitis, which requires treatment of the biliary system, and alcohol-induced acute pancreatitis, which requires a different form of treatment.     

The Timing of Biliary Surgery in Acute Pancreatitis

The timing of biliary surgery remains controversial in patients with acute pancreatitis associated with cholelithiasis. Eighty hospital admissions for acute pancreatitis, occurring in 74 patients with cholelithiasis, have therefore been reviewed. Among 22 patients who underwent abdominal surgery during the first week of treatment, there were five deaths (23%) and four patients (18%) who required more than seven days of intensive care. Fifty-eight episodes of pancreatitis were managed nonoperatively during the first week of treatment, with no deaths, although six (10%) required more than seven days of intensive care. Biliary surgery was undertaken later during the same admission in 37 patients, with no deaths. Twenty-one patients were discharged without biliary operation, but seven (33%) developed further pancreatitis. Previously reported prognostic signs were used to divide pancreatitis into 57 "mild" episodes (1.8% mortality) and 23 "severe" episodes (17% mortality). Early (day 0-7) definitive biliary surgery was undertaken in 11 patients with "mild" pancreatitis, with one death (9%), and in six patients with "severe" pancreatitis, with four deaths (67%). In three recent patients with "severe" pancreatitis, early biliary surgery was limited to cholecystostomy, with no deaths. These findings suggest that although early correction of associated biliary disease may be undertaken safely in many patients with "mild" acute pancreatitis, early definitive surgery is hazardous in "severe" pancreatitis and should, if possible, be deferred until pancreatitis has subsided. In most patients biliary surgery should precede hospital discharge.     

中药对重症急性胰腺炎疗效的分析

目的探讨中药在重症急性胰腺炎(SAP)的综合治疗措施中的作用。方法所有病例分为非中药治疗SAP组(A组,86例)、非中药治疗爆发性胰腺炎(FAP)组(B组,12例)和中药治疗SAP组(C组,95例)、中药治疗FAP组(D组,16例)。观察A组与C组、B组与D组中转手术率、死亡率、胰腺感染的发生率。结果C组在胃肠功能恢复时间、住院时间、中转手术率与A组比较,差异具有统计学意义,P<0.05。B组与D组差异无统计学意义。结论中药治疗重症胰腺炎可以减少重症急性胰腺炎住院时间及胃肠功能恢复时间,但对爆发性胰腺炎无明显意义。     

Acute pancreatitis: With special reference to pathogenesis and the diagnostic value of the blood amylase test

Although much confusion still exists as to the classification of acute pancreatitis, an attempt should be made to identify the type of disease, particularly since the treatment and prognosis are apt to be different in the various types. All cases of acute pancreatitis may be divided roughly into an acute edematous (interstitial) type, and an acute hemorrhagic or necrotic type. It is possible that the acute edematous type is caused primarily by obstruction, whereas the main factor in the production of the hemorrhagic or necrotic type is the development of tryptic digestion within the gland. The clinical manifestations of the two groups may be very similar indeed, except that the acute edematous type is invariably the milder and is never associated with shock. It should be remembered that an acute pancreatitis, particularly of the edematous type, may readily be overlooked unless the pancreas is palpated. Areas of fat necrosis may likewise be overlooked unless special care is taken to search for them, particularly since they are occasionally located only along the surface of the pancreas.The value of the blood amylase test as a diagnostic aid has been discussed. From the experiences of the author and others who are using this test, it appears that a rise in the blood amylase level is rather consistently encountered, particularly in the acute edematous type early in the disease. It is significantly true that the rise in the blood amylase may persist no longer than two or three days. The level may then fall to normal, or more commonly in the author's experience, below normal. Obviously, if the patient is not seen during the first two or three days of the attack, the blood amylase test may be of no diagnostic value. This fact must be remembered lest the test receive undue condemnation. However, the author has noted the persistence of a high blood amylase in several cases for many days after the onset of the attack.The treatment of the acute edematous type appears definitely to be conservative. After the acute phase of the disease has receded, attention should then be directed toward operative correction of the cholecystic disease which is so frequently present in acute pancreatitis. There is difference of opinion as to the treatment of acute hemorrhagic or acute necrotic pancreatitis. Many surgeons advise immediate operation. Others advise conservative treatment and operation on the biliary tract later, as indicated. The author is inclined to favor strongly the latter method of treatment.     

Acute pancreatitis]

Acute pancreatitis is an acute inflammatory process of the pancreas mainly due to biliary obstruction or alcohol consumption. Most episodes of acute pancreatitis are mild and resolve under conservative treatment. Severe forms of acute pancreatitis, especially the necrotising form, still have a high mortality rate and can be difficult to treat. The problem today is to identify the few cases that should be treated operatively. Infected necroses are well accepted as an indication for operative treatment. Surgery consists of débridement and necrosectomy followed by closed or open lavage. In biliary pancreatitis, ERCP is performed early in cases of biliary obstruction, with or without cholangitis. In these patients cholecystectomy should be performed electively after clinical recovery.