Gallstone pancreatitis

Acute gallstone pancreatitis: a constant challenge for the surgeon

INTRODUCTION

Acute pancreatitis is an inflammation of the pancreas caused by autodigestion of the gland by its enzymes. It includes a broad spectrum of pancreatic disease, which varies from parenchymal edema to necrosis. The objective of the current study was to describe the symptoms of the patients with gallstone-associated pancreatitis and to reinforce the opinion that operation, within the first 72 hours after the onset of the disease, has many advantages and has to be considered as a treatment option when ERCP is not available.

METHODS

The present retrospective study concerns all patients that were hospitalized in Mamatsio Hospital of Kozani during the period between Jan 1, 1997 and Dec 1, 2002 under the diagnosis of gallstone-associated acute pancreatitis. From the records 108 cases were identified (43 males and 65 females). The mean age was 62.93 (SD 15.85 years), ranging from 17 to 91 years.

RESULTS

24 patients (22.22%) fulfilled more than 3 of Ranson's criteria. 20 patients (18.52%) presented necrotizing pancreatitis. All patients underwent open cholecystectomy and common bile duct exploration. Necrosectomy concomitantly with cholecystectomy was performed in 7 patients (6.48%). The mean hospitalization was 10.53 days (S.D. 6.38 days), ranging from 2 to 36 days. The associated mortality reached 5.55% (6 patients) and no patient died in the operating theater. During the 12-month follow-up period, 2 patients (1.85%) developed pancreatic pseudocysts.

Gallstone pancreatitis: does discharge and readmission for cholecystectomy affect outcome?

BACKGROUND

Conventional surgical wisdom is that a patient with gallstone pancreatitis should have the gallbladder removed during their initial hospitalization. However, patients are now often discharged to await operating room availability.

METHODS

A retrospective review of all cases of gallstone pancreatitis at the Foothills Hospital between 1992 and 1996 was undertaken. Patients with a first attack of mild gallstone pancreatitis were studied.

RESULTS

In all, 164 patients were identified: 90 patients were discharged for readmission cholecystectomy (discharged group), and 74 patients had the cholecystectomy before discharge (in-hospital group). Over the 5-year time period the proportion of patients discharged for readmission cholecystectomy increased from 27% to 67% (p<0.01). The total number of days waited for operation was greater in the discharged group versus in-hospital group: 40+/-69 days versus 8+/-10 days respectively (mean+/-SD). There was a trend towards an increased total number of days in hospital in the in-hospital group, 15.5+/-17 days versus 10.7+/-16 days. In the discharged group 20% (18 of 90) of patients experienced an adverse event requiring readmission while awaiting operation. Three had documented recurrent pancreatitis, 10 experienced recurrent pain, and 5 developed acute cholecystitis. There were no deaths in either group.

DISCUSSION

Twenty percent of patients with gallstone pancreatitis who are discharged to await operating room time (average wait 40 days) will require readmission for biliary symptoms.

Usefulness of carbohydrate-deficient transferrin and trypsin activity in the diagnosis of acute alcoholic pancreatitis

OBJECTIVE

The aim of this study was to assess if carbohydrate-deficient transferrin (CDT) and trypsin activity differentiate acute alcoholic pancreatitis from nonalcohol-related pancreatitis, and as a secondary goal to evaluate its use in comparison to healthy controls.

METHODS

Serum levels of CDT and trypsin activity were measured in frozen sera from 70 nonconsecutive patients with acute pancreatitis and in 16 healthy controls.

RESULTS

Causes of pancreatitis were gallstones in 51%, chronic alcoholism in 23%, and other or unknown causes in 26% of the patients. Serum CDT was significantly higher in alcoholic pancreatitis than in the nonalcoholic disease (p < 0.0001) with a median (interquartile range) of 30.8 U/L (23.6-41.7 U/L) in chronic alcoholism, 16.7 U/L (13.05-21.1 U/L) in gallstones, 17.5 U/L (15.9-21.6 U/L) in unknown cause, 19.3 U/L (15.1-27.7 U/L) in other etiologies, and 16.1 U/L (12.1-18.8 U/L) in controls. At a cutoff over 22.5 U/L, CDT showed a sensitivity of 87.5% and a specificity of 85.2%. Serum levels of trypsin activity were significantly higher (p = 0.0007) in alcoholic pancreatitis, median 165 U/L (76-405 U/L) than in nonalcoholic pancreatitis, median 73 U/L (46.5-100.5 U/L). At a cutoff value over 152 U/L, the sensitivity of trypsin activity was 60% with a specificity of 100%. In the multivariate analysis, patient's age (< or = 44 yr), CDT (>22.5 U/L), and trypsin activity (>152 U/L) enabled correct prediction of acute alcoholic pancreatitis in 98% of the cases.

CONCLUSION

Serum CDT and trypsin activity are of clinical utility in differentiating alcoholic from nonalcoholic acute pancreatitis.

