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Patel D, Bhullar FA, Tagliaferri AR, Melki G, Grossman MA. Palliative Stenting for Gastric Outlet Obstruction Secondary to Pancreatic Adenocarcinoma. Cureus 2024; 16:e53186. [PMID: 38425636 PMCID: PMC10901673 DOI: 10.7759/cureus.53186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Pancreatic cancer is one of the most fatal malignancies due to its advanced stages at the time of presentation. Often, it is only diagnosed when patients present with late-stage complications, such as gastric outlet obstruction (GOO). Many patients experience a poor quality of life due to the side effects of GOO, such as persistent nausea, vomiting, and an inability to tolerate an oral diet, and as such, patients deteriorate quickly after their diagnosis. Because pancreatic cancer is diagnosed at advanced stages, many patients are not surgical candidates, and thus treatment is tailored for palliative measures. With GOO specifically, gastrojejunostomy has been the mainstay of palliative management; however, endoscopic stent placement is a new, innovative, and minimally invasive alternative option. Herein, we present a case of GOO as a complication of pancreatic adenocarcinoma, treated with palliative endoscopic stent placement. Further research is warranted to identify patients who would most benefit from this modality of palliation in the treatment of advanced pancreatic cancer.
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Affiliation(s)
- Dhruv Patel
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | - Furqan A Bhullar
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | | | - Gabriel Melki
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | - Matthew A Grossman
- Interventional Gastroenterology, St. Joseph's Regional Medical Center, Paterson, USA
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Singh A, Bush N, Bhullar FA, Faghih M, Moreau C, Mittal R, Seo JH, Talukdar R, Lakhtakia S, Singh VK, Akshintala VS. Pancreatic duct pressure: A review of technical aspects and clinical significance. Pancreatology 2023; 23:858-867. [PMID: 37798192 DOI: 10.1016/j.pan.2023.09.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/12/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023]
Abstract
Pancreatic duct pressure (PDP) dynamics comprise an intricately modulated system that helps maintain homeostasis of pancreatic function. It is affected by various factors, including the rate of pancreatic fluid secretion, patency of the ductal system, sphincter of Oddi function, and pancreatic fluid characteristics. Disease states such as acute and chronic pancreatitis can alter the normal PDP dynamics. Ductal hypertension or increased PDP is suspected to be involved in the pathogenesis of pancreatic pain, endocrine and exocrine pancreatic insufficiency, and recurrent pancreatitis. This review provides a comprehensive appraisal of the available literature on PDP, including the methods used in the measurement and clinical implications of elevated PDP.
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Affiliation(s)
- Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Nikhil Bush
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Mahya Faghih
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Chris Moreau
- Division of Gastroenterology, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Rajat Mittal
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Jung-Hee Seo
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
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Akshintala VS, Kanthasamy K, Bhullar FA, Sperna Weiland CJ, Kamal A, Kochar B, Gurakar M, Ngamruengphong S, Kumbhari V, Brewer-Gutierrez OI, Kalloo AN, Khashab MA, van Geenen EJM, Singh VK. Incidence, severity, and mortality of post-ERCP pancreatitis: an updated systematic review and meta-analysis of 145 randomized controlled trials. Gastrointest Endosc 2023; 98:1-6.e12. [PMID: 37004815 DOI: 10.1016/j.gie.2023.03.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 03/01/2023] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS The incidence, severity, and mortality of post-ERCP pancreatitis (PEP) largely remain unknown with changing trends in ERCP use, indication, and techniques. We sought to determine the incidence, severity, and mortality of PEP in consecutive and high-risk patients based on a systemic review and meta-analysis of patients in placebo and no-stent arms of randomized control trials (RCTs). METHODS The MEDLINE, Embase, and Cochrane databases were searched from the inception of each database to June 2022 to identify full-text RCTs evaluating PEP prophylaxes. The incidence, severity, and mortality of PEP from the placebo or no-stent arms of RCTs were recorded for consecutive and high-risk patients. A random-effects meta-analysis for a proportions model was used to calculate PEP incidence, severity, and mortality. RESULTS One hundred forty-five RCTs were found with 19,038 patients in the placebo or no-stent arms. The overall cumulative incidence of PEP was 10.2% (95% confidence interval [CI], 9.3-11.3), predominantly among the academic centers conducting such RCTs. The cumulative incidences of severe PEP and mortality were .5% (95% CI, .3-.7) and .2% (95% CI, .08-.3), respectively, across 91 RCTs with 14,441 patients. The cumulative incidences of PEP and severe PEP were 14.1% (95% CI, 11.5-17.2) and .8% (95% CI, .4-1.6), respectively, with a mortality rate of .2% (95% CI, 0-.3) across 35 RCTs with 3733 patients at high risk of PEP. The overall trend for the incidence of PEP among patients randomized to placebo or no-stent arms of RCTs has remained unchanged from 1977 to 2022 (P = .48). CONCLUSIONS The overall incidence of PEP is 10.2% but is 14.1% among high-risk patients based on this systematic review of placebo or no-stent arms of 145 RCTs; this rate has not changed between 1977 and 2022. Severe PEP and mortality from PEP are relatively uncommon.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kavin Kanthasamy
