Diagnostic criteria in predicting a biliary origin of acute pancreatitis in the era of endoscopic ultrasound: multicentre prospective evaluation of 213 patients

Practical management of severe acute pancreatitis

Acute pancreatitis (AP) represents one of the most common reasons for hospital admission and intensive care treatment in internal medicine. The incidence of AP is increasing, posing significant financial burden on healthcare systems due to the necessity for frequent medical interventions. Severe acute pancreatitis (SAP) is a potentially life-threatening condition with substantial morbidity and mortality. The management of SAP requires prolonged hospitalization and the expertise of a multidisciplinary team, comprising emergency physicians, intensivists, internists, gastroenterologists, visceral surgeons, and experts in nutrition, infectious disease, endoscopy, as well as diagnostic and interventional radiology. Effective management and beneficial patient outcomes depend on continuous interdisciplinary collaboration. This review synthesizes recent evidence guiding the practical management of SAP, with a particular focus on emergency and intensive care settings. Both established as well as new diagnostic and therapeutic paradigms are highlighted, including workup, risk stratification, fluid management, analgesia, nutrition, organ support, imaging modalities and their timing, along with anti-infective strategies. Furthermore, the review explores interventions for local and vascular complications of SAP, with particular attention to the indications, timing and selection between endoscopic (both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)), percutaneous and surgical approaches. Similarly, the management of biliary AP due to obstructive gallstones, including the imaging, timing of ERCP and cholecystectomy, are discussed. By integrating new evidence with relevant guidance for everyday clinical practice, this review aims to enhance the interdisciplinary approach essential for improving outcomes in SAP management.

Guidelines for the management of patients with severe acute pancreatitis, 2021

OBJECTIVE

To provide guidelines for the management of the intensive care patient with severe acute pancreatitis.

DESIGN

A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations.

CONCLUSIONS

There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.

Early Prediction of Acute Biliary Pancreatitis Using Clinical and Abdominal CT Features

Background Assessment of the biliary origin of acute pancreatitis (AP) is crucial because it affects patient treatment to avoid recurrence. Although CT is systematically performed to determine severity in AP, its usefulness in assessing AP biliary origin has not been evaluated. Purpose To assess abdominal CT features associated with acute biliary pancreatitis (ABP) and to evaluate the predictive value of a combination of CT and clinical data for determining a biliary origin in a first episode of AP. Materials and Methods From December 2014 to May 2019, all consecutive patients who presented with a first episode of AP and with at least 6 months of follow-up were retrospectively reviewed. Evidence of gallstones was mandatory for a clinical diagnosis of ABP. Abdominal CT images were reviewed by two abdominal radiologists. Univariable and multivariable statistical analyses were performed, and a nomogram was constructed on the basis of the combination of clinical and CT features. This nomogram was validated in a further independent internal cohort of patients. Results A total of 271 patients (mean age ± standard deviation, 56 years ± 20; 160 men) were evaluated. Of these, 170 (63%) had ABP. At multivariable analysis, age (odds ratio [OR], 1.06; 95% CI: 1.03, 1.09; P < .001), alanine aminotransferase level (OR, 1.00; 95% CI: 1.00, 1.01; P = .009), gallbladder gallstone (OR, 15.59; 95% CI: 4.61, 68.62; P < .001), choledochal ring sign (OR, 5.73; 95% CI: 2.11, 17.05; P < .001), liver spontaneous attenuation (OR, 1.07; 95% CI: 1.04, 1.11; P < .001), and duodenal thickening (OR, 0.17; 95% CI: 0.03, 0.61; P = .01) were independently associated with ABP. The matching nomogram combining both clinical and CT features displayed an area under the curve of 0.94 (95% CI: 0.91, 0.97) in the study sample (n = 271) and 0.91 (95% CI: 0.84, 0.99) in the validation cohort (n = 51). Conclusion Abdominal CT provided useful features for diagnosis of acute biliary pancreatitis (ABP). Combining CT and clinical features in a nomogram showed good diagnostic performance for early diagnosis of ABP. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Chang in this issue.

