Macroamylasemia as a Rare Cause of Hyperamylasemia: A Case Report

Macroamylasemia is a rare condition characterized by the formation of an amylase-globulin complex that is too large to be readily excreted by the kidneys and leads to elevated serum amylase levels. It is a benign condition lacking severe signs and symptoms that does not require treatment. This paper presents a case of a middle-aged man with unexplained elevated serum amylase levels. Despite an initially elevated triglyceride level, clinical findings, laboratory test results, and radiological findings were not suggestive of pancreatitis. The ratio of renal amylase clearance to creatinine clearance was calculated at <1%, consistent with macroamylasemia. No specific treatment was given, and he was monitored periodically. Nevertheless, macroamylasemia is a diagnostic challenge because of the need to differentiate it from other causes of hyperamylasemia to avoid unnecessary tests and treatments.

Investigation of factors affecting COVID-19 pancreatic injury: a single-center, retrospective study

Pancreatic injury is considered an organ-related complication in patients with coronavirus disease 2019 (COVID-19). However, it is unclear whether COVID-19 status affects pancreatic injury. This retrospective study aimed to determine whether COVID-19 affects the occurrence of pancreatic injuries. Consecutive patients diagnosed with sepsis admitted to the ICU between March 2020 and September 2021 were included. The primary endpoint was a pancreatic injury, which was defined as amylase or lipase levels > 3 times the upper limit of the normal range. Among the 177 patients included in the analysis, 40 (23%) were COVID-19 patients, and 54 (31%) had pancreatic injuries. Of these three patients, acute pancreatitis was diagnosed based on computed tomography. The pancreatic injury was significantly more common among COVID-19 patients (75 vs. 18%, p < 0.001). Multivariate analysis showed that COVID-19 and steroid use were independent risk factors for pancreatic injury (Odds Ratio (OR) 4.79 [95% confidence interval (CI) 1.48-15.5], p = 0.009; OR 4.02 [95% CI 1.42-11.4], p = 0.009). This study revealed that the proportion of pancreatic injury in septic patients with COVID-19 was significantly higher than in those without COVID-19. It may be difficult to diagnose pancreatitis based on amylase and lipase levels in COVID-19 patients.

High-dose intravenous glucocorticoid induces hyperamylasemia: a case series

BACKGROUND

Glucocorticoids have many side effects, and high-dose intravenous application may cause rare adverse reactions such as hyperamylasemia. The aim of this study is to explore the clinical characteristics, treatment, and prognosis of hyperamylasemia induced by high-dose intravenous glucocorticoids.

CASE PRESENTATION

Four Asian female patients, aged between 26 and 71 years, were diagnosed with hyperamylasemia after intravenous administration of high-dose glucocorticoid. Amylase levels were elevated to varying degrees in all patients, but the peaks were below three times the upper limit of normal, and imaging showed no significant pancreatic abnormalities. Two patients developed abdominal pain, which was resolved by inhibition of pancreatic secretion, while the other patients were asymptomatic. Two patients were discharged after a significant decrease in amylase levels, while the other two were discharged after improvement of the primary disease.

CONCLUSION

High-dose intravenous glucocorticoid can cause hyperamylasemia, which should be given enough attention by clinicians. Etiological differentiation of hyperamylasemia should be emphasized in clinical practice, especially when the diagnosis of acute pancreatitis is not clear.

Prophylactic effect of rectal indomethacin plus nitroglycerin administration for preventing pancreatitis after endoscopic retrograde cholangiopancreatography in female patients

BACKGROUND

Prophylactic pancreatic stent placement (PSP) and rectal indomethacin suppository are recommended to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk cases. Clinical trials on the use of nitroglycerin to reduce PEP have reached no definitive conclusion. Our study aimed to determine whether treatment with rectal indomethacin plus nitroglycerin could eliminate the need for PSP in patients.

METHODS

In this randomized clinical trial, patients were allocated into groups using a random number table, with each patient receiving a pre-made envelope containing their intervention prior to ERCP. The three treatment groups were: the placebo group, the indomethacin + nitroglycerin group, and the PSP group. The subjects were assessed for PEP and its severity by a panel of independent and blinded adjudicators.

RESULTS

A total of 526 patients were eligible for inclusion. The placebo group included 176 patients, the indomethacin + nitroglycerin group included 176 patients and the PSP group included 174.A diagnosis of PEP was made in 64 (12.2%) cases. The rate of PEP in the three study groups placebo group, indomethacin + nitroglycerin group and the PSP group was 19.3%, 5.1%, and 12.1%, respectively.

CONCLUSIONS

The risk of post-ERCP pancreatitis in the indomethacin + nitroglycerin group was 7% lower than that in the PSP. Indomethacin + nitroglycerin is superior to PSP in preventing and relieving the severity of post-ERCP pancreatitis in patients with difficult intubation. Indomethacin plus nitroglycerin can avoid the need for PSP in the prevention of post-ERCP pancreatitis.

TRIAL REGISTRATION

Current Controlled Trials ChiCTR2000033944.

