慢性胰腺炎的内镜治疗

慢性胰腺炎(CP)是一种进行性、不可逆性炎症疾病,可引起慢性腹痛、营养不良及其他并发症,药物、内镜、外科手术的治疗均很重要。内镜治疗可运用包括胰管括约肌切开术、支架置入、狭窄扩张、ESWL、取石、囊肿引流和超声内镜引导下的治疗等多种方法,为药物治疗失败及不适合外科手术的患者提供了治疗手段。本文对内镜治疗CP所致胆胰管结石及狭窄、胰漏、胰腺假性囊肿的效果进行了综述,对EUS引导下腹腔神经丛阻滞术治疗胰性疼痛也进行了讨论。     

慢性胰腺炎182例临床分析

目的:探讨慢性胰腺炎(CP)的病因、临床表现及诊治方法.方法:回顾分析1990年1月～2009年12月的182例CP患者的临床资料.结果:182例患者中胆源性73例,占40.1%,酒精性55例,占30.2%,特发性45例,占24.7%.患者临床表现主要为腹痛,少数伴有腹胀、黄疸、体质量下降、脂肪性腹泻等症状.本组非手术治疗127例,占69.8%,内镜下介入治疗21例,占11.5%,手术治疗34例,占18.7%.结论:胆管系统疾病仍是CP的主要致病因素,非手术治疗是CP主要治疗措施.     

Current concepts in diabetic gastroparesis

Diabetic gastroparesis is a common and debilitating condition affecting millions of patients with diabetes mellitus worldwide. Although gastroparesis in diabetes has been known clinically for more than 50 years, treatment options remain very limited. Until recently, the scientific literature has offered few clues regarding the precise aetiology of gastric dysfunction in diabetes.Up to 50% of patients with diabetes may experience postprandial abdominal pain, nausea, vomiting and bloating secondary to gastric dysfunction. There is no clear association between length of disease and the onset of delayed gastric emptying. Gastroparesis affects both type 1 (insulin dependent) and type 2 (non- insulin dependent) forms of diabetes. Diagnosis requires identifying the proper symptom complex, while excluding other entities (peptic ulcer disease, rheumatological diseases, medication effects). The diagnosis of gastroparesis may be confirmed by demonstrating gastric emptying delay during a 4-hour scintigraphic study. Treatment options are limited and rely on dietary modifications, judicious use of available pharmacological agents, and occasionally surgical or endoscopic placement of gastrostomies or jejunostomies. Gastric pacing offers promise for patients with medically refractory gastroparesis but awaits further investigation. Current pharmacological agents for treating gastroparesis include metoclopramide, erythromycin, cisapride (only available via a company-sponsored programme) and domperidone (not US FDA approved). All of these drugs act as promotility agents that increase the number or the intensity of gastric contractions. These medications are not uniformly effective and all have adverse effects that limit their use. Cisapride has been removed from the open market as a result of over 200 reported cases of cardiac toxicity attributed to its use. Unfortunately, there is a paucity of clinical studies that clearly define the efficacy of these agents in diabetic gastroparesis and there are no studies that compare these drugs to each other. The molecular pathophysiology of diabetic gastroparesis is unknown, limiting the development of rational therapies. New studies, primarily in animals, point to a defect in the enteric nervous system as a major molecular cause of abnormal gastric motility in diabetes. This defect is characterised by a loss of nitric oxide signals from nerves to muscles in the gut resulting in delayed gastric emptying. Novel therapies designed to augment nitric oxide signalling are being studied.     