Metabolomic-based clinical studies and murine models for acute pancreatitis disease: A review

Acute pancreatitis (AP) is one of the most common gastroenterological disorders requiring hospitalization and is associated with substantial morbidity and mortality. Metabolomics nowadays not only help us to understand cellular metabolism to a degree that was not previously obtainable, but also to reveal the importance of the metabolites in physiological control, disease onset and development. An in-depth understanding of metabolic phenotyping would be therefore crucial for accurate diagnosis, prognosis and precise treatment of AP. In this review, we summarized and addressed the metabolomics design and workflow in AP studies, as well as the results and analysis of the in-depth of research. Based on the metabolic profiling work in both clinical populations and experimental AP models, we described the metabolites with potential utility as biomarkers and the correlation between the altered metabolites and AP status. Moreover, the disturbed metabolic pathways correlated with biological function were discussed in the end. A practical understanding of current and emerging metabolomic approaches applicable to AP and use of the metabolite information presented will aid in designing robust metabolomics and biological experiments that result in identification of unique biomarkers and mechanisms, and ultimately enhanced clinical decision-making.

Clinical Observation of the Efficacy of Endoscopic Retrograde Cholangiopancreatography on Elder Choledocholithiasis and Its Effects on the Levels of TNF-α, IL-1, and IL-6

OBJECTIVE

We conducted this study to investigate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) on elder choledocholithiasis and its effects on the levels of TNF-α, IL-1, and IL-6.

METHODS

Elder patients with choledocholithiasis were enrolled in this study, and according to the surgical methods, they were divided into the ERCP group and the surgical group. After treatment, we compared the efficacy of these two methods on patients, inflammatory responses indicated by the levels of TNF-α, IL-1, and IL-6, and the complications.

RESULTS

No statistical significance was identified in the difference of the success rate in removal between the two groups (98% vs. 94%), but indicators of the ERCP group, including the surgical duration (28.5±12.8) min, remission duration of abdominal pain (1.2±0.2) d, recession time of jaundice (2.0±0.3) d, postoperative bedridden time (1.4±0.2) d, treatment time of the anti-infection (1.5±0.2) d, length of stay in hospital (6.5±0.3) d, levels of TNF-α (2.1±0.2) μg/L, IL-1 (6.3±0.8) μg/L, IL-6 (2.8±0.3) μg/L, and the incidence rate of complications (1.8%), were all significantly lower than those in the surgical group (p<0.05).

CONCLUSION

In the treatment of choledocholithiasis, ERCP is excellent in controlling the trauma, accelerating the recovery duration, reducing the occurrence of complications and ameliorating the inflammatory responses. Thus, it is an ideal choice for choledocholithiasis.

Predictive biomarkers for acute gallstone pancreatitis in the pediatric population

BACKGROUND

Early biomarkers for diagnosis of gallstone pancreatitis (GP) in pediatrics have not been well studied. Reliably differentiating GP from other causes of acute pancreatitis (AP) would allow for early diagnosis and prompt management. We sought to assess biomarkers and clinical variables for early GP diagnosis from a prospectively-enrolled registry of pediatric patients presenting with first AP episode.

METHODS

Cross-sectional analysis of a prospective acute pancreatitis registry of children enrolled from March 2013 through October 2016 was performed. Fisher's exact test and Wilcoxon rank sum test were used to compare demographic and clinical variables between GP and non-GP groups. A multivariable logistic regression model was derived, and receiver operating characteristic (ROC) curve was built using stepwise selection.

RESULTS

114 subjects were enrolled (21 with GP, 93 as non-GP). Median was statistically higher for GP patients in lipase values X upper limit of normal (ULN) on admission, weight percentile for age, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase. By multivariable analysis, significant predictors were ALT and Lipase xULN. A model built using these two variables for prediction of GP identified an AUROC of 0.85. At a predictive probability of 0.35, the model had an 80% sensitivity, 93% specificity, 76% positive predictive value and 95% negative predictive value.

CONCLUSIONS

We have developed a model for predicting GP in children that could help guide clinical management of AP patients. Future studies are needed to validate use of laboratory findings and clinical variables in evaluation of gallstone etiology in pediatric AP patients.

