A Case of Doxycycline-Induced Pancreatitis.

INTRODUCTION: Acute pancreatitis is a common cause of hospitalizations in the United States, causing approximately 230 000 to 275 000 annual admissions We present the case of a patient with acute pancreatitis likely due to doxycycline. CASE PRESENTATION: A 64-year-old male was admitted after developing acute epigastric pain radiating to his back, a lipase of 6611 (units/L), and a computed tomography scan showing moderate peripancreatic inflammation. He had no recent alcohol use, his gallbladder was surgically absent, and he had no gallbladder pathology on evaluation; however, he had been started on doxycycline 10 days prior. While hospitalized, he was treated with pain medications, fluids, and antibiotics for aspiration pneumonia. His acute symptoms resolved, except for minor intermittent abdominal pain 2 months after discharge. DISCUSSION: Doxycycline-induced pancreatitis has been reported within 3 to 17 days of medication initiation. Given the temporal correlation and lack of other inciting etiologies, we determined the most likely etiology was doxycycline. CONCLUSIONS: Further study is needed to understand the pathophysiology and incidence of doxycycline-induced pancreatitis.

A Good Prognosis of Patients with Acute Pancreatitis Combined with Pulmonary Embolism: Early Identification and Intervention.

BACKGROUND: Pulmonary embolism (PE) is a relatively rare vascular complication of acute pancreatitis (AP), and its mortality rate is high. To our knowledge, relevant literature reports still need to be summarized. In this study, we analyzed the clinical characteristics, treatment, and prognosis of five patients with AP complicated by PE and summarized and reviewed the relevant literature. METHODS: Clinical data of patients with AP complicated by PE treated in Taizhou Hospital of Zhejiang Province between January 2017 and September 2022 were retrospectively collected. Combined with the relevant literature, the clinical characteristics, treatment, and prognoses of patients with AP combined with PE were analyzed and summarized. RESULTS: Five patients were eventually enrolled in this study. Among the five patients with AP complicated by PE, all (100%) had symptoms of malaise, primarily chest tightness, shortness of breath, and dyspnea. All patients (100%) had varied degrees of elevated D-dimer levels and a significant decrease in the pressure of partial oxygen (PO2) and pressure of arterial oxygen to fractional inspired oxygen concentration ratio (PaO2/FiO2). Computed tomographic angiography (CTA) or pulmonary ventilation/perfusion imaging revealed a pulmonary artery filling defect in these patients. One patient (20%) had left calf muscular venous thrombosis before the occurrence of PE. Four patients (80%) were treated with lowmolecular- weight heparin (LMWH), and one patient (20%) was treated with rivaroxaban during hospitalization; all continued oral anticoagulant therapy after discharge. All patients (100%) were cured and discharged. No patients showed recurrence of AP or PE. CONCLUSION: PE is a rare but life-threatening complication of AP. However, once diagnosed, early treatment with anticoagulation or radiological interventional procedures is effective, and the prognosis is good. Core Tips: Pulmonary embolism (PE) is a rare but life-threatening complication of acute pancreatitis (AP). Its early diagnosis and timely anticoagulation or radiological intervention can reduce mortality. However, only nine cases have been reported in the English literature thus far, and they are all case reports. Our study is the first systematic analysis of patients with AP combined with PE with a review of the relevant literature. Our patients and those reported in the literature were discharged with good prognoses under treatment such as anticoagulation and vascular intervention. These cases remind clinicians that, in patients with AP, especially those with risk factors for venous thrombosis, it is necessary to monitor the D-dimer level dynamically. Clinicians should pay attention to AP patients' symptoms and related examinations to reduce the chance of a missed diagnosis or misdiagnosis of PE.

Serial monitoring of pancreatic lipase immunoreactivity, C-reactive protein, abdominal ultrasonography, and clinical severity in dogs with suspected pancreatitis.

