Clasificación de Rosemont para pancreatitis crónica / Rosemont classification for chronic pancreatitis

Chronic pancreatitis is a persistent fibroinflammatory disease of the pancreas, more common in smokers or alcoho- lics. Genetic predisposition with mutations in various genes has also been documented. It typically presents with recurrent abdominal pain and endocrine and exocrine dysfunction, potentially progressing to pancreatic cancer and severe complications in later stages. In Chile, an annual incidence of 0.8 cases per 100,000 inhabitants is estimated, with a prevalence of 6.1 cases per 100,000 inhabitants. Early diagnosis is a current challenge for which endosonography has emerged as a sensitive and specific diagnostic tool, especially with the implementation of the Rosemont classification. Various studies have validated the utility of this classification. However, the limited availability of endosonography in some countries, such as Chile, establishes challenges for generalizing its appli- cation. It is expected that in the future, the Rosemont classification will become a standard for the diagnosis of chronic pancreatitis.

La pancreatitis crónica es una enfermedad fibroinflamatoria persistente del páncreas, más común en fumadores o alcohólicos. De igual forma se ha documentado predisposición genética con mutaciones de distintos genes. Usualmente se manifiesta con dolor abdominal recurrente y disfunción endocrina y exocrina, pudiendo llegar a desarrollar cáncer de páncreas y graves complicaciones en fases tardías. En Chile, se estima una incidencia anual de 0,8 casos por 100.000 habitantes, con una prevalencia de 6,1 casos por cada 100.000 habitantes. El diagnóstico temprano es un desafío para el cual la endosonografía ha destacado como una herramienta diagnóstica sensible y específica, especialmente con la implementación de la clasificación de Rosemont. Distintos estudios han validado la utilidad de esta clasificación. Sin embargo, la limitada disponibilidad de endosonografía en algunos países, como Chile, plantea desafíos para generalizar su aplicación. Se espera que en un futuro la clasificación de Rosemont se convierta en un estándar para el diagnóstico de pancreatitis crónica.

Effect of pancreatic extracorporeal shock wave lithotripsy on chronic pancreatitis stones / 中华外科杂志

Objective: To analyze the therapeutic effect and safety of pancreatic extracorporeal shock wave lithotripsy(P-ESWL) for patients with chronic pancreatitis complicated by stones of the pancreatic duct and to investigate the influencing factors. Methods: A retrospective analysis was performed on clinical data from 81 patients with chronic pancreatitis complicated by pancreatic duct calculus treated with P-ESWL in the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi 'an Jiaotong University from July 2019 to May 2022. There were 55 males(67.9%) and 26 females(32.1%). The age was (47±15)years (range: 17 to 77 years). The maximum diameter(M(IQR)) of the stone was 11.64(7.60) mm, and the CT value of the stone was 869 (571) HU. There were 32 patients (39.5%) with a single pancreatic duct stone and 49 patients(60.5%) with multiple pancreatic duct stones. The effectiveness, remission rate of abdominal pain, and complications of P-ESWL were evaluated. Student's t test, Mann Whitney U test, χ2 test, or Fisher's exact test was used to compare the characteristics between the effective and ineffective groups of lithotripsy. The factors influencing the effect of lithotripsy were analyzed by univariate and multivariate logistic regression analysis. Results: Eighty-one patients with chronic pancreatitis were treated with P-ESWL 144 times, with an average of 1.78 (95%CI:1.60 to 1.96) times per person. Among them, 38 patients(46.9%) were treated with endoscopy. There were 64 cases(79.0%) with effective removal of pancreatic duct calculi and 17 cases(21.0%) with ineffective removal. Of the 61 patients with chronic pancreatitis accompanied by abdominal pain, 52 cases(85.2%) had pain relief after lithotripsy. After lithotripsy treatment, 45 patients(55.6%) developed skin ecchymosis, 23 patients(28.4%) had sinus bradycardia, 3 patients(3.7%) had acute pancreatitis, 1 patient(1.2%) had a stone lesion, and 1 patient(1.2%) had a hepatic hematoma. Univariate and multivariate logistic regression analysis showed that the factors affecting the efficacy of lithotripsy included the age of patient(OR=0.92, 95%CI: 0.86 to 0.97), the maximum diameter of the stone(OR=1.12,95%CI:1.02 to 1.24) and the CT value of the stone(OR=1.44, 95%CI: 1.17 to 1.86). Conclusions: P-ESWL is effective in the treatment of patients with chronic pancreatitis complicated by calculi of the main pancreatic duct.Factors affecting the efficacy of lithotripsy include patient's age, maximum stone diameter, and CT value of calculi.