The Diagnostic Usefulness of Serum Total Bile Acid Concentrations in the Early Phase of Acute Pancreatitis of Varied Etiologies

The most common causes of acute pancreatitis (AP) are biliary tract diseases with cholestasis and alcohol consumption. In 10%-15% of patients, etiology determination is difficult. Identification of the etiology allows for the implementation of adequate treatment. The aim of this study was to assess the utility of the serum concentrations of total bile acids (TBA) to diagnose AP etiology in the early phase of the disease. We included 66 patients with AP, admitted within the first 24 h from the onset of symptoms. TBA were measured in serum at 24, 48, and 72 h from the onset of AP, using an automated fifth generation assay. The bilirubin-to-TBA ratio (B/TBA) was calculated. TBA was highest on the first day of AP and decreased subsequently. In patients with biliary etiology, serum TBA was significantly higher compared to those with alcoholic and other etiologies. B/TBA was significantly higher in patients with alcoholic etiology. At admission, the cut-off values of 4.7 µmol/L for TBA and 4.22 for the B/TBA ratio allowed for a differentiation between biliary and other etiologies of AP with a diagnostic accuracy of 85 and 83%. Both TBA and B/TBA may help in the diagnosis of AP etiology in the early phase of AP.

Cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis in the PONCHO trial

Background

Same-admission cholecystectomy is indicated after gallstone pancreatitis to reduce the risk of recurrent disease or other gallstone-related complications, but its impact on overall costs is unclear. This study analysed the cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis.

Methods

In a multicentre RCT (Pancreatitis of biliary Origin: optimal timiNg of CHOlecystectomy; PONCHO) patients with mild gallstone pancreatitis were randomized before discharge to either cholecystectomy within 72 h (same-admission cholecystectomy) or cholecystectomy after 25–30 days (interval cholecystectomy). Healthcare use of all patients was recorded prospectively using clinical report forms. Unit costs of resources used were determined, and patients completed multiple Health and Labour Questionnaires to record pancreatitis-related absence from work. Cost-effectiveness analyses were performed from societal and healthcare perspectives, with the costs per readmission prevented as primary outcome with a time horizon of 6 months.

Results

All 264 trial participants were included in the present analysis, 128 randomized to same-admission cholecystectomy and 136 to interval cholecystectomy. Same-admission cholecystectomy reduced the risk of acute readmission for recurrent gallstone-related complications from 16·9 to 4·7 per cent (P = 0·002). Mean total costs from a societal perspective were €234 (95 per cent c.i. –1249 to 738) less per patient in the same-admission cholecystectomy group. Same-admission cholecystectomy was superior to interval cholecystectomy, with a societal incremental cost-effectiveness ratio of –€1918 to prevent one readmission for gallstone-related complications.

Conclusion

In mild biliary pancreatitis, same-admission cholecystectomy was more effective and less costly than interval cholecystectomy.

Endoscopic sphincterotomy and cholecystectomy in acute biliary pancreatitis

BACKGROUND

This review discusses current insights with regard to biliary tract management during and after acute biliary pancreatitis.

METHODS

A MEDLINE and EMBASE search was done and studies were selected based on methodological quality and publication date. The recommendations of recent guidelines are incorporated in this review. In absence of consensus in the literature, expert opinion is expressed.

RESULTS

There is no role for early endoscopic retrograde cholangiopancreatography (ERCP) in patients with (predicted) mild biliary pancreatitis to improve outcome. In case of persisting choledocholithiasis, ERCP with stone extraction is scheduled electively when the acute event has subsided. Whether early ERCP with sphincterotomy is beneficial in patients with predicted severe pancreatitis remains subject to debate. Regardless of disease severity, in case of concomitant cholangitis urgent endoscopic sphincterotomy (ES) is recommended. As a definitive treatment to reduce the risk of recurrent biliary events in the long term, ES is inferior to cholecystectomy and should be reserved for patients considered unfit for surgery. After severe biliary pancreatitis, cholecystectomy should be postponed until all signs of inflammation have subsided. In patients with mild pancreatitis, cholecystectomy during the primary admission reduces the risk of recurrent biliary complications.