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Merve Gurakar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Anthony N Kalloo
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Erwin-Jan M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Goenka MK, Akshintala VS, Kamal A, Bhullar FA, Bush N, Kumar V, Chakraborty M, Gurakar M, Lakhtakia S, Talukdar R, Trikudanathan G, Khashab MA, Kalloo AN, Reddy DN, Sinha SK, Singh VK, Kochhar R. Frequent guidewire passage into the pancreatic duct is an independent risk factor for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among high-risk individuals: A post-hoc analysis of a randomized controlled trial data. J Dig Dis 2023; 24:427-433. [PMID: 37505932 DOI: 10.1111/1751-2980.13208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/12/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVES To systematically evaluate the patient and procedural risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among patients receiving rectal indomethacin. METHODS Data from a randomized controlled trial (RCT) of high-risk patients undergoing ERCP who received rectal indomethacin with or without topical epinephrine was evaluated. PEP was defined based on the consensus criteria. Pancreatic stenting was excluded to avoid confounding results with the role of epinephrine spray. Multivariable logistic regression analysis was used to identify patient and procedural risk factors for PEP. RESULTS Among 960 patients enrolled in the RCT, the PEP incidence was 6.4%. An increased risk of PEP was seen with age <50 years and female gender (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.35-4.26), malignant biliary stricture(s) (OR 3.51, 95% CI 1.52-8.10), >2 guidewire passes into the pancreatic duct (PD) (OR 2.84, 95% CI 1.43-5.64), and pancreatic brush cytology (OR 6.37, 95% CI 1.10-36.90), whereas a decreased risk of PEP was seen with contrast- over guidewire-assisted cannulation (OR 0.14, 95% CI 0.02-0.99) and the use of lactated Ringer's (LR) over other fluid types (OR 0.52, 95% CI 0.27-0.98). There was a significant trend between the number of guidewire passes into the PD and PEP risk (P = 0.002). CONCLUSIONS More than two guidewire passes into the PD and pancreatic brush cytology increased while the use of LR decreased the risk of PEP among high-risk patients receiving rectal indomethacin. Pancreatic stent placement and/or LR should be considered in patients with >2 guidewire passes into the PD.
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Affiliation(s)
- Mahesh K Goenka
- Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, Kolkata, India
| | - Venkata S Akshintala
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ayesha Kamal
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Furqan A Bhullar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nikhil Bush
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vijay Kumar
- Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, Kolkata, India
| | | | - Merve Gurakar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Gurakar M, Faghih M, Akshintala VS, Bhullar FA, Kanthasamy K, Khashab MA, Kamal A, Zaheer A, He J, Afghani E, Singh VK. Factors Associated With Serial Lipase Measurement in Hospitalized Patients With Acute Pancreatitis. Pancreas 2023; 52:e293-e297. [PMID: 37816173 DOI: 10.1097/mpa.0000000000002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVES To determine the factors associated with serial lipase measurement in patients with acute pancreatitis (AP). METHODS Patients admitted to Johns Hopkins Health System between September 2019 and August 2020 with lipase ≥3 times upper limit normal were prospectively identified. Acute pancreatitis was defined using revised Atlanta criteria. Serial lipase measurement was defined as >2 lipase measurements on consecutive days within 7 days of presentation. RESULTS There were 294 patients with AP with mean age 52.4 ± 16 years (SD), and 155 (52.7%) were male. A total of 227 (77.2%) were admitted to a medical service. There were 111 (37.7%) who underwent serial lipase measurements. There were 89 (30.8%), 36 (12.2%), 6 (1%), and 40 (13.6%) patients with systemic inflammatory response syndrome at time of initial lipase measurement, persistent organ failure, necrosis on admission, and intensive care unit admission. Serial lipase measurements were more likely to be obtained in patients admitted to surgical services (odds ratio, 4.3; 95% confidence interval, 1.4-13.2; P = 0.01) and nontertiary hospitals (odds ratio, 1.8; 95% confidence interval, 1.0-2.9; P = 0.04). CONCLUSION More than one-third of AP patients undergo serial lipase measurements. This practice is more likely to occur on surgical services and in nontertiary hospitals.