The 501st case: elevated blood glucose, chronic pancreatitis, and post- pancreatoduodenectomy malnutrition / 中华内科杂志

A 50-year-old man with a 15-year history of elevated blood glucose and an approximately 2-year history of diarrhea was admitted to the Peking Union Medical College Hospital. The initial diagnosis was type 2 diabetes. After repeated pancreatitis and pancreatoduodenectomy, severe pancreatic endocrine and exocrine dysfunction including alternating high and low blood glucose and fat diarrhea occurred. Tests for type 1 diabetes-related antibodies were all negative, C-peptide levels were substantially reduced, fat-soluble vitamin levels were reduced, and there was no obvious insulin resistance. Therefore, a diagnosis of pancreatic diabetes was clear. The patient was given small doses of insulin and supplementary pancreatin and micronutrients. Diarrhea was relieved and blood glucose was controlled. The purpose of this article is to raise clinicians' awareness of the possibility of pancreatic diabetes after pancreatitis or pancreatic surgery. Timely intervention and monitoring may reduce the occurrence of complications.

Hemosuccus pancreaticus: A case of upper gastrointestinal bleeding arising from a pancreatic pseudoaneurysm

@#Pancreatic pseudoaneurysms are possible complications of chronic pancreatitis. These may present as hemosuccus pancreaticus, a rare cause of upper gastrointestinal tract bleeding where a pseudoaneurysm erodes into an adjacent pseudocyst or pancreatic duct, manifesting as bleeding through the pancreatic duct into the duodenal papilla. We report a case of a 32-year-old male with a history of chronic pancreatitis presenting as intermittent upper gastrointestinal tract bleeding secondary to hemosuccus pancreaticus from a pancreatic pseudoaneurysm. The patient underwent multiple sessions of endovascular embolization, which successfully controlled the bleeding despite some failed attempts; thus, a potentially morbid last-resort surgery was avoided.

Pancreatitis crónica: análisis de factores de progresión de la enfermedad / Chronic pancreatitis: analysis of disease progression factors

BACKGROUND: Alcohol and tobacco are important risk factors for chronic pancreatitis (CP). AIM: To analyze the effect of etiological factors such as tobacco and alcohol and pancreatic enzyme replacement therapy (PERT) in the progression of CP. MATERIAL AND METHODS: Patients with a diagnosis of CP were recruited and grouped according to variables such as tobacco, alcohol and PERT. They were followed for 18 months. Subsequently, different variables and analytical parameters involved in the progression of the disease were analyzed. RESULTS: A total of 50 patients diagnosed with CP were included. Of these, 28 patients underwent PERT, 39 were smokers and 33 were alcohol users. Compared with patients without PERT, those with PERT had a higher proportion of diabetes (64 and 32%, respectively), had a higher need for endoscopic treatment (25 and 0%, respectively) and a normal body mass index (71 and 27.3%, respectively. The smokers had higher calcium levels and increased lymphocytosis and leukocytosis. The alcohol consumption group had a higher mean age (p = 0.04) CONCLUSIONS: PERT may improve the nutritional status but does not reduce the need for endoscopic or surgical treatment. Smoking and alcohol consumption favored the progression of CP. Also, smoking induced a pro-inflammatory state.

Agenesia del páncreas dorsal: reporte de caso y revisión del tema / Agenesis of the dorsal pancreas: case report and topic review

Complete agenesis of the dorsal pancreas (ADP) is an exceedingly rare congenital anomaly, compatible with life. It may be asymptomatic and usually incidentally diagnosed. In symptomatic cases, the clinical manifestations vary from abdominal pain, pancreatitis and diabetes mellitus to exocrine insufficiency with steatorrhea. We present a case report of a 28 year old female with ADP, diagnosed incidentally during radiological evaluation for hyperglycemias in SARS COV2 concomitant affection. Magnetic resonance cholangiopancreatography confirmed the absence of, neck, body and tail of the pancreas. Knowing the pancreatic embryogenesis, the clinical presentation of their malformations and the main radiological characteristics is important for the proper diagnosis of these anomalies.

