Acetaminophen-induced pancreatic pseudocyst: first case report.

INTRODUCTION: Acetaminophen is known for its toxic effects onhepatic cells. Moreover, acetaminophen toxicity in the setting of hepatic failure has also been associatedwith dysfunction and failure of other organ systems, including the pancreas. Drug-induced pancreatitis (DIP) is rare and has been associated with acetaminophen. CASE: A 19-year-old female presents with a one-week history of abdominal pain associated with nausea, vomiting, and headache. One day earlier she was discharged from an outside hospital where she was admitted for fulminant hepatic failure secondary to acetaminophen toxicity. She had no other complaints and denied consuming alcohol or taking any medications. An examination showed epigastric tenderness. Labs obtained on admission revealed abnormal but improving liver function tests with worsening amylase and lipase. A computed tomography scan on day three of admission revealed what appeared to be a large pancreatic pseudocyst. A magnetic resonance cholangiopancreatographyconfirmed the diagnosis. DISCUSSION: Here we present the case of a young female with a delayed onset acetaminophen-induced pancreatitis. Although DIP is rare, acetaminophen should be recognized as a cause of acute pancreatitis. In addition, itis important for physicians to recognize the increased incidence of pancreatic pseudocyst amongst patients under age 20 with history of DIP, and include pseudocyst in the differential and workup for those presenting with recurrent abdominal pain.

Azathioprine induced pancreatitis in a patient with co-existing autoimmune pancreatitis and hepatitis.

CONTEXT: Azathioprine induced pancreatitis usually runs a benign self limited course with rapid disappearance of signs and symptoms upon with drawl of the drug. Azathioprine is used in treating relapses in patients with autoimmune pancreatitis and maintenance of remission in autoimmune hepatitis. Acute pancreatitis complicated by symptomatic pseudocysts requiring drainage is not usually associated with drug induced pancreatitis. The risk of azathioprine use in patients with underlying disease of pancreas including autoimmune pancreatitis is unclear. CASE REPORT: We report here a case of an African American patient with co-existing autoimmune pancreatitis and autoimmune hepatitis who developed azathioprine induced acute pancreatitis complicated by a large symptomatic pseudocyst compressing the duodenum requiring a cystoduodenostomy. CONCLUSIONS: Future studies to investigate the risk of azathioprine induced pancreatitis in the presence of underlying disease of the pancreas including autoimmune pancreatitis are required to further understand the safety of azathioprine in this sub group of patients.

α-Tocopherol treatment ameliorates chronic pancreatitis in an experimental rat model induced by trinitrobenzene sulfonic acid.

OBJECTIVE: To investigate the effects of α-tocopherol on pancreatic fibrosis and survival in rats with experimental chronic pancreatitis induced by trinitrobenzene sulfonic acid (TNBS). METHODS: Chronic pancreatitis was induced in male Sprague-Dawley rats by infusion of TNBS into the pancreatic duct. α-Tocopherol (300, 600 or 900 mg/kg) was orally administered to rats with experimental pancreatitis (treatment group) daily for 4 weeks. The relative pancreatic weight, pancreatic pseudocyst and death rate were observed. Paraffin-embedded tissue samples were sliced, stained by hematoxylin-eosin and histopathologically examined. RESULTS: α-Tocopherol administration significantly ameliorated the pancreatic weight loss induced by TNBS in chronic pancreatitis rats compared to the control group. There were pancreatic pseudocysts in 69% of the α-tocopherol group, and in 100% of the control group. α-Tocopherol administration led to a significant increase of the survival rate. The histopathologic scores were higher in the control group than in the α-tocopherol group. Subgroup analysis of histopathologic scores revealed that a high dose of α-tocopherol results in less pancreatic injuries. CONCLUSION: α-Tocopherol treatment elevates survival rate, extenuates fibrosis and increases relative pancreatic weight in the chronic pancreatitis model. α-Tocopherol therapy in chronic pancreatitis is now required to confirm these findings and establish the role of this treatment in the management of this disabling condition. and IAP.

Conservative management of pancreatic pseudocysts in children with acute lymphoblastic leukemia.

Treatment with asparaginase for acute lymphoblastic leukemia can cause acute pancreatitis. Complication of pancreatitis by pancreatic pseudocyst formation can prolong the hospital stay, delay chemotherapy, and necessitate long-term parenteral nutrition. We report 5 children with acute lymphoblastic leukemia who developed acute pancreatitis complicated by pancreatic pseudocysts. They required modifications to their chemotherapy regimen and prolonged parenteral nutrition but no surgical intervention. All 5 patients survive in first remission and their pseudocysts resolved after 3 to 37 months or continued to decrease in size at last follow-up. These cases illustrate that nonsurgical management of pancreatic pseudocyst is safe, though pseudocyst resolution may require many months. In addition, these patients demonstrate that oral feeding can be initiated after the acute episode of pancreatitis resolves even if a pseudocyst is present.

