Causes of mortality and morbidity in free-ranging mustelids in Switzerland: necropsy data from over 50 years of general health surveillance.

BACKGROUND: Although mustelids occur worldwide and include a wide range of species, little is known about the diseases affecting them. Mustelids have regularly been submitted for post mortem investigation in the framework of the program for general wildlife health surveillance in Switzerland, which has been in place for nearly 60 years. We performed a retrospective analysis of the necropsy reports on mustelids submitted to the diagnostic service of the University of Bern. The aims of this study were to present an overview of the causes of mortality and morbidity observed in these carnivores, to assess differences among species, to assess changes in disease detection over the study period, and to describe the pathology of selected diseases. RESULTS: Five hundred and sixty-six reports from 1958 to 2015 were analyzed. Most animals were stone martens (Martes foina, 46%) and badgers (Meles meles, 44%); the remaining species were polecats (Mustela putorius, 4.7%), pine martens (Martes martes, 2%), stoats (Mustela erminea, 1.4%), weasels (Mustela nivalis, 0.8%) and otters (Lutra lutra, 0.3%). Infectious diseases (n = 262) were frequent and were mostly bacterial or viral; non-infectious conditions (n = 169) were less common and were mostly traumatic or due to metabolic disorders. The most frequent diagnoses included distemper (75% were badgers), amyloidosis (96% were martens), bacterial respiratory infections (all mustelids), biting lice (badgers only) and pulmonary and gastro-intestinal helminths (all species). Less frequent diseases included histoplasmosis (badgers only), aspergillosis, toxoplasmosis, hepatozoonosis, and sarcoptic mange. Lesions due to infection with distemper virus were primarily appreciated in the respiratory tract and central nervous system; they presented species-specific characteristics such as necrosis in the ependyma in badgers and absence of syncytia in stone martens. Amyloidosis in martens was multisystemic in most cases and included both AA and AL amyloidosis; the main macroscopic change was severe splenomegaly. CONCLUSION: Infectious diseases were the most frequent causes of morbidity and mortality of mustelids, with marked species-specific differences. Lung and skin were the most commonly affected organs. Contagious diseases such as canine distemper, sarcoptic mange and rabies in mustelids showed a similar temporal pattern as in red foxes (Vulpes vulpes), suggesting pathogen spillovers from foxes to mustelids.

[Helminth control in the adult horse: the need for a re-orientation]. / Helminthenmanagement beim adulten Pferd: Notwendigkeit einer Neuorientierung.

The epidemiological situation of strongyle infections in adult horses in Switzerland is characterized by a strong dominance of small strongyles (Cyathostominae) and an overall low level of egg shedding in the faeces. The prevailing attitude towards anthelmintic therapy considers neither husbandry conditions nor pasture hygiene measures. Instead, calendar-based routine medication, comprising usually 3 to 4 annual treatments, is the typical strategy. Such an approach, however, often results in an excessive administration of anthelmintics. With respect to the continuous spread of drug resistant cyathostomins a change of strategy seems inevitable. A consensus has been agreed on between equine parasitologists and clinicians of the Vetsuisse Faculty in Zurich and Berne to focus on the concept of a selective control approach, based on individual faecal egg counts as the central element. It is now recommended that clinically healthy horses (> 4 y) are treated only when their strongyle egg count is equal to or higher than 200 eggs per gram of faeces. A regular analysis of the strongyle population based on larval cultures, the control of drug efficacy, and quarantine measures for incoming horses are mandatory components of the concept. Recent experiences in several pilot farms have indicated that only 4 % of the McMaster analyses resulted in a deworming treatment. For horses that did not receive any nematicidal anthelmintic during the current season, a "safety" treatment is recommended at the end of the grazing period.

