Structured alcohol cessation support program versus current practice in acute alcoholic pancreatitis (PANDA): Study protocol for a multicentre cluster randomised controlled trial

BACKGROUND/OBJECTIVES

The most important risk factor for recurrent pancreatitis after an episode of acute alcoholic pancreatitis is continuation of alcohol use. Current guidelines do not recommend any specific treatment strategy regarding alcohol cessation. The PANDA trial investigates whether implementation of a structured alcohol cessation support program prevents pancreatitis recurrence after a first episode of acute alcoholic pancreatitis.

METHODS

PANDA is a nationwide cluster randomised superiority trial. Participating hospitals are randomised for the investigational management, consisting of a structured alcohol cessation support program, or current practice. Patients with a first episode of acute pancreatitis caused by harmful drinking (AUDIT score >7 and < 16 for men and >6 and < 14 for women) will be included. The primary endpoint is recurrence of acute pancreatitis. Secondary endpoints include cessation or reduction of alcohol use, other alcohol-related diseases, mortality, quality of life, quality-adjusted life years (QALYs) and costs. The follow-up period comprises one year after inclusion.

DISCUSSION

This is the first multicentre trial with a cluster randomised trial design to investigate whether a structured alcohol cessation support program reduces recurrent acute pancreatitis in patients after a first episode of acute alcoholic pancreatitis, as compared with current practice.

TRIAL REGISTRATION

Netherlands Trial Registry (NL8852). Prospectively registered.

Thirty-Day Readmission Among Patients with Alcoholic Acute Pancreatitis

BACKGROUND/OBJECTIVES

Alcoholic acute pancreatitis (AAP) comprises the second most common cause of acute pancreatitis in the USA, and there is lack of data regarding 30-day specific readmission causes and predictors. We aim to identify 30-day readmission rate, causes, and predictors of readmission.

METHODS

Retrospective analysis of the 2016 National Readmission Database of adult patients readmitted within 30 days after an index admission for AAP.

RESULTS

Totally, 76,609 AAP patients were discharged from the hospital in 2016. The 30-day readmission rate was 12%. The main cause of readmission was another episode of AAP. Readmission was not associated with higher mortality (1.3% vs. 1.2%; P = 0.21) or prolonged length of stay (5.2 vs. 5.0 days; P = 0.06). The total health care economic burden was $354 million in charges and $90 million in costs. Independent predictors of readmission were having Medicaid insurance, a Charlson comorbidity index score ≥ 3, use of total parenteral nutrition, opioid abuse disorder, prior pancreatic cyst, chronic alcoholic pancreatitis, and other chronic pancreatitis. Obesity was associated with lower odds of readmission.

CONCLUSION

Readmission rate for AAP is high and its primary cause are recurrent episodes of AAP. Alcohol and substance abuse pose a high burden on our health care system. Public health strategies should be targeted to provide alcohol abuse disorder rehabilitation and cessation resources to alleviate the burden on readmission, the health care system and to improve patient outcomes.

Management of pancreatic ascites complicating alcoholic chronic pancreatitis

INTRODUCTION

Pancreatic ascites (PA) is an unusual and little studied complication of chronic alcoholic pancreatitis. Management is complex and is based mainly on empirical data. The aim of this retrospective work was to analyse the management of PA at our centre.

PATIENTS AND METHODS

A total of 24 patients with PA complicating chronic alcoholic pancreatitis were managed at the Lille University Hospital between 2004 and 2018. Treatment was initially medical and then, in case of failure, interventional (endoscopic, radiological and/or surgical). Data regarding epidemiology, therapeutic and follow-up data were collected retrospectively.

RESULTS

Twenty-four patients were analysed; median follow-up was 18.5 months [6.75-34.25]. Exclusively medical treatment was effective in three of four patients, but, based on intention to treat, medical therapy alone was effective in only two out of 24 patients. Of 17 patients treated endoscopically, treatment was successful in 15 of them. Of the 15 who underwent surgery, external surgical drainage was effective in 13. Multimodal treatment, initiated after 6.5 days [4-13.5] of medical treatment, was effective in 12 out of 14 patients. In total, 21 patients were successfully treated (87%) with a morbidity rate of 79% and a mortality rate of 12.5% (n=3).

CONCLUSION

PA gives rise to significant morbidity and mortality. Conservative medical treatment has only a limited role. If medical treatment fails, endoscopic and then surgical treatment allow a favourable outcome in more than 80% of patients.

Acute pancreatitis

Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years, treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach. Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.

The different course of alcoholic and idiopathic chronic pancreatitis: A long-term study of 2,037 patients

Background

Chronic pancreatitis (CP) is a chronic inflammatory disease of the pancreas. This study aimed to compare the natural course of alcoholic chronic pancreatitis (ACP) and idiopathic chronic pancreatitis (ICP).

