Nonsteroidal anti-inflammatory drugs before endoscopic ultrasound guided tissue acquisition to reduce the incidence of post procedural pancreatitis.

Endoscopic ultrasound (EUS) with fine needle aspiration or fine needle biopsy is the gold standard for sampling tissue to diagnose pancreatic cancer and autoimmune pancreatitis or to analyze cyst fluid. The most common reported adverse event of fine needle aspiration and/or fine needle biopsy is acute pancreatitis, which is likely induced by the same pathophysiological mechanisms as after endoscopic retrograde cholangiopancreatography (ERCP). According to the current European Society of Gastrointestinal Endoscopy guideline, nonsteroidal anti-inflammatory drugs are administered prior to ERCP as a scientifically proven treatment to reduce post-ERCP pancreatitis incidence rate. A single suppository of diclofenac or indomethacin prior to EUS guided tissue acquisition (TA) is harmless in healthy adults. Since it is associated with low costs and, most important, may prevent a dreadsome complication, we strongly recommend the administration of 100 mg diclofenac rectally prior to EUS-TA. We will explain this recommendation in more detail in this review as well as the risk and pathophysiology of post-EUS TA pancreatitis.

Pancreas-related persisting sequelae in ALL survivors with a history of asparaginase-associated pancreatitis: A part of the ALL-STAR study.

OBJECTIVES: Asparaginase-associated pancreatitis (AAP) occurs in up to 18% of patients treated for acute lymphoblastic leukemia (ALL); however, long-term sequelae are largely unexplored. We aimed to explore pancreatic sequelae among ALL survivors with and without AAP. METHODS: We investigated pancreatic sequelae in a national cohort of ALL survivors, aged 1-45 years at ALL diagnosis treated according to the NOPHO-ALL2008 protocol and included sex- and age-matched community controls. RESULTS: We included 368 survivors (median follow-up 6.9 years), including 47 survivors with AAP and 369 controls. The p-lipase and p-pancreas-type amylase levels were lower in AAP survivors compared with both non-AAP survivors (Medians: 23 U/L [IQR 14-32] and 18 U/L [IQR 10-25] versus 29 [IQR 24-35] and 22 [17-28], p < .001 and p = .002) and community controls (28 U/L [IQR 22-33] and 21 U/L [IQR 17-26], both p < .006). Fecal-elastase was more frequently reduced in AAP survivors compared with non-AAP survivors (7/31 vs. 4/144, p = .001). Persisting pancreatic sequelae were found in 15/47 of AAP survivors and 20/323 of non-AAP survivors (p < .001), including diabetes mellitus in 2/39 of AAP survivors and 2/273 of non-AAP survivors. CONCLUSIONS: ALL survivors with AAP are at increased risk of persisting pancreatic dysfunction and require special attention during follow-up.

Pancreatic injury in patients treated with immune checkpoint inhibitors: a retrospective multicenterstudy.

BACKGROUND: Immune checkpoint inhibitor-related pancreatic injury (ICI-PI) is a rare occurrence, which has not been reported in detail. We conducted a retrospective multicenter study to determine the clinical characteristics, risk factors, and treatment of ICI-PI. METHODS: We reviewed the medical records of patients who received ICIs for malignant tumors between April 2014 and April 2019 at 16 participating hospitals. Patients with elevated pancreatic enzymes or pancreatitis were identified and classified using the Common terminology Criteria for Adverse Events (CTCAE) ver.5.0). The number of patients with pancreatic enzyme elevation was determined and those with pancreatic enzyme elevation of ≥ grade 3 according to CTCAE ver.5.0, or pancreatitis underwent detailed analysis for ICI-PI. RESULTS: The study enrolled 1069 patients. Nineteen patients (1.8%) had ICI-PI, 5 (0.5%) of whom also had pancreatitis. Four patients had mild pancreatitis, whereas 1 patient had severe pancreatitis, culminating in death. Steroid therapy was administered to 7 of 19 patients, which led to ICI-PI improvement in 5 patients. On the other hand, ICI-PI improved in 9 of 12 patients who were not administered steroid therapy. Six of the 14 patients with ICI-PI improvement were rechallenged with ICI, and ICI-PI relapse occurred in only 1 patient (16.7%), which improved with ICI discontinuation and steroid therapy. CONCLUSIONS: ICI-PI is a rare occurrence, with a low incidence of pancreatitis, which followed a very serious course in one patient. Although the benefit of steroid therapy for ICI-PI is unclear, ICI rechallenge is acceptable after improvement of ICI-PI without pancreatitis.

Clinical features and long-term outcomes of patients with type 2 autoimmune pancreatitis.

