Gallstone pancreatitis: general clinical approach and the role of endoscopic retrograde cholangiopancreatography

Imaging-based biomarkers in acute pancreatitis: the predictive value of adrenal contrast ratios for intensive care unit admission

BACKGROUND

Early risk stratification is crucial in acute biliary pancreatitis (ABP) to optimize patient management and guide intensive care unit (ICU) admission decisions. Traditional biomarkers and scoring systems have limitations in early severity assessment. This study aimed to evaluate the predictive value of adrenal contrast ratios on contrast-enhanced CT (CECT) as imaging-based biomarkers for ICU admission and prolonged hospitalization in ABP patients.

METHODS

This retrospective study included 288 ABP patients who underwent CECT within 24 h of admission. Adrenal-to-inferior vena cava (IVC) and adrenal-to-spleen contrast ratios were measured from portal venous phase images. The predictive performance of these ratios for ICU admission was assessed using receiver operating characteristic (ROC) analysis, and their correlation with clinical outcomes was evaluated through regression analysis.

RESULTS

ICU-admitted patients had significantly higher adrenal contrast ratios compared to non-ICU patients (adrenal-to-IVC ratio: 1.15 vs. 0.99, p < 0.001; adrenal-to-spleen ratio: 0.97 vs. 0.75, p < 0.001). ROC analysis demonstrated strong predictive accuracy (AUC = 0.74 for adrenal-to-IVC, AUC = 0.81 for adrenal-to-spleen). Additionally, adrenal contrast ratios correlated significantly with prolonged hospital stay (r = 0.49-0.55, p < 0.001).

CONCLUSION

Adrenal contrast ratios serve as promising imaging-based biomarkers for early ICU admission prediction and risk stratification in ABP patients. Their integration into clinical decision-making may enhance early management strategies. Further prospective validation is warranted.

Glucagon-like peptide-1 receptor agonists in peri-operative care: Dispelling myths and unveiling insights with essential considerations for anaesthesiologists

With the growing use of glucagon-like-peptide-1 (GLP-1) receptor (GLP-1R) agonists as anti-obesity medication it is becoming increasingly important to examine its consequences in the peri-operative period. GLP-1R agonists are known for their effects of glucose-lowering and gastroparesis the latter causing some safety concerns regarding induction of anaesthesia, more specifically the risk of pulmonary aspiration. This article gathers the available evidence on this subject in addition to the already established guidelines. Current evidence makes us assume there is indeed an increased level of gastroparesis, but there are no studies to date with evidential confirmation of a presumed elevated risk of pulmonary aspiration. Future perspectives should focus on the actual risk of pulmonary aspiration and the possible implementation of ultrasound in the preoperative assessment.

[Improvement of surgical strategy for acute biliary pancreatitis]

OBJECTIVE

To improve surgical tactics for acute biliary pancreatitis.

MATERIAL AND METHODS

Treatment outcomes were analyzed in 502 patients with acute biliary pancreatitis. Patients were divided into two groups depending on surgical tactics: control group (n=293) - standard diagnosis and treatment of biliary pancreatitis, main group (n=209) - treatment of biliary pancreatitis based on original algorithm. In these patients, therapeutic and diagnostic program included functional state of biliary tract and stratification of patients depending on severity of acute pancreatitis (APACHE II and Imrie/Glasgow scale) in addition to standard procedures.

RESULTS

There are 2 fundamentally different clinical variants of ductal hypertension and biliary pancreatitis: with acute blockade of pancreatobiliary tract (obstructive variant) and without this blockade (non-obstructive variant). Each variant included various clinical forms of acute biliary pancreatitis etiologically associated with specific biliary disease. In the 2nd group, a differentiated surgical approach was applied taking into account clinical variant of biliary pancreatitis. The first stage implied correction of pancreatobiliary ductal hypertension through minimally invasive methods. At the second stage, radical surgical debridement of biliary tract was performed with elimination of etiological factor of biliary pancreatitis within the same hospitalization in patients with mild-to-moderate disease. In patients with severe biliary pancreatitis, the second stage of treatment was carried out 3 months after discharge. This treatment strategy reduced the number of infectious and inflammatory complications from 26.6% to 11.5%, mortality from 7.5% to 3.3% and avoid recurrent biliary pancreatitis.

CONCLUSION

Original therapeutic and diagnostic algorithm optimizes surgical strategy and improves the effectiveness of treatment of acute biliary pancreatitis.