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Affiliation(s)
| | - Mahya Faghih
- Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Furqan A Bhullar
- Division of Internal Medicine, St Joseph's University Medical Center, Paterson, NJ
| | | | | | | | | | - Jin He
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
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6
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Ghandour B, Bhullar FA, Szvarca D, Bejjani M, Brenner T, McKee K, Kamal A, Steinway SN, Kamal M, Ricourt E, Singh VK, Khashab MA, Akshintala VS. Effective, safe and efficient porcine model of Forrest Ib bleeding gastric and colonic ulcers. Indian J Gastroenterol 2023; 42:118-127. [PMID: 36701035 DOI: 10.1007/s12664-022-01299-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 09/15/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Developing effective gastrointestinal (GI) bleeding animal models is necessary to advance endoscopic hemostasis methods and train endoscopists on their use. Our aim, therefore, was to develop an effective and safe porcine GI bleeding model in the stomach and colon of large and small-sized oozing-type ulcers. METHODS Gastric and colonic bleeding ulcers were created using either a hybrid endoscopic submucosal dissection (ESD) technique or a cap-assisted endoscopic mucosal resection (EMR-C) technique in 14 pigs. Prior to ulcer creation, animals were treated with either oral apixaban or intravenous (IV) unfractionated heparin anticoagulation in combination with clopidogrel and aspirin. The primary outcome was the technical success of inducing oozing-type Forrest Ib bleeding ulcers. Secondary outcomes included ulcer diameter, number, creation time and the number of complications associated with each technique. RESULTS Using hybrid ESD and IV heparin anticoagulation, bleeding was observed in 21/23 (91.3%) gastric ulcers and 6/7 (85.7%) colonic ulcers created. The mean diameter and ulcer creation time were 2.3 ± 0.3 cm and 5.3 ± 0.5 min, respectively, for gastric ulcers and 2.2 ± 0.4 cm and 4.06 ± 0.6 min, respectively, for colonic ulcers. Using EMR-C and IV heparin anticoagulation, bleeding was observed in 14/15 (93.3%) gastric ulcers and 6/6 (100%) colonic ulcers created. The mean diameter and ulcer creation time were 0.8 ± 0.2 cm and 2.1 ± 0.5 min, respectively, for gastric ulcers and 0.7 ± 0.2 cm and 1.7 ± 0.3 min, respectively, for colonic ulcers. None of the ulcers created in animals anticoagulated with apixaban developed bleeding. None of the 14 pigs developed any complications. CONCLUSION We have demonstrated the effectiveness and safety of a porcine GI bleeding model utilizing IV heparin anticoagulation and either hybrid ESD or EMR-C techniques to create oozing-type bleeding ulcers in the stomach and colon with customizable size.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Furqan A Bhullar
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Daniel Szvarca
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Todd Brenner
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Katherine McKee
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Ayesha Kamal
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Steven N Steinway
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Mustafa Kamal
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Ernesto Ricourt
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Venkata S Akshintala
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA.
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Bhullar FA, Faghih M, Akshintala VS, Ahmed AI, Lobner K, Afghani E, Phillips AE, Hart PA, Ramsey ML, Bick BL, Kuhlmann L, Drewes AM, Yadav D, Olesen SS, Singh VK. Corrigendum to "Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis" [Pancreatology 22 (1) (January 2022) 20-29]. Pancreatology 2022; 22:448. [PMID: 35289278 DOI: 10.1016/j.pan.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Furqan A Bhullar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Venkata S Akshintala
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmed I Ahmed
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Katie Lobner
- William H. Welch Medical Library, Johns Hopkins University, Baltimore, MD, USA
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anna E Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mitchell L Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Benjamin L Bick
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indiana, USA
| | - Louise Kuhlmann
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Søren S Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Bhullar FA, Faghih M, Akshintala VS, Ahmed AI, Lobner K, Afghani E, Phillips AE, Hart PA, Ramsey ML, Bick BL, Kuhlmann L, Drewes AM, Yadav D, Olesen SS, Singh VK. Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis. Pancreatology 2022; 22:20-29. [PMID: 34840065 PMCID: PMC8785146 DOI: 10.1016/j.pan.2021.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND/OBJECTIVES While pain is the predominant symptom of chronic pancreatitis (CP), a subset of patients may experience a painless course. This systematic review aimed to determine the prevalence of primary painless CP. METHODS MEDLINE (PubMed), EMBASE and Web of Science Core Collection databases were searched for published studies through September 15, 2020 that included at least 10 consecutive patients with CP and which reported the number with painless CP. The presence of a history of recurrent acute pancreatitis (RAP), exocrine pancreatic insufficiency (EPI), diabetes mellitus (DM) and pancreatic adenocarcinoma (PA) in the painless CP patients was also recorded. A random effects model was used to determine pooled prevalence estimates with 95% confidence intervals (95% CI). RESULTS Among the 5057 studies identified and screened, 42 full-text articles were included in the final analysis. There were a total of 14,277 patients with CP among whom 1569 had painless CP. The pooled prevalence of painless CP was 12% (95% CI 10-15%). Among a subset of studies that reported on calcifications (n = 11), DM (n = 12), EPI (n = 8) and history of RAP (n = 14), the pooled prevalence estimates were 96% (95% CI 73-100%), 51% (95% CI 32-70%), and 47% (95% CI 15-81%), respectively. Alcohol, idiopathic/genetic and other etiologies were attributed to be the cause of painless CP in 32.4%, 56.9% and 8.9% patients, respectively. CONCLUSION Approximately one in ten patients with CP have primary painless disease with the majority being attributable to an idiopathic/genetic etiology. Further research is needed to determine the optimal management of these patients.
