Clinical and paraclinical characteristics in pediatric patients with acute recurrent and chronic pancreatitis: a cohort in Mexico

BACKGROUND

Acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) are infrequent clinical entities in pediatric patients, as less than 8% of the literature mentions this population. This study aimed to describe the clinical and paraclinical profile, and the etiology related to patients with ARP and CP attended at a tertiary-level healthcare institute in Mexico.

METHODS

We conducted a retrospective study from medical records of patients with ARP and CP attended between 2010 and 2020, analyzing the clinical characteristics, imaging studies, and the etiology associated with each patient.

RESULTS

We analyzed 25 patients: 17 were diagnosed with ARP, and eight with CP. The main etiology identified was an anatomical alteration of the pancreatic duct (32%); pancreas divisum was the most prevalent condition. In 48% of the population, the etiology was not identified. The group with CP was higher in frequency for calcifications and dilation of the pancreatic duct (p < 0.005) compared to the ARP group.

CONCLUSIONS

The main etiology for ARP and CP was an anatomical alteration of the pancreatic duct; however, in almost half of the cases, no established cause was identified. Although comparing our results with those offered by large cohorts such as the INSPPIRE group can be complex, we found relevant similarities. Currently, the data obtained from this first descriptive study are the foundation for future research in the field of Mexican pediatric pancreatology.

Favorable response after radiation therapy for intraductal papillary mucinous neoplasms manifesting as acute recurrent pancreatitis: A case report

BACKGROUND

There has been an increasing number of elderly patients with intraductal papillary mucinous neoplasm (IPMN), who are surgically intolerant and require less invasive treatment options, which are limited. In the present study, we report a case of IPMN presenting with acute recurrent pancreatitis (ARP), in which radiation therapy effectively prevented further attacks of ARP and reduced tumor volume.

CASE SUMMARY

An 83-year-old man was referred to our hospital with an asymptomatic incidental pancreatic cyst. Endoscopic ultrasound imaging and magnetic resonance cholangiopancreatography revealed a multiloculated tumor in the head of the pancreas, with dilated pancreatic ducts and mural nodules. The patient was diagnosed with mixed-type IPMN, and five years later, he developed ARP. Several endoscopic pancreatic ductal balloon dilatations failed to prevent further ARP attacks. Surgery was considered clinically inappropriate because of his old age and comorbidities. He was referred to our department for radiation therapy targeted at those lesions causing intraductal hypertension and radiation was administered at a dose of 50 Gy. An magnetic resonance imaging scan taken ten weeks after treatment revealed a decrease in tumor size and improvement of pancreatic duct dilatation. Fourteen months later, he remains symptom-free from ARP.

CONCLUSION

This case highlights the important role of radiation therapy in mitigating the signs and symptoms of ARP in patients with inoperable IPMN.

Digestive outcomes in Cystic fibrosis

Cystic fibrosis (CF) is the most frequent life-limiting autosomal recessive disease in Caucasians, affecting the respiratory tract, but also the pancreas, gut, and hepatobiliary tract. CF is caused by variants in the Cystic Fibrosis Transmembrane conductance Regulator (CFTR) gene. Prognosis of CF has markedly improved over the last 20 years because of the management in CF centers and recent introduction of CFTR modulators, aimed at correcting the defective CFTR protein. There are nowadays more CF adults than children, with a predicted median survival age of around 50 years in high-income countries. Around 85% of CF patients have pancreatic insufficiency present at birth. Gastroesophageal reflux disease (GERD) is more frequent in CF patients, but its role on decline in lung health is controversial. Distal small bowel obstruction syndrome (DIOS) caused by meconium-like stool plugs occurs at any age after the neonatal period, affecting up to 15-20% of CF patients. Because of increased life expectancy, most CF patients are expected to live to their fifties or beyond, when cancer is more frequent. In addition, CF is associated with a higher risk for GI malignancy as compared with the general population. Colorectal cancer represents the most significant risk, and colonoscopy-based screening is recommended from 40 years of age onwards. Other digestive outcomes in CF reviewed in this paper include meconium ileus, Clostridium difficile infection, intussusception, acute appendicitis, small intestinal bacterial overgrowth, appendiceal mucocele and rectal prolapse. Every CF Center should comprise a gastroenterologist with expertise in the care of CF patients.

