Incidence and management of biliary pancreatitis in cholecystectomized patients. Results of a 7-year study

Cholecystectomy as a risk factor for non-alcoholic fatty liver disease development

BACKGROUND

Hepatic steatosis and gallstone disease are highly prevalent in the general population; the shared risk factors are age, ethnicity, obesity, insulin resistance, metabolic syndrome, atherosclerosis, risk of cardiovascular disease, and mortality. The presence of insulin resistance is the critical element in this association because it represents a crucial link between metabolic syndrome and non-alcoholic fatty liver disease, as well as a higher susceptibility to gallstone formation.

METHODS

An exhaustive search engine investigation of gallstone disease, cholecystectomy, and liver steatosis latest literature was made.

RESULTS

Clinical studies and systematic reviews suggest an association between gallstone disease, cholecystectomy, and hepatic steatosis.

CONCLUSION

The bidirectional relationship between liver steatosis and gallstone disease and cholecystectomy is summarized in the role of insulin resistance, lipid metabolism, bile acids signaling pathways regulated by transcription factors expression, and to the gallbladder physiological role; however, more epidemiological and experimental studies should be complemented.

Acute biliary pancreatitis in cholecystectomised patients

OBJECTIVE

The present study is an evaluation of cases of acute biliary pancreatitis that developed subsequent to cholecystectomy.

METHODS

Total of 44 patients were assessed in this retrospective study. Demographic characteristics, severity of illness, time elapsed between cholecystectomy and development of pancreatitis, whether endoscopic sphincterotomy (ES) was performed, surgical procedure used, duration of hospitalization, and mortality data were recorded.

RESULTS

Mean age of all patients was 60.14±16.4 years (range: 20-85 years), and female:male ratio was 28:16. Mean length of time elapsed between cholecystectomy and development of acute pancreatitis was 80.6 months (range: 5-230 months). Gallstones and biliary sand were found in the choledochi of 36 patients upon endoscopic retrograde cholangiopancreatography (ERCP), but not observed in the remaining 8 patients. ES was performed and material was extracted in 32 of the 36 patients, but stone extraction was unsuccessful in 4 cases; 3 patients underwent open surgery with choledochus exploration and 1 patient died. Excluding this patient, mean duration of hospitalization was 7.5±2.5 days.

CONCLUSION

Stones in bile ducts may remain asymptomatic for long periods after cholecystectomy. However, some stones trigger acute pancreatitis months or years after cholecystectomy, causing risk of mortality. ERCP and ES are the standard treatments. If these are unsuccessful, the choledochus may be explored via open or laparoscopic surgery.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

BACKGROUND

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

METHODS

A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.

RESULTS

Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.

CONCLUSIONS

The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

ERCP and endoscopic sphincterotomy (ES): a safe and definitive management of gallstone pancreatitis with the gallbladder left in situ

BACKGROUND AND AIMS

UK guidelines recommend that patients with gallstone pancreatitis have cholecystectomy within 2 weeks of their pancreatitis. A proportion of these are elderly with significant comorbidities rendering them high risk for general anaesthesia and surgery. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) may offer a safe alternative to cholecystectomy as definitive treatment in these patients.

PATIENTS AND METHODS

A retrospective review of all cases of gallstone pancreatitis presenting between 1999 and 2009 was undertaken.

RESULTS

One hundred one patients underwent ERCP and ES as a definitive treatment for gallstone pancreatitis with a median age of 78 years (range, 43-96 years) and a median American Society of Anesthesiologists grade of 2. Three patients died from pancreatitis despite successful ERCP. Eighty-nine patients were successfully treated with an ERCP alone, and 84 patients (94%) had no recurrence of pancreatitis with a mean follow-up of 41 months (±32 months, range 4-118 months). The total patient follow-up was 3,260 months. Twenty-seven patients (33%) died within the follow-up period of unrelated causes, explaining the lower than expected median follow-up. Five patients had a recurrence of pancreatitis during follow-up (6%).