En Suisse, la situation épidémiologique des infestations des chevaux adultes par les strongylidés est caractérisée par une nette dominance des petits strongles (Cyathostominae) et par un faible niveau d'excrétion des œufs de parasites dans les selles. Cars les conditions de détention des chevaux et les mesures relatives à l'hygiène des pâtures ne sont que rarement prises en compte dans la planification des mesures de contrôle des parasitoses, il en résulte un schéma de traitement de routine basé sur 3 à 4 traitements par année, ce qui représente un usage d'anthelminthiques souvent supérieur à la nécessité. Vu le développement continu de populations de cyatostomes résistants aux anthelminthiques, un changement de stratégie dans le contrôle des helminthes est nécessaire. Le contrôle sélectif propagé par les parasitologues et les cliniciens des deux sites de la faculté Vetsuisse propose de seulement traiter les chevaux sains adultes (> de 4 ans) si l'excrétion des œufs de strongles dépasse 200 œufs par gramme de selles. Une différentiation régulière des populations de strongles, le contrôle de l'efficacité des anthelminthiques et des mesures de quarantaines chez les nouveaux venus sont des composants indispensables de ce concept. Les expériences faites jusqu'à présent avec cette stratégie dans plusieurs exploitations-pilotes montrent que seulement 4 % des analyses coprologiques sont suivies par une application d'anthelminthiques. Pour les chevaux qui n'ont pas été vermifugés pendant toute la saison, un traitement de sécurité à la fin de la saison de pâturage est recommandé.

Trypanosomiasis: An emerging disease in Alpine swift (Tachymarptis melba) nestlings in Switzerland?

Alpine swifts (Tachymarptis melba) are sub-Saharan migratory birds, which, in Switzerland, nest in colonies that have been continuously monitored for over 40 years. In the summer of 2022, despite favourable environmental conditions, an unexpectedly high number of sudden mortalities (30-80%) occurred in 20 to 45-day-old nestlings from several nesting sites, of which 3 were monitored in detail. Nestlings submitted for post-mortem analysis (n = 5) were in good body condition but exhibited extensive subcutaneous haematomas (n = 5), myocardial petechiae (n = 2) and stunted growth of primary feathers (n = 1). In all birds, 4-5 µm large, amastigote-like protozoans were identified in skeletal and cardiac muscle sections. These tissues tested positive in a PCR targeting the 18S-rRNA gene of Trypanosoma spp. Amplified sequences showed 99.63% identity with sequences of Trypanosoma corvi (JN006854 and AY461665) and Trypanosoma sp. (AJ620557, JN006841). 72 blood smears of 45-day-old nestlings from two colonies were assessed, of which 20 contained trypomastigote forms, some with high parasitaemia (highest average of 56.4 in 10 high power fields, 400x magnification). Trypomastigote morphometrics (n = 36; mean total length = 30.0 µm; length of free flagellum = 5.8 µm) were consistent with those of T. bouffardi. These findings suggest that an avian trypanosomiasis causing mass nestling mortality could be an emerging disease in Swiss Alpine swift populations.

Biliary Enterocytozoon bieneusi infection in a dog under immunomodulatory therapy.

An 8-year-old female spayed Labrador retriever was presented for the evaluation of severe weight loss 10 weeks after starting an immunomodulatory treatment, including prednisolone and cyclosporine, for meningoencephalitis of unknown origin. Plasma biochemistry analysis showed mild to moderate increases in liver enzyme activities and a moderate decrease in urea concentration. Abdominal ultrasound revealed mild hepatomegaly and a large gall bladder with unremarkable wall and content. Cholecystocentesis was performed and bile was examined both cytologically and by molecular methods, which revealed the presence of Enterocytozoon bieneusi. Treatment was initiated with albendazole but was discontinued due to the development of severe neutropenia. The medical management was subsequently changed to fenbendazole and the dog made a complete recovery. This report describes the first case of clinical manifestation and successful treatment of biliary E. bieneusi infection in a dog.

Strongyle faecal egg counts in Swiss horses: A retrospective analysis after the introduction of a selective treatment strategy.