Hereditary pancreatitis: An updated review in pediatrics

Hereditary Pancreatitis (HP) has emerged as a significant cause of acute, acute recurrent and chronic pancreatitis in the pediatric population. Given that it presents similarly to other causes of pancreatitis, a positive family history and/or isolation of a gene mutation are vital in its designation. Inheritance patterns remain complex, but mutations involving the PRSS1, SPINK1, CFTR and CTRC genes are commonly implicated. Since being first described in 1952, dozens of genetic alterations that modify the action of pancreatic enzymes have been identified. Among children, these variants have been isolated in more than 50% of patients with chronic pancreatitis. Recent research has noted that such mutations in PRSS1, SPINK1 and CFTR genes are also associated with a faster progression from acute pancreatitis to chronic pancreatitis. Patients with HP are at increased risk of developing diabetes mellitus, exocrine pancreatic insufficiency, and pancreatic adenocarcinoma. Management follows a multi-disciplinary approach with avoidance of triggers, surveillance of associated conditions, treatment of pancreatic insufficiency and use of endoscopic and surgical interventions for complications. With significant sequela, morbidity and a progressive nature, a thorough understanding of the etiology, pathophysiologic mechanisms, diagnostic evaluation, current management strategies and future research considerations for this evolving disease entity in pediatrics is warranted.

Clinical characteristics of acute pancreatitis in children: a single-center experience in Western China

Background

The diagnosis of pediatric pancreatitis has been increasing over the last 20 years. We aimed to compare the clinical characteristics for pediatric acute pancreatitis (AP) with adult AP, and investigate the risk factor for acute recurrent pancreatitis (ARP) in children.

Method

From June 2013 to June 2019, a total of 130 pediatric patients with AP at the inpatient database were enrolled. Univariate analysis and multivariate Cox regression analysis were performed to identify the risk factors for ARP in children.

Result

Major etiologic factors in 130 patients were biliary (31.5%), idiopathic (28.5%). The etiology of pancreatitis in children was markedly different from that in adults (p < 0.001). Compared with the adult patients, the pediatric patients had significantly lower severity (p = 0.018) and occurrence rate of pancreatic necrosis (p = 0.041), SIRS (p = 0.021), acute peripancreatic fluid collection (p = 0.014). Univariate and Multivariate Cox regression analysis showed that female (p = 0.020; OR 3.821; 95% CI 1.231–11.861), hypertriglyceridemia (p = 0.045; OR 3.111; 95% CI 1.024–9.447), pancreatic necrosis (p = 0.023; OR 5.768; 95% CI 1.278–26.034) were the independent risk factors of ARP. Hypertriglyceridemia AP had the highest risk of recurrence compared to other etiology (p = 0.035).

Conclusion

Biliary and idiopathic disease were the major etiologies of AP in children. Children have simpler conditions than adults. Female, hypertriglyceridemia, and pancreatic necrosis were associated with the onset of ARP.

Effect of acetyl-L-carnitine on hypersensitivity in acute recurrent caerulein-induced pancreatitis and microglial activation along the brain’s pain circuitry

BACKGROUND

Acute pancreatitis (AP) and recurring AP are serious health care problems causing excruciating pain and potentially lethal outcomes due to sepsis. The validated caerulein- (CAE) induced mouse model of acute/recurring AP produces secondary persistent hypersensitivity and anxiety-like behavioral changes for study.

AIM

To determine efficacy of acetyl-L-carnitine (ALC) to reduce pain-related behaviors and brain microglial activation along the pain circuitry in CAE-pancreatitis.

METHODS

Pancreatitis was induced with 6 hly intraperitoneal (i.p.) injections of CAE (50 µg/kg), 3 d a week for 6 wk in male C57BL/6J mice. Starting in week 4, mice received either vehicle or ALC until experiment’s end. Mechanical hyper-sensitivity was assessed with von Frey filaments. Heat hypersensitivity was determined with the hotplate test. Anxiety-like behavior was tested in week 6 using elevated plus maze and open field tests. Microglial activation in brain was quantified histologically by immunostaining for ionized calcium-binding adaptor molecule 1 (Iba1).

RESULTS

Mice with CAE-induced pancreatitis had significantly reduced mechanical withdrawal thresholds and heat response latencies, indicating ongoing pain. Treatment with ALC attenuated inflammation-induced hypersensitivity, but hypersensitivity due to abdominal wall injury caused by repeated intraperitoneal injections persisted. Animals with pancreatitis displayed spontaneous anxiety-like behavior in the elevated plus maze compared to controls. Treatment with ALC resulted in increased numbers of rearing activity events, but time spent in “safety” was not changed. After all the abdominal injections, pancreata were translucent if excised at experiment’s end and opaque if excised on the subsequent day, indicative of spontaneous healing. Post mortem histopathological analysis performed on pancreas sections stained with Sirius Red and Fast Green identified wide-spread fibrosis and acinar cell atrophy in sections from mice with CAE-induced pancreatitis that was not rescued by treatment with ALC. Microglial Iba1 immunostaining was significantly increased in hippocampus, thalamus (intralaminar nuclei), hypothalamus, and amygdala of mice with CAE-induced pancreatitis compared to naïve controls but unchanged in the primary somatosensory cortex compared to naïves.

