[International multidisciplinary classification of acute pancreatitis severity: the 2013 Spanish edition]. / Clasificación Internacional y Multidisciplinaria de la Pancreatitis Aguda: Edición Española 2013.

OBJECTIVE: To develop a new classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of the published evidence, and worldwide consultation. BACKGROUNDS: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of specialist in pancreatic diseases, but are suboptimal because these definitions are based on the empiric description of events not associated with severity. METHODS: A personal invitation to contribute to the development of a new classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists and radiologists currently active in the field of clinical acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global web-based survey was conducted, and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions. RESULTS: The new classification of severity is based on the actual local and systemic determinants of severity, rather than on the description of events that are non-causally associated with severity. The local determinant relates to whether there is (peri) pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another, whereby the presence of both infected (peri) pancreatic necrosis and persistent organ failure has a greater impact upon severity than either determinant alone. The derivation of a classification based on the above principles results in four categories of severity: mild, moderate, severe, and critical. CONCLUSIONS: This classification is the result of a consultative process among specialists in pancreatic diseases from 49 countries spanning North America, South America, Europe, Asia, Oceania and Africa. It provides a set of concise up to date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

[Multidisciplinar international classification of the severity of acute pancreatitis: Italian version 2013]. / Classificazione Internazionale Multidisciplinare della Gravità della Pancreatite Acuta Versione Italiana 2013.

AIM: The aim of this paper was to present the 2013 Italian edition of a new international classification of acute pancreatitis severity. The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity. METHODS: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. A global web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions. RESULTS: The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical. CONCLUSION: This classification provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research.

[Determinant-based classification of acute pancreatitis severity. International multidisciplinary classification of acute pancreatitis severity: the 2013 German edition]. / Einteilung des Schweregrads der akuten Pankreatitis. Internationale, multidisziplinäre klinische Klassifikation auf Basis pathogenetischer Determinanten: Deutsche Version 2013.

OBJECTIVE: The aim of this study was to develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation. BACKGROUND: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric descriptions of occurrences that are merely associated with severity. METHODS: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensive medicine specialists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organised to bring contributors from different disciplines together and discuss the concept and definitions. RESULT: The new international classification is based on the actual local and systemic determinants of severity, rather than descriptions of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity - mild, moderate, severe, and critical. CONCLUSIONS: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Neuroendocrine tumors diagnosed at the Antonio Cardarelli hospital (Naples, Italy) between 2006-2009: a single-institution analysis.

Neuroendocrine tumors (NETs) are rare, with an incidence of about 5 per 100,000 inhabitants. As no study on NETs has ever been specifically conducted on the population of Campania, we performed a retrospective analysis of all newly diagnosed NETs at the Antonio Cardarelli hospital between 2006-2009. A search of the registry of the Pathology Department of the Antonio Cardarelli hospital was carried out to retrieve available data on all newly diagnosed NET cases. Two hundred and ninety-nine NET tumors were diagnosed at our Institution from January, 2006 to December, 2009. Globally, 121 patients (40% of the population) had a lung NET, while 92 patients (30% of the population) presented a GEP-NET. The most common primary tumor site varied by sex, with female patients being more likely to have a primary NET in the lung, breast or colon, and male patients being more likely to have a primary tumor in the lung. Also, twenty-three cases of breast NETs were identified, and clinical information regarding therapy and response was available for 22 patients. Our study represents a pioneering effort to provide the medical community in Campania with basic information on a large number of patients with different types of NETs. The Antonio Cardarelli hospital could greatly benefit from cooperation with other hospitals in order to become a highly specialized center for NETs in the region and Southern Italy.

Chronic asymptomatic hyperamylasemia unrelated to pancreatic diseases.