The standard parasite management of horses based on regular anthelmintic treatments, now practiced for decades has resulted in a worrying expansion of resistant helminth populations, which may considerably impair control on the farm level. The aim of the present study was to obtain a retrospective (year 2010 - 2016) nationwide analysis of faecal egg count (FEC) data from the Swiss adult horse population, related to horse age and geographic region. Thirteen labs provided a total of 16,387 FEC data of horses aged four to 39 years (average: 13.6 years). The annual number of performed FEC tests increased from 38 to 4,939 within the observation period. Independent of the annual sample size the yearly patterns of the FEC were very similar. Seventy-eight percent (n = 12,840) of the samples were negative and 90 % (n = 14,720) showed a FEC below 200 strongyle eggs per gram (EPG) of faeces. The annual mean strongyle FEC ranged between 60 and 88 EPG with a total mean of 75 EPG. Horses aged 4-7 years showed a significantly (p < 0.00001) higher mean FEC compared with the other age groups, differences were not significant among the older horses. Based on ZIP codes, samples were allocated by 70.0 %, 6.0 % and 0.2 % to the German-, French- and Italian-speaking regions of Switzerland, respectively. With 222 EPG the mean FEC in the French part of Switzerland was significantly higher (p < 0.05) than in the German-speaking region (60 EPG). Eggs of Parascaris spp., anoplocephalids and Strongyloides westeri were found in 0.36 %, 0.32 % and 0.01 % of the samples, respectively. Based on 3,813 questionnaire feedbacks from owners in 2017 covering a total of 12,689 horses, sixty-eight percent (n = 8,476) were dewormed without diagnosis, two percent (n = 240) were not dewormed at all, whereas for 30 % (n = 3,721) the selective anthelmintic treatment (SAT) concept was applied. The SAT implementation rate differed significantly (p < 0.0005) between regions, with 33 %, 20 % and 25 % for the German-, French- and Italian-speaking areas, respectively. The rate of horses spending 16-24 h on pasture per day was significantly higher in the French-speaking region compared to the German-speaking part of Switzerland (p < 0.0001). In addition, pasture hygiene was practiced at a significantly lower rate in the French-speaking part compared to the German- and Italian-speaking regions (both p < 0.0001). Overall, the shift towards the SAT-concept represents a very promising development with respect to mitigating the further spread of anthelmintic resistance.

The golden jackal (Canis aureus): A new host for Echinococcus multilocularis and Trichinella britovi in Switzerland.

INTRODUCTION: The golden jackal (Canis aureus) is a wild canid new to Switzerland. It is an officially monitored species and all deceased individuals are submitted for post-mortem examination to collect baseline health data. This includes parasitological examinations, with an emphasis on zoonotic, reportable infections, such as those caused by Trichinella spp. or Echinococcus spp. From 2016 to 2021, five golden jackals originating from four Swiss cantons were submitted for full post-mortem examination. In one case only organ samples were available, and therefore parasitological examination was not possible. Parasite stages recovered during necropsy, as well as by routine coproscopical techniques, were morphologically identified. Taeniid eggs and adult tapeworms were processed for molecular species identification. Additionally, tongue and diaphragm were analysed for Trichinella spp. by the artificial digestion technique followed by multiplex-PCR in positive cases. Of the four jackals investigated for parasites, hookworm eggs were detected in one animal, both adult worms and eggs of Echinococcus multilocularis were present in another case, and one animal was free of parasites. Eggs of E. multilocularis as well as eggs of Toxocara canis and sporocysts of Sarcocystis sp. were detected in the intestinal content, and Trichinella britovi larvae were found in the muscle samples of the last case. The health monitoring programme in place for protected carnivores in Switzerland allowed us to add the golden jackal to the list of hosts for the endemic zoonotic parasites E. multilocularis and T. britovi in this country. Hunters, farmers, and other persons who could come in contact with golden jackals should be aware of the associated health risk and handle faeces and carcasses with caution.

INTRODUCTION: Le chacal doré (Canis aureus) est un canidé sauvage nouvellement présent en Suisse. Il s'agit d'une espèce officiellement surveillée et tous les individus morts sont soumis à un examen post-mortem afin de recueillir des données sanitaires de base. Cela inclut un examen parasitologique mettant l'accent sur les infections zoonotiques à déclaration obligatoire, telles que celles causées par Trichinella spp. ou Echinococcus spp. De 2016 à 2021, cinq chacals dorés originaires de quatre cantons suisses ont été soumis à un examen post-mortem complet. Dans un cas, seuls des échantillons d'organes ont été envoyés, l'examen parasitologique n'a pas été possible pour cet animal. Les stades parasitaires trouvés lors de l'examen pathologique et de la coprologie de routine ont été identifiés morphologiquement. Les espèces de ténias (œufs et stades adultes) ont été déterminées par des techniques de biologie moléculaire. En outre, la recherche de Trichinella spp. a été effectuée sur du tissu musculaire lingual et diaphragmatique par la technique de digestion artificielle suivie d'une PCR multiplex dans les cas positifs. Sur les quatre chacals ayant fait l'objet d'une recherche de parasites, des œufs d'ankylostomes ont été détectés chez un animal, des vers adultes et des œufs d'Echinococcus multilocularis étaient présents chez un autre animal, et aucun parasite n'a été trouvé dans un autre cas. Chez le dernier cas, des œufs d'E. multilocularis ainsi que des œufs de Toxocara canis et des sporocystes de Sarcocystis sp. ont été détectés dans le contenu intestinal, et des larves de Trichinella britovi ont été trouvées dans les échantillons de muscle. Le programme de surveillance sanitaire mis en place pour les carnivores protégés en Suisse a donc permis d'ajouter le chacal doré à la liste des hôtes des parasites zoonotiques endémiques E. multilocularis et T. britovi. Les chasseurs, agriculteurs et autres personnes susceptibles d'entrer en contact avec le chacal doré doivent être conscients du risque sanitaire associé et manipuler les fèces et les carcasses avec précaution.