CONCLUSION

CAE-induced pancreatitis caused increased pain-related behaviors, pancreatic fibrosis, and brain microglial changes. ALC alleviated CAE-induced mechanical and heat hypersensitivity but not abdominal wall injury-induced hypersensitivity caused by the repeated injections.

Etiology of Acute Recurrent Pancreatitis in Vietnamese Children: an Initial Report

Objectives:

The aim of this study was to describe the epidemiological characteristics of acute recurrent pancreatitis (ARP) among children who were admitted at Children’s Hospital 2, Ho Chi Minh City, Vietnam, from May 2014 to May 2019.

Methods:

Authors presented Case series study.

Results:

A total of 33 cases met the criteria for study inclusion. The mean age of first onset 7.3 ± 4.4 years (range, 1.4–15 years), the male to female ratio was 18:15 (1.2:1). The median number of ARP admissions per patient was 3 (range, 2–14), and the median time between ARP-related hospitalization was 168 days (range, 82–240 days). The chief complaint upon hospitalization was abdominal pain, accounting for 96.9% of cases, vomiting in 87.9% of cases, and severe ARP was observed in 24% of cases. All patients underwent magnetic resonance cholangiopancreatography (MRCP), and abdominal computed tomography (CT) scans. Genetic testing was performed in 14 of 33 cases, and 5 cases had at least 1 mutation, whereas 9 were negative. The most common etiology of ARP was biliary tract disease, in 17 cases (51.5%; 11 choledochal cysts, 6 gallstones), abnormalities of the pancreas were observed in 18.2% (abnormalities of pancreatic structures in 3 cases), hypertriglyceridemia and metabolic disease were observed in 6.1% of cases, and genetic mutations were identified in 15.2% of cases.

Conclusion:

ARP is not a rare disease, and ARP patients may be admitted to the hospital many times. The chief complaints resulting in hospitalization were abdominal pain and vomiting. The most common causes were biliary tract diseases (bile duct cysts in 33.3% and gallstones in 18.2% of cases), with abnormalities of the pancreatic structure identified in 9.1% of cases, and genetic mutations detected in 15.2% of patients.

Web-based cognitive-behavioral intervention for pain in pediatric acute recurrent and chronic pancreatitis: Protocol of a multicenter randomized controlled trial from the study of chronic pancreatitis, diabetes and pancreatic cancer (CPDPC)

INTRODUCTION

Abdominal pain is common and is associated with high disease burden and health care costs in pediatric acute recurrent and chronic pancreatitis (ARP/CP). Despite the strong central component of pain in ARP/CP and the efficacy of psychological therapies for other centralized pain syndromes, no studies have evaluated psychological pain interventions in children with ARP/CP. The current trial seeks to 1) evaluate the efficacy of a psychological pain intervention for pediatric ARP/CP, and 2) examine baseline patient-specific genetic, clinical, and psychosocial characteristics that may predict or moderate treatment response.

METHODS

This single-blinded randomized placebo-controlled multicenter trial aims to enroll 260 youth (ages 10-18) with ARP/CP and their parents from twenty-one INSPPIRE (INternational Study Group of Pediatric Pancreatitis: In search for a cuRE) centers. Participants will be randomly assigned to either a web-based cognitive behavioral pain management intervention (Web-based Management of Adolescent Pain Chronic Pancreatitis; WebMAP; N = 130) or to a web-based pain education program (WebED; N = 130). Assessments will be completed at baseline (T1), immediately after completion of the intervention (T2) and at 6 months post-intervention (T3). The primary study outcome is abdominal pain severity. Secondary outcomes include pain-related disability, pain interference, health-related quality of life, emotional distress, impact of pain, opioid use, and healthcare utilization.

CONCLUSIONS

This is the first clinical trial to evaluate the efficacy of a psychological pain intervention for children with CP for reduction of abdominal pain and improvement of health-related quality of life. Findings will inform delivery of web-based pain management and potentially identify patient-specific biological and psychosocial factors associated with favorable response to therapy. Clinical Trial Registration #: NCT03707431.