Anterior Cingulate Cortex Mediates Hyperalgesia and Anxiety Induced by Chronic Pancreatitis in Rats / 神经科学通报·英文版

Central sensitization is essential in maintaining chronic pain induced by chronic pancreatitis (CP), but cortical modulation of painful CP remains elusive. Here, we examined the role of the anterior cingulate cortex (ACC) in the pathogenesis of abdominal hyperalgesia in a rat model of CP induced by intraductal administration of trinitrobenzene sulfonic acid (TNBS). TNBS treatment resulted in long-term abdominal hyperalgesia and anxiety in rats. Morphological data indicated that painful CP induced a significant increase in FOS-expressing neurons in the nucleus tractus solitarii (NTS) and ACC, and some FOS-expressing neurons in the NTS projected to the ACC. In addition, a larger portion of ascending fibers from the NTS innervated pyramidal neurons, the neural subpopulation primarily expressing FOS under the condition of painful CP, rather than GABAergic neurons within the ACC. CP rats showed increased expression of vesicular glutamate transporter 1, and increased membrane trafficking and phosphorylation of the N-methyl-D-aspartate receptor (NMDAR) subunit NR2B and the α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor (AMPAR) subunit GluR1 within the ACC. Microinjection of NMDAR and AMPAR antagonists into the ACC to block excitatory synaptic transmission significantly attenuated abdominal hyperalgesia in CP rats, which was similar to the analgesic effect of endomorphins injected into the ACC. Specifically inhibiting the excitability of ACC pyramidal cells via chemogenetics reduced both hyperalgesia and comorbid anxiety, whereas activating these neurons via optogenetics failed to aggravate hyperalgesia and anxiety in CP rats. Taken together, these findings provide neurocircuit, biochemical, and behavioral evidence for involvement of the ACC in hyperalgesia and anxiety in CP rats, as well as novel insights into the cortical modulation of painful CP, and highlights the ACC as a potential target for neuromodulatory interventions in the treatment of painful CP.

Pancreatitis recurrente en pediatría: serie de casos / Recurrent pancreatitis in children: Case series

La pancreatitis recurrente (PR) ocurre en el 15-36 % de las pancreatitis agudas, en la edad pediátrica. Se realizó un estudio descriptivo y transversal, para determinar la etiología y la evolución en menores de 18 años con diagnóstico de PR entre 2008-2016 en el Hospital Garrahan. Se incluyeron 10 pacientes, el 90 % de sexo femenino. La mediana de edad fue de 11 años. La mediana del número de episodios fue de nueve. La ecografía abdominal y/o la colangioresonancia iniciales mostraron hallazgos patológicos en cuatro pacientes. De los seis pacientes con estudios iniciales normales, tres desarrollaron signos de pancreatitis crónica (PC), uno con estenosis del Wirsung sugestiva de pancreatitis autoinmune. El 40 % de los pacientes tuvo diagnóstico etiológico. En el seguimiento, tres pacientes con pancreatitis idiopática desarrollaron PC. Los factores genéticos podrían jugar un papel en los casos considerados idiopáticos.

Recurrent pancreatitis (RP) occurs in children between 15-35 % of the cases. To determine the etiology and outcome of RP in children a descriptive, cross-sectional cohort study was conducted in children under 18 years of age with RP seen at Hospital Garrahan between 2008-2016. Of 10 patients with RP, 90 % were girls. Median age of the diagnoses of RP was 11. Median number of episodes was 9. Initial abdominal ultrasonography and/or magnetic resonance cholangiopancreatography were abnormal in four patients. Of six patients with normal studies at onset, three developed signs of chronic pancreatitis (CP) and one stenosis of the duct of Wirsung suggestive of autoimmune pancreatitis. In 40 % of our patients, the etiology was determined. On follow-up, three patients with idiopathic pancreatitis developed CP. Genetic factors may play a role in patients considered to have idiopathic pancreatitis.

Pancreatitis del surco (groove) que imita cáncer de páncreas: presentación de un caso y revisión de la literatura / Groove pancreatitis mimicking pancreatic cancer: Case report and literature review

Resumen La pancreatitis del surco (PS) o "groove pancreatitis", es una forma de pancreatitis crónica infrecuente; nombrada así por su localización en el surco pancreatoduodenal. Suele predominar en varones con antecedente de ingesta de alcohol. Es de gran importancia realizar diagnóstico diferencial con cáncer de páncreas, dada su ubicación. Los avances en los métodos diagnósticos, como la ultrasonografía endoscópica, han permitido un abordaje más certero, sin embargo, no se cuenta con guías de manejo y las aproximaciones terapéuticas siguen siendo basadas en patologías similares.