[Analysis of prognostic factors for hyperamylasemia following pancreaticoduodenectomy]

Objective: To investigate the prognostic factors of hyperamylasemia following pancreaticoduodenectomy (PD) . Methods: Clinical data of 359 patients were collected prospectively who underwent PD by the same group at Changhai Hospital of Navy Medical University from January 2017 to June 2018.There were 212 males and 147 females.The median age was 63 years old (range: 23 to 82 years old) .According to whether the patient's serum amylase was greater than 120 U/L at 0 or 1 day after surgery,the patients were divided into hyperamylasemia group and non-hyperamylasemia group. Univariate analysis and multivariate analysis were used to find out the prognostic factors of hyperamylasemia after PD. Results: Of the 359 patients, 238 cases (66.3%) developed hyperamylasemia.The incidence rate of clinically related pancreatic fistula (15.1% vs.2.5%, P<0.01) , grade B/C post pancreatectomy hemorrhage (8.8% vs. 2.5%, P<0.01) , and surgical site infection (9.2% vs. 3.3%, P=0.04) was significantly higher in the hyperamylasemia group.The severity of complications (CD grade≥Ⅲ: 11.3% vs.4.1%, P=0.023) and postoperative hospital stay (11 days vs. 9 days, P=0.001) were higher in the hyperamylasemia group.In the multivariate analysis, the main pancreatic duct diameter (MPD) ≤3 mm (OR=4.469, 95% CI: 2.563-7.793, P<0.01) , pathological type of disease (pancreatic cancer or pancreatitis) (OR=0.230, 95% CI: 0.122-0.436, P<0.01) and soft texture of pancreas (OR=3.297, 95%CI: 1.930-5.635, P<0.01) were independent prognostic factors for hyperamylasemia. Conclusions: Post-PD hyperamylasemia increased the incidence and severity of postoperative complications after PD.MPD≤3 mm, soft texture of pancreas and pathological type of disease were independent prognostic factors of hyperamylasemia.

Effect of Aggressive Fluid Therapy on Outcomes after Endoscopic Retrograde Cholangiopancreatography: A Randomized Controlled Clinical Trial

BACKGROUND Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP), which may lead to death. The purpose of this study was to evaluate the preventive effect of aggressive fluid therapy on the incidence of post-ERCP pancreatitis. METHODS In double-blind controlled condition, 240 patients were selected and divided into two groups. The treatment of the intervention group (n = 120) included a dose of 20 mL/kg of ringer lactate infusion within 90 minutes before ERCP and 3 mL/kg/h during ERCP followed by 3 mL/kg/h up to 8 hours. The treatment of the control group (n = 120) included a dose of 1.5 mL/kg of ringer lactate infusion during ERCP up to 8 hours later. Firstly, the patients were evaluated in terms of excessive fluid and serum amylase and pain level, and then they were re-evaluated 2, 8, and 24 hours after ERCP. RESULTS The mean age of the patients was 51.57 ± 13.5 years. Most of the patients were female (54.5%). Pancreatitis was developed in 26 patients including 5.83% of the patients in the intervention group and 15.83% of the patients in the control group (p = 0.013). Pancreatic pain was seen in 7.5% of the patients in the intervention group and in 27.5% of the control group (p < 0.005). Hyperamylasemia was seen in 20.83% of the patients in the intervention group and in 35% of the control group (p = 0.014). The mean days of hospital admission was 1.308 ± 0.807 in the intervention group and 1.425 ± 0.876 in the control group (p = 0.275). CONCLUSION Aggressive fluid therapy with ringer lactate solution before ERCP can effectively prevent postERCP pancreatitis, pancreatic pain, and hyperamylasemia.

Chronic Asymptomatic Pancreatic Hyperenzymemia (CAPH): Meta-analysis of pancreatic findings at second-level imaging

BACKGROUND/OBJECTIVES

Data estimating the prevalence of significant findings during the investigation of patients with Chronic Asymptomatic Pancreatic Hyperenzymemia (CAPH) are scanty and heterogeneous, and the diagnostic approach is therefore uncertain. The aim of this study was to meta-analyze pancreatic abnormalities detected at second-level imaging in patients with CAPH.

METHODS

Pubmed database was searched until September 2018 for articles evaluating CAPH patients through MRI-Cholangio-Pancreatography with/without secretin (MRCP or s-MRCP) or Endoscopic Ultrasound (EUS). The methodology was developed from PRISMA checklist. Pooled prevalences of pancreatic findings were calculated, with subgroup analyses according to imaging modality. Quality of the studies, publication bias and heterogeneity were analyzed.

RESULTS

In 8 articles describing 521 patients with CAPH, pooled prevalence of normal imaging was 56.6% [95%CI (CI) 41.9-70.2; I² = 88.6%). Prevalences of neoplasia, chronic pancreatitis, pancreatic cysts and benign abnormalities were 2.2% [CI1.2-4.1; I² = 0%], 16.2% [CI10.2-24.8; I² = 71.5%], 12.8% [CI8.2-19.3; I² = 64.7%] and 17.2% [CI11.9-24.2; I² = 71.5%] respectively. In sub-analyses, EUS and s-CPRM were less frequently normal and diagnosed more "early" chronic pancreatitis, while neoplastic lesions were still rare.