Successful management of severe L-asparaginase-associated pancreatitis by continuous regional arterial infusion of protease inhibitor and antibiotic.

BACKGROUND: L-asparaginase is a key drug in the treatment of childhood acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL). However, L-asparaginase can cause a fatal complication of pancreatitis, and an effective treatment for L-asparaginase-associated pancreatitis (AAP) has not been developed to date. The authors investigated whether rapidly treating children with AAP by continuous regional arterial infusion (CRAI) of protease inhibitor and antibiotic would quickly resolve AAP. METHODS: Between 2000 and 2007, 104 pediatric patients with ALL or LBL were treated at the authors' affiliated hospitals with intensive regimens that included Escherichia coli-derived L-asparaginase. Six of 104 patients developed severe AAP. One patient was treated with intravenous infusion of protease inhibitor, and the remaining 5 patients received CRAI of protease inhibitor and antibiotic within 48 hours of the onset of AAP. RESULTS: The patient who received intravenous protease inhibitor had pseudocyst formation and developed a subsequent leukemic recurrence after the interruption of chemotherapy for 4.5 months. In the other patients, AAP subsided within 2 to 6 days after the start of CRAI, and serious complications did not emerge. Significantly, chemotherapy could be resumed within 4 weeks (range, 12-23 days) after the onset of AAP, and the patients were in complete remission from 4 months to 44 months with further chemotherapy that excluded L-asparaginase. CONCLUSIONS: The current results indicated that early introduction of CRAI of protease inhibitor and antibiotic is suitable for treating severe AAP.

Pancreatic pseudocyst development due to organophosphate poisoning.

BACKGROUND/AIMS: Acute pancreatitis is a serious complication of organophosphate poisoning. There is no report in the literature dealing with the development of a pancreatic pseudocyst after complication of organophosphate-induced acute pancreatitis. Therefore, we present a case who developed pancreatic pseudocyst after complication of organophosphate-induced acute pancreatitis. METHODS: A 17-year-old female patient with a history of ingestion of complication of organophosphate insecticide (DDVP EC 550, dichlorvos) was admitted with cholinergic symptoms. On admission, serum amylase and lipase levels were high and abdominal ultrasonography showed an edematous pancreas. No etiological factor for acute pancreatitis was evident. RESULTS: We diagnosed complication of organophosphate-induced acute pancreatitis. After four weeks, abdominal abdominal ultrasonography and computerized tomography revealed a pancreatic pseudocyst of 6 cm diameter. During follow-up, the pancreatic pseudocyst size regressed to 4 cm. CONCLUSION: Complication of organophosphate poisoning can cause acute pancreatitis and its complications. Early diagnosis and appropriate treatment may reduce morbidity and mortality.

Pancreas pseudocyst associated with L-asparaginase treatment: a case report.

A major complication of L-asparaginase used in the treatment of paediatric malignancies in children is pancreatitis (2%-16%). However, only seven paediatric cases of pancreatic pseudocyst caused by the utilization of the agent have been reported in literature. We present the case of a 5-year old girl who had abdominal pain and epigastric dullness after the third course of BMF-95 protocol with a diagnosis of ALL. A pancreatic pseudocyst of 10 x 10 cm size was found by abdominal tomography. The cyst was treated by percutaneous external drainage, total parenteral nutrition (TPN), administration of octreotide and antibiotherapy for one month. Percutaneous external drainage has proven to be an effective, noninvasive method in this special case with a systemic disorder and the high risk of mortality should a surgical intervention have been performed.

Pancreatic pseudocyst caused by valproic acid: case report and review of the literature.

The author reports one case of pseudocyst of the pancreas, an uncommon disorder in children, secondary to pancreatitis in a 9-year-old girl treated with valproic acid for epilepsy.

Pancreatitis aguda grave y pseudoquiste pancreático por uso de drogas en niños: presentación de tres casos clínicos y revisión de la literatura / Severe acute pancreatitis and pancreatic pseudocyst formation caused by drugs in children: presentation of 3 clinical cases and review of the literature

La incidencia de pancreatitis aguda grave asociada a medicamentos, una patología inhabitual en niños, ha aumentado con relación al mayor uso de ciertas drogas. Se presentan tres niños con pancreatitis aguda grave inducida por drogas (ácido valproico y asparaginasa), que evolucionaron hacia la formación de pseudoquistes pancreáticos. Los tres niños requirieron manejo médico en la Unidad de Cuidados Intensivos, necesitando uno de ellos manejo quirúrgico de los pseudoquistes pancreáticos. Se realiza una revisión del tema tanto en la literatura nacional como internacional. Se discute la etiología, formas de presentación, métodos de diagnóstico más adecuados y manejo actual tanto de la pancreatitis aguda grave como de la pancreatitis aguda con formación de pseudoquistes en niños

[Evaluation of somatostatin or octreotide efficacy in the treatment of external pancreatic fistulas]. / Evaluation de l'efficacité de la somatostatine ou de l'octréotide dans le traitement des fistules pancréatiques externes.