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Affiliation(s)
- Furqan A. Bhullar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Venkata S. Akshintala
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmed I. Ahmed
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Katie Lobner
- William H. Welch Medical Library, Johns Hopkins University, Baltimore, MD, USA
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA,Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anna E. Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mitchell L. Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Benjamin L. Bick
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indiana, USA
| | - Louise Kuhlmann
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M. Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Søren S. Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Vikesh K. Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA,Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Akshintala VS, Sperna Weiland CJ, Bhullar FA, Kamal A, Kanthasamy K, Kuo A, Tomasetti C, Gurakar M, Drenth JPH, Yadav D, Elmunzer BJ, Reddy DN, Goenka MK, Kochhar R, Kalloo AN, Khashab MA, van Geenen EJM, Singh VK. Non-steroidal anti-inflammatory drugs, intravenous fluids, pancreatic stents, or their combinations for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:733-742. [PMID: 34214449 DOI: 10.1016/s2468-1253(21)00170-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs), intravenous fluid, pancreatic stents, or combinations of these have been evaluated in randomised controlled trials (RCTs) for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the comparative efficacy of these treatments remains unclear. Our aim was to do an exploratory network meta-analysis of previous RCTs to systematically compare the direct and indirect evidence and rank NSAIDs, intravenous fluids, pancreatic stents, or combinations of these to determine the most efficacious method of prophylaxis for post-ERCP pancreatitis. METHODS We searched PubMed, Embase, and the Cochrane Central Register from inception to Nov 15, 2020, for full-text RCTs that evaluated the efficacy of NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for post-ERCP pancreatitis prevention in adult (aged ≥18 years) patients undergoing ERCP. Summary data from intention-to-treat analyses were extracted from published reports. We analysed incidence of post-ERCP pancreatitis across studies using network meta-analysis under the frequentist framework, obtaining pairwise odds ratios (ORs) and 95% CIs. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system for the confidence rating. This study is registered with PROSPERO, CRD42020172606. FINDINGS We identified 1503 studies, of which 55 RCTs evaluating 20 interventions in 17 062 patients were included in the network meta-analysis. The mean incidence of post-ERCP pancreatitis in the placebo or active control group was 12·2% (95% CI 11·4-13·0). Normal saline plus rectal indometacin (OR 0·02, 95% CI 0·00-0·40), intramuscular diclofenac 75 mg (0·24, 0·09-0·69), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (0·30, 0·16-0·55), intravenous high-volume Ringer's lactate (0·31, 0·12-0·78), 5-7 Fr pancreatic stents (0·35, 0·26-0·48), rectal diclofenac 100 mg (0·36, 0·25-0·52), 3 Fr pancreatic stents (0·47, 0·26-0·87), and rectal indometacin 100 mg (0·60, 0·50-0·73) were all more efficacious than placebo for preventing post-ERCP pancreatitis in pairwise comparisons. 5-7 Fr pancreatic stents (0·59, 0·41-0·84), intravenous high-volume Ringer's lactate plus rectal diclofenac 100 mg (0·49, 0·26-0·94), intravenous standard-volume normal saline plus rectal indometacin 100 mg (0·04, 0·00-0·66), and rectal diclofenac 100 mg (0·59, 0·40-0·89) were more efficacious than rectal indometacin 100 mg. The GRADE confidence rating was low to moderate for 98·3% of the pairwise comparisons. INTERPRETATION This systematic review and network meta-analysis summarises the available literature on NSAIDs, pancreatic stents, intravenous fluids, or combinations of these for prophylaxis of post-ERCP pancreatitis. Rectal diclofenac 100 mg is the best performing rectal NSAID in this network meta-analysis. Combinations of prophylaxis might be more effective, but there is little evidence. These findings help to establish prophylaxis of post-ERCP pancreatitis for future research and practice, and could reduce costs and increase adoption of prophylaxis. FUNDING None.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | | | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ayesha Kamal
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kavin Kanthasamy
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Albert Kuo
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cristian Tomasetti
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Biostatistics & Bioinformatics, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Merve Gurakar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dhiraj Yadav
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, USA
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mahesh K Goenka
- Department of Gastroenterology, Apollo Gleneagles Hospital, Kolkata, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Anthony N Kalloo
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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