CONCLUSION

Recent research has provided valuable data to guide biliary tract management in the setting of acute biliary pancreatitis with great value and benefit for patients and clinicians. Some important clinical dilemmas remain, but it is anticipated that on-going clinical trials will deliver some important insights and additional guidance soon.

Repeated transabdominal ultrasonography is a simple and accurate strategy to diagnose a biliary etiology of acute pancreatitis

OBJECTIVES

Transabdominal ultrasonography (US) usually reveals diagnosis of biliary acute pancreatitis (AP). Guidelines suggest repeating US in AP patients without cause at first examination. This approach has been poorly investigated, as well as the accuracy of repeated US as compared with that of magnetic resonance cholangiopancreatography. This study aims at evaluating the diagnostic accuracy of repeated US for biliary AP.

METHODS

The accuracy of each test for diagnosis of biliary AP was evaluated according to the final diagnosis. Comparison between tests was obtained by examining the areas under the receiver operating characteristic curves.

RESULTS

Among 155 patients, the etiology was biliary in 52% and alcoholic in 20%. The accuracy of the first US alone and of the 2 combined examinations for a biliary etiology were 66% and 83%, respectively. Comparison of receiver operating characteristic curves showed a better performance of repeated US (difference between areas under the curve, 0.135; 95% confidence interval, 0.02-0.24; P = 0.021). Magnetic resonance cholangiopancreatography had high specificity (93%) but low sensitivity (62%), with 76% accuracy. The accuracy of the combination of the 2 US examinations and of elevated alanine transferase was 87%.

CONCLUSIONS

Repeated US is effective for biliary AP diagnosis. The combination of repeated US examinations and biochemical tests seems an effective approach, whereas magnetic resonance cholangiopancreatography might be restricted to selected cases.

Predicting a biliary aetiology in paediatric acute pancreatitis

OBJECTIVE

Acute biliary pancreatitis (ABP) is a common cause of pancreatitis which may require timely intervention. We aimed to identify routine laboratory parameters for early prediction of biliary aetiology in paediatric acute pancreatitis (AP).

DESIGN

A retrospective review of children with AP (January 2000-July 2011) was performed at two tertiary paediatric hospitals in New South Wales, Australia. Predictors of ABP using laboratory parameters (measured within 48 h of presentation) were determined using a multivariate logistic regression model and evaluated.

RESULTS

Of the 131 pancreatitis episodes reviewed, 21 (16%) were biliary-related. Raised serum lipase, alkaline phosphatase, γ-glutamyl transpeptidase (GGT), alanine aminotransferase (ALT) and aspartate aminotransferase were associated with biliary aetiology (all p<0.0016) on univariate analysis. In multiple logistic regression, serum GGT ≥40 U/L, ALT ≥150 U/L, and lipase ≥15 × the upper limit of normal (ULN) were predictive of ABP. To improve clinical applicability, the predictive performance when at least two of the three ABP predictors (coined the 'biliary pancreatitis triad') were satisfied was evaluated. The triad performed with a specificity, sensitivity, positive predictive value and negative predictive value of 95, 89, 76 and 98%, respectively.

CONCLUSIONS

The biliary pancreatitis triad of serum GGT ≥40 U/L, ALT ≥150 U/L and lipase ≥15×ULN within 48 h of presentation may be used as simple clinical predictors of ABP in children. Children with values falling below 2 or 3 of these thresholds are very unlikely to have AP due to a biliary cause.

Endoscopic management of acute biliary pancreatitis

Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to severe acute illness with a significant risk of death. Urgent endoscopic treatment of acute pancreatitis is considered when there is causal evidence of biliary pancreatitis. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.

Endoscopic ultrasound and magnetic resonance cholangiopancreatography in patients with idiopathic acute pancreatitis

BACKGROUND

The efficacy of endoscopic ultrasonography (EUS) to diagnose idiopathic acute pancreatitis has been demonstrated but that of magnetic-resonance cholangiopancreatography (MRCP) remains unclear.