ATN-161 alleviates caerulein-induced pancreatitis

Pancreatitis is a common gastrointestinal disorder that causes hospitalization with significant morbidity and mortality. The mechanistic pathophysiology of pancreatitis is complicated, limiting the discovery of pharmacological intervention methods. Here, we show that the administration of ATN-161, an antagonist of Integrin-α5, significantly mitigates the pathological condition of acute pancreatitis induced by caerulein. We find that CK19-positive pancreatic ductal cells align parallel to blood vessels in the pancreas. In the caerulein-induced acute pancreatitis model, the newly emergent CK19-positive cells are highly vascularized, with a significant increase in vascular density and endothelial cell number. Single-cell RNA sequencing analysis shows that ductal and endothelial cells are intimate interacting partners, suggesting the existence of a ductal-endothelial interface in the pancreas. Pancreatitis dramatically reduces the crosstalk in the ductal-endothelial interface but promotes the Spp-1/Integrin-α5 signaling. Blocking this signaling with ATN-161 significantly reduces acinar-to-ductal metaplasia, pathological angiogenesis, and restores other abnormal defects induced by caerulein. Our work reveals the therapeutic potential of ATN-161 as an uncharacterized pharmacological method to alleviate the symptoms of pancreatitis.

The link between serum cotinine levels and gallstones prevalence in adults: a cross-sectional analysis using NHANES data (2017-2020)

Background

Gallstones represent a prevalent health issue globally, resulting in significant annual healthcare costs. While tobacco exposure is recognized for its association with numerous diseases, its correlation with gallstones remains contentious. Serum cotinine, a metabolite of nicotine, serves as a widely utilized indicator for assessing tobacco exposure. Crucially, no research has yet examined the association between serum cotinine levels and the gallstones.

Methods

This study is designed as a cross-sectional analysis, utilizing data from the NHANES public database. The relationship between serum cotinine levels and gallstones was analyzed using multinomial logistic regression models and smooth curve fitting. Subgroup analyses and interaction tests were performed to examine the potential contributions of different populations and covariates to the findings.

Results

A total of 5,856 participants were included in this study. After adjusting for relevant covariates, the multiple logistic regression model results indicated that for each unit increase in serum cotinine concentration above 0.29 ng/mL, there was a 29% increase in the prevalence of gallstones. Furthermore, smooth curve fitting analysis revealed a positive correlation between these variables. These findings underscore the impact of tobacco exposure on gallstone prevalence.

Conclusion

This study demonstrates a positive correlation between tobacco exposure, as measured by serum cotinine levels, and the prevalence of gallstones, thus adding to the body of existing research on this relationship.

Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis

Acute biliary pancreatitis (ABP) with cholangitis requires endoscopic retrograde cholangiopancreatography (ERCP) within 24 h to resolve ductal obstruction. However, this recommendation is based on the timing of emergency room (ER) visits. We wanted to determine the optimal timing of ERCP for ABP based on the timing of symptom onset, not the timing of the ER visit. We retrospectively reviewed 162 patients with ABP with cholangitis who underwent urgent ERCP (within 24 h of ER admission). Area under the receiver operating characteristic (ROC) curve (AUC) was analyzed to determine differences in complication rates according to time from symptom onset. A difference in ERCP-related adverse events (AEs) was identified, and Youden's J statistic was used to determine a cutoff time from symptom onset (18 h). We compared mortality and complications based on this cutoff. Based on time to symptom onset, significantly higher rates of aspiration pneumonia (odds ratio [OR] 4.00, 95% confidence interval [CI] 1.15-13.92, P = 0.021) and post-ERCP hypotension (OR 11.9, 95% CI 1.39-101.33, P = 0.005) were observed in the ≤ 18-h group than in the > 18-h group. The study found that patients who underwent ERCP within 18 h of symptom onset is associated with an increased risk of ERCP-related AEs.

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.

Indication and Timing of Cholecystectomy in Acute Biliary Pancreatitis - Systematic Review

Acute biliary pancreatitis (ABP) poses significant challenges in determining the optimal timing and approach for cholecystectomy, particularly in mild, moderately severe, and severe forms. This article reviews the existing literature on cholecystectomy timing and its impact on outcomes in ABP. A systematic literature search yielded 41 relevant articles from PubMed and Scopus databases. In mild ABP, early cholecystectomy within 72 hours of onset is increasingly favoured due to reduced technical difficulty and lower risk of recurrent pancreatitis. Conversely, delayed cholecystectomy, although traditionally practiced, may lead to higher recurrence rates and prolonged hospital stays. For moderate severe ABP, evidence remains limited, but early cholecystectomy appears to decrease hospital stay without increasing perioperative complications. In severe ABP, consensus suggests delaying cholecystectomy until peripancreatic collections resolve, typically 6 to 10 weeks post-onset, to minimize surgical morbidity. The role of endoscopic retrograde cholangiopancreatography (ERCP) alongside cholecystectomy remains contentious, with guidelines recommending its use in specific scenarios such as cholangitis or biliary obstruction. However, routine ERCP in mild ABP lacks robust evidence and may increase complications. Challenges persist regarding the management of residual choledocholithiasis post-ABP, highlighting the need for improved diagnostic criteria and management protocols. Overall, this review underscores the evolving landscape of cholecystectomy timing in ABP and provides insights into current best practices and areas for future research.