Cervicogenic headache: practical approaches to therapy

Cervicogenic headache is a relatively common and still controversial form of headache arising from structures in the neck. The estimated prevalence of the disorder varies considerably, ranging from 0.7% to 13.8%. Cervicogenic headache is a 'side-locked' or unilateral fixed headache characterised by a non-throbbing pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area. In patients with this disorder, attacks or chronic fluctuating periods of neck/head pain may be provoked/worsened by sustained neck movements or stimulation of ipsilateral tender points. The pathophysiology of cervicogenic headache probably depends on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction, cytokines and nitric oxide. Frequent coexistence of a history of head traumas suggests these also play an important role. A reliable diagnosis of cervicogenic headache can be made based on the criteria established in 1998 by the Cervicogenic Headache International Study Group. Positive response after an appropriate nerve block is an essential diagnostic feature of the disorder. Differential diagnoses of cervicogenic headache include hemicrania continua, chronic paroxysmal hemicrania, occipital neuralgia, migraine and tension headache. Various therapies have been used in the management of cervicogenic headache. These range from lowly invasive, drug-based therapies to highly invasive, surgical-based therapies. This review evaluates use of drug therapy with paracetamol and NSAIDs, infliximab and botulinum toxin type A; manual modalities and transcutaneous electrical nerve stimulation therapy; local injection of anaesthetic or corticosteroids; and invasive surgical therapies for the treatment of cervicogenic headache. A curative therapy for cervicogenic headache will not be developed until increased knowledge of the aetiology and pathophysiology of the condition becomes available. In the meantime, limited evidence suggests that therapy with repeated injections of botulinum toxin type A may be the most safe and efficacious approach. The surgical approach, which includes decompression and radiofrequency lesions of the involved nerve structures, may also provide physicians with further options for refractory cervicogenic headache patients. Unfortunately, the paucity of experimental models for cervicogenic headache and the relative lack of biomolecular markers for the condition mean much is still unclear about cervicogenic headache and the disorder remains inadequately treated.     

慢性胰腺炎手术方式的选择与评价

目的 总结慢性胰腺炎外科手术方式的选择以及治疗效果的评价.方法 回顾分析2002年10月至2011年10月24例北京友谊医院以慢性胰腺炎行外科手术治疗的24例患者资料.结果 24例患者术前均诊断为慢性胰腺炎,其中22例术中及术后病理证实为慢性胰腺炎,2例根据术中所见及术后病理结果证实为慢性胰腺炎癌变;临床表现包括上腹痛24例,梗阻性黄疸4例,十二指肠梗阻1例,门静脉高压症伴腹腔积液2例,脂肪泻1例,继发性糖尿病者5例;有单纯酗酒史者9例,有单纯胆石症病史者4例,酗酒合并胆石症病史者5例,特发型慢性胰腺炎6例.手术方式包括胰十二指肠切除术(Whipple手术)6例,保留十二指肠的胰头切除加胰肠侧侧吻合术(Frey手术)1例,改良Frey手术(Izbicki手术)1例,胰管纵行切开减压胰肠侧侧吻合术加空肠侧侧吻合术(改良Partington-Rochelle手术)15例,胰体尾及脾切除术1例.无手术死亡病例,术后并发症有胆漏1例.患者均获得随访,随访时间7个月至9年,无一例发现癌变,腹痛复发同术前者4例.结论 对于慢性胰腺炎患者,建议根据其临床分型选择手术方式;胰头肿块型慢性胰腺炎应积极手术治疗;术后应鼓励戒酒.     

Use and perceived effectiveness of non-analgesic medical therapies for chronic pancreatitis in the United States

Aliment Pharmacol Ther 2011; 33: 149–159

Summary

Background Effectiveness of medical therapies in chronic pancreatitis has been described in small studies of selected patients. Aim To describe frequency and perceived effectiveness of non‐analgesic medical therapies in chronic pancreatitis patients evaluated at US referral centres. Methods Using data on 516 chronic pancreatitis patients enrolled prospectively in the NAPS2 Study, we evaluated how often medical therapies [pancreatic enzyme replacement therapy (PERT), vitamins/antioxidants (AO), octreotide, coeliac plexus block (CPB)] were utilized and considered useful by physicians. Results Oral PERT was commonly used (70%), more frequently in the presence of exocrine insufficiency (EI) (88% vs. 61%, P < 0.001) and pain (74% vs. 59%, P < 0.002). On multivariable analyses, predictors of PERT usage were EI (OR 5.14, 95% CI 2.87–9.18), constant (OR 3.42, 95% CI 1.93–6.04) or intermittent pain (OR 1.98, 95% CI 1.14–3.45). Efficacy of PERT was predicted only by EI (OR 2.16, 95% CI 1.36–3.42). AO were tried less often (14%) and were more effective in idiopathic and obstructive vs. alcoholic chronic pancreatitis (25% vs. 4%, P = 0.03). Other therapies were infrequently used (CPB – 5%, octreotide – 7%) with efficacy generally <50%. Conclusions Pancreatic enzyme replacement therapy is commonly utilized, but is considered useful in only subsets of chronic pancreatitis patients. Other medical therapies are used infrequently and have limited efficacy.     