The role of ERCP and endoscopic sphincterotomy in the era of laparoscopic cholecystectomy

The advent of laparoscopic cholecystectomy (LC) has led to some controversy regarding the best method of managing bile duct calculi. This paper reviews the cases of 38 patients who underwent LC and endoscopic retrograde cholangiopancreatography (ERCP), from a series of 600 consecutive laparoscopic cholecystectomies. Twenty-nine patients had ERCP performed pre-operatively because of suspicion of choledocholithiasis. Duct stones were confirmed in eight patients. Recent or current jaundice was the best predictor of bile duct stones. Nine patients had ERCP done postoperatively because of duct stones seen on operative cholangiography. In two patients bile duct cannulation was not possible and a third procedure, open duct exploration, was necessary. Techniques in laparoscopic management of duct stones are improving and the role of ERCP and sphincterotomy should be limited to jaundiced patients or those with proven bile duct stones in whom laparoscopic procedures have been unsuccessful.

Gallstone pancreatitis

Gallstone pancreatitis is caused by transient obstruction of the ampulla of Vater by a migrating gallstone. Intraglandular activation of pancreatic enzymes occurs (by an unclear mechanism), and their entry into the circulation causes most of the local and systemic events of pancreatitis. The diagnosis is based on history and physical examination, an elevation of serum amylase above 1000 IU/L, and ultrasound and CT scans. Endoscopic retrograde cholangiopancreatography can be used in less certain cases to confirm the presence of common bile duct stones. Because of the absence of an agent that can abort progression of the disease, therapy should consist of adequate resuscitation, nutritional support, and careful monitoring to detect early complications. In patients with mild pancreatitis, surgery usually can be performed within 48 or 72 hours of admission or as soon as symptoms and amylase levels return to normal. For patients with severe disease, endoscopic sphincterotomy is emerging as the therapeutic modality of choice. Elective treatment of the associated biliary disease should be performed during the same hospitalization after the acute phase of the disease has subsided.

Early endoscopic sphincterotomy in the management of acute gallstone pancreatitis in elderly patients

Eighteen elderly patients with acute attacks of gallstone pancreatitis underwent early endoscopic sphincterotomy of the papilla of Vater. Eleven patients were considered to be at high risk for surgery due to chronic cardiorespiratory or renal problems. The outcome of these patients was compared with that of 20 consecutive elderly patients with gallstone pancreatitis treated at the same time by means other than endoscopic sphincterotomy. Endoscopic sphincterotomy resulted in an immediate clinical improvement in all patients, except in one patient who developed transient cholangitis; there was no mortality. In contrast, there was one death (5%) and 20% morbidity in the controls. Mean hospitalization period was shorter in patients undergoing sphincterotomy (6 compared with 9.5 days), although the patients managed by sphincterotomy were initially more seriously ill than controls. Only two of the 11 high-risk patients underwent elective cholecystectomy; all others were well during a mean follow-up of 22 months. It is concluded that early endoscopic sphincterotomy is highly effective and safe in acute attacks of gallstone pancreatitis in elderly high-risk patients.

Management of gallstone pancreatitis

The clinical course of 143 patients with gallstone pancreatitis is reviewed. Thirty-one patients (22%) had three or more positive prognostic factors on admission and 24 (77%) of these had a complicated course. Thirteen patients died, giving an overall mortality rate of 9%. Patients were divided into three groups on the basis of performance and timing of surgery. In group 1 (n = 56), surgery was undertaken during the first admission with acute pancreatitis; eight of these patients had a complicated course and three died. In group 2 (n = 40), biliary surgery was deferred to a subsequent admission; none of these patients died but 10 experienced further attacks of pancreatitis while awaiting reoperation. Group 3 patients (n = 47) did not undergo surgery; nine patients were diagnosed as having gallstone pancreatitis for the first time at autopsy, five refused operation, seven were lost to follow-up, six were dealt with by endoscopic sphincterotomy, and in 20 cases surgery was not considered appropriate because of general debility or advanced age. Despite the zero mortality rate in group 2, it is advocated that biliary surgery be carried out during the index hospital admission. Endoscopic sphincterotomy can now be considered as an alternative to cholecystectomy and duct clearance in the elderly and unfit, and may be used as a preliminary manoeuvre when severe acute pancreatitis fails to settle promptly on conservative management.

Detection of biliary origin of acute pancreatitis. Comparison of laboratory tests, ultrasound, computed tomography, and ERCP

Fifty consecutive patients with acute pancreatitis were assessed with respect to a biliary origin of the disease. Endoscopic retrograde cholangiopancreaticography, surgery, and autopsy were used to define biliary pancreatitis. Ultrasound, computed tomography, and several laboratory tests (SGOT, SGPT, alkaline phosphatase, and bilirubin) were analyzed for their ability to detect a biliary origin of the disease. Ultrasound and computed tomography could not reliably make the diagnosis in the 10 patients found to have biliary disease. Receiver-operator-characteristic curves revealed that none of the laboratory tests assessed had sufficient sensitivity and specificity to determine the diagnosis, although all tests showed higher mean values in biliary pancreatitis. SGPT gave the best discrimination (positive predictive value 53%, negative predictive value 94%, cut off 40 units/liter). Therefore, initial ERCP is suggested for a reliable diagnosis of biliary origin of acute pancreatitis.