BACKGROUND: Diagnosis of pancreatitis is based on clinical signs, pancreatic lipase immunoreactivity (cPLI), and abdominal ultrasonography (AUS). Diagnostic discrepancies exist between test results which might be related to differences in the timeline for resolution of these abnormalities after pancreatic injury. HYPOTHESIS/OBJECTIVES: To evaluate disease severity, ultrasonographic findings, and serum biomarkers of pancreatitis in dogs over a period of 28-days. ANIMALS: Sixteen client-owned dogs with a clinical suspicion for acute pancreatitis based on history/physical examination, an abnormal SNAP cPLI, and ultrasonographic evidence of pancreatitis. METHODS: Prospective observational study. Clinical severity (modified clinical activity index [MCAI]), cPLI, C-reactive protein (CRP), and AUS were evaluated at days 0, 2, 7, and 28. Owner assessed overall health (OH) was noted. Dogs were stratified into baseline cPLI ≥400 µg/L vs <400 µg/L groups for reporting. RESULTS: The median CRP, MCAI, and OH were 111.9 mg/L, 10, and 4/10 respectively in the cPLI ≥400 µg/L group. The median CRP, MCAI, and OH were 58.0 mg/L, 6, and 6/10 respectively in the cPLI <400 µg/L group. None of these variables were significantly different between groups. Most dogs (4/5) in the cPLI <400 µg/L group had a history of suspected pancreatitis (ie, suspect acute on chronic disease). cPLI and MCAI rapidly decreased in dogs with a baseline cPLI ≥400 µg/L, whereas sonographic evidence of pancreatitis persisted for a longer time period. CONCLUSIONS AND CLINICAL IMPORTANCE: Ultrasonographic evidence of pancreatitis in the absence of overt clinical or biochemical abnormalities might represent a resolving injury rather than active disease.

Development and validation of a multimodal model in predicting severe acute pancreatitis based on radiomics and deep learning.

OBJECTIVE: Aim to establish a multimodal model for predicting severe acute pancreatitis (SAP) using machine learning (ML) and deep learning (DL). METHODS: In this multicentre retrospective study, patients diagnosed with acute pancreatitis at admission were enrolled from January 2017 to December 2021. Clinical information within 24 h and CT scans within 72 h of admission were collected. First, we trained Model α based on clinical features selected by least absolute shrinkage and selection operator analysis. Second, radiomics features were extracted from 3D-CT scans and Model ß was developed on the features after dimensionality reduction using principal component analysis. Third, Model γ was trained on 2D-CT images. Lastly, a multimodal model, namely PrismSAP, was constructed based on aforementioned features in the training set. The predictive accuracy of PrismSAP was verified in the validation and internal test sets and further validated in the external test set. Model performance was evaluated using area under the curve (AUC), accuracy, sensitivity, specificity, recall, precision and F1-score. RESULTS: A total of 1,221 eligible patients were randomly split into a training set (n = 864), a validation set (n = 209) and an internal test set (n = 148). Data of 266 patients were for external testing. In the external test set, PrismSAP performed best with the highest AUC of 0.916 (0.873-0.960) among all models [Model α: 0.709 (0.618-0.800); Model ß: 0.749 (0.675-0.824); Model γ: 0.687 (0.592-0.782); MCTSI: 0.778 (0.698-0.857); RANSON: 0.642 (0.559-0.725); BISAP: 0.751 (0.668-0.833); SABP: 0.710 (0.621-0.798)]. CONCLUSION: The proposed multimodal model outperformed any single-modality models and traditional scoring systems.

Magnetic resonance imaging in the evaluation and management of acute pancreatitis: a review of current practices and future directions.

Acute pancreatitis is a condition marked by inflammation of the pancreas and surrounding tissues. While the majority of cases of acute pancreatitis are mild, a minority of severe cases are the primary contributors to the morbidity and mortality attributed to this condition. Retroperitoneal morphologic changes can be detected by utilization of various imaging modalities, and their accurate evaluation is crucial for effective management. Acute pancreatitis is commonly diagnosed using computed tomography (CT). However, there are certain clinical scenarios where magnetic resonance imaging (MRI) may have superiority over CT. In particular, MRI is useful in cases where patients cannot receive iodinated CT contrast, or where there is a need to investigate the underlying cause of acute pancreatitis. Additionally, MRI can be utilized to evaluate ductal disconnection and guide interventions for necrotic collections. The unique features of MRI can be particularly useful, including its ability to provide superior contrast resolution and to offer greater functional information through techniques such as diffusion-weighted imaging. The aim of this review is to discuss the MRI assessment of individuals with acute pancreatitis. Additionally, the recent advances in MRI for evaluation of acute pancreatitis will also be introduced.

Complementary comments on diagnosis, severity and prognosis prediction of acute pancreatitis.

The radiological differential diagnosis of acute pancreatitis includes diffuse pancreatic lymphoma, diffuse autoimmune pancreatitis and groove located mass lesions that may mimic groove pancreatitis. Dual energy computed tomography and diffusion weighted magnetic resonance imaging are useful in the early diagnosis of acute pancreatitis, and dual energy computed tomography is also useful in severity assessment and prognosis prediction. Walled off necrosis is an important complication in terms of prognosis, and it is important to know its radiological findings and distinguish it from pseudocyst.