AIMS

The aim of our study was to prospectively compare the results of EUS and MRCP to diagnose idiopathic acute pancreatitis when performed later after an acute attack.

METHODS

All patients admitted to our center for acute pancreatitis over a 2-year period received first-line investigations that included medical history, standard biological measurements, abdominal ultrasound, and computerized tomography. If no etiology was found, second-line investigations were scheduled at 2 months (or more if there was severe pancreatitis), which included clinical examinations, biological parameters, EUS, and MRCP.

RESULTS

A total of 128 consecutive patients were included (male: 80, mean age: 55.3 years). After first-line investigations, 41 patients with idiopathic acute pancreatitis underwent second-line investigations and were followed-up (38 patients had both EUS and MRCP). EUS and/or MRCP led to recognize a possible etiology of pancreatitis in 19 patients (50 %). The diagnostic yield for EUS was higher than for MRCP (29 vs. 10.5 %). EUS more accurately detected biliary stones whereas MRCP identified pancreatic duct abnormalities, such as intraductal papillary mucinous neoplasm of the pancreas or chronic pancreatitis.

CONCLUSIONS

The combination of EUS and MRCP, when performed later after idiopathic acute pancreatitis, revealed 50 % of etiologies. The association of these two procedures and the subsequent follow-up reduced the rate of idiopathic pancreatitis by ~66 %.

Enhanced recovery in the management of mild gallstone pancreatitis: a prospective cohort study

PURPOSE

The aim of this study was to establish enhanced recovery protocols for the management of mild gallstone pancreatitis.

METHODS

Sixty consecutive patients were divided into enhanced recovery and traditional recovery (TR) groups in a randomized observational study. The basic enhanced recovery elements included early laparoscopic cholecystectomy, restrictive endoscopic intervention, and early oral nutrition. The incidence of complications, readmission, length of stay, and total medical cost were analyzed during the hospital course.

RESULTS

The length of hospital stay and medical cost were significantly lower in the enhanced recovery group in comparison to the TR group: 5.9 days vs. 10.6 days (P < 0.01) and ¥10,023 vs. ¥15,035 (P < 0.01). The complications and readmission rates in the two groups were similar.

CONCLUSIONS

The implementation of enhanced recovery protocols is feasible in the management of mild gallstone pancreatitis. The utilization of these protocols can achieve shorter hospital stays and reduced costs, with no increase in either the re-admission or peri-operative complication rates.

Clinical characteristics of intraductal papillary mucinous neoplasm manifesting as acute pancreatitis or acute recurrent pancreatitis

BACKGROUND AND AIM

Comparatively little is known about acute pancreatitis or acute recurrent pancreatitis (AP/ARP) with intraductal papillary mucinous neoplasm of the pancreas (IPMN) as the causative lesion although there have been many reports about the malignant potential of IPMN as a premalignant lesion.

METHODS

From 2000 to 2008, in a single tertiary referral center, out of 784 patients coded by the International Classification of Disease-10 with IPMN, 489 patients fulfilled our diagnostic criteria of IPMN. After careful exclusion of all known causes of AP/ARP, 34 patients with IPMN as the cause of AP/ARP were enrolled.

RESULTS

AP/ARP caused by IPMN occurred in 34 (7%) out of 488 patients with IPMN, and the prevalence rate of AP/ARP was higher in the main-duct/combined type than in the branch-duct type (14% [16/111] vs 5% [18/378], respectively, P = 0.002). The severity of pancreatitis was mild, based on the computed tomography severity index score (median 2, range 0-4). Histologic review of 24 patients with surgical resection revealed four adenomas (17%), 17 borderline malignancies (71%), two carcinomas in situ (8%), and one invasive carcinoma (4%). AP/ARP did not recur in any of the 24 surgically resected patients during the follow-up period (median 52 months, range 38-115 months).

CONCLUSIONS

AP/ARP caused by IPMN was of infrequent occurrence. AP/ARP caused by IPMN occurred more frequently in the main-duct/combined type than in the branch-duct type. Most cases were mild in severity and benign in histopathology. AP/ARP can be an initial manifestation of IPMN, though uncommon, which leads to diagnosis.

Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial): study protocol for a randomized controlled trial

Background

After an initial attack of biliary pancreatitis, cholecystectomy minimizes the risk of recurrent biliary pancreatitis and other gallstone-related complications. Guidelines advocate performing cholecystectomy within 2 to 4 weeks after discharge for mild biliary pancreatitis. During this waiting period, the patient is at risk of recurrent biliary events. In current clinical practice, surgeons usually postpone cholecystectomy for 6 weeks due to a perceived risk of a more difficult dissection in the early days following pancreatitis and for logistical reasons. We hypothesize that early laparoscopic cholecystectomy minimizes the risk of recurrent biliary pancreatitis or other complications of gallstone disease in patients with mild biliary pancreatitis without increasing the difficulty of dissection and the surgical complication rate compared with interval laparoscopic cholecystectomy.

Methods/Design

PONCHO is a randomized controlled, parallel-group, assessor-blinded, superiority multicenter trial. Patients are randomly allocated to undergo early laparoscopic cholecystectomy, within 72 hours after randomization, or interval laparoscopic cholecystectomy, 25 to 30 days after randomization. During a 30-month period, 266 patients will be enrolled from 18 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite endpoint of mortality and acute re-admissions for biliary events (that is, recurrent biliary pancreatitis, acute cholecystitis, symptomatic/obstructive choledocholithiasis requiring endoscopic retrograde cholangiopancreaticography including cholangitis (with/without endoscopic sphincterotomy), and uncomplicated biliary colics) occurring within 6 months following randomization. Secondary endpoints include the individual endpoints of the composite endpoint, surgical and other complications, technical difficulty of cholecystectomy and costs.

Discussion

The PONCHO trial is designed to show that early laparoscopic cholecystectomy (within 72 hours) reduces the combined endpoint of mortality and re-admissions for biliary events as compared with interval laparoscopic cholecystectomy (between 25 and 30 days) after recovery of a first episode of mild biliary pancreatitis.

Trial registration

Current Controlled Trials: ISRCTN72764151

Pancreas divisum is not a cause of pancreatitis by itself but acts as a partner of genetic mutations

OBJECTIVES

The role of pancreas divisum (PD) as a cause of acute recurrent or chronic pancreatitis (AR/CP) is still a matter of debate.

METHODS

The aims of this study were to evaluate the frequency of PD diagnosed using magnetic resonance cholangiopancreatography (MRCP) in patients with AR/CP of unknown origin (n=40) after careful exclusion of all known causes and to test the hypothesis of an interaction between anatomical (PD) and functional genetic anomalies (SPINK1, PRSS1, or CFTR gene mutations or polymorphisms (n=19, 25, and 30, respectively)) that could result in AR/CP. Patients with alcohol-induced pancreatitis (n=29) and subjects who had MRCP for a nonpancreatic disease (n=45) served as controls.

RESULTS

PD frequency was 7% in subjects without pancreatic disease, 7% in patients with alcohol-induced pancreatitis, and 5, 16, 16, and 47% in those with idiopathic, and PRSS1-, SPINK1-, and CFTR-associated pancreatitis, respectively (P<0.0001). There was no significant difference between idiopathic pancreatitis and the two control groups. The frequency of PD was higher in patients with CFTR gene-associated pancreatitis as compared with those with idiopathic and alcoholic pancreatitis (P<0.0001) and with those with SPINK1 and PRSS1 gene-associated pancreatitis (P<0.02).

CONCLUSIONS

The frequency of PD was not different in patients with idiopathic pancreatitis as compared with controls, demonstrating that PD by itself is not a cause of pancreatitis. PD frequency was higher in patients with genetic pancreatitis, especially in those with CFTR mutations or polymorphisms, suggesting a cumulative effect of these two cofactors.