CONCLUSIONS

In CAPH patients, second-level pancreatic imaging is normal in 56% of the cases, neoplastic lesions are rare and the rate of pancreatic cysts is similar to that seen as incidental findings. More than one third of patients are diagnosed with abnormalities whose prognostic significance is uncertain. Despite the superior sensitivity of EUS or s-CPRM, the less costly/invasive and more available contrast-enhanced MRCP does not seem to miss relevant findings in this setting.

Effect of somatostatin on prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis and hyperamylasemia: A systematic review and meta-analysis

OBJECTIVE

To perform a meta-analysis of all available studies on the effect of prophylactic somatostatin administration on prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and post-ERCP hyperamylasemia (PEHA).

METHODS

Electronic databases, including PubMed, EMBASE, the Cochrane library, and the Science Citation Index were searched to retrieve relevant trials. Randomized, placebo-controlled trials in adult patients that compared somatostatin versus placebo in prevention of PEP were included. Meta-analysis was performed using a random-effects model to assess the ratios of PEP, PEHA and post-ERCP abdominal pain.

RESULTS

Total ratio of PEP of somatostatin group was significantly lower than that of placebo group. For the short-term injection or bolus injection there were no heterogeneity and no significance between the ratio of PEP of somatostatin group and placebo group. For the long-term injection subgroup there was heterogeneity, and the ratio of PEP of somatostatin group was significantly lower than that of placebo group. There was no significance between the ratio of PEP of somatostatin group and placebo group for the low-risk PEP subgroup, while the ratio of PEP of somatostatin group was significantly lower than that of placebo group for the high-risk PEP subgroup. The ratio of PEP of somatostatin group was significantly lower than that of placebo group for the long-term injection high-risk PEP subgroup. There was no significance between the ratio of PEHA of somatostatin group and placebo group for the short-term injection subgroup or bolus injection subgroup. The ratio of PEHA of somatostatin group was significantly lower than that of placebo group for the long-term injection subgroup. The total ratio of post-ERCP abdominal pain of somatostatin group was significantly lower than that of placebo group. The funnel plot of incidence of PEP and PEHA showed no asymmetry with a negative slope.

CONCLUSION

Prophylactic use of long-term injection of somatostatin can significantly reduce the incidence of PEP, PEHA and post-ERCP abdominal pain for the high-risk PEP patients, while it is not necessary to be used for the low-risk PEP patients.

Value of Raw Rhubarb Solution in the Precaution of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis in Patients with High-Risk Factors: A Predictive Random Compared Research in One Center

BACKGROUND AND AIMS

Post-ERCP pancreatitis and hyperamylasemia are common complications of endoscopic retrograde cholangiopancreatography (ERCP), especially in high-risk patients. The aim of this study is to evaluate whether a raw rhubarb solution can reduce the incidence of PEP and post-ERCP hyperamylasemia.

METHODS

From October 2012 to October 2013, 2100 patients received ERCP in our Endoscopic Center. Five hundred patients with high-risk factors were enrolled randomly into the raw rhubarb group (RG, 250 cases drank a raw rhubarb soak solution per 3 h until defecation after ERCP) and the control group (CG, 250 cases drank water after ERCP) in the study. The serum amylase concentration was measured. The abdominal pain, purge time and symptoms of patients were observed in the two groups.

RESULTS

There were no differences in patient demographics, medical history, ERCP procedure, and patient- and procedure-related high-risk factors between the two groups. PEP incidence was 2% (5/250) in the RG group, which was lower than that in the CG group (7.6%, 19/250) (P < 0.01). The rate of post-ERCP hyperamylasemia was 5.2% (13/250) and 16.8% (42/250) in the RG group and CG group, respectively. The incidence of hyperamylasemia in the RG group was significantly lower than that in the CG group (P < 0.01). The incidence of abdominal pain 24 h after ERCP in the RG group was lower than that in the CG group (P < 0.01). No side effects were observed for raw rhubarb solution.

CONCLUSIONS

A raw rhubarb solution is safe and effective in preventing the incidence of PEP and hyperamylasemia in high-risk patients.

Risk Factors of Acute Pancreatitis in Oral Double Balloon Enteroscopy

Double balloon enteroscopy (DBE) was introduced 15 years ago. The complications of diagnostic DBE are rare, acute pancreatitis is most redoubtable one (incidence about 0.3%). Hyperamylasemia after DBE seems to be a rather common condition respectively. The most probable cause seems to be a mechanical straining of the pancreas. We tried to identify patients in a higher risk of acute pancreatitis after DBE. We investigated several laboratory markers before and after DBE (serum cathepsin B, lactoferrin, E-selectin, SPINK 1, procalcitonin, S100 proteins, alfa-1-antitrypsin, hs-CRP, malondialdehyde, serum and urine amylase and serum lipase). Serum amylase and lipase rose significantly with the maximum 4 hours after DBE. Serum cathepsin and procalcitonin decreased significantly 4 hours after DBE compared to healthy controls and patients values before DBE. Either serum amylase or lipase 4 hours after DBE did not correlate with any markers before DBE. There was a trend for an association between the number of push-and-pull cycles and procalcitonin and urine amylase 4 hours after DBE; between procalcitonin and alfa-1-antitrypsin, cathepsin and hs-CRP; and between E-selectin and malondialdehyde 4 hours after DBE. We found no laboratory markers determinative in advance those patients in a higher risk of acute pancreatitis after DBE.

Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis by pancreatic duct stenting using a loop-tipped guidewire

AIM: To examine whether it is possible to prevent the occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients experiencing difficulties with selective biliary duct cannulation by pancreatic duct stenting using a loop-tipped guidewire.

METHODS: Procedure success rate, frequency of unintended insertion of the guidewire into side branches of the pancreatic duct, and incidence of procedural accidents were examined using a loop-tipped guidewire (Group A, 20 patients), and a conventional straight-type guidewire (Group B, 20 patients).

RESULTS: The success rate of the procedure was 100% in both groups. Unintended insertion of the guidewire into a side branch of the pancreatic duct occurred 0.056 ± 0.23 (0-1) times in Group A and 2.3 ± 1.84 (0-5) times in Group B; thus, unintended insertion of the guidewire into a side branch of the pancreatic duct was seen significantly less frequently in Group A. There were no procedural accidents in Group A, whereas pancreatitis occurred in one Group B patient; however, the difference between the two groups was not statistically significant. The serum amylase level after ERCP was 257.15 ± 136.4 (88-628) IU/L in Group A, and 552.05 ± 534.57 (101-2389) IU/L in Group B, showing a significantly lower value in Group A. Hyperamylasemia was found in two patients (10%) in Group A, and nine (45%) in Group B, showing a significantly lower value in Group A.

CONCLUSION: The results suggest that in patients who experience difficulties with biliary cannulation, the use of a loop-tipped guidewire for pancreatic duct stenting may assist with the prevention of post-ERCP pancreatitis, and thereby to a reduction of the risk of post-ERCP pancreatitis or hyperamylasemia.

Common adverse events associated with ribavirin therapy for Severe Fever with Thrombocytopenia Syndrome

Severe Fever with Thrombocytopenia Syndrome (SFTS) is associated with high mortality rate, for which antiviral therapy with ribavirin was recommended. Based on our previous study, no visible effect of ribavirin therapy in improving clinical outcome was observed. Here we have accumulated the sample size to 634, and by performing prospective observation on the clinical progress and laboratory parameters, we found a significantly higher incidence of anemia and hyperamylasemia in patients who received ribavirin therapy in comparison with those who received no therapy. Generalized estimating equation model disclosed a significant effect on hemoglobin reduction and blood amylase augmentation from ribavirin administration. The occurrence of anemia and hyperamylasemia was associated with SFTS patients receiving ribavirin therapy, which might be adverse event of this drug administration. The recommendation of ribavirin for treating SFTS should be applied with caution.

Nasobiliary drainage after endoscopic papillary balloon dilatation may prevent postoperative pancreatitis

AIM: To evaluate the necessity of endoscopic nasobiliary drainage (ENBD) catheter placement after clearance of common bile duct (CBD) stones.

METHODS: Patients enrolled in this study were randomly divided into two groups, according to whether or not they received ENBD after the removal of CBD stones. Group 1 (ENBD group) was then subdivided into three groups: G1a patients received an endoscopic papillary balloon dilatation (EPBD), G1b patients received an endoscopic sphincterotomy (EST), and G1c patients received neither. Group 2 (non-ENBD group) patients were also subdivided into three groups (G2a, G2b, and G2c), similar to Group 1. The maximum CBD diameter, the time for C-reactive protein (CRP) to normalize, levels of serum amylase, total serum bilirubin (TB) and alanine aminotransferase (ALT), and postoperative hospitalization duration (PHD) were measured.

RESULTS: A total of 218 patients (139 males, 79 females), with an average age of 60.1 ± 10.8 years, were enrolled in this study. One hundred and thirteen patients who received ENBD were included in Group 1, and 105 patients who did not receive ENBD were included in Group 2. The baseline clinical characteristics were similar in both groups. There were no significant differences in post-endoscopic retrograde cholangiopancreatography (ERCP)-related complications when Groups 1 and 2 were compared. Seventy-seven patients underwent EPBD, and 41 received an ENBD tube (G1a) and 36 did not (G2a). Seventy-three patients underwent EST, and 34 patients received an ENBD tube (G1b) and 39 did not (G2b). The remaining 68 patients underwent neither EPBD nor EST; of these patients, 38 received an ENBD tube (G1c) and 30 did not (G2c). For each of the three pairs of subgroups (G1a vs G2a, G1b vs G2b, G1c vs G2c), there were no significant differences detected in the PHD or the time to normalization of CRP, TB and ALT. In the EPBD group, the incidence of post-ERCP pancreatitis, hyperamylasemia and overall patient complications was significantly higher for G2a (post-ERCP pancreatitis: 6/36 vs 0/41, P = 0.0217; hyperamylasemia: 11/36 vs 4/41, P = 0.0215; overall patient complications: 18/36 vs 7/41, P = 0.0029).

CONCLUSION: After successful CBD stone clearance, ENBD is only beneficial when an EPBD procedure has been performed.

