Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

How to predict a high rate of inappropriateness for upper endoscopy in an endoscopic centre?

BACKGROUND

Inappropriateness of upper endoscopy (EGD) indication causes decreased diagnostic yield. Our aim of was to identify predictors of appropriateness rate for EGD among endoscopic centres.

METHODS

A post-hoc analysis of two multicentre cross-sectional studies, including 6270 and 8252 patients consecutively referred to EGD in 44 (group A) and 55 (group B) endoscopic Italian centres in 2003 and 2007, respectively, was performed. A multiple forward stepwise regression was applied to group A, and independently validated in group B. A <70% threshold was adopted to define inadequate appropriateness rate clustered by centre.

RESULTS

discrete variability of clustered appropriateness rates among the 44 group A centres was observed (median: 77%; range: 41-97%), and a <70% appropriateness rate was detected in 11 (25%). Independent predictors of centre appropriateness rate were: percentage of patients referred by general practitioners (GP), rate of urgent examinations, prevalence of relevant diseases, and academic status. For group B, sensitivity, specificity and area under receiver operating characteristic curve of the model in detecting centres with a <70% appropriateness rate were 54%, 93% and 0.72, respectively.

CONCLUSIONS

A simple predictive rule, based on rate of patients referred by GPs, rate of urgent examinations, prevalence of relevant diseases and academic status, identified a small subset of centres characterised by a high rate of inappropriateness. These centres may be presumed to obtain the largest benefit from targeted educational programs.

Appropriateness guidelines and predictive rules to select patients for upper endoscopy: a nationwide multicenter study

OBJECTIVES

Selecting patients appropriately for upper endoscopy (EGD) is crucial for efficient use of endoscopy. The objective of this study was to compare different clinical strategies and statistical methods to select patients for EGD, namely appropriateness guidelines, age and/or alarm features, and multivariate and artificial neural network (ANN) models.

METHODS

A nationwide, multicenter, prospective study was undertaken in which consecutive patients referred for EGD during a 1-month period were enrolled. Before EGD, the endoscopist assessed referral appropriateness according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, also collecting clinical and demographic variables. Outcomes of the study were detection of relevant findings and new diagnosis of malignancy at EGD. The accuracy of the following clinical strategies and predictive rules was compared: (i) ASGE appropriateness guidelines (indicated vs. not indicated), (ii) simplified rule (>or=45 years or alarm features vs. <45 years without alarm features), (iii) logistic regression model, and (iv) ANN models.

RESULTS

A total of 8,252 patients were enrolled in 57 centers. Overall, 3,803 (46%) relevant findings and 132 (1.6%) new malignancies were detected. Sensitivity, specificity, and area under the receiver-operating characteristic curve (AUC) of the simplified rule were similar to that of the ASGE guidelines for both relevant findings (82%/26%/0.55 vs. 88%/27%/0.52) and cancer (97%/22%/0.58 vs. 98%/20%/0.58). Both logistic regression and ANN models seemed to be substantially more accurate in predicting new cases of malignancy, with an AUC of 0.82 and 0.87, respectively.

CONCLUSIONS

A simple predictive rule based on age and alarm features is similarly effective to the more complex ASGE guidelines in selecting patients for EGD. Regression and ANN models may be useful in identifying a relatively small subgroup of patients at higher risk of cancer.

Ranitidine bismuth citrate with either clarithromycin 1 g/day or 1.5 g/day is equally effective in the eradication of H. pylori and healing of duodenal ulcer

BACKGROUND

No randomized double-blind studies have been performed to compare clarithromycin 1 g/day with higher doses of the macrolide (1.5 g/day) when combined with ranitidine bismuth citrate (RBC).

AIM

To compare H. pylori eradication and ulcer healing rates of RBC 400 mg b.d. for 4 weeks combined for the first 2 weeks either with clarithromycin 500 mg b.d. (Group A) or clarithromycin 500 mg t.d.s. (Group B).