PURPOSE: This study was addressed to assess the clinical characteristics of patients presenting with chronic hyperamylasemia unrelated to pancreatic diseases (CHUPD). Almost all patients presenting with chronic hyperamylasemia undergo expensive, long, difficult, and often unnecessarily repeated diagnostic procedures. This is in conjunction with the poor knowledge of the fact that besides hyperenzymemia secondary to pancreatic diseases and systemic illnesses, various non-pathological forms of chronic hyperamylasemia without relevant pathologic consequence can occur in clinical practice. MATERIAL AND METHODS: Data of all patients with CHUPD were retrospectively reviewed (June 1997-December 2009). Fifty one patients were included in the study; median follow up was 48 months (range 8-112 months). Their pre-enrolment diagnoses were: chronic pancreatitis in 31 cases (60.7%) and recurrent pancreatitis in 13 cases (25.4%); the remaining 7 patients (13.7%) were without a specific diagnosis. RESULTS: Our observations, supported by diagnostic procedures (Ca19-9 serum levels, abdominal ultrasonography, computed tomography and magnetic resonance, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography) revealed that CHUPD was secondary to: a) benign pancreatic hyperamylasemia, 20 patients (39.2%); b) macroamylasemia, 18 patients (35.2 %) and c) salivary hyperamylasemia, 13 patients (25.4%). CONCLUSIONS: Due to the poor familiarity with CHUPD, the occurrence of this condition quite frequently leads to unnecessarily repeated diagnostic procedures.

Pancreatic functional impairment following acute necrotizing pancreatitis: long-term outcome of a non-surgically treated series.

OBJECTIVES: Patients who survive an episode of acute necrotizing pancreatitis may develop endocrine and exocrine pancreatic functional impairment; often these patients have undergone pancreatic surgery during the acute episode. Aim of this study is to report the results of a long-term follow-up of patients recovering from an episode of acute necrotizing pancreatitis which had not been treated surgically during the index hospital admission. DESIGN AND SUBJECTS: Sixty-five consecutive patients enrolled between January 1990 and December 1993, prospectively followed through December 2006. RESULTS: Median follow-up period was 179.5 months (range 156-203). 40 patients (61.5%) who completed follow-up were analysed. Endocrine function: 2 patients (5%) were diabetic before the pancreatitis episode, and 6 (15.7%) developed overt diabetes; diabetes appeared within the 3rd year after acute pancreatitis in 2 patients, between the 3rd and 4th year in 2 patients, and between the 5th and 6th year in the last 2 patients. Exocrine function: 9 patients (22.5%) showed fecal elastase impairment; in all patients ultrasound was normal and fecal elastase returned above the normal limit during follow-up. CONCLUSIONS: After an episode of acute necrotizing pancreatitis treated without surgery, the endocrine and exocrine function is not frequently impaired after long-term follow-up. Reduction in exocrine function is transient and complete recovery is achieved in all patients within a few years.

Persistent elevation of serum CA 19-9 with no evidence of malignant disease.

BACKGROUND: Serum CA 19-9 is the mainstay marker for the diagnosis of biliopancreatic malignancies, though a persistent elevation can also be observed in various benign diseases. AIMS: In this study, a marked increase of serum CA 19-9 was seen in 10 patients who had no evidence of malignant disease. The possible causes of this finding are discussed. PATIENTS: Nine women and one man were studied, whose admitting diagnoses were as follows: pulmonary fibrosis in two, diabetes in two, non-ulcer dyspepsia in two, obesity in one, acute diarrhoea in one, colon diverticula in one and gastric ulcer in one. METHODS: Routine blood tests, tumour marker determinations, imaging studies and endoscopy were carried out at admission. RESULTS: Serum CA 19-9 levels ranged from 112 to 1338 IU/ml (mean 517 IU/ml). Abdominal ultrasonography, CT-scan, upper gastrointestinal X-ray series and gastrointestinal endoscopies were negative for malignancy. During the follow-up period (range 2-7 years) serum CA 19-9 values were persistently elevated in all patients. CONCLUSIONS: Our study shows that persistent and significant elevation of serum CA 19-9 can be found in non-malignant and non-cholestatic disease.

Chronic pancreatitis: report from a multicenter Italian survey (PanCroInfAISP) on 893 patients.