Placement of prophylactic pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A meta-analysis

AIM: To assess the effectiveness of pancreatic stents for preventing pancreatitis in high-risk patients after endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: PubMed, Embase, Science Citation Index, and Cochrane Controlled Trials Register were searched to identify relevant trials published in English. Inclusion and exclusion criteria were used to screen for suitable studies. Two reviewers independently judged the study eligibility while screening the citations. The methodological quality of the included trials was assessed using the Jadad scoring system. All results were expressed as OR and 95%CI. Data were analyzed using Stata12.0 software.

RESULTS: Ten eligible randomized controlled trials were selected, including 1176 patients. A fixed-effects model in meta-analysis supported that pancreatic duct stents significantly decreased the incidence of post-ERCP pancreatitis (PEP) in high-risk patients (OR = 0.25; 95%CI: 0.17-0.38; P < 0.001). Pancreatic stents also alleviated the severity of PEP (mild pancreatitis after ERCP: OR = 0.33; 95%CI: 0.21-0.54; P < 0.001; moderate pancreatitis after ERCP: OR = 0.30; 95%CI: 0.13-0.67; P = 0.004). The result of severe pancreatitis after ERCP was handled more rigorously (OR = 0.24; 95%CI: 0.05-1.16; P = 0.077). Serum amylase levels were not different between patients with pancreatic stents and control patients (OR = 1.08; 95%CI: 0.82-1.41; P = 0.586).

CONCLUSION: Placement of prophylactic pancreatic stents may lower the incidence of post-ERCP pancreatitis in high-risk patients and alleviate the severity of this condition.

Hyperamylasemia is associated with increased intestinal permeability in patients undergoing diagnostic oral double-balloon enteroscopy

AIM: To investigate the correlations between serum amylase levels, intestinal permeability (IP), and pancreatic injury and to explore the mechanisms responsible for hyperamylasemia in double-balloon enteroscopy (DBE).

METHODS: A prospective study was conducted in 20 patients who underwent DBE from August 1, 2008 to February 28, 2009. Serum amylase was examined 0, 2, 6 and 24 h post-DBE, C-reactive protein and lipase were examined at 24 h, and urine lactulose, mannitol, and trypsinogen-II (TRY-II) levels were measured at 6 h. Lactulose/mannitol ratio indicated IP, and TRY-IIindicated pancreatic injuries. Procedure duration and enteroscope insertion length were recorded.

RESULTS: Twelve patients underwent oral DBE (M:F, 5:7; mean age 50.42 ± 11.11 years) and 8 underwent anal DBE (M:F, 5:3; mean age 44.75 ± 12.66 years). They all showed significantly increased post-DBE serum amylase. Amylase and lipase levels were higher in the oral DBE group (P < 0.05). Hyperamylasemia was diagnosed in 9 (75.0%) patients undergoing oral DBE. Only patients receiving oral DBE showed increased post-procedure IP, which correlated with increased serum amylase (r = 0.611, P = 0.035) and procedure duration (r = 0.668, P = 0.018). Adverse events included one oral case with pancreatic injury (elevated TRY-II) and two cases of abdominal discomfort in each group. Pancreatitis was not reported.

CONCLUSION: Hyperamylasemia correlates with increased IP and clinically undetectable pancreatic injuries. DBE could cause intestinal mucosa damage, which may result in IP elevation and increased amylase absorption, necessitating improvements and standardization of DBE methods.

Effects of new-type NSAIDs in preventing post-ERCP pancreatitis

AIM: To compare the effects of new-type versus traditional non-steroid antiinflammtory drugs (NSAIDs) in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).

METHODS: One hundred and ninety-seven patients who underwent ERCP for choledocholithiasis between May 2012 and May 2013 were randomly divided into three groups: a lornoxicam group, a parecoxib group and a control group. Different drugs were applied for each group. Mean visual analogue score (VAS) and serum levels of amylase and C-reactive protein (CRP) were measured before ERCP and 4, 24 and 48 h after ERCP. Incidences of hyperamylasemia and PEP were observed.

RESULTS: The incidences of PEP in the lornoxicam group, parecoxib group and control group were 4.55%, 9.09% and 10.8%, respectively, and the difference was statistically significant between the parecoxib group and control group (P < 0.05), but not between the lornoxicam group and control group (P > 0.05). The incidences of post-ERCP hyperamylasemia in the parecoxib group and lornoxicam group were significantly lower than that in the control group (9.09%, 15.2% vs 21.5%, both P < 0.01). Serum CRP level at 4 h after ERCP was significantly lower in both treatment groups than in the control group (both P < 0.01). Mean VAS at 4 h after ERCP was significantly lower in both treatment groups than in the control group (both P < 0.01).

CONCLUSION: NSAIDs like lornoxicam and parecoxib can prevent the occurrence of hyperamylasemia induced by ERCP. Parecoxib could prevent the occurrence of PEP. Both drugs can alleviate pain and inflammatory reactions after the endoscopic procedure. As a new type of NSAIDs, selective cyclooxygenase-2 (COX-2) inhibitors might be more useful in preventing PEP.

Detection of painless pancreatitis by computed tomography in patients with post-endoscopic retrograde cholangiopancreatography hyperamylasemia

OBJECTIVES

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is diagnosed on the basis of pancreatic pain and hyperamylasemia. However, because the diagnosis of abdominal pain is not objective, there may be some cases of painless pancreatitis among patients with post-ERCP hyperamylasemia (PEH). We reviewed the computed tomography (CT) findings of PEH cases to determine the incidence of painless pancreatitis.