Abstract Groove pancreatitis (GP) is a rare form of chronic pancreatitis located in the pancreaticoduodenal groove, hence its name. It is predominant in males with a history of alcohol intake. Making a differential diagnosis between this condition and pancreatic cancer is highly relevant given its location. Advances in diagnostic methods, such as endoscopic ultrasonography, have allowed a more accurate approach. However, no management guidelines are available and therapeutic approaches are still based on similar pathologies.

Descripción clínica y epidemiológica de pacientes con pancreatitis crónica en un hospital de alta complejidad en Cali, 2011 a 2017 / Clinical and epidemiological description of patients with chronic pancreatitis treated at a quaternary care hospital in Cali, 2011-2017

Resumen Introducción: la pancreatitis crónica (PC) es una inflamación progresiva del páncreas que puede llevar a su destrucción e insuficiencia irreversibles. Es una patología desafiante para el médico, debido a que establecer su diagnóstico puede tomar meses e incluso años, el seguimiento de pacientes suele ser problemático y el conocimiento sobre la clínica y epidemiología en Colombia es incompleto. Este estudio pretende hacer una descripción de pacientes con PC en un centro de referencia en gastroenterología de Cali, Colombia. Metodología: estudio de corte transversal de pacientes adultos con PC confirmada por criterios clínicos y radiológicos entre 2011 y 2017. Resultados: se incluyeron 36 pacientes con PC. La mayoría fueron hombres (72,2%) y la media de edad fue 56 (+ 15,1) años. El dolor abdominal crónico fue la presentación clínica más común (83,3%). Cerca de un cuarto de pacientes presentaba diabetes mellitus (22,2%). Se consideró etiología idiopática en 58,3%, alcohólica en el 11,0% y biliar en el 11,0%. La tomografía axial computarizada (TAC), resonancia magnética (RMN) y colangiopancreatografía por RMN fueron los métodos diagnósticos más usados (60,5%), con los que en su mayoría se visualizó atrofia (53,1%), dilatación de conductos (49,0%) y calcificaciones del páncreas (34,7%). Conclusión: los síntomas inespecíficos de la PC en fases iniciales y su largo curso clínico favorecen al subdiagnóstico de esta patología. Los resultados presentados pueden contribuir a la futura creación de escalas clínicas locales que orienten estudios radiológicos y genéticos tempranos, con el fin de lograr un diagnóstico oportuno y mejorar la calidad de vida de estos pacientes.

Abstract Introduction: Chronic pancreatitis (CP) is a progressive inflammation of the pancreas that can lead to irreversible damage and failure. This condition poses great challenges to physicians since its diagnosis can take months or even years. Patient follow-up is often problematic and knowledge about its clinical presentation and epidemiology in Colombia is scarce. This study aims to describe patients with CP treated at a gastroenterology reference center in Cali, Colombia. Methodology: Cross-sectional study in adult patients with CP confirmed based on clinical and radiological criteria between 2011 and 2017. Results: 36 patients with CP were included. The majority were men (72.2%), and the mean age was 56 (+15.1) years. Chronic abdominal pain was the most common clinical presentation (83.3%). About a quarter of patients had diabetes mellitus (22.2%). Etiology was idiopathic in 58.3%, alcoholic in 11.0%, and biliary in 11.0%. Computed tomography (CT), magnetic resonance imaging (MRI), and MRI cholangiopancreatography were the most commonly used diagnostic methods (60.5%), showing mostly atrophy (53.1%), duct dilation (49.0%), and pancreatic calcifications (34.7%). Conclusion: Nonspecific symptoms of CP in early stages and its long clinical course favor the underdiagnosis of this condition. The results presented may contribute to the future creation of local clinical scales that guide early radiological and genetic studies to achieve a timely diagnosis and improve the quality of life of these patients.