When Blood Is Thicker Than Water: A Case of Acute Pancreatitis Secondary to Familial Hypertriglyceridemia

Hypertriglyceridemia is one of the major causes of acute pancreatitis in addition to gallstones and alcohol use. These etiologies are often associated with underlying comorbidities. Acute pancreatitis secondary to hypertriglyceridemia is associated with an increase in clinical severity and further complications. We present a case of a 56-year-old man with a past medical history of hypertension, diabetes mellitus, and familial hypertriglyceridemia who was diagnosed with acute pancreatitis secondary to hypertriglyceridemia. The patient presented with 9/10 pressure across the abdomen radiating to the sternum. Labs revealed elevated triglyceride count > 8000 mg/dL and cholesterol > 705 mg/dL. Abdominal CT showed fat stranding along the anterior aspect of the pancreatic head. The patient was managed with IV fluids, nil per os (NPO), and statin management for hypertriglyceridemia. Seven days later, triglycerides decreased to 658 mg/dL, and abdominal pain resolved. This case highlights an unusual presentation of acute pancreatitis and demonstrates the importance of understanding the spectrum of etiologies for this condition.

Risk of Complications After Endoscopic Retrograde Cholangiopancreatography in Pregnancy: A Propensity-Matched Analysis

BACKGROUND

Studies have suggested higher complication rates after endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy.

AIMS

We performed a propensity-matched cohort analysis to assess the risk of ERCP-related complications among pregnant women in the United States.

METHODS

The TriNetX database was analyzed to identify pregnant and non-pregnant females between 18 and 50 years of age who underwent ERCP. One-to-one propensity score matching was performed for age and race. Outcomes included risk of post-ERCP pancreatitis (PEP), gastrointestinal (GI) bleeding, perforation within 7 days, and infections within 30 days of ERCP. Subgroup analysis was performed to assess the risk of PEP based on indication for ERCP.

RESULTS

The risk of PEP was higher in the pregnant cohort compared to controls, 10.3% vs 6.08%, adjusted odds ratio (aOR) 1.77, 95% confidence interval (CI) 1.20-2.61; p = 0.003. We found no difference in the risk of GI bleeding, perforation, and infections between the two cohorts. There was no difference in the risk of PEP in the pregnant cohort compared to controls who underwent ERCP for acute choledocholithiasis (4.2% vs 2.1%, aOR 1.98, 95% CI 0.97-4.03, p = 0.5) or ascending cholangitis (18.6% vs 14.7%, aOR 1.32, 95% CI 0.52-3.39, p = 0.55). There was no difference in the risk of PEP in the pregnant cohort after sensitivity analysis based on age, race, obesity, and indomethacin use.

CONCLUSION

Pregnant females are at an increased risk of PEP but not GI bleeding, perforation, and infections when compared to non-pregnant controls. Clinicians should be cautious when proceeding with ERCP during pregnancy.

Acute edematous pancreatitis caused by Fasciola hepatica infection: A rare case report

Acute edematous pancreatitis is a medical emergency characterized by a sudden pancreas inflammation. It can be caused by various factors, primarily gallstones, alcohol consumption, or medication. Acute edematous pancreatitis caused by Fasciola hepatica infection is exceptionally rare and could be overlooked. We report a case of a 24-year-old female patient who presented with onsets of clinical and paraclinical signs of acute pancreatitis (AP). The patient was diagnosed with Fasciola hepatica-induced edematous pancreatitis, a rare parasitic infection that can cause AP. This case highlights the importance of considering parasitic infections in the differential diagnosis of edematous pancreatitis, particularly in young patients with no significant medical history.

Therapeutic outcomes of early and delayed endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangial drainage in patients with obstructive severe acute biliary pancreatitis

Background

Obstructive severe acute biliary pancreatitis (SABP) is a clinical emergency with a high rate of mortality that can be alleviated by endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) selectively. However, the optimal timing of ERCP and PTCD requires elucidation.

Aim

The aim of this study was to evaluate outcome parameters in patients with SABP subjected to ERCP and PTCD compared to SABP patients who were not subjected to any form of invasive intervention.