Acute pancreatitis with an emphasis on infection

Acute pancreatitis is an inflammatory disease that is mild and self-limiting in about 80% of cases. However, severe necrotizing disease still has a mortality of up to 30%. Differentiated multimodal treatment concepts are needed for these patients, including a multidisciplinary team (intensivists, gastroenterologists, interventional radiologists, and surgeons). The primary therapy is supportive. Patients with infected pancreatic necrosis who are septic undergo interventional or surgical treatment, ideally not before the fourth week after onset of symptoms. This article reviews the pathophysiologic mechanisms of acute pancreatitis and describes clinical pathways for diagnosis and management based on the current literature and guidelines.

Practical guidelines for acute pancreatitis

INTRODUCTION

The following is a summary of the official guidelines of the Italian Association for the Study of the Pancreas regarding the medical, endoscopic and surgical management of acute pancreatitis.

STATEMENTS

Clinical features together with elevation of the plasma concentrations of pancreatic enzymes are the cornerstones of diagnosis (recommendation A). Contrast-enhanced computed tomography (CT) provides good evidence for the presence of pancreatitis (recommendation C) and it should be carried out 48-72 h after the onset of symptoms in patients with predicted severe pancreatitis. Severity assessment is essential for the selection of the proper initial treatment in the management of acute pancreatitis (recommendation A) and should be done using the APACHE II score, serum C-reactive protein and CT assessment (recommendation C). The etiology of acute pancreatitis should be able to be determined in at least 80% of cases (recommendation B). An adequate volume of intravenous fluid should be administered promptly to correct the volume deficit and maintain basal fluid requirements (recommendation A); analgesia is crucial for the correct treatment of the disease (recommendation A). Enteral feeding is indicated in severe necrotizing pancreatitis and it is better than total parenteral nutrition (recommendation A). The use of prophylactic broad-spectrum antibiotics reduces infection rates in CT-proven necrotizing pancreatitis (recommendation A). Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention, including surgery and radiological drainage (recommendation B).

CONCLUSIONS

The participants agreed to revise the guidelines every 3 years in order to re-evaluate each question on the management of acute pancreatitis patients according to the most recent literature.

Etiology and diagnosis of acute biliary pancreatitis

Establishing a biliary etiology in acute pancreatitis is clinically important because of the potential need for invasive treatment, such as endoscopic retrograde cholangiopancreatography. The etiology of acute biliary pancreatitis (ABP) is multifactorial and complex. Passage of small gallbladder stones or biliary sludge through the ampulla of Vater seems to be important in the pathogenesis of ABP. Other factors, such as anatomical variations associated with an increased biliopancreatic reflux, bile and pancreatic juice exclusion from the duodenum, and genetic factors might contribute to the development of ABP. A diagnosis of a biliary etiology in acute pancreatitis is supported by both laboratory and imaging investigations. An increased serum level of alanine aminotransferase (>1.0 microkat/l) is associated with a high probability of gallstone pancreatitis (positive predictive value 80-90%). Confirmation of choledocholithiasis is most accurately obtained using endoscopic ultrasonography or magnetic resonance cholangiopancreatography. This Review discusses the pathogenesis of ABP and the clinical techniques used to predict and establish a biliary origin in patients with suspected ABP.

Alanine transaminase rather than abdominal ultrasound alone is an important investigation to justify cholecystectomy in patients presenting with acute pancreatitis

OBJECTIVES

The aims of this study were to investigate the predictive value of an elevated level of alanine transaminase (ALT) for biliary acute pancreatitis (AP) and to reconsider the role of abdominal ultrasound (AUS).

METHODS

All patients admitted to Christchurch Public Hospital with AP between July 2005 and December 2008 were identified from a prospectively collected database. Peak ALT within 48 h of presentation was recorded. Aetiology was determined on the basis of history, AUS and other relevant investigations.

RESULTS

A total of 543 patients met the inclusion criteria. Patients with biliary AP had significantly higher median (range) ALT than those with non-biliary causes (200 units/l [63-421 units/l] vs. 33 units/l [18-84 units/l]; P < 0.001). An ALT level of >300 units/l had a sensitivity of 36%, specificity of 94%, positive predictive value of 87% and positive likelihood ratio of 5.6 for gallstones. An elevated ALT and negative AUS had a probability of 21-80% for gallstones.