BACKGROUND: No data on chronic pancreatitis in Italy are available yet. AIM: To evaluate demographic, clinical, diagnostic and therapeutic aspects in patients suffering from chronic pancreatitis. PATIENTS AND METHODS: Eligible patients were prospectively enrolled from 2000 to 2005. Information concerning demographic data, lifestyle risk factors, family and clinical history, associated factors (alcohol, autoimmunity, cystic dystrophy of the duodenal wall, obstruction, genetic mutations) concomitant diseases, diagnostic findings, and pharmacological, endoscopic and surgical therapy were gathered. RESULTS: 893 patients (74% males, mean age 53.7+/-15.2 years) were evaluated. 519/859 patients (60%) were drinkers and 555/840 (66%) were smokers. A strong positive correlation between drinking and cigarette consumption (R=0.53; p<0.0001) was found. Heavy alcohol consumption (>80g of alcohol/day for more than 5 years) was considered the most important risk factor in 300 patients (34%), obstruction in 238 (27%), alcohol and obstruction in 82 (9%), autoimmunity in 34 (4%), cystic dystrophy of the duodenal wall/groove pancreatitis in 55 (6%), gene mutations in 36 (4%), and none (idiopathic) in 148 (17%). Bile stones were diagnosed in 287 patients (33%) and cholecystectomy was performed in 329 patients (38%). Pancreatic calcifications were diagnosed in 547/879 patients (62%). Pancreatic surgery was performed in 273 patients (31%). Endoscopic sphincterotomy was performed in 371 patients (42%). Exocrine and endocrine insufficiency were found, respectively, in 373/834 (45%) and 275/885 patients (31%). CONCLUSIONS: An unexpected low frequency of alcohol abuse and new emerging associated risk factors for chronic pancreatitis were observed in Italy.

Indications and results of videocapillaroscopy in clinical practice.

Nailfold videocapillaroscopy (NVC) is one of the best diagnostic non-invasive imaging techniques to evaluate microcirculation in vivo and is increasingly employed in the field of rheumatology. Indeed, at present, the most important utility of NVC is in the identification of microvascular involvement in many rheumatic diseases, particularly in systemic sclerosis. More recently, this technique has been shown to be applicable to the study of many other extra-rheumatic diseases, such as arterial hypertension, diabetes mellitus, acromegaly, hyperthyroidism, cardiac syndrome X, primary biliary cirrhosis, Crohn's disease, psoriasis, familial Mediterranean fever. This article sets down the methodology of examination and normal pattern of capillary vessels and reviews the applications of NVC in clinical practice and its results in rheumatic and non-rheumatic diseases.

Diagnosis and treatment of acute pancreatitis: the position statement of the Italian Association for the study of the pancreas.

This medical position statement has been developed by the board of ProInf AISP (Computerized Project on Acute Pancreatitis) Study Group. The evidence and key recommendations were discussed at a dedicated meeting held in Milan on September 2007 and during this meeting the main clinical and therapeutic medical topics were extensively discussed. Each of the proposed recommendations was discussed and an initial consensus was reached. Acute pancreatitis in Italy is a disease of increasing annual incidence. The diagnosis of the disease should be established within 48hours of admission. Early identification of patients at risk of developing a severe attack of acute pancreatitis is of great importance because rapid therapeutic interventions improve outcome. The endoscopic approach seems to be most beneficial measure in patients with acute pancreatitis with jaundice and in those with cholangitis. The development of infected necrosis should be assessed using fine-needle aspiration and the sample should be cultured for germ isolation and characterization. The role of early ERCP in all patients with severe acute pancreatitis of biliary origin is still controversial. The data supporting the efficacy of antibiotic prophylaxis to prevent infection of necrosis are conflicting. The refeeding is a crucial topic in patients who have recovered from an acute episode of mild acute pancreatitis, but there are very few studies on this issue.

Diagnostic assessment and outcome of acute pancreatitis in Italy: results of a prospective multicentre study. ProInf-AISP: Progetto informatizzato pancreatite acuta, Associazione Italiana Studio Pancreas, phase II.

BACKGROUND AND AIM: Up till now, only one study providing practically complete information on acute pancreatitis in Italy has been published. The aim of this prospective study was to evaluate the clinical characteristics, in terms of diagnostic assessment and outcome, of a large series of patients affected by acute pancreatitis in Italy. MATERIALS AND METHODS: The study involved 56 Italian centres, homogeneously distributed throughout the entire national territory. Each participating centre was furnished with an ad hoc software including 530 items along with subsequent collection, tabulation and quality control of the data. RESULTS: One thousand five hundred and forty case report forms of patients affected by acute pancreatitis were collected but 367 of them (24%) were subsequently eliminated from the final analysis. Therefore, 1173 patients (581 females and 592 males) were recruited. Mean age of patients was 62.0+/-18.2 years (95% confidence interval, 60.9-63.0). On the basis of Atlanta classification, 1006 patients (85.8%) were defined as mild and 167 (14.2%) as severe pancreatitis. Biliary forms represented the most frequent aetiological category (813 cases, 69.3%) while alcoholic forms only 6.6% (77 cases); the remaining aetiologies accounted for 7.1% (83 cases) while 200 cases (17.1%) remained without a definite aetiological factor. Complete recovery was achieved in 1016 patients (86.6%) whereas morphological sequelae were found in 121 patients (10.3%) and mortality in 36 patients (3.1%; 0.4% in mild and 19.2% in severe acute pancreatitis). Ultrasonography was largely utilised as a first line diagnostic tool in all patients, with valuable visualisation of the pancreas in 85% of patients. Computer tomography scan was also widely used, with 66.7% of exams in mild and 33.3% in severe pancreatitis. Patients affected by biliary pancreatitis presented more severe (p=0.004) and necrotizing forms (p=0.021). Mortality was significantly related (p<0.001) with the extension of pancreatic necrosis and with an age of over 70 years. Body mass index presented significantly greater values in severe than in mild forms (p<0.001). CONCLUSIONS: Association of creatinine serum level over 2mg/dl with an abnormal chest X-ray showed a high significant correlation with a more severe outcome in terms of morphological sequelae and mortality (p=0.0001). Acute pancreatitis in Italy more commonly presents biliary aetiology and favourable outcome with low rate of complications and mortality. From a cost-effectiveness standpoint, diagnostic approach to this disease needs to be better standardised.