OBJECTIVES: Type 2 is a rare form of autoimmune pancreatitis (AIP). Despite being considered a benign disease, only few studies with limited sample size and short follow-up have been published on type 2 AIP. The aim of this observational study was to evaluate long-term outcomes, such as the risk of relapse, pancreatic insufficiency and cancer in a large type 2 AIP cohort with long follow-up. METHODS: Patients with definitive or probable diagnosis of type 2 AIP by International Consensus Diagnostic Criteria (ICDC) present in our prospectively maintained database since 1995 at 31.12.2021 were identified. All patients were clinically evaluated during the year 2022. Clinical, radiological, serological, and pathological data were evaluated. RESULTS: Eighty-eight out of 420 patients present in the database (21%) were diagnosed with type 2 AIP (mean age 33.5 ± 13.5 years). According to the ICDC, 21 patients (23.8%) had a definitive and 67 (76.2%) a probable diagnosis of type 2 AIP. The mean follow-up was 9.2 ± 7.1 years (range 1-27 years). No differences were observed when comparing patients with definitive and probable type 2 AIP diagnosis. Concomitant IBD was reported in 77 patients (87.5%). The probability of disease relapse was lower in patients treated with steroids versus surgery (at 5 years 13% vs. 33%; p = 0.038) but this difference was not statistically significant at multivariable analysis. The risk of endocrine or severe exocrine insufficiency was low (5% and 25%). Four extra-pancreatic malignancies (5%) were diagnosed, none pancreatic. One patient died in a car accident. CONCLUSIONS: Type 2 AIP has benign long-term clinical outcomes. Mortality and cancer rates are low and no specific follow-up is needed after radiological remission.

Frequency of Post Endoscopic Retrograde Cholangiopancreatography Acute Pancreatitis in an Academic Hospital of Bangladesh.

Post-ERCP acute pancreatitis (PEP) is a common and serious complication with high morbidity and mortality rates. There is a paucity of data on the frequency of PEP in a resource constraint setting like Bangladesh. Hence we have conducted a prospective study to determine the frequency of PEP and the factors associated with its occurrence. This prospective, observational study was carried out in Gastroenterology Department of Dhaka Medical College & Hospital, Dhaka, Bangladesh from April 2018 to December 2018 on the consecutive patients who underwent ERCP. PEP and its severity were diagnosed according to consensus definition. Serum lipase was done in all patients before procedure and 24 hours after procedure or if patient develops abdominal pain after the procedure which became earlier. Total 168 patients were included (mean age 46.97±14.35 years; male 72(43.0%). The most common indication of ERCP was choledocholithiasis 97(58.0%) followed by malignant biliary obstruction 45(27.0%), recurrent pyogenic cholangitis 8(5.0%), chronic pancreatitis 4(2.3%), biliary ascariasis 4(2.3%) and others 10(6.0%). Overall post ERCP complication rate was 46(27.3%) including cholangitis 29(17.3%), pancreatitis 16(9.5%), bleeding 12(7.1%), aspiration pneumonia 4(2.4%) and death 3(1.8%). Regarding the severity of PEP, 50.0%, 43.7% and 6.3% patients developed mild, moderate and severe pancreatitis respectively. Number of cannulation attempts >5 times [22(48%) vs. 17(14%); p=0.001], cannulation attempts duration more than 10 minutes [25(55%) vs. 27(22%); p=0.001], unintentional passage of guide wire into the pancreatic duct [8(17%) vs. 18(15%); p=0.001], pancreatic duct contrast injection [12(26%) vs. 2(1.6%); p=0.001] and pre-cut sphincterotomy [16(35%) vs. 6(4.9%); p=0.001] were significantly different between the patients who developed PEP compared to those who did not. In multiple logistic regressions analysis, pancreatic duct contrast injection was significantly associated with PEP [OR 25.523 with 95% CI (4.049- 100.0%)]. Around ten percent patients had developed PEP. Regarding the severity half of them were mild, 44.0% patients had moderate and 6.0% patient had severe type of pancreatitis. Difficult cannulation, unintentional passage of guide wire into the pancreas, pancreatic duct contrast injection and pre-cut sphincterotomy were associated with PEP. Among them pancreatic duct contrast injection had independent significance in the causation of PEP.

Drug-Induced Acute Pancreatitis: A Real-World Pharmacovigilance Study Using the FDA Adverse Event Reporting System Database.