Methods

CP patients admitted to our center from January 2000 to December 2013 were enrolled. Characteristics were compared between ACP and ICP patients. Cumulative rates of diabetes mellitus (DM), steatorrhea, pancreatic stone, pancreatic pseudocyst, biliary stricture, and pancreatic cancer after the onset and the diagnosis of CP were calculated, respectively. The cumulative rates of DM and steatorrhea after diagnosis of pancreatic stone were also calculated.

Results

A total of 2,037 patients were enrolled. Among them, 19.8% (404/2,037) were ACP and 80.2% (1,633/2,037) were ICP patients. ACP and ICP differs in many aspects, especially in gender, age, smoking, complications, morphology of pancreatic duct, and type of pain. The development of DM, steatorrhea, PPC, pancreatic stone, and biliary stricture were significantly earlier and more common in ACP patients. No significant difference was observed for pancreatic cancer development. There was a rather close correlation between exocrine/endocrine insufficiency and pancreatic stone in ACP patients, which was much less correlated in ICP patients.

Conclusion

The long-term profile of ACP and ICP differs in some important aspects. ACP patients usually have a more severe course of CP. These differences should be recognized in the diagnosis and treatment of CP.

Modified single transluminal gateway transcystic multiple drainage technique for a huge infected walled-off pancreatic necrosis: A case report

We report a successful endoscopic ultrasonography-guided drainage of a huge infected multilocular walled-off necrosis (WON) that was treated by a modified single transluminal gateway transcystic multiple drainage (SGTMD) technique. After placing a wide-caliber fully covered metal stent, follow-up computed tomography revealed an undrained subcavity of WON. A large fistula that was created by the wide-caliber metal stent enabled the insertion of a forward-viewing upper endoscope directly into the main cavity, and the narrow connection route within the main cavity to the subcavity was identified with a direct view, leading to the successful drainage of the subcavity. This modified SGTMD technique appears to be useful for seeking connection routes between subcavities of WON in some cases.

Acute pancreatitis

Acute pancreatitis, an inflammatory disorder of the pancreas, is the leading cause of admission to hospital for gastrointestinal disorders in the USA and many other countries. Gallstones and alcohol misuse are long-established risk factors, but several new causes have emerged that, together with new aspects of pathophysiology, improve understanding of the disorder. As incidence (and admission rates) of acute pancreatitis increase, so does the demand for effective management. We review how to manage patients with acute pancreatitis, paying attention to diagnosis, differential diagnosis, complications, prognostic factors, treatment, and prevention of second attacks, and the possible transition from acute to chronic pancreatitis.

Chronic pancreatitis: an update for home care and hospice clinicians

Chronic pancreatitis is a relentlessly painful condition associated most commonly with alcoholism. Patients suffer wasting and depression as a result of chronic pain. It is important for home care clinicians to recognize the signs of pancreatitis and understand the current evidence-based treatment strategies to control the symptoms. Although alcoholism and depression are frequent comorbidities of pancreatitis, a full discussion of alcoholism and depression is outside the scope of this article.

[Chronic pancreatitis]

Chronic pancreatitis is characterized by recurrent abdominal pain due to chronic inflammation resulting in loss of exocrine and endocrine function. The main complications of chronic pancreatitis are pancreatic pseudocysts and pancreatic carcinoma. In most cases chronic pancreatitis is induced by excessive chronic alcoholism, but intake of small amounts of alcohol may be enough to induce chronic pancreatitis. Treatment of pain includes discontinuation of alcohol abuse, use of analgetics and endoscopic interventional and surgical treatment options.

[Nutritional management of patients with acute pancreatitis: when the past is present]

Patients with acute pancreatitis usually present nutritional status impairment. In alcoholic pancreatitis this impairment is usually presented before hospital admission. In patients with long-term complicated pancreatitis, malnutrition develops during the course of the disease. Besides, these patients present an increased stress and protein hypercatabolism. Treatment of acute pancreatitis usually maintains patients in a short period of starvation. In mild pancreatitis, starvation is needed for a few days, beginning progressively oral feeding. These patients don't need special nutritional support, unless they were previously malnourished. Patients with severe acute pancreatitis should always receive artificial nutritional support in order to preserve the nutritional status as starvation will be maintained for more than one week. In this paper, we review the nutritional treatment in these situations, trying to answer some different questions: type of nutritional support, when it should be started and when it is indicated to withdraw.

