Disconnected Pancreatic Duct Syndrome: Pancreatitis of the Disconnected Pancreas and Its Role in the Development of Diabetes Mellitus.

INTRODUCTION: Disconnected pancreatic duct syndrome (DPDS) is a recognized complication of necrotizing pancreatitis (NP). Manifestations include recurrent peripancreatic fluid collections (R-PFC) and pancreatocutaneous fistulae (PC-Fistulae). Pancreatitis of the disconnected pancreatic segment (DPDS-P) and its relationship to new-onset diabetes after pancreatitis (NODAP) are not well characterized. METHODS: We performed a retrospective cohort study of consecutive patients with NP admitted to University of California, San Francisco from January 2011 to June 2019. A diagnosis of a disconnected pancreatic duct (PD) was confirmed using computed tomography and magnetic resonance cholangiopancreatography/endoscopic retrograde cholangiopancreatography. DPDS was defined as a disconnected PD presenting with R-PFC, PC-Fistulae, or DPDS-P. The primary outcome was NODAP, defined as diabetes mellitus (DM) occurring >3 months after NP. Cox proportional hazards regression was used to evaluate the relationship between DPDS and NODAP. RESULTS: Of 171 patients with NP in this study, the mean clinical follow-up was 46 ± 18 months and the imaging follow-up was 38 ± 20 months. Twenty-seven patients (16%) developed DPDS-P at a median of 28 months. New-onset DM occurred in 54 of the 148 patients (36%), with 22% developing DM within 3 months of NP and 14% developing NODAP at a median of 31 months after AP. DPDS-P was associated with NODAP when compared with non-DPDS patients (adjusted hazard ratio 5.63 95% confidence interval: 1.69-18.74, P = 0.005) while R-PFCs and PC-Fistulae were not. DISCUSSION: DPDS and NODAP occurred in 28% and 14% of the patients, respectively. Pancreatitis of the disconnected pancreas occurred in 16% of the patients and was associated with higher rates of NODAP when compared with patients with other manifestations of DPDS and patients without DPDS.

The Pancreatitis Activity Scoring System Predicts Clinical Outcomes in Patients With Infected Pancreatic Necrosis.

OBJECTIVES: The Pancreatitis Activity Scoring System (PASS) is an objective tool validated in acute pancreatitis but not in infected pancreatic necrosis (IPN). Our aim was to evaluate the role of PASS in IPN. METHODS: We performed a retrospective cohort study of IPN patients admitted to the University of California, San Francisco from January 2011 to March 2019. Daily PASS scores were calculated for each patient. Receiver operator characteristic analysis was used to define the optimal cutoff PASS score to predict outcomes. The primary and secondary outcomes were 72 hours postintervention multiorgan failure (MOF) and early readmission (within 30 days), respectively. RESULTS: One hundred and four patients underwent intervention (median age, 55 years). Thirty-five patients (33.6%) developed MOF postintervention. A 72-hour postintervention PASS greater than 250 was strongly associated with postintervention MOF (area under curve, 0.87; adjusted odds ratio, 26.83; 95% confidence interval, 6.37-112.86; P < 0.001). Discharge PASS greater than 150 was associated with 30-day readmission (area under curve, 0.82; adjusted odds ratio, 26.44; 95% confidence interval, 8.48-82.43; P < 0.001). CONCLUSIONS: The PASS score was associated with postintervention clinical outcomes and early readmission, suggesting it is a valid measure of disease activity in patients with IPN. Further prospective validation of PASS in IPN is needed.

Burden of Ionizing Radiation in the Diagnosis and Management of Necrotizing Pancreatitis.

INTRODUCTION: A step-up endoscopic or percutaneous approach improves outcomes in necrotizing pancreatitis (NP). However, these require multiple radiographic studies and fluoroscopic procedures, which use low-dose ionizing radiation. The cumulative radiation exposure for treatment of NP has not been well defined. METHODS: We conducted a retrospective study of consecutive patients with NP admitted to University of California San Francisco Medical Center from January 2011 to June 2019. We calculated effective doses for fluoroscopic procedures using the dose area product and used the National Cancer Institute tool for computed tomography studies. The primary outcome was the cumulative effective dose (CED). Multivariable logistic regression was used to evaluate risk factors of high exposure (CED > 500 mSv). RESULTS: One hundred seventy-one patients with NP (mean follow-up 40 ± 18 months) underwent a median of 7 (interquartile range [IQR] 5-11) computed tomography scans and 7 (IQR 5-12) fluoroscopic procedures. The median CED was 274 mSv (IQR 177-245) and 30% (51) of patients received high exposure. Risk factors of high exposure include multiorgan failure (aOR 3.47, 95%-CI: 1.53-9.88, P = 0.003), infected necrosis (adjusted odds ratio [aOR] 3.89 95%-CI:1.53-9.88, P = 0.005), and step-up endoscopic approach (aOR 1.86, 95%-CI: 1.41-1.84, P = 0.001) when compared with step-up percutaneous approach. DISCUSSION: Patients with NP were exposed to a substantial amount of ionizing radiation (257 mSv) as a part of their treatment, and 30% received more than 500 mSv, which corresponds with a 5% increase in lifetime cancer risk. Severity of NP and a step-up endoscopic approach were associated with CED > 500 mSv. Further studies are needed to help develop low-radiation treatment protocols for NP, particularly in patients receiving endoscopic therapy.

Metabolic syndrome and liver steatosis occur at lower body mass index in US Asian patients with chronic hepatitis B.

We have previously shown that ultrasound identifies significant steatosis in patients with chronic HBV (CHB). However, the relationship between CHB, metabolic syndrome (MS) and steatosis is poorly understood. In this tertiary care, single-centre retrospective cohort study of 617 CHB patients, we examined the prevalence of MS and steatosis in a predominantly Asian US cohort. Patients were predominantly male (57%) with a mean age of 53 years, Asian (88%), on HBV therapy (64%) and had undetectable DNA (65%). 21% had MS, of which hypertension (41%), dyslipidemia (41%) and obesity (32%) were most common. Patients with MS were more likely to be older (60 vs 52 [P < 0.001]), have steatosis (40% vs 17% [P < 0.001]) and have a higher ALT (29 vs 25 [P = 0.003]). Of the 22% of patients with steatosis by ultrasound, a higher prevalence of MS (38% vs 16% [P < 0.001]) and higher ALT (31 vs 24 [P < 0.001]) was observed. Asian patients had a lower BMI than non-Asians (mean 24 vs 26 [P = 0.001]) but similar prevalence of MS risk factors and steatosis. Asian patients with a BMI between 25 and 30 and two other MS risk factors had steatosis at the same rate as patients with a BMI > 30 and at least two other MS risk factors. We found a strong association between MS, steatosis and elevated ALT in HBV patients. Asian HBV patients have lower BMI than non-Asians yet have the same prevalence of steatosis and other MS risk factors, supporting guidelines for lower BMI targets in Asians.