Timely identification and discontinuation of culprit-drug is the cornerstone of clinical management of drug-induced acute pancreatitis (AP), but the comprehensive landscape of AP culprit-drugs is still lacking. To provide the current overview of AP culprit-drugs to guide clinical practice, we reviewed the adverse event (AE) reports associated with AP in the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database from 2004 to 2022, and summarized a potential AP culprit-drug list and its corresponding AE report quantity proportion. The disproportionality analysis was used to detect adverse drug reaction (ADR) signals for each drug in the drug list, and the ADR signal distribution was integrated to show the risk characteristic of drugs according to the ADR signal detection results. In the FAERS database, a total of 62,206 AE reports were AP-related, in which 1,175 drugs were reported as culprit-drug. On the whole, metformin was the drug with the greatest number of AE reports, followed by quetiapine, liraglutide, exenatide, and sitagliptin. Drugs used in diabetes was the drug class with the greatest number of AE reports, followed by immunosuppressants, psycholeptics, drugs for acid-related disorders, and analgesics. In disproportionality analysis, 595 drugs showed potential AP risk, whereas 580 drugs did not show any positive ADR signal. According to the positive-negative distribution of the ADR signal for drug classes, the drug class with the greatest number of positive drugs was antineoplastic agents. In this study, we provided the current comprehensive landscape of AP culprit-drugs from the pharmacovigilance perspective, which can provide reference information for clinical practice.

Post-ERCP Pancreatitis Risk Factors: Is Post-Sphincterotomy Bleeding Another Risk Factor?

BACKGROUND: Despite advancements in technology and expertise, ERCP carries risks of significant complications, such as pancreatitis, bleeding, and perforation. Post-ERCP pancreatitis is the most common and important complication following ERCP. In our study, we aimed to examine the relationship between patient and procedure-related parameters and the development of pancreatitis. METHODS: Four hundred patients who underwent ERCP between January 1, 2019 and December 31, 2020, at the General Surgery Clinic of the Bakirköy Dr. Sadi Konuk Health Application and Research Center of the University of Health Sciences Faculty of Medicine were retrospectively evaluated. Patient and procedure-related factors were analyzed statistically through univariate and multivariate analyses. RESULTS: Age, urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, pancreatic cannulation, pancreatic stent, and bleeding were statistically significant risk factors for post-ERCP pancreatitis (+). In multivariate analysis, the effects of urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, and pancreatic cannulation on post-ERCP pancreatitis were statistically significant risk factors ( P <0.05). DISCUSSION: This study demonstrates that emergency indication, ERCP history, cholangitis, precut sphincterotomy, and pancreatic cannulation are significant risk factors for the development of post- ERCP pancreatitis. One notable contribution of our study to the existing literature is the unique analysis of post-sphincterotomy bleeding as an independent factor.

Artificial intelligence in a prediction model for postendoscopic retrograde cholangiopancreatography pancreatitis.

OBJECTIVES: In this study we aimed to develop an artificial intelligence-based model for predicting postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). METHODS: We retrospectively reviewed ERCP patients at Nagoya University Hospital (NUH) and Toyota Memorial Hospital (TMH). We constructed two prediction models, a random forest (RF), one of the machine-learning algorithms, and a logistic regression (LR) model. First, we selected features of each model from 40 possible features. Then the models were trained and validated using three fold cross-validation in the NUH cohort and tested in the TMH cohort. The area under the receiver operating characteristic curve (AUROC) was used to assess model performance. Finally, using the output parameters of the RF model, we classified the patients into low-, medium-, and high-risk groups. RESULTS: A total of 615 patients at NUH and 544 patients at TMH were enrolled. Ten features were selected for the RF model, including albumin, creatinine, biliary tract cancer, pancreatic cancer, bile duct stone, total procedure time, pancreatic duct injection, pancreatic guidewire-assisted technique without a pancreatic stent, intraductal ultrasonography, and bile duct biopsy. In the three fold cross-validation, the RF model showed better predictive ability than the LR model (AUROC 0.821 vs. 0.660). In the test, the RF model also showed better performance (AUROC 0.770 vs. 0.663, P = 0.002). Based on the RF model, we classified the patients according to the incidence of PEP (2.9%, 10.0%, and 23.9%). CONCLUSION: We developed an RF model. Machine-learning algorithms could be powerful tools to develop accurate prediction models.

Endoscopic ultrasound-guided gallbladder drainage with long-term lumen-apposing metal stent indwell: 1-year results from a prospective nationwide observational study.

