Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment.

BACKGROUND: Post endoscopic retrograde cholangiopancreatography (ERCP) is comparatively complex application. Researchers has been investigated prevention of post-ERCP pancreatitis (PEP), since it has been considered to be the most common complication of ERCP. Although ERCP can lead various complications, it can also be avoided.AIMSTo study the published evidence and systematically review the literature on the prevention and treatment for PEP. METHODS: A systematic literature review on the prevention of PEP was conducted using the electronic databases of ISI Web of Science, PubMed and Cochrane Library for relevant articles. The electronic search for the review was performed by using the search terms "Post endoscopic retrograde cholangiopancreatography pancreatitis" AND "prevention" through different criteria. The search was restricted to randomized controlled trials (RCTs) performed between January 2009 and February 2019. Duplicate studies were detected by using EndNote and deleted by the author. PRISMA checklist and flow diagram were adopted for evaluation and reporting. The reference lists of the selected papers were also scanned to find other relevant studies. RESULTS: 726 studies meeting the search criteria and 4 relevant articles found in the edited books about ERCP were identified. Duplicates and irrelevant studies were excluded by screening titles and abstracts and assessing full texts. 54 studies were evaluated for full text review. Prevention methods were categorized into three groups as (1) assessment of patient related factors; (2) pharmacoprevention; and (3) procedural techniques for prevention. Most of studies in the literature showed that young age, female gender, absence of chronic pancreatitis, suspected Sphincter of Oddi dysfunction, recurrent pancreatitis and history of previous PEP played a crucial role in posing high risks for PEP. 37 studies designed to assess the impact of 24 different pharmacologic agents to reduce the development of PEP delivered through various administration methods were reviewed. Nonsteroidal anti-inflammatory drugs are widely used to reduce risks for PEP. Rectal administration of indomethacin immediately prior to or after ERCP in all patients is recommended by European Society for Gastrointestinal Endoscopy guidelines to prevent the development of PEP. The majority of the studies reviewed revealed that rectally administered indomethacin had efficacy to prevent PEP. Results of the other studies on the other pharmacological interventions had both controversial and promising results. Thirteen studies conducted to evaluate the efficacy of 4 distinct procedural techniques to prevent the development of PEP were reviewed. Pancreatic Stent Placement has been frequently used in this sense and has potent and promising benefits in the prevention of PEP. Studies on the other procedural techniques have had inconsistent results. CONCLUSION: Prevention of PEP involves multifactorial aspects, including assessment of patients with high risk factors for alternative therapeutic and diagnostic techniques, administration of pharmacological agents and procedural techniques with highly precise results in the literature.

Evaluation of upper gastrointestinal system in acromegaly.

PURPOSE: Acromegaly causes multiple comorbidities, including gastrointestinal disorders. The present study evaluated the frequency of hiatal hernia and other upper gastrointestinal pathologies in patients with acromegaly, given that visceromegaly and reduced nitric oxide levels in acromegaly may impact diaphragm and lower esophageal sphincter function and thus possibly the development of hiatal hernia. METHODS: Thirty-nine acromegaly patients followed our center for the previous 6months were recruited. Upper gastrointestinal endoscopy was performed once in all patients to evaluate hiatal hernia, esophagitis, gastroduodenitis and ulcer. RESULTS: Twenty-three patients were male and 16 female. Upper gastrointestinal endoscopy found hiatal hernia, esophagitis and gastroduodenitis or gastric ulcer in 3 (7.6%), 2 (1.7%) and 31 (79.4%) patients, respectively. Pathologic examination of gastric antrum biopsy found intestinal metaplasia in 12 (30.7%) patients, and Helicobacter pylori was positive in 13 (33.3%). There were no significant correlations between age, gender, disease duration or preoperative adenoma size on the one hand and hiatal hernia or other endoscopic findings on the other. Similarly, neither surgical success nor recurrence was associated with endoscopic findings. CONCLUSIONS: The study showed that prevalence of gastritis, duodenitis, peptic ulcer and intestinal metaplasia is higher and prevalence of hiatal hernia lower in acromegaly patients than in the healthy population. Various unknown disease-related pathophysiological conditions may play a role; there is a need for further studies.

Sudden blastic crisis and additional chromosomal abnormalities during chronic myeloid leukemia in the imatinib era.

Imatinib has shown significant clinical and cytogenetic success in the treatment of chronic myeloid leukemia. Although resistance has been observed in a proportion of patients, sudden blastic crisis is a rare event during imatinib therapy. We describe a 24-year-old male patient with Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase who developed sudden blastic crisis in the 24th month of imatinib therapy, with loss of complete cytogenetic response. At this time, the patient had splenomegaly, severe anemia, thrombocytopenia, and leukocytosis. Bone marrow aspirate revealed the presence of massive blastic infiltration with myeloid morphology. Flow cytometric analysis of the bone marrow cells showed positivity for CD45, CD34, CD13, CD33, CD19, CD41, CD61, and glycophorin-A. Trephine biopsy specimens showed 100% cellular marrow with diffuse infiltrate by blasts. A reticulin stain of the bone marrow biopsy section demonstrated severe diffuse fibrosis. Cytogenetic analysis by fluorescence in situ hybridization (FISH) revealed that 92% of the cells were positive for the BCR/ABL fusion signal and had increased copy numbers for chromosomes 8, 13, 19, and 21. The patient's prognosis was unfavorable. In conclusion, chronic myeloid leukemia remains complex and includes unanswered questions. The presented case with a rare event during imatinib therapy highlights the need for the continued monitoring of residual disease and the development of strategies to eliminate residual leukemia cells in patients showing a complete cytogenetic response.