Alcoholic vs. non-alcoholic chronic pancreatitis: surgeons' perspective from a tertiary centre in india / Perspectiva dos cirurgiões sobre pancreatite crônica alcoólica vs. não-alcoólica de um centro terciário na índia

ABSTRACT Background: Although alcohol is the most common cause for chronic pancreatitis worldwide, idiopathic type is prevalent in India. Natural history and disease progression are different between these two groups. There is paucity of data comparing surgical outcome and quality of life in these patients. Aim: To evaluate clinical features, surgical outcome and quality of life between these two groups of patients. Method: All patients with chronic pancreatitis who underwent surgery were prospectively reviewed. Results: From 98 patients, 42 were alcoholic. Number of male and the mean age at the time of operation was significantly more in alcoholic patients. Smoking, preoperative hospital admission rate and the prevalence of local complications like inflammatory pancreatic head mass, biliary stricture and left sided portal hypertension were distinctly more common in alcoholic group. Frey procedure was required more commonly in alcoholic group. Mean postoperative hospital stay and overall postoperative complication rate were comparable between the two groups. Over a median follow up of 18 months there was significant improvement in quality of life and pain score in both the groups. Improvement of physical functioning score at follow-up was significantly more in alcoholic group but the requirement for analgesic medications were significantly more in alcoholic group. However, appetite loss was more perceived by non-alcoholic group. Conclusion: Alcoholic chronic pancreatitis presents with more local complications associated with chronic pancreatitis. Frey procedure is a safe and well accepted surgery in this group. Though they required more analgesic requirement in short term follow up, other aspects of quality of life are similar to non-alcoholic group.

RESUMO Racional: Embora o álcool seja a causa mais comum de pancreatite crônica em todo o mundo, a forma idiopática é prevalente na Índia. A história natural e a progressão da doença são diferentes entre esses dois grupos. Há escassez de dados comparando o resultado cirúrgico e a qualidade de vida entre eles. Objetivo: Avaliar as características clínicas, o resultado cirúrgico e a qualidade de vida entre esses dois grupos de pacientes. Método: Todos os pacientes com pancreatite crônica operados foram revisados ​​retrospectivamente. Resultados: Do total de 98 pacientes, 42 eram alcoolistas. O número de homens e a idade média no momento da operação foi significativamente maior nos alcoolistas. Tabagismo, taxa de internação pré-operatória e prevalência de complicações locais como massa inflamatória da cabeça do pâncreas, estenose biliar e hipertensão portal do lado esquerdo foram distintamente mais comuns no grupo de alcoolistas e o procedimento de Frey foi exigido mais comumente neste grupo. A média de internação pós-operatória e a taxa geral de complicações pós-operatórias foram comparáveis ​​entre os dois grupos. Ao longo de acompanhamento médio de 18 meses houve melhora significativa na qualidade de vida e pontuação de dor em ambos os grupos. A melhora no escore de funcionamento físico foi significativamente maior no grupo de alcoolistas, mas a necessidade de medicamentos analgésicos foi significativamente maior nos alcoolistas. No entanto, a perda de apetite foi mais percebida pelo grupo não alcoólico. Conclusão: A pancreatite crônica alcoólica se apresenta com mais complicações locais associadas à pancreatite crônica. O procedimento de Frey é operação segura e bem aceita neste grupo. Embora exigissem mais necessidade de analgésicos no acompanhamento em curto prazo, outros aspectos da qualidade de vida são semelhantes ao grupo não alcoólico.

Estado actual del diagnóstico y manejo de la pancreatitis crónica / The current state of diagnosis and management of chronic pancreatitis

Resumen La pancreatitis crónica (PC) es una condición inflamatoria que lleva a fibrosis, con destrucción y compromiso del parénquima pancreático y de los ductos. Estos cambios permanentes pueden llevar a alteración de la función pancreática tanto exocrina como endocrina, estenosis biliares y pancreáticas, que llevan a su vez a otras consecuencias, como la formación de pseudoquistes, incluso incrementa la posibilidad de desarrollar cáncer de páncreas. La principal característica clínica de estos pacientes es el dolor, el cual altera de forma importante su calidad de vida. Para diagnosticar la PC contamos con pruebas funcionales, las cuales se pueden dividir en directas o indirectas, y pruebas de estructura pancreática. El gran reto de estos métodos consiste en diagnosticar la enfermedad en estadios iniciales, donde la aproximación diagnóstica es más difícil por la sutileza de los cambios. Una vez diagnosticada la PC, el manejo también debe ser escalonado; este se puede dividir a su vez en manejo médico, como paso inicial, manejo endoscópico y manejo quirúrgico o, en los casos más difíciles, la combinación de estos. El objetivo es manejar y entender al paciente y su enfermedad como un todo, con el fin de proporcionarle la mejor calidad de vida posible al paciente. A continuación, se presenta una revisión enfocada en el diagnóstico y manejo de esta entidad a la luz de la evidencia actual disponible.