A prospective multicentre survey on the treatment of acute pancreatitis in Italy.

BACKGROUND: The Italian Association for the Study of the Pancreas released a diagnostic and therapeutic algorithm for acute pancreatitis in 1999. AIM: This study focused on the analysis of the therapeutic approach for the treatment of acute pancreatitis in Italy. PATIENTS: One thousand, one hundred and seventy-three patients were recruited: 1006 patients (85.8%) had mild acute pancreatitis (MAP) and 167 (14.2%) had the severe acute pancreatitis (SAP); 161 patients showed pancreatic necrosis at computed tomography; 121 patients (10.3%) had sequelae and 36 (3.1%) died. RESULTS: Non-steroidal anti-inflammatory drugs and tramadol were used more frequently in patients with the MAP whereas opioids and the association schedules were used more frequently in patients with the SAP (P<0.001). Gabexate mesilate was utilised in 831 out of 1173 patients (70.8%); in particular, gabexate mesilate was used in 70.6% patients with MAP and in 73.1% of those with SAP (P=0.521). The duration of the drug administration was significantly shorter in those having MAP than in those having the SAP (P<0.001). The antibiotics most frequently used for the prophylaxis against infection from pancreatic necrosis (43.1%) were carbapenems. Only a small number of patients received enteral nutrition (4.7%). Endoscopic retrograde cholangiopancreatography was carried out in 344 of the 1173 patients (29.3%). Surgery was performed in 48 with SAP (19 had elective biliary surgery and 29 had pancreatic surgery). CONCLUSIONS: The results of this survey indicate a lack of compliance with the guidelines which regard the indications mainly for interventional endoscopy and surgery.

Primary sternoclavicular septic arthritis in patients without predisposing risk factors.

BACKGROUND: Septic arthritis (SA) of the sternoclavicular joint (SCJ) is an uncommon form of arthritis, generally described in patients with predisposing risk factors such as primary or secondary immunosuppressive disorders, systemic or localized infections and central venous catheters. More rarely the infection occurs in patients without these risk factors, thus rendering difficult an early diagnosis. MATERIAL AND METHODS: We report two cases of SA of the SCJ occurred in two patient, without known predisposing risk factors, hospitalized in our Internal Medicine Unit. RESULTS: The clinical characteristics didn't significantly differ from clinical course of the disease occurring in patients with predisposing risk factors. Imaging techniques were useful to suspect diagnosis, but only fine-needle aspiration biopsy with culture of specimens leaded to identify the pathogen and its antibiotic sensitivity (in both patients Staphylococcus aureus). One patient was treated with surgical adequate curettage, drainage and intravenous methicillin, while the other one received only medical treatment with intravenous teicoplanin and ceftazidime. The outcome was uneventful with a complete recovery in both cases. CONCLUSIONS: Even if SA of SCJ is uncommon in subjects without predisposing risk factors, the clinician must have a high index of suspicion to consider this disease in differential diagnosis of arthritis also in previously healthy subjects with negative or unsettling instrumental investigations. In fact, prompt diagnosis is essential to obtain a successful outcome, avoiding the prolongation of the hospitalization and the sequelae of a chronic infection.

Antibiotic treatment in acute pancreatitis.