[Nutritional repercussions and management of chronic pancreatitis]

The pancreas is a retroperitoneal organ that releases water, bicarbonate and digestive enzymes by the main pancreatic duct (MPD) into the duodenum. Chronic pancreatitis (CP) is typically caused, in adults, by chronic alcohol abuse and, less frequently hypertriglyceridemia, primary hyperparathyroidism or cystic fibrosis. Exocrine dysfunction results in malabsorption of fat and subsequent steatorrhea. Damage to pancreatic endocrine function is a late finding in CP and results in hyperglycaemia or overt diabetes mellitus. Care of patients with CP principally involves management of pain. A significant change in the pain pattern or the sudden onset of persistent symptoms suggests the need to rule out other potential etiologies, including peptic ulcer disease, biliary obstruction, pseudocysts, pancreatic carcinoma, and pancreatic duct stricture or stones, then is important to establish a secure diagnosis. Management of pain should then proceed in a judicious stepwise approach avoiding opioids dependence. Patients should be advised to stop alcohol intake. Fat malabsorption and other complications may also arise. Management of steatorrhea should begin with small meals and restriction in fat intake. Pancreatic enzyme supplements can relieve symptoms and reduce malabsorption in patients who do not respond to dietary restriction. Enzymes at high doses should be used with meals. Treatment with acid suppression to reduce inactivation of the enzymes from gastric acid are recommended. Supplementation with medium chain triglycerides and fat soluble vitamin replacement may be required. Management of other complications (such as pseudocysts, bile duct or duodenal obstruction, pancreatic ascites, splenic vein thrombosis and pseudoaneurysms) often requires aggressive approach with the patient kept on total parenteral nutrition to minimize pancreatic stimulation.

[Spontaneously reversible portal vein thrombosis complicating acute pancreatits--computed tomographic findings]

Portal vein thrombosis complicating acute pancreatitis is more often diagnosed today due to the improved imaging techniques (computed tomography, ultrasound, nmr). Nevertheless the outcome of recent portal vein thrombosis is ill-known. We report on the computed tomographic findings and clinical course of portal vein thrombosis in two patients suffering from acute pancreatitis. Both patients showed spontaneous recanalization of the thrombosis.

Endovascular Treatment of Pseudoaneurysm of the Common Hepatic Artery with Intra-aneurysmal Glue (N-Butyl 2-Cyanoacrylate) Embolization

A 40-year-old man, a chronic alcoholic, presented with acute epigastric pain. Selective celiac arteriography showed a pseudoaneurysm arising from the common hepatic artery. We hereby describe a technical innovation where complete pseudoaneurysm exclusion was seen after intra-aneurysmal N-butyl 2-cyanoacrylate (glue) injection with preservation of antegrade hepatic arterial flow and conclude that intra-aneurysmal liquid injection may have potential as a therapeutic option to reconstruct a defective vessel wall and thereby maintain the antegrade flow.

Diagnosis and treatment of hemosuccus pancreaticus: development of endovascular management

OBJECTIVES

The purpose of this study was to analyze the diagnostic and therapeutic features of hemosuccus pancreaticus.

METHODS

We reviewed our experience with management of 17 patients admitted to surgery or gastroenterology units for hemosuccus pancreaticus between 1981 and 2005. We studied symptoms, contribution of established morphological examinations (upper digestive endoscopy, computed tomography, and selective digestive angiography), and treatment.

RESULTS

Fifteen men and two women with a mean age of 57 years presented hemosuccus pancreaticus. All the men had a history of chronic alcoholic pancreatitis. Thirteen patients (76.5%) presented overt digestive bleeding (5 melena, 2 hematochezia, 2 melena with hematochezia, and 4 hematemesis). The inaugural sign was anemia in 2 patients and epigastric pain another 2 patient. An upper digestive endoscopy was performed in 15 patients and visualized hemosuccus pancreaticus directly in 9 patients. Arteriography was performed in 16 patients (94.1%) and made the diagnosis in 14 (87.5%). Surgery was performed in 9 patients, after embolization in 2 patients. Embolization was performed in 9 patients and effective in 7 patients. Therapeutic abstention proved successful in 1 patient. There were no death and no recurrent bleeding.

CONCLUSIONS

Hemosuccus pancreaticus is a rare cause of digestive bleeding. Upper digestive endoscopy and angiography during active bleeding can provide the diagnosis. Most cases can be managed by angioembolization. However, in patients with recurrent bleeding or failed embolization, emergency surgery is required.

Pancreatic pseudocyst located in the liver

Pancreatic pseudocyst is a common complication of acute and chronic pancreatitis. Extrapancreatic locations of pancreatic pseudocyst in the liver, pleura, mediastinum, or pelvis have been described. However, a pancreatic pseudocyst located in the liver is an infrequent condition. We present the case of a 46-year-old man with pancreatic pseudocyst located in the liver secondary to chronic alcoholic pancreatitis. During admission, the patient underwent an abdominal CT scan that showed a mass located in the head and body of the pancreas, as well as a thrombosis of the splenic vein. A percutaneous needle aspiration biopsy of the pancreas was obtained under CT guidance, which showed no tumoral involvement. Fourty-eight hours after the procedure the patient developed abdominal pain and elevated serum amylase levels. A pancreatic MRI exam showed two pancreatic pseudocysts, one of them located in the left hepatic lobe, the other in the pancreatic tail. Chronic pancreatitis signs also were found. Enteral nutrition via a nasojejunal tube was administered for two weeks. The disappearance of the pancreatic pseudocyst located in the pancreatic tail, and a subtotal resolution of the pancreatic pseudocyst located in the liver were observed. To date twenty-seven cases of pancreatic pseudocyst located in the liver have been published, most of them managed with percutaneous or surgical drainage.