BACKGROUND AND AIM: This study aimed to determine safety and risk factors for adverse events (AEs) of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with long-term indwell of lumen-apposing metal stents (LAMS). METHODS: This study is a multicenter prospective observational study on consecutive high surgical-risk patients requiring gallbladder drainage who underwent EUS-GBD with LAMS over 12 months. Centralized telephone follow-up interviews were conducted every 3 months for 1 year. Patients were censored at LAMS removal, cholecystectomy, or death. AE-free survival was determined using log-rank tests. Cumulative risks were estimated using life-table analysis. RESULTS: Eighty-two patients were included (53.7% male, median [interquartile range] age of 84.6 [76.5-89.8] years, and 85.4% with acute cholecystitis). Technical success was achieved in 79 (96.3%), and clinical success in 73 (89%). No patient was lost to follow-up; 45 patients (54.9%) completed 1-year follow-up with in situ LAMS. Median (interquartile range) LAMS indwell time was 364 (47-367) days. Overall, 12 (14.6%) patients presented 14 AEs, including 5 (6.1%) recurrent biliary events (3 acute cholangitis, 1 mild acute pancreatitis, and 1 acute cholecystitis). Patients with pancreatobiliary malignancy had an increased risk of recurrent biliary events (33% vs 1.5%, P = 0.001). The overall 1-year cumulative risk of recurrent biliary events was 9.7% (4.1-21.8%). The 1-year risk of AEs and of severe AEs was 18.8% (11-31.2%) and 7.9% (3.3-18.2%), respectively. Pancreatobiliary malignancy was the single risk factor for recurrent biliary events; LAMS misdeployment was the strongest risk factor for AEs. CONCLUSIONS: Long-term LAMS indwell does not increase the risk of delayed AEs following EUS-GBD.

Acute pancreatitis in childhood - a comparative international study and tale of two cities.

BACKGROUNDS: To compare factor(s) contributing to aetiology, management and clinical outcome(s) of paediatric patients acquiring acute pancreatitis (AP) at two major university paediatric surgical centres in Liverpool and Bangkok. METHODS: All patients (<18 years) with an index diagnosis of AP (ICD 10 coding) during 2006-2016 were studied. RESULTS: 121 patients included n = 79 (65.3%) in Thailand versus n = 42 (34.7%) in the UK centre with no difference(s) in age at diagnosis at 10.4 ± 4.5 and 11.7 ± 6 years. (P = 0.12). Major AP aetiology(s) in Thailand were medications (39.2%) and choledochal cysts (8.9%). In the UK-gallstone disease (21.4%), and medications (16.7%) were leading factors (P < 0.01). Ultrasonography was deployed more frequently in the UK versus Thai centre (74.3% vs. 49.1%; P < 0.01). Pancreatitis was confirmed by imaging in 67.9% (Thai) and 62.9% (UK) patients (P = 0.47). Most patients at both centres had a mild-grade pancreatitis illness (95% Thai vs. 90.5% UK; P = 0.28) while 12.7% of Thai and 19% of UK children developed pancreatitis-related complication (P = 0.37). Overall mortality rate (%) was significantly higher in the Thai versus UK centre (27.8% vs. 9.5%; P = 0.02). CONCLUSIONS: Aetiology of acute pancreatitis appears to vary between UK and Thailand children. Timely early diagnosis and healthcare pathways may be driven by local patient-related factor(s). The higher mortality (%) observed in Thailand versus UK in this comparative study was linked to underlying co-existent chronic medical condition(s) in vulnerable patient cohorts.

Pancreatitis and Hyperlipasemia in the Setting of Immune Checkpoint Inhibitor Therapy.

BACKGROUND: Immune checkpoint inhibitor-induced pancreatic injury (ICI-PI) ranges from asymptomatic hyperlipasemia to symptomatic acute pancreatitis (AP). The proportion of pancreatic injury while receiving ICIs that is attributable to therapy remains unclear. We evaluated the etiology of hyperlipasemia in patients receiving ICIs, and the clinical characteristics, management, and outcomes of ICI-PI. PATIENTS AND METHODS: We assessed 6,450 consecutive adult patients with cancer who received ICI doses between 2011 and 2019, 364 of whom had at least 1 instance of elevated serum lipase after ICI initiation and were included in our trial. Primary outcomes were the development of ICI-PI and ICI-induced acute pancreatitis (ICI-AP). RESULTS: Pancreatic injury was attributable to ICI use in 105 individuals (29% of those with hyperlipasemia; 1.6% overall). Of 27 patients with ICI-AP, 4 (15%) presented asymptomatically with hyperlipasemia and pancreatic inflammation on imaging. In multivariable regression, the presence of other immune-related adverse events was positively associated with ICI-AP (≥2 events: odds ratio, 5.43; 95% CI, 1.47-26.03). Compared with patients with other ICI-PI, those with ICI-AP more frequently required steroids (74% vs 4%), intravenous fluids (85% vs 10%), hospitalization (89% vs 9%), and permanent cessation of ICIs due to pancreatic injury (70% vs 3%), and less frequently continued therapy uninterrupted (0% vs 40%) (P<.01 for all). Of the 105 patients, 3 (3%) developed exocrine insufficiency and 9 (9%) developed endocrine insufficiency, which were concentrated among those with ICI-AP. CONCLUSIONS: A minority of occurrences of pancreatitis and hyperlipasemia in patients receiving ICIs are due to these therapies, supporting NCCN recommendations to exclude alternative etiologies. Because a notable proportion of patients with ICI-AP were asymptomatic but warranted treatment per current guidelines, abdominal imaging is diagnostically valuable in those with significant hyperlipasemia. Patients with ICI-AP should be monitored for exocrine pancreatic insufficiency. Many with hyperlipasemia who do not meet the criteria for AP can continue therapy uninterrupted.