Systematic review: endoscopic and imaging-based techniques in the assessment of portal haemodynamics and the risk of variceal bleeding

Background  Invasive measurement of the hepatic venous pressure gradient (HVPG) is regarded as the gold standard for risk stratification and the evaluation of pharmaceutical agents in patients with portal hypertension.
Aim  To review the techniques for endoscopic and imaging-based assessment of portal haemodynamics, with particular emphasis on trials where the results were compared with HVPG or direct portal pressure measurement.
Methods  Systematic search of the MEDLINE electronic database with keywords: portal hypertension, variceal bleeding, variceal pressure, endoscopic ultrasound, Doppler ultrasonography, magnetic resonance angiography, CT angiography, hepatic venous pressure gradient.
Results  Computed tomography angiography and endoscopic ultrasound (EUS) have been both employed for the diagnosis of complications of portal hypertension and for the evaluation of the efficacy of endoscopic therapy. Colour Doppler ultrasonography and magnetic resonance angiography has given discrepant results. Endoscopic variceal pressure measurements either alone or combined with simultaneous EUS, correlate well with HVPG and risk of variceal bleeding and have a low interobserver variability.
Conclusions  Endoscopic and imaging-based measurements of portal haemodynamics provide an alternate means for the assessment of complications of portal hypertension. Further studies are required to validate their use in risk stratification and the evaluation of drug therapies in patients with portal hypertension.     

Review article: the current and evolving treatment of colonic diverticular disease

Background  Formation of colonic diverticula, via herniation of the colonic wall, is responsible for the development of diverticulosis and consequently diverticular disease. Diverticular disease can be associated with numerous debilitating abdominal and gastrointestinal symptoms (including pain, bloating, nausea, constipation and diarrhoea).
Aims  To review the state of treatment for diverticular disease and its complications, and briefly discuss potential future therapies.
Methods  PubMed and recent conference abstracts were searched for articles describing the treatment of diverticular disease.
Results  Many physicians will recommend alterations to lifestyle and increasing fibre consumption. Empirical antibiotics remain the mainstay of therapy for patients with diverticular disease and rifaximin seems to be the best choice. In severe or relapsing disease, surgical intervention is often the only remaining treatment option. Although novel treatment options are yet to become available, the addition of therapies based on mesalazine (mesalamine) and probiotics may enhance treatment efficacy.
Conclusions  Data suggest that diverticular disease may share many of the hallmarks of other, better-characterized inflammatory bowel diseases; however, treatment options for patients with diverticular disease are scarce, revolving around antibiotic treatment and surgery. There is a need for a better understanding of the fundamental mechanisms of diverticular disease to design treatment regimens accordingly.     

Tyrosine kinase inhibitors, pancreatic hyperenzymemia and acute pancreatitis: a review

The advent of new drugs can rapidly increase the number of substances causing acute pancreatitis. This is the case of tyrosine kinase inhibitors; these drugs are currently used for chronic myeloid leukemia, gastrointestinal stromal tumors, unresectable hepatocellular carcinomas and advanced renal cell carcinomas that and they have been reported to cause acute pancreatitis or asymptomatic elevations of serum pancreatic enzymes. Of the classes of drugs capable of inducing acute pancreatitis, we aimed to evaluate, in which class tyrosine kinase inhibitors can be allocated. A search was carried out using the MEDLINE database in order to select the data existing in the literature on pyrimidines and acute pancreatitis or serum lipase/amylase elevation covering the period from January 1966 to January 2010; thirteen papers were found and utilized for this review. Based on the data in the literature, we found that tyrosine kinase inhibitors may often cause an increase in pancreatic enzymes in plasma and patients treated with these drugs, especially those who are treated with sorafenib, might be at risk of developing acute pancreatitis. Whether acute pancreatitis due to tyrosine kinase inhibitors is associated only with sorafenib or may also be caused by other drugs of the same class remains an open question. Recent patents on tyrosine kinase inhibitors and acute pancreatitis are pointed out in this review.     