CONCLUSIONS

An elevated ALT strongly supports a diagnosis of gallstones in AP. Abdominal ultrasound effectively confirms this diagnosis; however, a negative ultrasound in the presence of a raised ALT does not exclude gallstones. In some patients consideration could be given to proceeding to laparoscopic cholecystectomy based on ALT alone.

Detection of gallstones in acute pancreatitis: when and how?

The detection and management of bile duct stones in acute pancreatitis have improved considerably. Now it is possible to identify non-invasively stones in the duct before definitive treatment. Recently new evidence has confirmed that the indication for early endoscopic sphincterotomy should be severe acute pancreatitis with evidence of bile duct obstruction. This review analyses the evidence that defines current best practice in this area. and IAP.

Acute pancreatitis at the beginning of the 21st century: the state of the art

Acute pancreatitis is an acute inflammatory disease of the pancreas which can lead to a systemic inflammatory response syndrome with significant morbidity and mortality in 20% of patients. Gallstones and alcohol consumption are the most frequent causes of pancreatitis in adults. The treatment of mild acute pancreatitis is conservative and supportive; however severe episodes characterized by necrosis of the pancreatic tissue may require surgical intervention. Advanced understanding of the pathology, and increased interest in assessment of disease severity are the cornerstones of future management strategies of this complex and heterogeneous disease in the 21st century.

Acute pancreatitis at the beginning of the 21st century: The state of the art

Acute pancreatitis is an acute inflammatory disease of the pancreas which can lead to a systemic inflammatory response syndrome with significant morbidity and mortality in 20% of patients. Gallstones and alcohol consumption are the most frequent causes of pancreatitis in adults. The treatment of mild acute pancreatitis is conservative and supportive; however severe episodes characterized by necrosis of the pancreatic tissue may require surgical intervention. Advanced understanding of the pathology, and increased interest in assessment of disease severity are the cornerstones of future management strategies of this complex and heterogeneous disease in the 21st century.

The choledochal ring sign: a specific finding in acute biliary pancreatitis

We investigated a marked common bile duct wall contrast-enhancement in acute pancreatitis on CT scans as an accurate sign of biliary pancreatitis. Contrast-enhanced CT scans of 80 patients with clinically and biologically confirmed acute pancreatitis were reviewed by two gastrointestinal radiologists without knowledge of the cause of acute pancreatitis. Since this study was retrospective and then did not modify the CT examination routinely performed in acute abdomen, no institutional review board approval and informed consent was requested. A systematic measure of the difference between the CT number of common bile duct wall and the CT number of pancreatic parenchyma was performed. The "choledochal ring" sign, defined by a difference greater than 15 HU was specifically studied and compared to other factors often associated with biliary pancreatitis through univariate and multivariate analyses. Compared to other factors classically associated with acute biliary pancreatitis, the "choledochal ring" sign showed high specificity (100%) and high positive predictive value (100%). In patients with acute pancreatitis, the "choledochal ring" sign is a new and accurate finding of acute biliary pancreatitis on CT scans.

Pancreatitis in children and adolescents

Several clinical and methodologic difficulties occur when diagnosing acute pancreatitis in the pediatric age group. Due to its uncommonness and heterogeneous symptoms, acute pancreatitis in children is often misdiagnosed, and prospective studies are lacking. Guidelines for classifying, diagnosing, and managing acute pancreatitis are frequently based on standards that are developed and validated in adult patients. Among the broad range of etiologies of pediatric acute pancreatitis in children, gallstones and biliary disease may play a greater role than previously believed. Although it is typically a benign disease in the pediatric population, complications such as pseudocysts may occur. When there are fatalities, they are usually attributed to systemic illness rather than the pancreatitis itself. Improvements in diagnostic and imaging methods and growing awareness cannot account for the recent increases in the observed incidence of pediatric acute pancreatitis.

When is pancreatitis considered to be of biliary origin and what are the implications for management?

Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm.

Endoscopic management of acute pancreatitis

Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to devastating acute illness with a significant risk of death. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.