Incidence, clinical features, and risk factors for acute pancreatitis following posterior instrumented fusion surgery for lumbar degenerative disease: a single-center, retrospective analysis of 20,929 patients.

PURPOSE: The aim of this study is to identify the incidence, clinical features, and risk factors for postoperative acute pancreatitis (PAP) after lumbar surgery. METHODS: We retrospectively analyzed patients who developed PAP after posterior lumbar fusion surgery. For each PAP patient, data were collected for four controls who underwent procedures in the same period and did not develop PAP. Statistical methods included univariate and multivariate analyses. RESULTS: Totally, 21 out of 20,929 patients were diagnosed with PAP (0.10%) after posterior lumbar fusion surgery. Patients with degenerative lumbar scoliosis were at higher risk of developing PAP (P < 0.05). With atypical clinical features, PAP occurred within 3 days (0-5) after surgery. PAP patients had significantly higher incidence of osteoporosis (47.6 vs. 22.6%, P = 0.030) and fusion of L1/2(42.9 vs. 4.3%, P = 0.010), lower albumin (42.2 ± 4.1 vs. 44.3 ± 3.2 g/L, P = 0.010), more fusion segments (median 4 vs. 3, P = 0.022), larger surgical invasiveness index (median 9 vs. 8, P = 0.007), longer operation duration (232 ± 109 vs. 185 ± 90 min, P = 0.041), greater estimated blood loss (median 600 vs. 400 mL, P = 0.025), lower intraoperative mean arterial pressure (87.2 ± 9.9 vs. 92.1 ± 8.8 mmHg, P = 0.024). Multivariate logistic regression analysis found three independent risk factors: fusion of L1/2, surgical invasiveness index > 8, and intraoperative mean arterial pressure < 90 mmHg. All patients were treated with conservative therapy and fully recovered after 8.1 (4-22) days. CONCLUSION: The incidence of PAP following posterior surgery for degenerative lumbar disease was 0.10%, and its clinical features were not typical. The fusion of L1/2, high surgical invasiveness index, and low intraoperative mean arterial pressure were independent risk factors for PAP after surgery for lumbar degenerative disease.

Effects of Somatostatin and Indomethacin Mono or Combination Therapy on High-risk Hyperamylasemia and Post-pancreatitis Endoscopic Retrograde Cholangiopancreatography Patients: A Randomized Study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive technique widely used to diagnose and treat pancreatic and biliary diseases; however, it is linked with imminent hyperamylasemia and post-ERCP pancreatitis (PEP). Somatostatin and indomethacin are the classic recommended drugs used for PEP prevention. OBJECTIVE: To elucidate the effects of somatostatin and indomethacin mono or in combination to prevent hyperamylasemia and PEP in high-risk individuals. METHODS: Altogether 1458 patients who underwent ERCP in our hospital from January 2016 to May 2022 were included in this investigation and categorized into 4 groups based on the treatment regimen: placebo, indomethacin, somatostatin, and indomethacin + somatostatin. The pre operation and post operation (at 6, 12, and 24 h) hospitalization cost, length of stay, the occurrence of hyperamylasemia and PEP, levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), IL-8, and VAS pain score were determined in the 4 groups. In all the groups, VAS and IL-6, TNF-α, and IL-8 levels substantially increased in the pretreatment and decreased sequentially from 6 to 24 h post operation. The individuals in the indomethacin revealed substantially reduced hyperamylasemia, VAS, and levels of IL-6, TNF-α, and IL-8, 6 h post operation, whereas the hospitalization fee, length of stay, PEP incidence, VAS, levels of IL-6, TNF-α, and IL-8, 12 and 24 h post operation were not statistically important in comparison with the individuals who received placebo therapy. The somatostatin and the indomethacin + somatostatin groups indicated markedly alleviated hospitalization fee, length of stay, the occurrence of hyperamylasemia and PEP, VAS, and the levels of IL-6, TNF-α, and IL-8 at 6, 12, and 24 h post operation compared with the placebo cohort. Furthermore, compared with the indomethacin group, the above-determined factors notably reduced at 6, 12, and 24 h post operation in somatostatin and indomethacin + somatostatin groups. It was also observed that the indomethacin + somatostatin group has substantially decreased the occurrence of hyperamylasemia, VAS score, and levels of IL-6, TNF-α, and IL-8, 6 hours post operation, while at 12 and 24 h post operation, the hospitalization fee, length of stay and incidence of PEP, VAS, levels of IL-6, TNF-α, and IL-8 were not statistically important compared with the somatostatin group. It is also worth noting that the side effects of both drugs are rare and mild. RESULTS: For high-risk PEP patients, indomethacin and somatostatin can efficiently alleviate post-operative hyperamylasemia and improve their life standard within 6 hours and 24 hours, respectively. Indomethacin is suitable for individuals who underwent simple, short-duration ERCP with expected mild post-operative abdominal pain, whereas somatostatin is given to patients with complicated, long-duration ERCP and expected severe post-operative abdominal pain. Their combinational therapy produces a synergistic effect and can reduce the incidence of hyperamylasemia, thereby improving patients' quality of life within 6 h and is also effective against individuals who received a more complicated, longer-duration ERCP and were expected to have severer and longer post-operative abdominal pain.