[Chronic pancreatitis--rational diagnosis and therapy. Which procedures are relevant for general practice?]

Chronic pancreatitis is characterized clinically by recurrent or persistent abdominal pain, as well as exocrine, and possibly also endocrine, pancreatic insufficiency. The diagnosis is established with the aid of imaging procedures and the investigation of pancreatic function. Treatment comprises pain amelioration, possibly also applying endoscopic and surgical measures, and the treatment of exocrine and endocrine insufficiency.

[Correction of endotoxicosis in alcoholic pancreatitis in elderly and senile patients using discrete plasmapheresis]

The majority of critical conditions in man occur in diseases accompanied with development of endogenic intoxication syndrome. The search for universal criterion and design of highly effective programs for correction of this condition are of great importance for internal medicine and surgical practice. Discrete plasmapheresis for endotoxicosis in elderly and gerontological patients has its specific features which should be taken into consideration because of low adaptation abilities of such group of patients.

Treatment of alcoholic pancreatitis

Chronic pancreatitis is characterized by progressive and irreversible loss of pancreatic exocrine and endocrine function. The majority of cases in the Western world are related to alcohol consumption. Treatment of alcoholic chronic pancreatitis has been difficult, since the mechanisms of disease progression and the causes of pain are poorly understood. The conservative management of chronic pancreatitis focuses on (a) avoidance of precipitating factors such as alcohol and smoking; (b) treatment of pain, and (c) replacement of exocrine and endocrine function. There is a lack of good controlled, randomized treatment trials in alcoholic pancreatitis. However, there is good evidence that lifestyle changes, such as alcohol cessation, hamper progression of the disease. Conservative treatment of pain should be based on a stepwise approach; however, underlying causes such as pseudocysts may require endoscopic or surgical therapy. Treatment of exocrine insufficiency requires pancreatic enzyme supplementation and adjustment to several smaller meals per day, while treatment of endocrine insufficiency requires insulin treatment.

Percutaneous drainage of spontaneous subcapsular haematoma of the spleen complicating chronic pancreatitis

Subcapsular haematoma of the spleen is a rare complication of chronic pancreatitis. In the literature only a handful of cases have been documented. The exact aetiology and natural history of this complication remains speculative and its management controversial. A case of spontaneous subacute haematoma of the spleen in a patient with chronic relapsing alcohol-related pancreatitis was reported. A percutaneous drainage was performed with good outcome. A review of the literature has demonstrated only one previous similar report.

Alcohol-induced pancreatic injury

Alcoholic pancreatitis is a major complication of alcohol abuse. Until recently, it was generally accepted that alcoholic pancreatitis was a chronic disease from the outset. However, evidence is now emerging in support of the 'necrosis-fibrosis' hypothesis that alcoholic pancreatitis begins as an acute process and that repeated episodes of acute injury lead to the changes of chronic pancreatitis (acinar atrophy and fibrosis) resulting in exocrine and endocrine dysfunction. The treatment of acute pancreatitis follows the regimen of bed rest, nasogastric suction, analgesia and intravenous support. The role of additional therapeutic measures such as prophylactic antibiotics, antioxidants and enteral nutrition in severe cases has not yet been precisely defined. The treatment of chronic pancreatitis involves attention to its three cardinal features: pain, maldigestion and diabetes. With respect to the pathogenesis of alcoholic pancreatitis, the focus of research over the past 30 years has shifted from the sphincter of Oddi and ductular abnormalities to the acinar cell itself. It has now been established that the acinar cell is capable of metabolizing alcohol and that direct toxic effects of alcohol and/or its metabolites on acinar cells may predispose the gland to injury in the presence of an appropriate trigger factor. A significant recent development relates to the characterization of pancreatic stellate cells, increasingly implicated in alcoholic pancreatic fibrosis. This chapter summarizes the natural history, clinical features, current trends in treatment as well as recent advances in our understanding of the pathogenesis of alcoholic pancreatitis.

[Importance of a clinical protocol in the treatment of severe acute pancreatitis]

BACKGROUND

Selection of the optimal treatment strategy in severe acute pancreatitis (SAP) is a serious clinical challenge largely due to difficult differential diagnosis of patients with early SAP. The aim of this study is a retrospective evaluation of the first experiences in the treatment of patients with SAP and early SAP according to a new complex clinical protocol (CCP).

