Clinical diversity in biliary pancreatitis--classification of two types

Pathophysiology of severe gallstone pancreatitis: A new paradigm

Severe gallstone pancreatitis (GSP) refractory to maximum conservative therapy has wide clinical variations, and its pathophysiology remains controversial. This Editorial aimed to investigate the pathophysiology of severe disease based on Opie’s theories of obstruction, the common channel, and duodenal reflux and describe its types. Severe GSP might be a hybrid disease with pathology polarized between acute cholangitis with mild pancreatitis (biliary type) and necrotizing pancreatitis uncomplicated with biliary tract disease (pancreatic type), in which hepatobiliary and pancreatic lesion severity is inversely related to the presence or absence of impacted ampullary stones. Severe GSP is caused by stones that are persistently impacted at the ampulla with biliopancreatic obstruction (biliary type), and probably, stones that are either temporarily lodged at the duodenal orifice or passed into the duodenum, thereby permitting reflux of bile or possible duodenal contents into the pancreas (pancreas type). When the status of the stones and the presence or absence of impacted ampullary stones with biliopancreatic obstruction are determined, the clinical course and outcome can be predicted. Gallstones represent the main cause of acute pancreatitis globally, and clinicians are expected to encounter GSP more often. Awareness of the etiology and pathogenesis of severe disease is mandatory.

LDH to AST ratio in biliary pancreatitis--a possible indicator of pancreatic necrosis: preliminary results

OBJECTIVE

Lactate dehydrogenase (LDH) has been reported to be a sensitive indicator of pancreatic necrosis (PN). In patients with biliary pancreatitis (BP), however, liver enzymes are generally elevated early in the course of the disease because of acute inflammatory liver cell injury caused by ampullary stones impacted during their transpapillary passage. Accordingly, the identification of PN using the initial high LDH activity as an indicator of PN in BP may not be accurate. In patients with ongoing PN, LDH would be expected to increase thereafter. We hypothesized that an elevation of the ratio of LDH to aspartate aminotransferase (AST) (LDH/AST) would better reflect PN in BP.

METHODS

The plasma concentrations of the LDH/AST ratio over a 3-wk postadmission period were evaluated and compared with serial computed tomograpy (CT) scans of the abdomen in two groups of patients with BP, consisting of 5 PN patients and 17 non-PN patients. A group of 50 healthy adults served as controls for the LDH/AST ratio measurement.

RESULTS

On postadmission days 1 and 2, the LDH/AST ratios in both groups of patients were low, with no significant difference. In the PN patients, the LDH/AST ratio increased thereafter, reached peak values, and decreased. In the non-PN patients, the LDH/AST ratio increased gradually, but remained within the control range. In the PN patients, the LDH/AST ratios on postadmission days 3, 5, and 7 were significantly higher than those of the non-PN patients. The CT scans of the abdomen of the PN patients showed an initial edematous pancreas with the development of late PN. The peak values of the LDH/AST ratio correlated well with the extent of PN.

CONCLUSION

An elevated LDH/AST ratio identifies patients who develop PN. The LDH/AST ratio could be used as an indicator of PN in BP patients.

Pancreatic ascites: a rare complication of necrotizing pancreatitis. A case report and review of the literature

We describe a young patient with a family history of hereditary pancreatitis who developed extensive pancreatic necrosis complicated by pancreatic ascites. Because of failure of medical management, he was successfully treated with operative necrosectomy and primary wound closure over peripancreatic drains. A postoperative low-output pancreaticocutaneous fistula resolved with time. Pancreatic ascites, as a result of pancreatic duct disruption, is more common in chronic rather than acute pancreatitis and is exceedingly uncommon in the context of necrotizing pancreatitis. When it complicates the latter, treatment should be guided by the principles of management of necrotizing pancreatitis. However, when true pancreatic ascites persists, the pancreatic duct anatomy and site of leak should be defined with endoscopic retrograde pancreatography (ERP). Treatment options include endoscopic duct dilatation and stent placement (if a stricture exists proximal to the leak), onlay pancreaticojejunostomy, or distal pancreatectomy (especially if the leak is located in the distal pancreas or in an enterically isolated distal pancreas).