Frequent guidewire passage into the pancreatic duct is an independent risk factor for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among high-risk individuals: A post-hoc analysis of a randomized controlled trial data.

OBJECTIVES: To systematically evaluate the patient and procedural risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among patients receiving rectal indomethacin. METHODS: Data from a randomized controlled trial (RCT) of high-risk patients undergoing ERCP who received rectal indomethacin with or without topical epinephrine was evaluated. PEP was defined based on the consensus criteria. Pancreatic stenting was excluded to avoid confounding results with the role of epinephrine spray. Multivariable logistic regression analysis was used to identify patient and procedural risk factors for PEP. RESULTS: Among 960 patients enrolled in the RCT, the PEP incidence was 6.4%. An increased risk of PEP was seen with age <50 years and female gender (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.35-4.26), malignant biliary stricture(s) (OR 3.51, 95% CI 1.52-8.10), >2 guidewire passes into the pancreatic duct (PD) (OR 2.84, 95% CI 1.43-5.64), and pancreatic brush cytology (OR 6.37, 95% CI 1.10-36.90), whereas a decreased risk of PEP was seen with contrast- over guidewire-assisted cannulation (OR 0.14, 95% CI 0.02-0.99) and the use of lactated Ringer's (LR) over other fluid types (OR 0.52, 95% CI 0.27-0.98). There was a significant trend between the number of guidewire passes into the PD and PEP risk (P = 0.002). CONCLUSIONS: More than two guidewire passes into the PD and pancreatic brush cytology increased while the use of LR decreased the risk of PEP among high-risk patients receiving rectal indomethacin. Pancreatic stent placement and/or LR should be considered in patients with >2 guidewire passes into the PD.

Logistic regression analysis of risk factors for hemorrhagic fever with renal syndrome complicated with acute pancreatitis.

BACKGROUND: Hantavirus infection is the main cause of hemorrhagic fever with renal syndrome (HFRS), which is common in Asia and Europe. There is a considerable risk of morbidity and mortality from the uncommon Hantavirus complication known as acute pancreatitis (AP). METHODS: Retrospective analysis of the medical records of individuals with HFRS was performed. Relevant variables were assessed by univariate analyses and the variables with a p value <.05 were entered into the multivariable regression analysis. RESULTS: In this study, 114 individuals with HFRS in total were included, and 30 of them (26.32%) had AP. The univariate analyses showed that living in Xuancheng city (Anhui Province); an alcohol consumption history; white blood cell (WBC) count; lymphocyte (lym%) and eosinophil percentages (EO%); neutrophil (neut), eosinophil (EO), and red blood cell (RBC) counts; hemoglobin (Hb); hematocrit (HCT); proteinuria; hematuria; albumin (ALB), blood urea nitrogen (BUN), creatinine (Cr), uric acid (UA), cystatin-C (Cys-C) levels; carbon dioxide-combining power (CO2CP); fibrinogen degradation products (FDPs); and D-dimer level were significantly associated with HFRS complicated with AP (p < .05). In the multivariable regression analysis, an alcohol consumption history, lym%, proteinuria, FDPs and D-dimer level were found to be risk factors for HFRS complicated with AP (p < .05). CONCLUSION: Our findings indicate that HFRS patients with a history of consuming alcohol, a high lym%, intense proteinuria, high levels of FDPs, and a low level of D-dimer might be more prone to the development of AP.KEY MESSAGESThis is the first report employing Logistic regression analysis methods for exploring the risk factors for HFRS complicated with AP in China.Many factors (most are laboratory parameters) were significantly associated with HFRS complicated with AP.We found that HFRS patients with a history of consuming alcohol, a high lym%, intense proteinuria, high levels of FDPs, and a low level of D-dimer might be more prone to the development of AP.