METHODS

Between July, 2005 and December, 2011, CT was performed in 91 patients with hyperamylasemia 18 h after ERCP. We reviewed the CT findings and graded the severity of pancreatitis according to the Balthazar grading system. Grades C, D, and E were defined as pancreatitis.

RESULTS

Thirty-four patients (37%) had pancreatitis according to the CT findings. There was a significant difference in the serum amylase levels between the positive- and negative-CT finding groups (1306 ± 833 vs. 786 ± 315 IU/L, respectively; p = 0.0012). Receiver operating characteristic curve analysis showed that the amylase cut-off value for discriminating between the 2 groups was 795 IU/L (6.36 times the upper normal limit).

CONCLUSIONS

Thirty-seven percent of PEH patients had painless pancreatitis. CT is useful to determine pancreatitis in patients taking analgesics, steroids, or anti-immunological drugs and those with diabetes mellitus and 18-h serum amylase levels of >6 times the normal upper limit.

Amylase: sensitive tumor marker for amylase-producing lung adenocarcinoma

Hyperamylasemia in patients with lung cancer is rarely, comprising 1% to 3% of all lung cancers. This report describes two cases of lung adenocarcinoma coexisting with hyperamylasemia in two women aged 77 and 57, respectively. In these two cases, CT revealed a normal pancreas. We monitored the serum and urine amylase levels during therapy and found it paralleled tumor response to chemotherapy and metastasis. We suggest that the amylase levels are related to the tumor size and might be a valuable factor in predicting chemotherapy and progression of disease for amylase-producing lung cancer.

Indomethacin for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis

AIM: To assess the effectiveness and safety of indomethacin in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

METHODS: Electronic searches were conducted to retrieve randomized controlled trials (RCTs) comparing indomethacin to placebo in the prevention of PEP from the PubMed, Embase, CBM, CNKI, WANFANG and VIP databases. Data collection and literature evaluation were performed by two reviewers independently. Review Manager 5.0 was used for statistical analysis.

RESULTS: A total of 11 RCTs involving 2718 patients were included. The meta-analysis showed that indomethacin could reduce the incidence of PEP (OR = 0.39, 95%CI: 0.30-0.52, P < 0.00001) and hyperamylasemia (OR = 0.50, 95%CI: 0.37-0.67, P < 0.00001).

CONCLUSION: Indomethacin is safe and effective in reducing the incidence of PEP and hyperamylasemia.

Comparative analysis of endoscopic precut conventional and needle knife sphincterotomy

AIM: To compare the efficacy, complications and post-procedural hyperamylasemia in endoscopic pre-cut conventional and needle knife sphincterotomie.

METHODS: We performed a retrospective analysis of two pre-cut sphincterotomy (PS) techniques, pre-cut conventional sphincterotomy (PCS), and pre-cut needle knife (PNK). The study included 143 patients; the classic technique was used in 59 patients (41.3%), and the needle knife technique was used in 84 patients (58.7%). We analyzed the efficacy of bile duct access, the need for a two-step procedure, the rates of complications and hyperamylasemia 4 h after the procedure, “endoscopic bleeding” and the need for bleeding control. Furthermore, to assess whether the anatomy of the Vater’s papilla, indications for the procedure or the need for additional procedures could inform the choice of the PS method, we evaluated the additive hyperamylasemia risk 4 h after the procedure with respect to the above mentioned variables.

RESULTS: The bile duct access efficacy with PNK and PCS was 100% and 96.6%, respectively, and the difference between the two groups was not significant (P = 0.06). However, the needle knife technique required two-step access significantly more often, in 48.8% vs 8.5% of cases (P < 0.0001). The only complication noted was post-ercp pancreatitis (PEP), which was observed in 4/84 (4.8%) and 2/59 (3.4%) patients submitted to PNK and PSC, respectively; the difference between the two procedures was not significant (P = 0.98). An analysis of other consequences of the techniques yielded the following results in the PNK and PCS groups: hyperamylasemia 4 h after the procedure > 80 U/L, 41/84 vs 23/59 (P = 0.32); hyperamylasemia 4 h after the procedure > 240 U/L, 19/84 vs 11/59 (P = 0.71); pancreatic pain, 13/84 vs 7/59 (P = 0.71); endoscopic bleeding, 10/84 vs 8/59 (P = 0.97); and the need for bleeding control, 10/84 vs 7/59 (P = 0.79). In the next part of the study, we analyzed the influence of the method chosen on the risk of hyperamylasemia with respect to an indication for endoscopic retrograde cholangiopancreatography, papillary anatomy and concomitant procedures performed. We determined that the hyperamylasemia risk was increased by more than threefold [odds ratio (OR) = 3.38; P = 0.027] after PCS in patients with a flat Vater’s papilla and more than fivefold (OR = 5.3; P = 0.049) after the PNK procedure in patients who required endoscopic homeostasis.

CONCLUSION: PCS and PNK do not differ in terms of efficacy or complication rates, but PNK is more often associated with the necessity for a two-step procedure.