Pathophysiology and pharmacotherapy of gastroparesis: current and future perspectives

Introduction: Gastroparesis is an important clinical disorder characterised by delayed gastric emptying in the absence of mechanical outlet obstruction. Idiopathic, diabetes and postsurgical causes represent the most common aetiologies. The condition commonly manifests as upper gastrointestinal symptoms, including nausea, vomiting, postprandial fullness, early satiety, abdominal pain and bloating.

Areas covered: This paper provides a review of the prevalence, pathophysiology and clinical features associated with gastroparesis, with a particular focus on current pharmacological management options and novel and emerging therapies. A literature search was undertaken using the search terms: gastroparesis, diabetic gastroparesis, idiopathic gastroparesis, gastric emptying, prokinetic, metoclopramide, domperidone, erythromycin, motilin, alemcinal, KC11458, mitemcinal, ghrelin, TZP-101, TZP-102, RM-131, tegaserod, prucalopride, naronapride, velusetrag, levosulpiride, itopride, botulinum toxin, gastric electrical stimulation, Enterra.

Expert opinion: Strategies for the management of gastroparesis include correction of malnutrition, dehydration and electrolyte imbalance, relief of symptoms by appropriate use of prokinetic and antiemetic agents and, in patients with gastroparesis associated with diabetes or critical illness-induced hyperglycaemia, optimisation of glycaemic control. Conventional prokinetic agents form the mainstay of treatment. While novel pharmacotherapies are in development, compelling evidence for their efficacy, particularly in symptom relief, remains to be established.     

Current concepts in the management of pancreatitis.

Acute pancreatitis is often a mild, self-limiting illness that responds to simple supportive therapy in the form of intravenous fluids and analgesics. More severe attacks may result in organ failure or pancreatic necrosis. Such patients should be identified early in the course of an attack and actively monitored within an intensive care unit or high dependency area. Supportive therapy remains the basis of management. Attention to the adequacy of the fluid balance and oxygenation are of prime importance and supportive therapy may include inotropic support, assisted ventilation and renal dialysis. Pancreatic necrosis should be sought by contrast-enhanced computed tomography (CT) scanning, and surgical intervention may be required if the patient's clinical condition continues to deteriorate. Surgery should ideally be delayed until the second or subsequent week when necrosectomy (debridement of necrotic pancreatic tissue) may be possible rather than formal pancreatic resection. The role of various drugs to suppress pancreatic secretion and inhibit pancreatic enzymes, although shown to be consistently effective in experimental pancreatitis, has not been established by controlled clinical trials in humans. Recent controlled studies examining peritoneal lavage in humans have failed to confirm the beneficial results suggested in earlier studies. Early endoscopic sphincterotomy for patients with severe gallstone pancreatitis and ductal calculi has been reported to reduce mortality and morbidity in one controlled clinical trial and may prove to be an important advance.     

Treating acne with antibiotic-resistant bacterial colonization

INTRODUCTION: Acne is a chronic skin disorder of the pilosebaceous unit; it has a multifactorial pathogenesis. Propionibacterium acnes within the follicle is considered to be a triggering factor of inflammation in acne. Antibiotics have been the primary treatment against P. acnes for more than 40 years. However, a gradual increase in the prevalence of antibiotic-resistant strains of P. acnes has been observed. AREAS COVERED: This review discusses the pathophysiology of antibiotic-resistant acne development. It focuses on strategies to minimize the development of resistance and, most importantly, confront the development of antibiotic-resistant acne. The literature search was conducted up to August 2010, using the search terms 'acne', 'antibiotic-resistant acne' and 'bacterial resistance'. EXPERT OPINION: Antibiotic-resistant acne is a real phenomenon. Strategies to prevent and confront it should include not only the use of certain treatment regimens but also rational prescribing policies, combination therapies, use of antibacterial non-antibiotic agents and treatment options targeting all the pathogenetic components of acne. Benzoyl-peroxide-based treatment is the most evidence-based approach. Oral isotretinoin remains the most efficacious option for severe acne.     