Prevalence of neoplasia and concurrent diseases in dogs and cats with hypercobalaminemia: A retrospective case-control study.

BACKGROUND: Hypercobalaminemia is infrequently reported in companion animals and is considered of low clinical significance. Recent studies have described its association with inflammatory, immune-mediated, endocrine, and neoplastic conditions in dogs and cats. OBJECTIVES: We aimed to investigate the association between hypercobalaminemia and neoplasia in companion animals and to identify other concurrent diseases or clinicopathologic changes. METHODS: This is a retrospective, case-control study. Medical records of patients with measured serum cobalamin concentration (2015-2020) and no history of prior supplementation were reviewed. Hypocobalaminemic animals were excluded. Variables were compared between groups (hypercobalaminemic vs. normocobalaminemic) using non-parametric statistics. Data are presented as median (range). RESULTS: Thirty-five dogs and eight cats were hypercobalaminemic. At baseline, neoplasia was confirmed in 4/35 hypercobalaminemic dogs versus 11/70 control dogs (P = 0.77) and 0/8 hypercobalaminemic cats versus 3/16 control cats (P = 0.53). Cases without neoplasia at baseline were followed for 409 (13-1854) days (dogs, n = 78) and 395 (28-1670) days (cats, n = 21). During follow-up, neoplasia was diagnosed in 4/27 hypercobalaminemic dogs versus 3/51 control dogs (P = 0.23) and 1/8 hypercobalaminemic cats versus 0/13 control cats (P = 0.38). Pancreatitis was more frequent in hypercobalaminemic dogs (P = 0.006). Hypercobalaminemic dogs had higher serum total protein (P = 0.014), globulin (P = 0.001), and CRP (P = 0.032) concentrations and lower serum sodium (P = 0.012) and chloride (P = 0.033) concentrations than controls. Hypercobalaminemic cats had higher serum total protein concentrations than controls (P = 0.008). CONCLUSION: Our results suggest that hypercobalaminemia is not associated with the presence or development of neoplasia in dogs and cats but may be associated with systemic inflammatory conditions, including pancreatitis, in dogs.

Acute peripancreatic fluid collection in acute pancreatitis: Incidence, outcome, and association with inflammatory markers.

Background: The hospital outcomes and predictors of acute peripancreatic fluid collection (APFC) have not been well-characterized. In this study, we aimed to investigate the clinical outcomes of APFC in patients with acute pancreatitis (AP) and the role of the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and C-reactive protein (CRP) level in predicting the occurrence of APFC. Methods: In this retrospective study, the complicated group (patients with APFC) and the uncomplicated group (patients without APFC) were compared for their clinical characteristics, hospital outcomes (mortality rate, intensive care unit admission rate, and length of hospital stay), pseudocyst formation, CRP levels, SII, and SIRI on admission and at 48 hours. Results: Of 132 patients with AP, 51 (38.6%) had APFC and eight (6.1%) had pancreatic pseudocysts. Of 51 patients with APFC, 15.7% had pancreatic pseudocysts. Pseudocyst did not develop in the uncomplicated group. SII value at 48 h [median 859 (541-1740) x 109/L vs. 610 (343-1259) x 109/L, P = 0.01] and CRP level at 48 h [89 (40-237) mg/L vs. 38 (12-122) mg/L, P = 0.01] were higher in the complicated group than in the uncomplicated group. The length of hospital stay was longer in the complicated group, compared with the uncomplicated group [median 8 days (5-15), vs. 4 days (3-7), P < 0.001, respectively]. No significant difference was detected between the two study groups' mortality rates and intensive care unit admission rates. Conclusions: While 38.6% of the AP patients had APFC, 6.1% of all patients and 15.7% of the patients with APFC had pancreatic pseudocysts. APFC was found to lengthen the hospital stay and to be associated with the SII value and CRP level measured at 48 h.

Recurrence rates and risk factors for recurrence after first episode of acute pancreatitis: A systematic review and meta-analysis.