Abstract Chronic pancreatitis (CP) is an inflammatory condition that leads to fibrosis, damage, and even destruction of the pancreatic parenchyma and ducts. These permanent changes can alter pancreatic exocrine and endocrine functioning, cause biliary and pancreatic stenosis, lead to formation of pseudocysts and even increase the possibility of developing pancreatic cancer. The main clinical characteristic is pain which significantly alters quality of life. To diagnose the CP, we have direct and indirect functional tests and the pancreatic structure test. The great challenge of these methods is early diagnosis, but this is difficult due to the subtlety of changes. Once CP is diagnosed, management must be staggered. Medical management is the initial step which can be followed by endoscopic management, surgical management, and for the most difficult cases a combination of these. The goal is to manage and understand the whole patient and illness to provide the best possible quality of life. This review article focuses on CP diagnosis and management in light of the currently available evidence.

Intervencionismo endoscópico en la pancreatitis crónica / Endoscopic Intervention in Chronic Pancreatitis

Resumen La pancreatitis crónica es un trastorno irreversible y progresivo del páncreas caracterizado por inflamación, fibrosis y cicatrización. Las funciones exocrinas y endocrinas se pierden, lo que a menudo conduce al dolor crónico. La etiología es multifactorial, aunque el alcoholismo es el factor de riesgo más importante en los adultos. Si se sospecha pancreatitis crónica, la tomografía computarizada con contraste es la mejor modalidad de diagnóstico por imágenes. Aunque los narcóticos y los antidepresivos proporcionan el mayor alivio del dolor, más de la mitad de los pacientes eventualmente requiere una intervención por endoscopia o cirugía. La colangiopancreatografía retrógrada endoscópica es una alternativa eficaz para una variedad de terapias en el tratamiento de enfermedades benignas y malignas del páncreas. En los últimos 50 años, la endoterapia ha evolucionado hasta convertirse en la terapia de primera línea en la mayoría de las enfermedades inflamatorias agudas y crónicas del páncreas. A medida que avanza este campo, es importante que los gastroenterólogos mantengan un conocimiento adecuado de la indicación del procedimiento, mantengan el volumen de procedimiento suficiente para manejar la endoterapia pancreática compleja y comprendan enfoques alternativos a las enfermedades pancreáticas, incluidos el tratamiento médico, la terapia guiada por ecografía endoscópica, el manejo de las estenosis sintomáticas y cálculos, las intervenciones sobre el plexo celíaco y el drenaje de los pseudoquistes pancreáticos.

Abstract Chronic pancreatitis is an irreversible and progressive disorder of the pancreas characterized by inflammation, fibrosis and scarring. Exocrine and endocrine functions are lost often leading to chronic pain. Its etiology is multifactorial, although alcoholism is the most important risk factor in adults. If chronic pancreatitis is suspected, computed tomography with contrast is the best imaging modality. Although narcotics and antidepressants provide the greatest pain relief, more than half of all patients eventually require intervention by endoscopy or surgery. Endoscopic retrograde cholangiopancreatography (ERCP) is an effective alternative for a variety of therapies for treating benign and malignant diseases of the pancreas. In the last 50 years, endoscopic treatment has evolved to become the first-line therapy for most acute and chronic inflammatory diseases of the pancreas. As this field progresses, it has become important for gastroenterologists to keep their knowledge of indications for this procedure up-to-date and to perform a sufficient volume of procedures to allow them to manage complex pancreatic endoscopic therapy. Keeping up-to-date should include an understanding of alternative approaches to pancreatic diseases including medical treatment, therapy guided by endoscopic ultrasound, management of symptomatic stenoses and stones, interventions on the celiac plexus, and drainage of pancreatic pseudocysts.

Utilidad de la colangiopancreatoscopia directa en el manejo del cálculo pancreático, a propósito de un caso (con video) / Usefulness of Direct Cholangiopancreatoscopy for Management of Pancreatic Calculi: Case Study (with video)

Resumen Se presenta el caso de un paciente con pancreatitis crónica y hallazgo de lesión quística en el ducto pancreático principal, a quien se le realizó colangioscopia directa tipo Spyglass y se encontró un gran cálculo impactado a nivel de la cabeza del páncreas, condicionando una formación pseudoquística. Se realizó litotricia láser y se logró la extracción en su totalidad, con lo cual se logró la remisión sintomática.

