The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment).

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis).

Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.

[Prospective study of the prognostic value of C reactive protein, alpha 1-antitrypsin and alpha 1-acid glycoprotein in acute pancreatitis]. / Estudio prospectivo del valor pronóstico de la proteína C reactiva, alpha 1-antitripsina y alpha 1-glicoproteína ácida en la pancreatitis aguda.

Early recognition of severity of acute pancreatitis is very uncertain. For this reason it is necessary to have objective criteria to predict with accuracy the course of the disease. The aim of this study was to examine the value of the determination of the acute phase reactants: C reactive protein (CRP), alpha 1-antitrypsin (alpha-AT) and alpha 1-glycoprotein acid (alpha-GA) as prognostic indicators of acute pancreatitis on admission and on the third day. We have studied 40 patients with acute pancreatitis and serum concentrations of CRP, alpha-AT and alpha-GP were related to the Ranson Index. On admission the median levels of CRP: 74 mg/L, alpha-AT: 208 mg% and alpha-GA: 303 mg% were significantly higher (p less than 0.001) in patients with Ranson Index greater than or equal to 3 than in those with Ranson Index less than or equal to 2 (CRP: 166 mg/L, alpha-AT: 303 mg% and alpha-GA: 121 mg%). The values which differentiated patients with better and worse prognosis were: CRP 100 mg/L (sensitivity 100% and specificity 86%); alpha--AT 275 mg% (sensitivity 71% and specificity 85%); and alpha-GA 90 mg% (sensitivity 87.5% and specificity 57.9%). CRP, and to a lesser degree the alpha-AT and alpha-GA, were related to the duration of the ileus, and to the severe complications of the acute pancreatitis.

[Duodenal diverticula associated with acute pancreatitis]. / Asociación de divertículos duodenales y pancreatitis aguda.

UNLABELLED: The purpose of this study was to assess the role of duodenal diverticula as an etiologic factor in acute pancreatitis. METHODS AND PATIENTS: We have reviewed the records of patients with diverticulum of the second portion of the duodenum diagnosed by gastroduodenal radiology or endoscopy during the period 1991-1992 in our hospital. As a control group we studied patients without duodenal diverticulum. All subjects underwent biliary-pancreatic ultrasonography. Thirty-eight patients had a duodenal diverticulum and gallstones 36 had a duodenal diverticulum but no gallstones; 21 had gallstones alone; and, finally, 42 patients were free of duodenal diverticulum and gallstones. RESULTS: Patients with duodenal diverticula had a greater prevalence of gallstones than those without (51.3% VS 33.3%, p < 0.005). Of the thirty-eight patients with duodenal diverticula and gallstones 23.7% had acute pancreatitis. None of the 21 patients without duodenal diverticulum and with gallstones had acute pancreatitis, p < 0.05. The median age of patients with duodenal diverticulum without gallstones was 64.25 years, range 34-85, and the age of those with duodenal diverticulum and gallstones was 70.4 years, range 37-87, p < 0.05. CONCLUSIONS: 1) Gallstones may cause acute pancreatitis in patients with D2 duodenal diverticula. 2) Patients with a D2 duodenal diverticulum frequently have gallstones. 3) The fact that the age of patients with duodenal diverticulum was lower than that of patients with both duodenal diverticulum and gallstones suggests that duodenal diverticula may play a role in the pathogenesis of gallstones.

[Prospective study of gastroesophageal reflux after esophageal variceal band ligation]. / Estudio prospectivo del reflujo gastroesofágico tras ligadura de varices esofágicas con bandas elásticas.

UNLABELLED: In recent years, variceal ligation has been introduced as an alternative treatment to endoscopic sclerotherapy. AIM: To evaluate the occurrence of excess gastroesophageal reflux in cirrhotic patients with esophageal varices eradicated by band ligation. PATIENTS AND METHODS: Twenty-six cirrhotic patients with esophageal varices underwent band ligation until variceal eradication. pH monitoring was carried out in all patients before inclusion in the eradication program and again at the end. The results were evaluated according to De Meester's criteria. RESULTS: Five patients presented excess gastroesophageal reflux before the beginning of treatment. A further six patients developed excess gastroesophageal reflux after endoscopic treatment. The only factor implicated in the development of excess gastroesophageal reflux was the use of sclerosant at the end of treatment to ensure complete eradication: five of the eight who needed sclerosant developed excess gastrophageal reflux, while only two of the 16 treated without sclerosant did so (p < 0.01). CONCLUSION: Esophageal variceal band ligation does not significantly provoke excess gastroesophageal reflux if sclerosant is not used in the endoscopic technique.

[Selective intestinal bacterial decontamination in experimental acute pancreatitis]. / Descontaminación bacteriana selectiva intestinal en la pancreatitis aguda experimental.

BACKGROUND: Bacterial translocation implies the transit of viable gastric microflora from the intestinal lumen through the intestinal wall to the mesenteric ganglia and seems to be the mechanism by which microflora reach necrotic tissue in acute pancreatitis (AP). This occurs in 40-70% of necrotizing hemorrhagic AP and plays a major role in up to 80% of deaths from this cause. AIMS: To analyze the possible influence of bacterial decontamination in the gut on bacterial translocation in severe experimental AP. METHODS: Severe AP was induced in 43 male Sprague-Dawley rats by administration of 0.2 ml of 2.5% taurodeoxycholate sodium in NaOH glycyl-glycine buffer after cannulizing the bilio-pancreatic duct through the duodenum and clamping the common bile duct in the hepatic junction. The rats were divided into two groups: a) control group: 24 rats in which only AP was induced; b) problem group: 19 rats that underwent bacterial decontamination through the administration of 4 mg/ml gentamicin, bacitracin and neomycin in the drinking water during the 5 days prior to AP induction. Twenty-four hours after AP induction, laparotomy was performed and a sample for the culture of mesenteric lymphatic ganglia, pancreas, liver, spleen, peritoneum and cecum was obtained. RESULTS: Seven rats in the control group died. Of the 17 rats that survived 24 hours, positive cultures in the pancreas were obtained in nine. In the problem group, two rats died within 24 hours. Of the remaining 17 rats, positive pancreatic cultures were obtained in 2 while in 15 pancreatic cultures were negative. No microflora were cultured in the peritoneum. The microflora most frequently cultivated were Escherichia coli, enterococcus and proteus. No differences were found in the percentage of Gram-positive and Gram-negative bacteria between the two groups. CONCLUSIONS: a) The majority of the bacteria in AP tissue originate in the intestinal microflora, E. coli being the most prevalent. b) One of the main mechanisms in this process is bacterial translocation via the lymphatic pathway; transit directly through the transperitoneal pathway is not essential. c) Bacterial translocation already occurs in the earlier phases of AP. d) Bacterial decontamination prior to AP decreases the frequency of bacterial translocation and does not interfere in the Gram-positive/Gram negative balance, nor does it increase fungal infections.