BACKGROUND: There are a certain number of acute pancreatitis (AP) patients who may suffer from multiple episodes and develop recurrent acute pancreatitis (RAP), but recurrence rates and associated risk factors for RAP vary significantly in the published literature. METHODS: We searched PubMed, Web of Science, Scopus, and Embase databases to identify all publications reporting AP recurrence until October 20th, 2022. Meta-analysis and meta-regression were performed to calculate the pooled estimates using the random-effects model. RESULTS: A total of 36 studies met the inclusion criteria and all were used in pooled analyses. The overall rate of recurrence after first-time AP was 21% (95% CI, 18%- 24%), and pooled rates in biliary, alcoholic, idiopathic, and hypertriglyceridemia etiology patients were 12%, 30%, 25%, and 30%, respectively. After managing underlying causes post-discharge, the recurrence rate decreased (14% versus 4% for biliary, 30% versus 6% for alcoholic, and 30% versus 22% for hypertriglyceridemia AP). An increased risk of recurrence was reported in patients with a smoking history (odds ratio [OR] = 1.99), alcoholic etiology (OR = 1.72), male sex (hazard ratio [HR] = 1.63), and local complications (HR = 3.40), while biliary etiology was associated with lower recurrence rates (OR = 0.38). CONCLUSION: More than one-fifth of AP patients experienced recurrence after discharge, with the highest recurrence rate in alcoholic and hypertriglyceridemia etiologies, and managing underlying causes post-discharge was related to decreased incidence. In addition, smoking history, alcoholic etiology, male gender, and presence of local complications were independent risks for the recurrence.

Autoimmune Pancreatitis in Patients with Inflammatory Bowel Disease: A Real-World Multicentre Collaborative ECCO CONFER Study.

BACKGROUND: Autoimmune pancreatitis [AIP] is rarely associated with inflammatory bowel disease [IBD]. The long-term outcomes of AIP and IBD in patients with coexisting AIP-IBD and predictors of complicated AIP course have rarely been reported. METHODS: An ECCO COllaborative Network For Exceptionally Rare case reports project [ECCO-CONFER] collected cases of AIP diagnosed in patients with IBD. Complicated AIP was defined as a composite of endocrine and/or exocrine pancreatic insufficiency, and/or pancreatic cancer. We explored factors associated with complicated AIP in IBD. RESULTS: We included 96 patients [53% males, 79% ulcerative colitis, 72% type 2 AIP, age at AIP diagnosis 35 ±â€…16 years]. The majority of Crohn's disease [CD] cases [78%] had colonic/ileocolonic involvement. In 59%, IBD preceded AIP diagnosis, whereas 18% were diagnosed simultaneously. Advanced therapy to control IBD was used in 61% and 17% underwent IBD-related surgery. In total, 82% of patients were treated with steroids for AIP, the majority of whom [91%] responded to a single course of treatment. During a mean follow-up of 7 years, AIP complications occurred in 25/96 [26%] individuals. In a multivariate model, older age at AIP diagnosis was associated with a complicated AIP course (odds ratio [OR] = 1.05, p = 0.008), whereas family history of IBD [OR = 0.1, p = 0.03], and CD diagnosis [OR = 0.2, p = 0.04] decreased the risk of AIP complications. No IBD- or AIP-related deaths occurred. CONCLUSIONS: In this large international cohort of patients with concomitant AIP-IBD, most patients have type 2 AIP and colonic IBD. AIP course is relatively benign and long-term outcomes are favourable, but one-quarter develop pancreatic complications. Age, familial history of IBD, and CD may predict uncomplicated AIP course.

Drug-induced acute pancreatitis due to medications used for inflammatory bowel disease: A VigiBase pharmacovigilance database study.

BACKGROUND: Nearly all medications used for inflammatory bowel disease (IBD) have been reported as causes of acute pancreatitis (AP), with the thiopurines being among the most frequently described. However, with the development of newer medications, thiopurine monotherapy has largely been replaced by newer immunosuppressive drugs. There are few data on the association between AP and biologic/small molecule agents. METHODS: VigiBase, the World Health Organization's Global Individual Case Safety Report database, was used to assess the association between AP and common IBD medications. A case/non-case disproportionality analysis was performed and disproportionality signals were reported as a reporting odds ratio (ROR) with 95% confidence intervals (CIs). RESULTS: A total of 4,223 AP episodes were identified for common IBD medications. Azathioprine (ROR 19.18, 95% CI 18.21-20.20), 6-mercaptopurine (ROR 13.30, 95% CI 11.73-15.07), and 5-aminosalicylic acid (ROR 17.44, 95% CI 16.24-18.72) all had strong associations with AP, while the biologic/small molecule agents showed weaker or no disproportionality. The association with AP was much higher for thiopurines when used for Crohn's disease (ROR 34.61, 95% CI 30.95-38.70) compared to ulcerative colitis (ROR 8.94, 95% CI 7.47-10.71) or rheumatologic conditions (ROR 18.87, 95% CI 14.72-24.19). CONCLUSIONS: We report the largest real-world database study investigating the association between common IBD medications and AP. Among commonly used IBD medications including biologic/small molecule agents, only thiopurines and 5-aminosalicylic acid are strongly associated with AP. The association between thiopurines and AP is much stronger when the drug is used for Crohn's disease compared to ulcerative colitis and rheumatologic conditions.