METHODS

A total of 210 patients complied with Atlanta recommendations for SAP and were included in the retrospective study. Patients were stratified into two groups according to the diagnostic and treatment strategy. Non-protocol (NP) group comprised 154 patients who had received their treatment based on previous clinical routine and subjective decision of physicians in charge. 56 patients who were managed according to the new CCP developed for SAP comprised the CCP group. CCP included:- Early assessment of the severity of acute pancreatitis (APACHE II score, presence of SIRS and/or organ dysfunction); - Immediate ICU monitoring including routine measurement of the intraabdominal pressure; - Conservative treatment including early enteral nutrition, colloids, antibacterial prophylaxis and early continuous venovenous hemofiltration (CVVHF) when indicated; - Surgical treatment when conservative treatment was not effective (progression of the organ dysfunction) or presence of infection was evident. Hospital, ICU stays and outcomes were analysed. Statistical comparison was done by Mann-Whitney U-test and Chi-square test.

RESULTS

The age structure and severity of the disease were similar in both groups with mean of 51.3 (15.6) vs. 46.8 (15.2) years and 9.7 (5.1) vs. 9.8 (4.4) APACHE II points in groups NP and CCP, respectively. Male/female ratio was 2 : 1, and alcohol was the main etiologic factor in about 55 % of cases in both groups. Early SAP was diagnosed in 33 % to 46 % of patients according to the results of the SOFA scoring. The results of the conservative therapy considerably improved after implementation of the CCP treatment. Surgical intervention was done in 46-52 % of patients. MODS was the main cause of death in both groups. Remarkable decrease in early mortality (within the first week from admission) was a real advantage of CCP treatment comprising 1.8 % vs. 22.1 % in NP patients, p < 0.01. Mortality from early SAP was reduced by CCP treatment to 3.8 % compared to 33 % in NP group, p < 0.01. There was a considerable reduction in postoperative mortality with CCP treatment comprising 10.3 % vs. 32.7 % in patients who did not receive CCP treatment, p < 0.05. Overall mortality associated with CCP treatment ranged to 5 %, compared to 34 % mortality in the NP treatment group, p < 0.01. Due to the considerable number of early deaths among NP patients, there was statistically longer ICU and hospital stay in CP group with mean of 14.1 (14.1) vs. 9.6 (15.2) days and 37.9 (26.7) vs. 23.4 (21.8) days, compared to NP group, p < 0.01.

CONCLUSIONS

Timely recognition and complex therapy of SAP including ICU monitoring, colloids, antibacterial prophylaxis, early enteral nutrition, and CVVHF is the most effective way how to manage this category of patients. Implementation of a specialised treatment protocol considerably improves outcome and reduces the number of deaths associated with surgery and early SAP.

[Ascites--a complication of chronic alcoholic pancreatitis]

We present the case a 44 year old patient previously diagnosed with chronic alcoholic pancreatitis with pancreatic ascites during hospitalization in the Gastro-Enterology department. As the conservative therapy performed for 21 days was not effective in diminishing the ascites, the patient was admitted in our Surgical Department and scheduled for surgical intervention. He was operated and we discovered a small dimension cyst (7/4 cm) developed in the body and tail of the pancreas, fistulized in the peritoneal cavity through an outlet positioned below the insertion of the mesocolonum transversum, fairly close to the duodeno-jejunal angle. We executed a cysto-jejunal anastomosis by using the first loop of the jejunum, secured with a politer drainage positioned as in WITZEL technique and drive out in the left upper quadrant. The postoperative evolution of the patient was difficult, but constantly positive. The patient left the hospital 32 days after the intervention. The clinical and ultrasound follow-up after three months were normal.

[Therapy of patients with chronic pancreatitis of alcoholic etiology by dalagrin and laser therapy of the blood]

Effectiveness of dalargin and intravenous laser blood beaming (ILBB) in combined treatment of chronic alcoholic pancreatitis (CAP) was studied in 105 patients (8 females and 97 males) with CAP duration 1 to 25 years. Pancreatic function and treatment effects were studied by routine clinical investigations, advanced laboratory, biochemical tests, radioimmunossays. Pancreatic disorders in alcoholics present with high blood levels of trypsin and lipase, low levels of insulin and C-peptide. Serum concentrations of hydrocortisone and gastrin were elevated. Combined treatment of CAP with adjuvant dalargin and ILBB not only relieves clinical symptoms but also promotes normalization of pancreatic function.

Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis

OBJECTIVES

Chronic pancreatic pain is difficult to treat. Surgical and medical therapies directed at reducing pain have met with little long-term success. In addition, there are no reliable predictors of response including pancreatic duct diameter. A differential neuroaxial blockade allows characterization of chronic abdominal pain into visceral and nonvisceral pain origins and may be useful as a guide to the treatment. Pain from an inflamed, and scarred pancreas should be visceral in origin. The purpose of our study was to determine the frequency with which patients with chronic pancreatitis have visceral pain and whether our modified differential neuroaxial blockade technique using thoracic epidural analgesia can accurately predict which patients will respond to medical or surgical therapy.