Severe acute pancreatitis is characterized by a poor prognosis with local and systemic complications, high morbidity and mortality. From the morphological standpoint, almost all patients suffering from severe forms of acute pancreatitis present various degree of pancreatic necrosis. In these patients the occurrence of infection of pancreatic necrosis certainly represents a very important prognostic factor as it has worldwide accepted as the leading cause of death. In addition, the discovery of an infected necrosis represents a crucial point in the treatment of these patients as it is the only clear-cut shift from medical to surgical treatment in necrotizing pancreatitis. Over the last years, earlier and more precise identification of pancreatic necrosis together with availability of new classes of antibiotics with documented activity against the most commonly involved bacteria and able to reach in therapeutic concentration the pancreatic necrosis give us the opportunity to perform some important controlled clinical trials on antibiotic prophylaxis in necrotizing acute pancreatitis. The great majority of these studies showed the usefulness of a prophylactic regimen (using antibiotics such as fluoroquinolones and carbapenems) in terms of reduction of pancreatic and extrapancreatic infections in comparison with untreated controls. Nevertheless, some questions on this topic still present controversial aspects such as the antibiotic of choice, the duration of treatment, the possible opportunistic infections with fungi and/or resistant strains. Antibiotics may prove very useful in patients with documented infected necrosis and high anaesthesiological risk unfit for surgical debridement and drainage; some initial experiences show the possibility that antibiotic treatment may be curative without surgery in these selected cases.

Staphylococcus aureus septicemia in non-neutropenic adult patients hospitalized in internal medicine units.

PURPOSE: Staphylococcus aureus septicemia (SAS) is usually described in immunocompromised patients and during serious weakening diseases, associated with a neutropenic condition. Over the last recent years, clinic relevance of SAS has become more prominent owing to the progressive rise of methicillin-resistent strains in hospital-acquired infections and to its development in non-neutropenic patients. MATERIAL AND METHODS: The aim of our study was to evaluate the clinical features and outcome of non-neutropenic patients with positive blood culture for Staphylococcus aureus (SA) hospitalized in Internal Medicine Wards of our hospital during 1 year of observation. 24 patients with those characteristics were retrospectively recruited; five of them were then excluded from the analysis because of concomitant oncohematologic disease. The median age of the study group of patients (19 cases) was 56 years (range 18-87); 10 (52.6%) patients were male. RESULTS: Infection was hospital-acquired in 10 patients (52.6%). Predisposing factors were: central venous catheter (CVC) (47.4%), recent surgical intervention (21.0%), drug-addiction (15.8%). Main comorbidities were diabetes mellitus in 10 patients (52.6%), heart disease in 4 (21.0%), chronic renal failure in 3 (15.8%), cerebral vascular disease in 3 (15.8%). Fever >38 degrees C was found in all patients at the moment of SA isolation in blood culture. SA isolated-strains were methicillin-resistant in 7 patients (36.8%). Complications of bacteremia were: pneumonia in 4, endocarditis in 3, vertebral osteomyelytis in 2, septic splenic embolization in 1 and endophtalmitis in 1 patient. The septicemia-attributable mortality was 36.8% (7 patients). CONCLUSIONS: SAS in non-neutropenic patients observed in Internal Medicine Units are associated with significant morbidity and mortality, closer to that reported for neutropenic illnesses.

Prospective multicentre survey on acute pancreatitis in Italy (ProInf-AISP): results on 1005 patients.