Long-term outcomes of therapeutic ERCP in pediatric patients with pancreas divisum presenting with acute recurrent or chronic pancreatitis

OBJECTIVES

The aim of this study was to evaluate the long-term outcomes of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for pediatric patients with pancreas divisum (PD) presenting with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP).

METHODS

Between May 2008 and August 2017, pediatric patients with PD who received endotherapy at Ruijin Hospital were identified and grouped according to clinical presentation, namely ARP and CP. Primary success was defined as patients' improvement in symptoms after index ERCPs, without further intervention or any analgesic.

RESULTS

A total of 74 ERCPs were performed in 38 pediatric patients. The frequency of at least 1 genetic mutation identified in patients with ARP and CP was 44.4% and 68.4%, respectively. Patients with CP required more ERCPs than those with ARP (2.4 ± 1.7 vs. 1.1 ± 0.4, P = 0.005). The incidence of post-ERCP complications was 14.9%, including pancreatitis of 13.5% and hemorrhage of 1.4%. During a median follow-up duration of 41 months (range, 12-123 months), the frequency of pancreatitis episodes decreased significantly from 2.31 to 0.45 (P < 0.0001). The 25% recurrence and reintervention rates were estimated at 25 and 48 months, respectively, without significant difference between patients with ARP or CP. There was a nonsignificant trend towards a higher rate of primary success in patients with ARP than those with CP (92.9% vs. 69.6%, P = 0.123). After further endotherapy, 91.3% patients with CP improved clinically.

CONCLUSIONS

Therapeutic ERCP is an effective and safe intervention for pediatric patients with symptomatic PD. Patients presenting with CP seem to achieve improvement after additional ERCPs.

Chronic Pancreatitis: Current Status and Challenges for Prevention and Treatment

This paper reviews the current status of our understanding of the epidemiology, diagnosis, and management of the continuum of pancreatic diseases from acute and recurrent acute pancreatitis to chronic pancreatitis and the diseases that are often linked with pancreatitis including diabetes mellitus and pancreatic cancer. In addition to reviewing the current state of the field, we identify gaps in knowledge that are necessary to address to improve patient outcomes in these conditions.

Pancreatic Disorders

Once considered uncommon, pancreatic diseases are increasingly recognized in the pediatric age group. Acute pancreatitis, acute recurrent pancreatitis, and chronic pancreatitis occur in children with an incidence approaching that of adults. Risk factors are broad, prompting the need for a completely different diagnostic and therapeutic approach in children. Although cystic fibrosis remains the most common cause of exocrine pancreatic insufficiency, other causes such as chronic pancreatitis may be as common as Shwachman Diamond syndrome. Long-term effects of pancreatic diseases may be staggering, as children suffer from significant disease burden, high economic cost, nutritional deficiencies, pancreatogenic diabetes, and potentially pancreatic cancer.

Acute recurrent pancreatitis and hyperlipidemia: Reciprocal causal relationship and clinical features

AIM

To investigate the influence of serum levels of lipids on the occurrence, development and prognosis of acute recurrent pancreatitis (ARP) to discuss the reciprocal causal relationship between ARP and hyperlipidemia (HL) and their clinical features.

METHODS

Clinical data and follow-up information for 121 patients with ARP who were treated at the First Hospital of China Medical University from January 2013 to December 2015 were retrospectively analyzed. All these patients were divided into a hyperlipidemia group (HL group) and a non-hyperlipidemia group (non-HL group) according to the serum lipid levels within 24 h after admission. General data, severity, recrudescence, complications, operation rate, and mortality were compared between the two groups.

RESULTS

The average age was significantly lower in the HL group than in the non-HL group (38.5 ± 8.9 vs 49.8 ± 13.2, P < 0.01). The operation rate was significantly lower (11.3% vs 21.9%, P < 0.05) and the proportion of male patients was significantly higher (41/53 vs 40/68, P < 0.05) in the HL group. BMI (28.2 ± 6.0 vs 22.5 ± 5.2, P < 0.01), serum levels of glucose (9.65 ± 6.00 vs 6.88 ± 3.26, P < 0.01) and lipids (13.94 ± 8.91 vs 3.22 ± 1.47, P < 0.01) were significantly higher in the HL group than in the non-HL group, while serum amylase was significantly lower in the HL group (332.02 ± 246.71 vs 490.79 ± 417.11, P < 0.05). The HL group was more frequently complicated with diabetes (34.0% vs 13.2%, P < 0.01) and fatty liver (22.6% vs 7.4%, P < 0.05). For the causes of ARP, elevated serum lipid levels in the observation group were mainly caused by primary HL itself (62.3%, P < 0.01), and HL appeared as a concomitant symptom in other ARP patients induced by other factors. In the non-HL group, ARP was predominantly caused by gallstones (66.1%, P < 0.01). There was no statistical difference about alcoholic pathogenesis, severity or prognosis of disease between the two groups.