METHODS

We retrospectively reviewed the medical records of patients with a firmly established diagnosis of chronic pancreatitis (Cambridge classification, calcifications) who had undergone a differential neuroaxial block for their chronic abdominal pain evaluation. Patient demographics and medical or surgical treatment for pancreatic pain was recorded. Response to therapy was defined by a 50% reduction in pain by verbal response score.

RESULTS

A total of 23 patients were identified. Alcohol was the most common etiology for chronic pancreatitis (15 of 23, 55%). Surprisingly, the majority of chronic pancreatitis patients had nonvisceral pain (18 of 23, 78%) and only 22% (5 of 23) had visceral pain by differential neuroaxial block. Four of five patients (80%) with visceral pain responded to therapy, whereas only 5 of 17 (29%) of patients with nonvisceral pain responded.

CONCLUSIONS

Surprisingly, patients with chronic pancreatitis commonly have nonvisceral pain. Differential neuroaxial blockade can predict which patients will respond to therapy.

[Diabetic ketoacidosis presenting as acute abdomen]

Three patients, two women aged 21 and 67 and a man aged 43 years, presented at the emergency department with diabetic ketoacidosis and abdominal symptoms mimicking an acute abdominal condition. In two of them laparotomy was performed which proved to be negative. Abdominal symptoms resolved after correction of metabolic, fluid and electrolyte disturbances. Symptoms indicating a possible diagnosis of acute abdomen have to be regarded as being compatible with diabetic ketoacidosis per se. However, a potential acute abdominal problem prompting surgical intervention should not be overlooked; it may have been the precipitating factor for diabetic ketoacidosis.

The application of immobilized polymyxin B fiber in the treatment of septic shock associated with severe acute pancreatitis: report of two cases

The elimination of endotoxin by direct hemoperfusion over immobilized polymyxin B fiber (PMX-F) was carried out in two patients who developed septic shock associated with severe acute pancreatitis. Parameters such as blood pressure, body temperature, and plasma endotoxin level improved after PMX-F treatment, and the infected lesions were successfully and safely removed by surgery. Although an aggressive operative strategy of debridement with ultimate closure over drains is generally associated with low mortality in patients with this devastating disease, we often hesitate to perform this operation due to the poor condition of the patient in the acute period, with multiple organ failure and/or septic shock status, and also because of the difficulty in diagnosing the pancreatic infection. In this situation, endotoxin elimination using PMX-F is a useful tool for treating secondary pancreatic infections to help the patient recover in preparation for surgery, or for treating perioperative endotoxemia.

Endoscopic pancreatic duct stenting to treat pancreatic ascites

BACKGROUND

Management of pancreatic ascites with conservative medical therapy or surgery has met with limited success. Decompression of the pancreatic ductal system through transpapillary stent placement, an alternative strategy, has been reported in only a handful of cases of pancreatic ascites.

METHODS

We reviewed all cases from 1994 to 1997 in which patients with pancreatic ascites underwent an endoscopic retrograde pancreatogram documenting pancreatic duct disruption with subsequent placement of a transpapillary pancreatic duct stent. Clinical end points were resolution of ascites and need for surgery.

RESULTS

There were 8 cases of pancreatic ascites in which a 5F or 7F transpapillary pancreatic duct stent was placed as the initial drainage procedure. Pancreatic ascites resolved in 7 of 8 patients (88%) within 6 weeks. Ascites resolved in the eighth patient, a poor candidate for surgery, following placement of a 5 mm expandable metallic pancreatic stent. No infections, alterations in ductal morphology, or other complications related to stent placement were noted. There was no recurrence of pancreatic ascites or duct disruption at a mean follow-up of 14 months.

CONCLUSIONS

Our experience doubles the number of reported cases in which transpapillary pancreatic stent placement safely obviated the need for surgical intervention in the setting of pancreatic ascites. This therapeutic endoscopic intervention should be seriously considered in the initial management of patients with pancreatic ascites.

[Pancreaticolithiasis and pancreatic pseudocysts--interventional therapy]

Interventional (non-surgical) therapy is a relative new approach in the management of chronic pancreatitis. Indications for endoscopic therapy are pseudocysts and strictures or stones of the main pancreatic duct. Endoscopic sphincterotomy, extraction of pancreatic duct stones, extracorporal shock-wave lithotripsy (ESWL), pancreatic duct stenting and drainage of pseudocysts are all methods with a high success rate but with a low complication rate. Therefore in patients with chronic pancreatitis and with a failure of conservative management interventional techniques have to be considered. They may be an alternative to surgical procedures.