Somatostatin versus endoscopic nasal biliary drainage in the prevention of post-ERCP pancreatitis and hyperamylasemia

AIM: To investigate the preventive effect of somatostatin versus endoscopic nasal biliary drainage (ENBD) on post-ERCP pancreatitis (PEP) and hyperamylasemia.

METHODS: A total of 110 patients were enrolled and randomly divided into 3 groups to receive somatostatin, ENBD or placebo. Incidences of PEP, hyperamylasemia and adverse reactions were observed.

RESULTS: The overall incidences of PEP and hyperamylasemia were 17.2% (19/110) and 4.54% (5/110), respectively. The levels of serum amylase at 6 h in the somatostatin group and ENBD group were significantly lower than that in the control group (467 IU/L ± 63 IU/L 501 IU/L ± 405 IU/L vs 1 323 IU/L ± 46 IU/L, both P < 0.05), while the levels of serum amylase at 24 h showed no significant differences among the three groups (P > 0.05). The time to disappearance of abdominal symptoms, the time to recovery of blood parameters, and average length of hospital stay in the somatostatin group and ENBD group were significantly shorter than those in the control group (all P < 0.05). The costs were significantly lower in the somatostatin group than in the ENBD group (P < 0.05).

CONCLUSION: Both somatostatin and ENBD can effectively prevent post-ERCP pancreatitis and hyperamylasemia, and somatostatin is associated with lower medical expenses.

Oral magnesium prevents the development of pancreatitis and hyperamylasemia in patients after ERCP

AIM: To investigate the effect of oral magnesium on the development of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and hyperamylasemia.

METHODS: One hundred and twenty patients with cholelithiasis were randomly divided into two groups: magnesium group (n = 60), in which 50% magnesium was given 30 min before ERCP, and control group (n = 60), in which no magnesium was given. Serum levels of amylase were measured in all the patients before ERCP and at 3 and 24 h after ERCP. The incidences of hyperamylasemia and PEP were also observed.

RESULTS: Serum levels of amylase did not differ significantly before ERCP between the two groups (P > 0.05), but were higher in both groups at 3 and 24 h after ERCP than before ERCP, and were lower in the magnesium group than in the control group at 3 and 24 h after ERCP. The incidences of hyperamylasemia and PEP in magnesium group were significantly lower than those in the control group (both P < 0.05).

CONCLUSION: Oral magnesium may decrease serum levels of amylase and prevent the occurrence of PEP and hyperamylasemia in patients after ERCP.

Efficacy of ENBD in the prevention of post-ERCP pancreatitis and hyperamylasemia in patients with common bile duct stones: an analysis of 65 cases

AIM: To investigate the value of endoscopic nasobiliary drainage (ENBD) in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and hyperamylasemia in patients with common bile duct stones.

METHODS: The clinical data of 141 patients with common bile duct stones, including 65 undergoing ENBD and 77 undergoing routine treatment, were retrospectively reviewed. The efficacy and complication rate were compared between the two groups.

RESULTS: Serum amylase levels at 2 and 24 h postoperatively were significantly lower in the ENBD group than in the routine treatment group (67.3 U/L ± 9.1 U/L vs 98.3 U/L ± 11.2 U/L, 89.5 U/L ± 13.0 U/L vs 126.2 U/L ± 14.2 U/L, both P < 0.01). The incidence of post-ERCP pancreatitis and hyperamylasemia was also significantly lower in the ENBD group than in the routine treatment group.

CONCLUSION: ENBD can effectively prevent the occurrence of post-ERCP pancreatitis and hyperamylasemia in patients with common bile duct stones.

Double balloon enteroscopy and acute pancreatitis

Double balloon enteroscopy (DBE) is a new technique, first published and introduced into clinical practice in 2001 by Yamamoto, the inventor of this outstanding method. DBE allows complete visualization, biopsy and treatment of the small bowel. Nowadays, we have some experience of this method for evaluation of the complication rate. Severe complications are described in 1%-1.7% of patients. Acute pancreatitis is a rare complication of the investigation. The incidence of acute pancreatitis after diagnostic DBE is 0.3% in most studies. More than 50 cases of acute pancreatitis have been described in the literature so far. On the contrary, hyperamylasemia after DBE seems to be a rather common condition. Association with acute pancreatitis is supposed to be possible, but not obligatory. The causal mechanism of post-DBE acute pancreatitis is uncertain, and there are several theories in the literature. The most probable cause seems to be a mechanical straining of the endoscope with over-tube on the pancreas or in the papillary area.

Clinical outcomes in patients with ICU-related pancreatitis

AIM: To identify risk factors predictive of intensive care unit (ICU) mortality in patients with ventilator-related pancreatitis. The clinical outcomes of patients with ventilator-related pancreatitis were compared with those of patients with pancreatitis-related respiratory failure as well as controls.

METHODS: One hundred and forty-eight patients with respiratory failure requiring mechanical ventilation and concomitant acute pancreatitis were identified from a prospectively collected dataset of 9108 consecutive patients admitted with respiratory failure over a period of five years. Sixty patients met the criteria for ventilator-related pancreatitis, and 88 (control patients), for pancreatitis-related respiratory failure.