CONCLUSION

ERCP with ES is a safe alternative to laparoscopic cholecystectomy to prevent further attacks of gallstone pancreatitis in high-risk surgical patients and the elderly.

Lack of significant liver enzyme elevation and gallstones and/or sludge on ultrasound on day 1 of acute pancreatitis is associated with recurrence after cholecystectomy: a population-based study

BACKGROUND

In a population-based study, we examined recurrence rates of acute pancreatitis (AP) after cholecystectomy performed to prevent recurrences of AP.

METHODS

We abstracted data from medical records of all Olmsted county residents who underwent cholecystectomy at Mayo Clinic for the management of presumed gallstone or idiopathic AP between 1990 and 2005 (n = 239). Based on (i) significantly elevated liver enzymes (≥threefold increase of alanine aminotransferase or aspartate aminotransferase) on day 1 and (ii) the presence of gallstones/sludge in the gall bladder, we categorized patients into 4 groups: A (i + ii), B (i but not ii), C (ii but not i), and D (neither i nor ii). Recurrence rates of AP after cholecystectomy were determined in all groups.

RESULTS

The median follow-up after cholecystectomy was 99 months (range, 8-220). AP recurred in 13 of 142 patients (9%) in group A, 1 of 17 patients (6%) in group B, 13 of 57 patients (23%) in group C, and 14 of 23 patients (61%) in group D (P < .0001 D vs. all other groups and P = .001 C vs. groups A and B). No difference was seen in recurrence rates in groups A vs. B (P = 1.0). Recurrences were more frequent in patients with normal liver enzymes (A + B vs. C + D; P = .000003) and in patients without sonographic evidence of gallstones/sludge (A + C vs. B + D; P = .0008).

CONCLUSION

When AP is associated with significantly elevated liver enzymes on day 1, recurrence rates after cholecystectomy are low (9%). However, postcholecystectomy recurrence rates of AP are high in those without such laboratory abnormalities (34%), especially in those without gall bladder stones/sludge (61%) on abdominal ultrasonography. Our results raise doubts about the efficacy of cholecystectomy to prevent recurrent AP in patients with the absence of either a significant elevation of liver tests on day 1 of AP or gallstones and/or sludge in the gall bladder on initial ultrasound examination.

Bakker OJ, van Santvoort HC, Hagenaars JC, Besselink MG, Bollen TL, Gooszen HG, Schaapherder AF. Timing of cholecystectomy after mild biliary pancreatitis

Background

The aim of the study was to evaluate recurrent biliary events as a consequence of delay in cholecystectomy following mild biliary pancreatitis.

Methods

Between 2004 and 2007, patients with acute pancreatitis were registered prospectively in 15 Dutch hospitals. Patients with mild biliary pancreatitis were candidates for cholecystectomy. Recurrent biliary events requiring admission before and after cholecystectomy, and after endoscopic sphincterotomy (ES), were evaluated.

Results

Of 308 patients with mild biliary pancreatitis, 267 were candidates for cholecystectomy. Eighteen patients underwent cholecystectomy during the initial admission, leaving 249 potential candidates for cholecystectomy after discharge. Cholecystectomy was performed after a median of 6 weeks in 188 patients (75·5 per cent). Before cholecystectomy, 34 patients (13·7 per cent) were readmitted for biliary events, including 24 with recurrent biliary pancreatitis. ES was performed in 108 patients during the initial admission. Eight (7·4 per cent) of these patients suffered from biliary events after ES and before cholecystectomy, compared with 26 (18·4 per cent) of 141 patients who did not have ES (risk ratio 0·51, 95 per cent confidence interval 0·27 to 0·94; P = 0·015). Following cholecystectomy, eight (3·9 per cent) of 206 patients developed biliary events after a median of 31 weeks. Only 142 (53·2 per cent) of 267 patients were treated in accordance with the Dutch guideline, which recommends cholecystectomy or ES during the index admission or within 3 weeks thereafter.