AIM OF THE STUDY: To evaluate the prevalence of pancreatic pseudocyst after persistent fistula closure with somatostatin or octreotide. To compare the patient characteristics according to the subsequent presence or absence of pseudocyst. PATIENTS AND METHODS: This retrospective study from January 1994 to August 1999 included 15 patients with an external pancreatic fistula. Fistula closure was observed for all patients with somatostatin or octreotide. CT scan was performed 66 +/- 34 days after the end of this treatment. RESULTS: CT scan was normal in 9 patients (favorable group) and showed pancreatic pseudocyst (failure group) in 6 patients. Pancreatic fistula etiologies were different between the two groups. The 5 patients presenting pancreatic fistula after duodenopancreatectomy belonged to the favorable group. Six of the 10 patients presenting pancreatic fistula after pseudocyst drainage belonged to the failure group. There were no other differences between the two groups. CONCLUSION: Persistent pancreatic fistula can be cured with somatostatin or octreotide. However, fistulas occurring after duodenopancreatectomy are more easily cured with somatostatin or octreotide than fistulas occurring after external pseudocyst drainage. Somatostatin or octreotide cannot be considered to be an effective treatment for pancreatic fistula occurring after pseudocyst drainage, despite the fact that 40% of them were permanently cured.

Surgical pancreatic complications induced by L-asparaginase.

Pancreatitis has been noted to be a potential complication in 2% to 16% of patients undergoing treatment with L-asparaginase for a variety of pediatric neoplasms, but rarely has surgical intervention been necessary. The authors present two fulminant cases of L-asparaginase-induced pancreatitis and review the current literature. The first patient is a 15-year-old boy who underwent induction chemotherapy with L-asparaginase for non-Hodgkin's lymphoma with bone marrow involvement. He presented with diffuse patchy necrosis of the pancreas as well as a large infected pancreatic pseudocyst. He subsequently required operative debridement of the pancreas and external drainage of the pseudocyst. He is currently doing well. The second patient is a 5-year-old boy who was treated with L-asparaginase for a diagnosis of acute lymphocytic leukemia. Within 3 weeks of initiation of therapy, fulminant pancreatitis developed, which progressed to multisystem organ failure. Computed tomography scan demonstrated extensive pancreatic necrosis involving 90% of the gland. He underwent surgical debridement of his necrotic pancreas and wide drainage of the lesser sac. Postoperatively he improved but subsequently multiple complications developed including erosion of his gastroduodenal artery with significant intraabdominal bleeding, which was controlled with angiographic embolization. Subsequently erosion of his endotracheal tube into the innominate vein developed, and he died. L-asparaginase-induced pancreatitis has been described after therapy for various pediatric neoplasms, and the reported cases have usually been self-limiting. However, our cases demonstrate potentially fatal sequelae of this complication and mandate early diagnosis with appropriate surgical intervention in this setting.

Dideoxyinosine-induced pancreatitis in human immunodeficiency virus-infected children.

Dideoxyinosine (ddI) is a widely used antiretroviral agent in treatment of HIV infection. Pancreatitis is a serious side effect. Two cases are reported, one with rapid development of a pseudocyst.

L-asparaginase-related pancreatic pseudocyst: report of a case.

Pancreatitis following the administration of L-asparaginase (L-asp) has been well documented. However, the progression of such pancreatitis to pseudocyst formation in some patients has been rarely reported. The few reported cases have been teenagers, with the exception of one adult. All pseudocysts required surgical management. This report documents a pancreatic pseudocyst in a seven-year-old girl with acute lymphoblastic leukemia whose treatment regimen included L-asp. The pseudocyst was managed medically with nasogastric decompression, intravenous hyperalimentation, and antibiotics. The pseudocyst resolved spontaneously in one month without complication.

[A case of ALL complicated with acute pancreatitis and pancreatic pseudocyst caused by L-asparaginase ].

We reported a case of ALL complicated with acute pancreatitis caused by L-asparaginase (L-Asp). The patient was a 42-year-old man, who showed eosinophilia in peripheral blood and an increase of lymphoblast in bone marrow. He was diagnosed as ALL (L2) and treated by JALSG '87 protocol. Remission induction chemotherapy including L-Asp was administered by 5,000 IU i.v. for 10 days. The day after giving all dose of L-Asp, slight epigastralgia developed and then became severe. After two days, s-amylase was markedly elevated, and the patient was diagnosed as acute pancreatitis caused by L-Asp. He was treated conservatively, but hyperglycemia occurred. The epigastrial tumor was palpable and gradually grew in size. CT-scan and abdominal ultrasonography revealed pancreatic pseudocyst, so he was treated by percutaneous cyst drainage. The patient died of a relapse of ALL. The prophylaxis and early diagnosis of the pancreatitis and hyperglycemia caused by L-Asp are very difficult. We have to examine more cases and pay greater attention to the chemotherapy, including L-Asp.