Methods

A total of 62 patients with obstructive SABP who had been treated from July 2013 to July 2019 were included in this retrospective case-control study and stratified into a PTCD group (N = 22), ERCP group (N = 24), and conservative treatment group (N = 16, control). Patients in the PTCD and ERCP groups were substratified into early (≤72 h) and delayed (>72 h) treatment groups based on the timing of the intervention after diagnosis. Clinical chemistry, hospitalization days, liver function, abdominal pain, and complications were determined to assess the treatment efficacy and safety of each modality and to establish the optimal timing for PTCD and ERCP.

Results

The average hospitalization time, time to abdominal pain relief, and time to normalization of hematological and clinical chemistry parameters (leukocyte count, amylase, alanine transaminase [ALT], and total bilirubin [TBiL]) were shorter in the PTCD and ERCP groups compared to the conservative treatment group (p < 0.05). The average hospitalization time in the ERCP group (16.7 ± 4.0 d) was shorter compared to the PTCD group (19.6 ± 4.3 d) (p < 0.05). Compared to the conservative treatment group (62.5%), there were more complications in patients treated with ERCP and PTCD (p < 0.05). In the early ERCP group, the average hospitalization time (13.9 ± 3.3 d) and the time to normalization of leukocyte count (6.3 ± 0.9 d) and TBiL (9.1 ± 2.0 d) were lower than in the delayed ERCP group (18.6 ± 4.1 d, 9.9 ± 2.4 d, 11.8 ± 2.9 d, respectively) and early PTCD group (16.4 ± 3.7 d, 8.5 ± 2.1 d, 10.9 ± 3.1 d, respectively) (p < 0.05). In the delayed ERCP group, the average hospitalization time (18.6 ± 4.1 d) and ALT recovery time (12.2 ± 2.6 d) were lower than in the delayed PTCD group (21.9 ± 4.3 d and 14.9 ± 3.9 d, respectively) (p < 0.05).

Conclusions

ERCP and PTCD effectively relieve SABP-associated biliary obstruction with comparable overall incidence of complications. It is recommended that ERCP is performed within 72 h after diagnosis; and PTCD drainage may be considered an alternative approach in cases where patients are unable or unwilling to undergo ERCP, or when ERCP is unsuccessful.

Relevance for Patients

ERCP and PTCD in patients with obstructive SABP can resolve biliary obstruction and delay progression of the disease. Performing ERCP and PTCD within 72 h (i.e., optimal treatment time window) can be beneficial to patients, especially in terms of post-operative recovery. Visual biliary endoscopy (oral or percutaneous transhepatic) may be used for concomitant therapeutic interventions in the biliary system.

The possible role of viral infections in acute pancreatitis: a review of literature

Acute pancreatitis, a potentially fatal disease, with symptoms including nausea and/or vomiting, indigestion, and abdominal pain, is known to range from a mild self-limiting state up to a more severe and lethal form. This review aims to provide a clearer picture to improve understanding the role of viral agents in the development of acute pancreatitis. Common databases including PubMed, Google Scholar, and Scopus were used for the literature search. In this review search terms including virus, viral, infection, and specific descriptive terms for a virus were considered in different combinations. Various causative agents are recognized in the development of acute pancreatitis as one of the most frequent gastrointestinal diseases, such as gallstones, alcoholism, and hypertriglyceridemia. Microbial pathogens with about 10% of acute pancreatitis cases, mainly viruses, among other factors, are thought to play a role in this regard. Once the pancreatitis diagnosis has been made, depending on the causative agent, the management approach and specific interventions affect the final outcome. Virus-induced acute pancreatitis in patients should be considered. Advanced diagnostic tests such as PCR, in situ hybridization, and biopsy can help for a better understanding of the role of viruses in causing acute pancreatitis. Improvement in the tests will lead to timely diagnosis, treatment, and better management of pancreatitis.

A Clinical Overview of Acute and Chronic Pancreatitis: The Medical and Surgical Management

An inflammatory process involving the pancreas, known as pancreatitis, can be categorized as either acute or chronic and may present in one of many ways. The clinical manifestations of acute pancreatitis are generally limited to epigastric or right upper quadrant pain, while manifestations of chronic pancreatitis are broader and may include abdominal pain in tandem with signs and symptoms of pancreatic endocrine and exocrine insufficiency. An understanding of the initial insult, proper classification, and prognosis are all factors that are of paramount importance as it pertains to managing patients who are afflicted with this disease. Our review delves into the depths of pancreatitis by exploring the embryology and anatomy of the pancreas, the pathophysiology and etiology of acute and chronic pancreatitis, and the medical and surgical management of acute and chronic pancreatitis.