METHODS

Two hundred and seventy-three patients with H. pylori-positive active duodenal ulcer were included. H. pylori infection was detected by CLO-test and histology on antral and corpus biopsies before and at least 4 weeks after the end of therapy. Eradication was assumed if both CLO-test and histology results were negative for H. pylori.

RESULTS

Eradication/healing rates according to intention-to-treat and per protocol analysis were 76/82% and 87/92% for Group A and 78/85% and 88/95% for Group B, respectively (P = N.S.). Adverse events were reported by 7% and 12% of patients in Groups A and B, respectively, and they were generally mild.

CONCLUSIONS

RBC in co-prescription with clarithromycin 500 mg b.d. is as effective as RBC plus clarithromycin 500 t.d.s. in eradicating H. pylori and healing duodenal ulcers.

Hyperplastic polyp of the stomach simulating hypertrophic pyloric stenosis

We describe a rare case of hyperplastic polyp of the stomach having its clinical origin in the neonatal period and initially stimulating hypertrophic stenosis of the pylorus. After this neoformation, which almost completely obstructed the pylorus, was endoscopically removed, vomiting ceased and a rapid weight gain was observed. It is known that tumors are a rare cause of gastric outlet obstruction if compared with hypertrophic stenosis of the pylorus. However, our experience suggests that in the case of atypical symptoms, the investigations should be extended, especially to endoscopic examination of the upper digestive tract.

Intrahepatic lithiasis. Study of thirty-six cases and review of the literature

In 2,700 operations for biliary tract stones, intrahepatic lithiasis (stones located proximal to the confluence of the main hepatic ducts) was discovered in 36 patients (1.3 per cent). The diagnosis of intrahepatic lithiasis was determined only via intraoperative chalangiography in thirty-two cases (88.9 er cent); in 23 per cent of our cases of intrahepatic lithiasis, jaundice was never observed. This confirms that intraoperative cholangiography should be performed routinely in every case of biliary lithiasis. The removal of stones was generally performed by an indirect approach (papillostomy and/or choledochotomy). In 16.7 per cent of our cases, a direct approach was indicated. It is extremely important, after removal of calculi, to assure ample bilioenteric flow. Our surgical approach was therefore based mostly on the caliber of the biliary tract. When the tract was dilated less that 2 cm (in 20 cases), choledochohepaticotomy with papillostomy was most often performed (12 cases, 60 per cent). When the dilatation was more that 2 cm (12 cases), Roux-en-Y hepaticojejunostomy was performed in all. There was no operative mortality, although the long-term follow-up results were poor in 9.6 per cent of the cases.

[Intrahepatic lithiasis. Apropos of 36 cases of "regional" intraheptic lithiasis]

Out of 2,700 operations for cholelithiasis and its sequelae (1960-1976), 36 cases (1.3%) of intrahepatic lithiasis (i.l.), namely proximal to the origin of the common hepatic, were observed. The prime objective of treatment namely removal of calculi, was achieved indirectly (hepatocholedochus and/or papilla) in 84% of cases, directly (hilar) in 16%. The second objective, that of ensuring optimal bilio-enteric drainage, was achieved by papillostomy or hepaticojejunostomy depending on the lumen of the bile way (respectively less or more than 2 cm.). Operative mortality was nil, while long-term results have proved poor in 9.6% of cases. The i.l. problematic is dealt with in detail on the basis of this series.

Spontaneous internal biliary fistulas

Etiology, diagnostic investigations and surgical procedures on 58 patients with spontaneous internal biliary fistulas are reported. Cholelithiasis and peptic ulcer were found to be the presumptive cause of fistula respectively in 53 and five patients. Preoperative diagnosis was established on 31 patients while in the remaining 27 fistula was found incidentally at surgery. Surgical treatment included a wide variety of operations which were performed on the basis of the pathologic features of fistula. Over all mortality rate was 5 percent and morbidity 13 percent. The unsatisfactory results of the surgical treatment of internal biliary fistulas are another strong argument for performing early cholecystectomy in all the patients with cholelithiasis.