Early encapsulation of peripancreatic fluid/necrosis collections on imaging (CECT) in acute pancreatitis: influential factors and clinical significance for prognosis.

BACKGROUND: To identify the factors influencing the early encapsulation of peripancreatic fluid/necrosis collections via contrast-enhanced computed tomography (CECT) and to determine the clinical significance of early encapsulation for determining the prognosis of acute pancreatitis (AP) patients. METHODS: AP patients who underwent CECT between 4 and 10 days after disease onset were enrolled in this study. Early encapsulation was defined as a continuous enhancing wall around peripancreatic fluid/necrosis collections on CECT. Univariate and multivariate logistic regression analyses were performed to assess the associations between the variables and early encapsulation. Clinical outcomes were compared between the non-encapsulation and early encapsulation groups with 1:1 propensity score matching. RESULTS: A total of 289 AP patients were enrolled. The intra-observer and inter-observer agreement were considered good (kappa statistics of 0.729 and 0.614, respectively) for identifying early encapsulation on CECT. The ratio of encapsulation increased with time, with a ratio of 12.5% on day 5 to 48.7% on day 9. Multivariate logistic regression analysis revealed that the longer time from onset to CECT examination (OR 1.55, 95% CI 1.23-1.97), high alanine aminotransferase level (OR 0.98, 95% CI 0.97-0.99), and high APACHE II score (OR 0.89, 95% CI 0.81-0.98) were found to be independent factors associated with delayed encapsulation. The incidence of persistent organ failure was significantly lower in the early encapsulation group after matching (22.4% vs 6.1%, p = 0.043). However, there was no difference in the incidence of infected pancreatic necrosis, surgical intervention, or in-hospital mortality. CONCLUSIONS: AP patients without early encapsulation of peripancreatic fluid/necrosis collections have a greater risk of persistent organ failure. In addition to longer time, the high APACHE II score and elevated alanine aminotransferase level are factors associated with delayed encapsulation.

Quantitative CT features on admission combined with laboratory biomarkers for predicting severe acute pancreatitis.

AIM: To assess the association of quantitative computed tomography (CT) features on admission with acute pancreatitis (AP) severity, and to explore the performance of combined CT and laboratory markers for predicting severe AP (SAP). MATERIALS AND METHODS: Data from 208 AP patients were reviewed retrospectively. Pancreas volume, the area of extrapancreatic inflammation, extrapancreatic fluid collection volume, and number were calculated based on CT images on admission. Laboratory biomarkers within 24 h of admission were collected. Interobserver agreement for CT measurements was measured by calculating interclass correlation coefficient (ICC). The associations of quantitative CT features with AP severity were evaluated. Predictive models for SAP were constructed based on CT and laboratory markers. Performances of single marker and the models were evaluated using receiver operating characteristic (ROC) curve and area under the ROC curve (AUC). RESULTS: Pancreas volume, area of extrapancreatic inflammation, extrapancreatic fluid collection volume, and number were significantly different between severe and non-severe AP groups. In predicting SAP, the AUCs of quantitative CT indicators ranged from 0.72 to 0.79; the AUCs of laboratory biomarkers were between 0.53 and 0.66. The combined model of area of extrapancreatic inflammation, serum calcium, and haematocrit yielded an AUC of 0.84, significantly higher than that of the laboratory model, single CT, or laboratory marker. Interobserver agreements for quantitative CT indicators were excellent, with ICC ranging from 0.91 to 0.98. CONCLUSION: Quantitative CT features on admission were significantly associated with AP severity; the combination of extrapancreatic inflammation area, serum calcium, and haematocrit could be taken as a new method for predicting SAP.

A case of acute recurrent pancreatitis caused by biliopancreatic reflux without pancreaticobiliary maljunction.