BACKGROUND AND AIM: Till now, no Italian studies providing information on acute pancreatitis have been published. The aim of this study was to evaluate the epidemiological and clinical characteristics of acute pancreatitis in Italy. MATERIALS AND METHODS: The study involved 37 Italian centres distributed homogeneously throughout the entire national territory and prospectively collected epidemiological, anamnestic, laboratory, radiological, therapeutic (pharmacological, endoscopic and surgical) data, relevant to each individual case of acute pancreatitis consecutively observed during the period from September 1996 to June 2000. RESULTS: One thousand two hundred and six case report forms were collected, but 201 patients (16.6%) were subsequently eliminated from the final analysis. We therefore studied 1005 patients, 533 (53%) males and 472 (47%) females, mean age 59.6 +/- 20 years. On the basis of the Atlanta classification of acute pancreatitis, 753 patients of the 1005 cases analysed (75%) were mild and 252 patients (25%) severe. The aetiology was biliary in 60% of the patients, related to alcohol abuse in 8.5%, while in 21% of the cases it could not be identified. Over 80% of the patients (83%) were admitted to hospital within 24 h from the onset of clinical symptoms, while only 6% were admitted after 48 h. In particular, 65% of the patients were admitted to hospital within the first 12 h. Antibiotics were used in 85% of the severe and 75% of mild forms. Endoscopic therapy was carried out in 65% of the severe cases, but only in 40% it was carried out prior to 72 h. Eighty-five patients (8.5% of the total, 34% of the severe forms) underwent surgical intervention: 20% on the first day, 38.5% within the fourth day, and the remaining (41.5% of the cases) later on for infected necrosis. The mean duration of hospitalisation for patients with mild pancreatitis was 13 +/- 8 days, while for the severe disease it was of 30 +/- 14 days. The overall mortality rate was 5%, 17% in severe and 1.5% in mild pancreatitis. CONCLUSIONS: Acute pancreatitis in Italy is more commonly a mild disease with a biliary aetiology. The treatment of the disease is not optimal and, on the basis of these data, needs to be standardised. Despite this, the overall mortality rate is low (5%).

Enalapril-induced acute recurrent pancreatitis.

Enalapril, an angiotensin-converting enzyme inhibitor, has several adverse effects, but acute pancreatitis is uncommon. The case of a patient with enalapril-induced pancreatitis is described. Development of severe, necrotizing pancreatitis after inadvertent rechallenge confirmed the causal relationship between enalapril and acute pancreatitis.

Endoscopic management of foreign bodies in the upper gastrointestinal tract: report on a series of 414 adult patients.

BACKGROUND AND STUDY AIMS: Ingestion of foreign bodies is a common occurrence. Few papers in the literature report experience and outcome at tertiary centers. The aim of this paper is to report the management and the outcomes in 414 patients admitted for suspected ingestion of foreign body between May 1995 and December 1999. METHODS: A plain radiographic film of the neck, chest or abdomen was obtained in the case of radiopaque objects, and in order to rule out suspected perforation: in such cases a computed tomography (CT) study was also performed. All patients were asked to give their informed consent, which was refused by three patients. Anesthesia was always used, either conscious sedation (86.8 %), or general anesthesia in the case of poor patient tolerance (13.2 %). All patients underwent an endoscopic procedure within six hours of admission. A flexible scope was used in all patients and a wide range of endoscopic devices was employed. RESULTS: Foreign bodies were found in 64.5 % of our patients. Almost all were found in the esophagus. The types of foreign body were very different, but they were chiefly food boluses, bones or cartilages, dental prostheses or fish bones. In three patients (1.1 %) it was impossible to endoscopically remove the foreign body, which was located in the cervical esophagus: all these three patients required surgery. No complications relating to the endoscopic procedure were observed, but 30.7 % of patients had an underlying esophageal disease, such as a stricture. Only eight patients required a second endoscopic procedure, performed by a more experienced endoscopist. CONCLUSION: Foreign body ingestion represents a frequent reason for emergency endoscopy. The endoscopic procedure is a successful technique which allows the removal of the foreign bodies in almost all cases without significant complications. Surgery is rarely required.

Antioxidant treatment in hereditary pancreatitis. A pilot study on three young patients.

BACKGROUND: Abdominal pain is the most challenging symptom of hereditary pancreatitis. No specific and proven therapy is yet available; analgesics, often in large doses, are required also in children and young patients. PATIENTS AND METHODS: We performed an open-label, pilot study on three young patients, coming from the same kindred, with hereditary pancreatitis. The study period lasted two years (July 1997-July 1999) and was divided into four sub-periods of six months each. In the first and third period the patients took only oral analgesics, if necessary; in the second and fourth period, an antioxidant regimen per os was added. This treatment consisted of sulphadenosyl-methionine (800 mg per day), Vitamin C (180 mg per day), Vitamin E (30 mg per day), Vitamin A (2,400 microg per day), and selenium (75 microg per day). RESULTS: Compliance of patients to the treatment schedule was satisfactory and no important side-effects were observed. Antioxidant treatment led to a significant reduction (p<0.05) in the number of days with abdominal pain experienced by the three patients and this was verified for both periods of treatment. Albeit, consumption of analgesics was lower in the antioxidant treatment periods. CONCLUSIONS: Oxidative stress may be one of the principle contributors to pain in hereditary pancreatitis and orally administered antioxidant treatment appears to be effective for control of the condition, in young patients, suffering from this rare disease.