Conclusion

A delay in cholecystectomy after mild biliary pancreatitis carries a substantial risk of recurrent biliary events. ES reduces the risk of recurrent pancreatitis but not of other biliary events.

Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy

BACKGROUND

Recurrent attacks of acute biliary pancreatitis (RABP) are prevented by (laparoscopic) cholecystectomy. Since the introduction of endoscopic retrograde cholangiopancreaticography (ERCP), several series have described a similar reduction of RABP after endoscopic sphincterotomy (ES). This report discusses the different treatment options for preventing RABP including conservative treatment, cholecystectomy, ES, and combinations of these options as well as their respective timing.

METHODS

A search in PubMed for observational studies and clinical (comparative) trials published in the English language was performed on the subject of recurrent acute biliary pancreatitis and other gallstone complications after an initial attack of acute pancreatitis.

RESULT

Cholecystectomy and ES both are superior to conservative treatment in reducing the incidence of RABP. Cholecystectomy provides additional protection for gallstone-related complications and mortality. Observational studies indicate that cholecystectomy combined with ES is the most effective treatment for reducing the incidence of RABP attacks.

CONCLUSION

From the literature data it can be concluded that ES is as effective in reducing RABP as cholecystectomy but inferior in reducing mortality and overall morbidity. The combination of ES and cholecystectomy seems superior to either of the treatment methods alone. A prospective randomized clinical trial comparing ES plus cholecystectomy with cholecystectomy alone is needed.

Recurrent acute pancreatitis and its relative factors

AIM: To evaluate the causes and the relative factors of recurrent acute pancreatitis.

METHODS: From 1997 to 2000, acute pancreatitis relapsed in 77 of 245 acute pancreatitis patients. By reviewing the clinical treatment results and the follow-up data, we analyzed the recurrent factors of acute pancreatitis using univariate analysis and multivariate analysis.

RESULTS: Of the 245 acute pancreatitis patients, 77 were patients with recurrent acute pancreatitis. Of them, 56 patients relapsed two times, 19 relapsed three times, each patient relapsed three and four times. Forty-seven patients relapsed in hospital and the other 30 patients relapsed after discharge. Eighteen patients relapsed in 1 year, eight relapsed in 1-3 years, and four relapsed after 3 years. There were 48 cases of biliary pancreatitis, 3 of alcohol pancreatitis, 5 of hyperlipidemia pancreatitis, 21 of idiopathic pancreatitis. Univariate analysis showed that the patients with local complications of pancreas, obstructive jaundice and hepatic function injury were easy to recur during the treatment period of acute pancreatitis (P = 0.022<0.05, P = 0.012<0.05 and P = 0.002<0.05, respectively). Multivariate analysis showed that there was no single factor related to recurrence. Of the 47 patients who had recurrence in hospital, 16 had recurrence in a fast period, 31 after refeeding.

CONCLUSION: Acute pancreatitis is easy to recur even during treatment. The factors such as changes of pancreas structure and uncontrolled systemic inflammatory reaction are responsible for the recurrence of acute pancreatitis. Early refeeding increases the recurrence of acute pancreatitis. Defining the etiology is essential for reducing the recurrence of acute pancreatitis.

Prevention of cholesterol gallstone disease by FXR agonists in a mouse model

Cholesterol gallstone disease is characterized by several events, including cholesterol precipitation in bile, increased bile salt hydrophobicity and gallbladder inflammation. Here, we describe the same phenotype in mice lacking the bile acid receptor, FXR. Furthermore, in susceptible wild-type mice that recapitulate human cholesterol gallstone disease, treatment with a synthetic FXR agonist prevented sequelae of the disease. These effects were mediated by FXR-dependent increases in biliary bile salt and phospholipid concentrations, which restored cholesterol solubility and thereby prevented gallstone formation. Taken together, these results indicate that FXR is a promising therapeutic target for treating or preventing cholesterol gallstone disease.