Acute recurrent pancreatitis (ARP) is a clinical condition characterized by repeated episodes of acute pancreatitis. In this case study, a 62-year-old man was diagnosed with mild pancreatitis five years ago, with alcohol intake initially considered the cause. Since then, he experienced three episodes of pancreatitis despite ceasing alcohol consumption completely. Consequently, the patient was diagnosed with ARP. Various diagnostic and imaging tests were performed to determine the etiology of his condition, including blood tests, magnetic resonance cholangiopancreatography, endoscopic ultrasonography, and contrast-enhanced computed tomography. The results were inconclusive; however, endoscopic retrograde cholangiopancreatography revealed the reflux of bile and pancreatic juice into the alternative ducts, despite the absence of anatomical abnormalities in the biliary tract or pancreatic duct. These findings subsequently led to the diagnosis of biliopancreatic reflux, which activated pancreatic enzymes causing ARP. Endoscopic biliary sphincterotomy was performed to alleviate the patient's symptoms. One year later, the patient remained symptom-free. This case highlights the importance of examining bile and pancreatic juice components before considering endoscopic sphincterotomy in patients with unexplained ARP.

Enhancement pattern of the pancreatic parenchyma predicts postpancreatectomy acute pancreatitis after pancreaticoduodenectomy.

OBJECTIVES: To assess the association between the enhancement pattern of the pancreatic parenchyma on preoperative multiphasic contrast-enhanced computed tomography (CECT) and the occurrence of postpancreatectomy acute pancreatitis (PPAP) after pancreaticoduodenectomy (PD). METHODS: A total of 513 patients who underwent PD were retrospective enrolled. The CT attenuation values of the nonenhanced (N), arterial (A), portal venous (P), and late (L) phases in the pancreatic parenchyma were measured on preoperative multiphasic CECT. The enhancement pattern was quantized by the CT attenuation value ratios in each phase. Receiver operating characteristic (ROC) curve analyses were computed to evaluate predictive performance. Regression analyses were used to identify independent risk factors for PPAP. RESULTS: PPAP developed in 102 patients (19.9%) and was associated with increased morbidity and a worse postoperative course. The A/P ratio, P/L ratio, and A/L ratio were significantly higher in the PPAP group. On the ROC analysis, the A/L ratio and A/P ratio both performed well in predicting PPAP (A/L: AUC = 0.7579; A/P: AUC = 0.7497). On multivariate analyses, the A/L ratio > 1.29 (OR 4.30 95% CI: 2.62-7.06, p < 0.001) and A/P ratio > 1.13 (OR 5.02 95% CI: 2.98-8.45, p < 0.001) were both independent risk factors of PPAP in each model. CONCLUSIONS: The enhancement pattern of the pancreatic parenchyma on multiphasic preoperative CECT is a good predictor of the occurrence of PPAP after PD, which could help clinicians identify high-risk patients or enable selective enhance recovery protocols. CLINICAL RELEVANCE STATEMENT: Preoperative identification of patients at high risk for postpancreatectomy acute pancreatitis by enhancement patterns of the pancreatic parenchyma allows surgeons to tailor their perioperative management and take precautions. KEY POINTS: PPAP is associated with increased risk of postoperative complications and a worse postoperative course. A rapid-decrease enhancement pattern of the pancreatic parenchyma is related to the occurrence of PPAP. The A/L and A/P ratios were both independent risk factors of PPAP in each multivariate model.

Low skeletal muscle quality extracted from CT is associated with poor outcomes in severe acute pancreatitis patients.

PURPOSE: To evaluate the association between body composition parameters derived from computed tomography (CT) scans and clinical outcomes in patients with severe acute pancreatitis (AP). METHODS: Patients who have been diagnosed AP with a CT scan at ICU admission were included. Body composition parameters were measured on a single slice at L2-3 of the unenhanced CT scans. The intermuscular adipose tissue (IMAT), visceral adipose tissue (VAT), skeletal muscle area (SMA) and skeletal muscle density (SMD) were assessed using HUs by image analysis software. Univariable and multivariable analyses were performed to analyze the association between body composition parameters and clinical outcomes including all-cause mortality or prolonged ICU stay. The area under the curve (AUC) of a receiver operating characteristic curve was used to explore the predictive value of the body composition on treatment clinical outcomes. RESULTS: A total of 158 patients were included. The IMAT (8.3 cm2 vs 6.0 cm2, P = 0.001) and VAT (190.3 cm2 vs 143.7 cm2, P < 0.001) were significantly higher in the severe AP group than in the moderately severe group, but were notassociatedwithoutcomes. For 1 HU of SMD increased, the risk of poor clinical outcomes decresed 11 % (adjusted OR 0.892, 95 %CI 0.806-0.987, P = 0.026), while an SMD below the median value (32.1 HU for males and 28.5 HU for females) was independently associated with worse outcomes in the multivariable analysis (adjusted OR 8.868, 95 % CI 2.146-36.650, P = 0.003). The SMD had a good predictive ability for clinical outcomes, AUC was 0.824 (95 % CI, 0.715-0.933) for males and 0.803 (95 % CI, 0.639-0.967) for females. CONCLUSION: Low SMD was associated with poor outcomes in patients with severe and moderately severe AP and might be used as a novel marker to predict outcomes in patients suffering from severe and moderately severe AP.