CONCLUSION

There is a reciprocal causal relationship between HL and ARP. High serum lipid levels in the observation group are mainly related to the primary HL itself. The ARP patients with concomitant HL tend to be younger, be male, have lower surgical intervention rate, and be easily complicated with diabetes or fatty liver.

Acute recurrent pancreatitis: Etiopathogenesis, diagnosis and treatment

Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term “idiopathic” is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches.

Endoscopic therapy for acute recurrent pancreatitis

Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.

Duodenal duplication cyst and pancreas divisum causing acute pancreatitis in an adult male

Duodenal duplication cysts are rare congenital abnormalities which are more commonly diagnosed in infancy and childhood. However, in rare cases, these lesions can remain asymptomatic until adulthood. The combination of duplication cyst and pancreas divisum is extremely rare and both conditions have been linked with acute recurrent pancreatitis. We present the case of a 37 years-old patient who presented with repeated episodes of acute pancreatitis. By means of magnetic resonance imaging and endoscopic ultrasonography we discovered a duplication cyst whose cavity received drainage from the dorsal pancreas. After opening the cyst cavity to the duodenal lumen with a needle knife the patient presented no further episodes in the clinical follow-up. Comparable literature findings and therapeutic options for these abnormalities are discussed with regard to the presented case.

Endoscopic ultrasonography for evaluating patients with recurrent pancreatitis

Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP: microlithiasis, sphincter of Oddi dysfunction (SOD), pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound (EUS) appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with ARP.

Diagnostic approach to patients with acute idiopathic and recurrent pancreatitis, what should be done?

Acute recurrent pancreatitis (ARP) is a common clinical condition that may be difficult to diagnose. Endoscopic ultrasound (EUS) is proposed to be a safe first line test of choice in the majority of patients. When interventions are needed to remove biliary stones, evaluate sphincter of Oddi or pancreas divisum, endoscopic retrograde cholangiopancreatography (ERCP) is recommended. Magnetic resonance cholangiopancreatography (MRCP) can be a suitable alternative from a diagnostic standpoint although may not be widely available. Finally, genetic testing is increasingly used to detect certain mutations that are associated with this diagnosis.

Role of genetic disorders in acute recurrent pancreatitis

There was remarkable progress in the understanding of the role genetic risk factors in chronic pancreatitis. These factors seem to be much more important than thought in the past. The rare autosomal-dominant mutations N29I and R122H of PRSS1 (cationic trypsinogen) as well as the variant N34S of SPINK1 (pancreatic secretory trypsin inhibitor) are associated to a disease onset in childhood or youth. Compared to chronic alcoholic pancreatitis the progression is slow so that for a long time only signs of acute-recurrent pancreatitis are found. Only at later time points (more than 10-15 years) there is evidence for chronic pancreatitis in the majority of patients. Acute recurrent pancreatitis may therefore be regarded as a transition state until definite signs of chronic pancreatitis are detectable.

Is acute recurrent pancreatitis a chronic disease?

Whether acute recurrent pancreatitis is a chronic disease is still debated and a consensus is not still reached as demonstrated by differences in the classification of acute recurrent pancreatitis. There is major evidence for considering alcoholic pancreatitis as a chronic disease ab initio while chronic pancreatitis lesions detectable in biliary acute recurrent pancreatitis (ARP) seem a casual association. Cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation, hereditary and obstructive pancreatitis seem an acute disease that progress to chronic pancreatitis, likely as a consequence of the activation and proliferation of pancreatic stellate cells that produce and activate collagen and therefore fibrosis. From the diagnostic point of view, in patients with acute recurrent pancreatitis Endoscopic ultrasound (EUS) seems the more reliable technique for an accurate evaluation and follow-up of some ductal and parenchymal abnormalities suspected for early chronic pancreatitis.

Ampullary adenomyoma presenting as acute recurrent pancreatitis

Adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. Despite its benign nature, ampullary adenomyoma is usually presented as biliary obstruction. Most cases are misdiagnosed as carcinoma or adenoma by preoperative endoscopic or radiologic procedure. Therefore, it is frequently treated with extensive surgery. To our knowledge, this is the first reported case in English literature of adenomyoma located in the peripancreatic orifice resulting in intermittent pancreatic duct obstruction and recurrent pancreatitis diagnosed by the endoscopic piecemeal resection.