急性胆源性胰腺炎52例临床分析

目的 探讨急性胆源性胰腺炎(ABP) 的治疗方法.方法 回顾性分析我院近年来收治的52例ABP患者的临床资料,对ABP的各种治疗方法 与疗效进行分析.结果 52例患者均治愈.根据有无胆管梗阻和ABP的轻重程度分别采取保守治疗、治疗性ERCP、内镜下胰管支架引流术、腹腔镜以及开腹手术的治疗方法.所有患者均首先采取保守治疗.对于有显著胆道梗阻的重症ABP患者采用治疗性ERCP的方法 ;ERCP失败的5例患者实施经内镜下胰管支架植入术,临床效果明显.除仅有1例患者因重症胰腺炎伴胰腺坏死伴感染而行手术治疗之外,其他所有患者的胆道病变均在胰腺炎治愈后1个月行外科处理.结论 ABP治疗以保守治疗为主,对于部分伴胆道梗阻的病例可以采用治疗性ERCP和胰管内支架引流的方法.总之,ABP的治疗需要对具体的情况采取个体化的治疗方案.     

重症胰腺炎的综合治疗体会

目的：探讨重症急性胰腺炎非手术治疗的效果和手术指征。方法：回顾分析本院收治的48例重症急性胰腺炎非手术治疗方案和手术情况。结果：48例患者中治愈46例（95.8％）,死亡2例（4．2％）,治疗过程中有12例（25％）出现各种并发症。其中多器官功能损伤2例,胰腺假性囊肿9例,急性肺损伤1例,尚有3例行手术治疗,2例因胆管感染不能控制行急诊手术后痊愈,1例胰腺假性囊肿继发感染行手术治疗后因内出血死亡。结论：重症急性胰腺炎经积极非手术治疗可获得满意疗效,应密切观察病情的变化和有无胰腺坏死组织继发感染的发生,必要时行手术治疗。     

胆源性急性胰腺炎的治疗体会

目的：探讨胆源性急性胰腺炎的手术时机及方式的选择。方法：回顾性总结和分析本院57例胆源性急性胰腺炎的临床资料。采用保守治疗、早期手术治疗和择期手术治疗。结果：本组保守治疗25例,治愈24例,死亡1例;手术治疗32例,治愈29例,死亡3例。结论：早期保守治疗,病情恶化时需急诊手术治疗;保守治疗至病情稳定后,择期手术治疗。选择合适手术时机是＂个体化＂治疗胆源性急性胰腺炎的重要环节。     

慢性胰腺炎70例临床分析

目的探讨慢性胰腺炎（CP）的诊断、病因和诊治方法。方法对70例慢性胰腺炎患者的临床资料进行回顾性分析。结果本组胆源性CP多于酒精性,是第一致病因素,本组45例经保守治疗症状缓解,25例经外科手术治疗,术后恢复良好。结论胆道疾病造成的实质损伤和长期酗酒造成的乙醇中毒是CP的主要致病因素;影像学检查在诊断中具有重要作用;治疗以内科药物保守治疗为主。     

Novel pharmacotherapy for fibromyalgia

Fibromyalgia is a common disorder that is characterized by chronic widespread pain, tenderness to light palpation, fatigue and sleep disturbances. The present lack of a well-accepted model of the disorder has hampered progress towards adequate treatment. A review of potential models to explain the pathophysiology underlying its primary symptom (i.e., chronic widespread pain) lends insight on the therapeutic potential of novel therapies. Following this, a mechanistic evaluation of those medications that are under consideration for the treatment of the disorder is offered. Adequate treatment will be likely to involve the identification of biologic subgroups within the greater fibromyalgia construct. Key insights from basic research are the basis for increased optimism for effective relief among patients and clinicians.     

Opioid receptor signaling: relevance for gastrointestinal therapy

Opiate drugs, such as morphine, are renowned for their analgesic properties. To date, opioid narcotics represent the largest and most potent class of pain relievers available to treat both acute and chronic pain conditions. The use of opiates, however, is severely limited by several adverse side effects. Upon chronic use, opiates can produce tolerance, physical dependence and addiction. Although these conditions warrant consideration, there are acute effects that present more immediate concerns when choosing opiate narcotics for pain therapy. One of the most prevalent side effects, which continues for as long as the opiate is used for pain control, is constipation. This can impact patient compliance, as it is often one of the top reasons why patients discontinue opiate treatment. The challenge, therefore, is to develop pain therapies that preserve potent analgesia while preventing constipation.