Using Fuzzy Mathematical Model in the Differential Diagnosis of Pancreatic Lesions Using Ultrasonography and Echographic Texture Analysis.

Malignant tumors of the pancreas are the fourth leading cause of cancer-related deaths. This is mainly because they are often diagnosed at a late stage. One of the challenges in diagnosing focal lesions in the pancreas is the difficulty in distinguishing them from other conditions due to the unique location and anatomy of the organ, as well as the similarity in their ultrasound characteristics. One of the most sensitive imaging modalities of the pancreas is endoscopic ultrasonography. However, clinicians recognize that EUS is a difficult and highly operator-dependent method, while its results are highly dependent on the experience of the investigator. Hybrid technologies based on artificial intelligence methods can improve the accuracy and objectify the results of endosonographic diagnostics. Endoscopic ultrasonography was performed on 272 patients with focal lesions of the pancreatobiliary zone, who had been treated in the surgical section of the Kursk Regional Clinical Hospital in 2014-2023. The study utilized an Olympus EVIS EXERA II video information endoscopic system, along with an EU-ME1 ultrasound unit equipped with GF UM160 and GF UC140P-AL5 echo endoscopes. Out of the focal formations in the pancreatobiliary zone, pancreatic cancer was detected in 109 patients, accounting for 40.1% of the cases. Additionally, 40 patients (14.7%) were diagnosed with local forms of chronic pancreatitis. The reference sonograms displayed distinguishable focal pancreatic pathologies, leading to the development of hybrid fuzzy mathematical decision-making rules at the South-West State University in Kursk, Russian Federation. This research resulted in the creation of a fuzzy hybrid model for the differential diagnosis of chronic focal pancreatitis and pancreatic cancer. Endoscopic ultrasonography, combined with hybrid fuzzy logic methodology, has made it possible to create a model for differentiating between chronic focal pancreatitis and pancreatic ductal adenocarcinoma. Statistical testing on control samples has shown that the diagnostic model, based on reference endosonograms of the echographic texture of pancreatic focal pathology, has a confidence level of 0.6 for the desired diagnosis. By incorporating additional information about the contours of focal formations obtained through endosonography, the reliability of the diagnosis can be increased to 0.9. This level of reliability is considered acceptable in clinical practice and allows for the use of the developed model, even with data that is not well-structured.

Imaging Diagnosis and Management of Fistulas in Pancreatitis.

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

[Acute pancreatitis triggered by an impacted minor papillary stone in a patient with pancreas divisum improved after spontaneous evacuation of the pancreatic stone:a case report].

A 56-year-old woman with epigastric pain was admitted to our hospital. Blood tests and abdominal computed tomography (CT) suggested acute pancreatitis. Abdominal CT revealed a pancreas divisum and stone in the minor papilla. Stone impaction was the most likely cause of the acute pancreatitis. The patient's abdominal pain promptly improved after admission. The patient was treated conservatively, and the pancreatitis resolved. Abdominal CT on the 10th day confirmed spontaneous evacuation of the pancreatic stone. This is a rare case of acute pancreatitis in a patient with pancreas divisum triggered by an impacted stone in the minor papilla, which improved after spontaneous evacuation of the pancreatic stone.

Recombinant Tissue Plasminogen Activator: The New Concept for Dissolving Septae in Loculated Peri-pancreatic Fluid Collection prior to Endoscopic Drainage. A Case Report.

Peri-pancreatic fluid collections are late complications of acute pancreatitis. Loculated peri-pancreatic fluid collections, even rare, remain the "black sheep" in terms of drainage, due to difficulty to puncture all compartments, thus prohibiting proper drainage of all compartments. Recombined tissue plasminogen activator (r-tPA) has been advocated as treatment of the loculated collections, due to its ability to dissolve the fibrinous strands and thus facilitate proper drainage. We report the case of a 58 years-old male presenting with a painful loculated peri-pancreatic fluid collection secondary to acute pancreatitis. We performed Alteplase injection, followed by successful endosonographic drainage with lumen apposing metal stent of the collection after 48 hours. Our observation suggests that r-tPA could be a new strategy for loculated collections management, ensuring better drainage and limiting the indication for surgical treatment.