RESULTS: Mortality rate in ventilator-related pancreatitis was comparable to that in ICU patients without pancreatitis by case-control methodology (P = 0.544). Multivariate logistic regression analysis identified low PaO₂/FiO₂ (OR: 1.032, 95% CI: 1.006-1.059, P = 0.016) as an independent risk factor for mortality in patients with ventilator-related pancreatitis. The mortality rate in patients with ventilator-related pancreatitis was lower than that in patients with acute pancreatitis-related respiratory failure (P < 0.001).

CONCLUSION: We found that low PaO₂/FiO₂ was an independent clinical parameter predictive of ICU mortality in patients with ventilator-related pancreatitis.

Nafamostat for Prophylaxis against Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Compared with Gabexate

BACKGROUND/AIMS

The protease inhibitors, nafamostat and gabexate, have been used to prevent pancreatitis related to endoscopic retrograde cholangiopancreatography (ERCP). In vitro, nafamostat inhibits the pancreatic protease activities 10-100 times more potently than gabexate. We evaluated the efficacy of nafamostat for prophylaxis against post-ERCP pancreatitis in comparison with gabexate.

METHODS

Five hundred patients (208 patients in the nafamostat-treated group and 292 in the gabexate-treated group) were analyzed retrospectively after selective exclusion. The incidences of pancreatitis and hyperamylasemia after the ERCP were compared between the nafamostat and gabexate groups.

RESULTS

The incidences of acute pancreatitis and hyperamylasemia were 9.1% and 40.9%, respectively, in the nafamostat-treated group, and 8.6% and 39.4% in the gabexate-treated group. The frequencies of post-ERCP pancreatitis and hyperamylasemia did not differ significantly between the two groups, Post-ERCP pancreatitis in two group did not vary according to the different ERCP procedures. The mean serum amylase level at 6 h after ERCP was significantly lower in the nafamostat-treated group than in the gabexate-treated group (p=0.020). However, the difference in serum amylase level did not persist at 18 h and 36 h post-ERCP.

CONCLUSIONS

Administration of nafamostat before ERCP was not inferior to gabexate in protecting against the development of pancreatitis.

Oral allopurinol to prevent hyperamylasemia and acute pancreatitis after endoscopic retrograde cholangiopancreatography

AIM: To assess the efficacy of allopurinol to prevent hyperamylasemia and pancreatitis after endoscopic retrograde cholangiopancreatography (PEP).

METHODS: One hundred and seventy patients were enrolled and randomized to two groups: a study group (n = 85) who received 300 mg of oral allopurinol at 15 h and 3 h before endoscopic retrograde cholangiopancreatography (ERCP) and a control group (n = 85) receiving an oral placebo at the same times. Main Outcome Measurements included serum amylase levels and the number severity of the episodes of pancreatitis. Serum amylase levels were classified as normal (< 150 IU/L) or hyperamylasemia (> 151 IU/L). Episodes of PEP were classified following Ranson’s criteria and CT severity index.

RESULTS: Gender distribution was similar between groups. Mean age was 53.5 ± 18.9 years for study group and 52.8 ± 19.8 years for controls. Also, the distribution of benign pathology was similar between groups. Hyperamylasemia was more common in the control group (P = 0.003). Mild PEP developed in two patients from the study group (2.3%) and eight (9.4%) from control group (P = 0.04), seven episodes were observed in high-risk patients of the control group (25%) and one in the allopurinol group (3.3%, P = 0.02). Risk factors for PEP were precut sphincterotomy (P = 0.02), pancreatic duct manipulation (P = 0.002) and multiple procedures (P = 0.000). There were no deaths or side effects.

CONCLUSION: Oral allopurinol before ERCP decreased the incidences of hyperamylasemia and pancreatitis in patients submitted to high-risk procedures.

N-acetylcysteine does not prevent post-endoscopic retrograde cholangiopancreatography hyperamylasemia and acute pancreatitis

AIM: Acute pancreatitis (AP) is the most common and often severe complication of endoscopic retrograde cholangiopancreatography (ERCP). The early step in the pathogenesis of acute pancreatitis is probably the capillary endothelial injury mediated by oxygen-derived free radicals. N-acetylcysteine - a free radical scavenger may be potentially effective in preventing post-ERCP acute pancreatitis and it is also known that N-acetylcysteine (ACC) can reduce the severity of disease in experimental model of AP.

METHODS: One hundred and six patients were randomly allocated to two groups. Fifty-five patients were given N-acetylcysteine (two 600 mg doses orally 24 and 12 h before ERCP and 600 mg was given iv, twice a day for two days after the ERCP). The control group consisted of 51 patients who were given iv. isotonic saline twice a day for two days after the ERCP. Serum and urine amylase activities were measured before ERCP and 8 and 24 h after the procedure. The primary outcome parameter was post-ERCP acute pancreatitis and the secondary outcome parameters were differences between groups in serum and urine amylase activity.

RESULTS: There were no significant differences in the rate of post-ERCP pancreatitis between two groups (10 patients overall, 4 in the ACC group and 6 in the control group). There were also no significant differences in baseline and post-ERCP serum and urine amylase activity between ACC group and control group.

CONCLUSION: N-acetylcysteine fails to demonstrate any significant preventive effect on post-ERCP pancreatitis, as well as on serum and urine amylase activity.