[Chronic pancreatitis: nutrition and pain therapy]

Therapy of chronic pancreatitis rests on five arms: Avoidance of alcohol, treatment of pain, replacement therapy for exocrine and endocrine insufficiency and adequate nutrition. Alcohol withdrawal improves pain and the patient's compliance. It also seems to retard the chronic inflammatory process. Therapy of pain depends on the pathomechanism of pain. There is a lack of prospective, controlled studies comparing various treatment regimens. Thus, treatment options are partly dependent on the experience of the physician taking care of the patient and include i.e. for pseudocysts: surgical vs percutaneous or endoscopic drainage; for stenosis of the main pancreatic duct close to the papilla: surgical vs endoscopic drainage (stents); for distal bile duct stenosis: endoscopic stents vs biliodigestive anastomosis vs pancreatic head resection; for pancreatic stones: extracorporal shock wave lithotripsy followed by endoscopic stone extraction vs surgery (pancreaticojejunostomy), finally for inflammatory tumor of the pancreatic head combined with pain with or without compression of the distal bile duct or duodenum: duodenum-preserving pancreatic head resection vs Whipple resection. Patients with pain resistant to medical treatment may be candidates for a transcutaneous blockade of the plexus coeliacus or for epidural nerve blockade before one choses a surgical procedure. Application of pancreatic enzymes does not seem to have a major beneficial effect on pancreatic pain. Modification of nutrition has become less restrictive. Thanks to improved substitution with acid resistant porcine pancreatic extracts with high lipase activity, fat restriction is no longer of paramount importance. However, supply with sufficient calories is still difficult due to pain, inadequate compliance and hypermetabolism.

Alcohol and the pancreas

Alcoholic pancreatitis may be one of the most serious adverse consequences of alcohol abuse. Its diagnosis, as it has for many years, depends primarily on clinical acumen in interpreting properly the symptoms and signs of abdominal distress, buttressed by elevated pancreatic enzymes (amylase and lipase). More recently, the use of computerized tomography (CT) in selected situations has been both of confirmatory and prognostic value. Severity of abnormality by CT correlates reasonably well with a variety of clinical-laboratory clusters (APACHE system, Ranson's criteria, etc.) and aids in therapy. The pathogenesis of alcoholic pancreatitis is not fully defined. The ultimate picture is one of tissue autolysis by activated proteolytic enzymes. The triggers for such activation, however, are still not known. They are represented by three main theories: (1) large duct obstruction and/or increased permeability relative to pancreatic secretion, (2) small duct obstruction due to proteinaceous precipitates, and (3) a direct toxic-metabolic effect of ethanol on pancreatic acinar cells. While not mutually exclusive, we favor the last hypothesis as being most consistent with the effects of ethanol on other organ systems. The direct effects of ethanol and/or its metabolites may be mediated, at least in part, via oxidative stress or the generation of fatty acid ethyl esters. Autolysis (regardless of proximate mechanism(s)) leads to inflammation likely mediated via release of various cytokines. It also should be appreciated that "acute" pancreatitis (the topic of this chapter) likely represents an acute process within a chronic pancreatic exposure and injury from alcoholic abuse. The key question of why pancreatitis develops in only a small number of alcohol abusers is not resolved. Therapy depends on the severity of alcoholic pancreatitis, which is defined by clinical-laboratory and often CT criteria. Mild pancreatitis usually resolves acutely with alcohol abstention and supportive therapy. Severe pancreatitis has a significant morbidity and mortality, mainly related to the degree of pancreatic necrosis and infection. It requires meticulous combined medical-surgical care.

Ethanol administration delays recovery from acute pancreatitis induced by exocrine hyperstimulation

Alcohol consumption causes acute alcohol pancreatitis and worsens the prognosis; however, there is no useful model for elucidation of the mechanism underlying this worsening. The aim of our study was to establish a new prognostic model of acute alcohol pancreatitis in rats. To ascertain the effect of continuous infusion of ethanol on each phase, i.e., progression and recovery, in caerulein-induced pancreatic injury in rats, we infused a physiological or supramaximal dose of caerulein intravenously to conscious Wistar rats for up to 6 h (time: 0-6 h) with or without ethanol infusion for 9 h (time: 3-12 h). Ethanol did not induce the pancreatic injury alone or when combined with a physiological dose of caerulein. In the progression phase, ethanol infusion for 3 h (time: 6 h) did not aggravate the pancreatic injury induced by a supramaximal dose of caerulein in terms of plasma amylase and lipase activities but did increase the pancreatic calcium level. In the recovery phase, however, ethanol infusion for 9 h (time: 12 h) significantly restrained the recovery from pancreatic injury as monitored in terms of these activities. Further, ethanol infusion for 9 h significantly increased the cumulative urinary excretion of amylase from 12 to 27 h but did not do the same from 0 to 12 h. In the histological evaluation at 27 h, the induction of acinar cell vacuolization and dilation of the glandular lumina and ducts were significant in the caerulein plus ethanol-treated group. Our findings suggest that ethanol administration delays the recovery rather than worsens the progression in acute pancreatic injury induced by exocrine hyperstimulation, and we consider our experimental model to be a useful tool for studying the pathogenesis of worsening prognosis in acute alcohol pancreatitis.