Abstract We present the case of a patient with chronic pancreatitis. After finding a cystic lesion in the main pancreatic duct, the patient underwent direct cholangioscopy using the SpyGlass DS System. A large impacted calculus and pseudocyst formation was found in the head of the pancreas. Laser lithotripsy was used to extract the entire calculus and symptomatic remission was achieved.

A pancreatic hemorrhagic pseudocyst with pseudoaneurysm and the role of doppler ultrasonography: a case report

SUMMARY Hemorrhagic pseudocysts with pseudoaneurysms are a rare and fatal complication of chronic pancreatitis due to the erosion of pancreatic to peripancreatic arteries. The timing of the rupture cannot be accurately predicted, but prompt diagnosis and management are essential to prevent further bleeding. We describe the case of a 68-year-old man who presented acute epigastric pain and anemia and had a history of chronic pancreatitis with a pseudocyst. A biliary and pancreas MRI showed an enlarged size of a known pancreatic pseudocyst with internal high signal intensity material. Color-Doppler ultrasonography showed pulsating signals in the pseudocyst, and our final diagnosis was a pseudoaneurysm in the pancreatic hemorrhagic pseudocyst. The pseudoaneurysm was successfully treated with coil embolization of the feeding artery. We report this case of a rare complication of chronic pancreatitis to show that color-Doppler ultrasound is a non-invasive and effective diagnostic tool for pseudoaneurysm, which enables early detection and prompt treatment without the need for invasive diagnostic modalities.

Docosahexaenoic Acid Inhibits Expression of Fibrotic Mediators in Mice With Chronic Pancreatitis

BACKGROUND: Chronic pancreatitis (CP) is an irreversible progressive disease that destroys exocrine parenchyma, which are replaced by fibrous tissue. As pancreatic fibrosis is a key feature of CP, reducing fibrotic protein content in the pancreas is crucial for preventing CP. Studies suggest that NF-κB facilitates the expression of fibrotic mediators in pancreas and protein kinase C-δ (PKC-δ) regulates NF-κB activation in stimulated pancreatic acinar cells. Docosahexaenoic acid (DHA) is an omega-3 fatty acid having anti-inflammatory and anti-fibrotic effects. It has been shown to inhibit NF-κB activity in cerulein-stimulated pancreatic acinar cells which is a cellular model of CP. In the present study, we investigated if DHA inhibits expression of fibrotic mediators by reducing PKC-δ and NF-κB expression in mouse pancreatic tissues with CP.METHODS: For six weeks, mice were weekly induced for acute pancreatitis to develop CP. Furthermore, acute pancreatitis was induced by hourly intraperitoneal injections of cerulein (50 μg/kg × 7). Mice were administered DHA (10 μM) via drinking water before and after CP induction.RESULTS: Cerulein-induced pancreatic damages like decreased pancreatic weight/total body weight, leukocyte infiltration, necrosis of acinar cells, and vacuolization were found to be inhibited by DHA. Additionally, DHA inhibited cerulein-induced fibrotic mediators like alpha-smooth muscle actin and fibronectin in pancreas. DHA reduced expression of PKC-δ and NF-κB p65 in pancreatic tissues of cerulein-treated mice.CONCLUSIONS: DHA may be beneficial in preventing CP by suppressing pancreatic expression of fibrotic mediators.

Recurrent Pancreatitis Caused by Afferent Loop Syndrome with Pathologic Features of Type II Autoimmune Pancreatitis / 대한내과학회지

Afferent loop syndrome (ALS) is a rare cause of recurrent pancreatitis. Recurrent pancreatitis in association with ALS can develop due to impaired outflow of pancreatic juice or reflux of enteric secretions caused by increased intraluminal duodenal pressure. Here, we report a case of ALS presenting as recurrent acute pancreatitis due to chronic intermittent partial obstruction of the third portion of the duodenum caused by postoperative adhesion. Interestingly, pancreatic histology showed a granulocytic epithelial lesion, which is a diagnostic feature of type 2 autoimmune pancreatitis (AIP, idiopathic duct centric chronic pancreatitis [IDCP]). From this case we learned that the diagnosis of type 2 AIP should be made in the appropriate clinical setting.