Pancreatic fluid collections: diagnosis and endoscopic management

Pancreatitis may be acute or chronic, mild or severe. Acute necrotizing pancreatitis remains the most serious form of acute pancreatitis and accounts for the majority of complications. Although there is an established nomenclature for pancreatitis and pancreatic fluid collections, such as pancreatic pseudocysts, it is not widely understood or recognized by gastroenterologists. Because the management options for the treatment of pancreatic fluid collections continues to evolve with an increased use of endoscopic therapy, gastroenterologists will be increasingly called on to treat patients with pancreatitis and its complications. This article addresses and summarizes pancreatic fluid collections and their management, with an emphasis on endoscopic drainage.

Transcatheter embolization of pseudoaneurysms complicating pancreatitis

PURPOSE

To evaluate the therapeutic role of angiography in patients with pseudoaneurysms complicating pancreatitis.

METHODS

Thirteen symptomatic pseudoaneurysms were treated in nine patients with pancreatitis. Eight patients had chronic pancreatitis and pseudocyst and one had acute pancreatitis. Clinical presentation included gastrointestinal bleeding in seven patients and epigastric pain without bleeding in two. All patients underwent transcatheter embolization.

RESULTS

Transcatheter embolization resulted in symptomatic resolution in all patients. Rebleeding occurred in two patients, 18 and 28 days after embolization respectively, and was successfully treated by repeated embolization. One patient with severe pancreatitis died from sepsis 28 days after embolization. Follow-up was then available for eight patients with no relapse of bleeding after a mean follow-up of 32 months (range 9-48 months).

CONCLUSION

Transcatheter embolization is safe and effective in the management of pseudoaneurysms complicating pancreatitis.

[Non-operative management of pancreatitis with splenic involvement]

Pancreatitic pseudocysts of the spleen are rare events. We report two cases of conservative management of splenic involvement in pancreatitis by ultrasound-guided aspiration. The first patient was admitted with clinical and biochemical signs of acute exacerbation of chronic pancreatitis. The ultrasound examination showed a subcapsular anechoic zone in the spleen as well as pancreatic pseudocysts. The laboratory examination of the fluid obtained by ultrasound-guided aspiration confirmed the presence of an intrasplenic pancreatitic pseudocyst which disappeared completely after a second percutaneous aspiration. The second patient was admitted with acute exacerbation of chronic pancreatitis and septic symptoms caused by an abscess near the left lobe of the liver. After successful surgical drainage of the abscess the patient developed an expanding anechoic subcapsular fluid zone in the spleen. Quantitative decompression by ultrasound guided fine needle-aspiration confirmed the pancreatitic origin of the lesion which vanished within a few days without further treatment. We conclude that fine-needle aspiration of splenic pseudocysts under ultrasound control permits a differential diagnostic distinction from splenic abscess or hematoma and accelerates healing. There is thus a nonsurgical option for treatment of pancreatitic intrasplenic pseudocysts, provided that the patient is under close clinical observation.

Cardiac tamponade--a rare complication in acute pancreatitis

A patient with recurrent acute pancreatitis developed pericardial effusion and cardiac tamponade. His systolic blood pressure fell to 70 mmHg and sinus tachycardia (150/min) developed. The central venous pressure rose from 3 cm H2O to 27 cm H2O. A chest radiograph showed an enlargement of the cardiac shadow. Pericardial paracentesis was performed and 300 ml fluid was aspirated. This produced rapid clinical improvement. The literature related to this uncommon complication is reviewed and possible pathogenetic mechanisms are discussed.

Alcohol-related pancreatic damage: mechanisms and treatment

Pancreatitis is a potentially fatal inflammation of the pancreas often associated with long-term alcohol consumption. Symptoms may result from blockage of small pancreatic ducts as well as from destruction of pancreatic tissue by digestive enzymes. In addition, by-products of alcohol metabolism within the pancreas may damage cell membranes. Research on the causes of pancreatitis may support more effective disease management and provide hope for a potential cure.

Recurrent pericardial effusion as a result of chronic pancreatitis. Successful treatment with somatostatin

We report a well-documented case of relapsing chronic calcifying pancreatitis with recurrent pleural and pericardial effusions during episodes of clinical and biochemical relapse of the pancreatitis. Pericardial effusions in association with pancreatitis have been reported only very occasionally, almost exclusively in chronic alcoholic pancreatitis with pseudocyst formation. Our successful conservative treatment consisted of parenteral nutrition and a continuous infusion of somatostatin for 6 weeks. We discuss other reported cases and proposed mechanisms of pathogenesis.