Comparing the demonstration of freedom from Trichinella infection of domestic pigs by traditional and risk-based surveillance.

Traditionally, the routine artificial digestion test is applied to assess the presence of Trichinella larvae in pigs. However, this diagnostic method has a low sensitivity compared to serological tests. The results from artificial digestion tests in Switzerland were evaluated over a time period of 15 years to determine by when freedom from infection based on these data could be confirmed. Freedom was defined as a 95% probability that the prevalence of infection was below 0.0001%. Freedom was demonstrated after 12 years at the latest. A new risk-based surveillance approach was then developed based on serology. Risk-based surveillance was also assessed over 15 years, starting in 2010. It was shown that by using this design, the sample size could be reduced by at least a factor of 4 when compared with the traditional testing regimen, without lowering the level of confidence in the Trichinella-free status of the pig population.

Increased parasite resistance and recurrent airway obstruction in horses of a high-prevalence family.

BACKGROUND: Equine recurrent airway obstruction (RAO) shares many characteristics with human asthma. In humans, an inverse relationship between susceptibility to asthma and resistance to parasites is suspected. HYPOTHESIS/OBJECTIVES: Members of a high-incidence RAO half-sibling family (F) shed fewer strongylid eggs compared with RAO-unaffected pasture mates (PM) and that RAO-affected horses shed fewer eggs than RAO-unaffected half-siblings. ANIMALS: Seventy-three F and 73 unrelated, age matched PM. METHODS: Cases and controls kept under the same management and deworming regime were examined. Each individual was classified as RAO affected or RAO unaffected and fecal samples were collected before and 1-3 weeks and 3 months after deworming. Samples were analyzed by combined sedimentation-flotation and modified McMaster methods and classified into 3 categories of 0 eggs per gram of feces (EpG), 1-100 EpG, and > 100 EpG, respectively. RESULTS: PM compared with RAO-affected F had a 16.7 (95% confidence interval [CI]: 2.0-136.3) times higher risk for shedding > 100 EpG compared with 0 EpG and a 5.3 (95% CI: 1.0-27.4) times higher risk for shedding > 100 EpG compared with 0 EpG. There was no significant effect when RAO-unaffected F were compared with their PM. RAO-unaffected compared with RAO-affected offspring had a 5.8 (95% CI: 0.0-1.0) times higher risk for shedding 1-100 EpG. Age, sex, breed, and sharing pastures with other species had no significant confounding effects. CONCLUSION AND CLINICAL IMPORTANCE: RAO is associated with resistance against strongylid parasites in a high-prevalence family.

[A survey on intestinal parasites of livestock guardian dogs and herding dogs in Switzerland]. / Überblick über intestinale Parasiten bei Herdenschutzhunden und Hütehunden in der Schweiz.

The present study describes the occurrence of intestinal parasite infections in livestock guardian dogs and herding dogs. A total of 71 guardian dogs (more than half of the total number of guardian dogs in Switzerland) and 21 herding dogs were coprologically examined, using a combined sedimentation-flotation method. In 21 (23 %) of the dogs intestinal parasites were detected, and 8 (8.7 %) of these dogs shed either sporocysts of Sarcocystis sp. (n = 6) or taeniid eggs (n = 2). The evaluation of questionnaires providing data on age, origin and deworming schemes of the dogs completed the study.

Validation of a Western Blot for the detection of anti-Trichinella spp. antibodies in domestic pigs.

Trichinellosis is a zoonotic disease in humans caused by Trichinella spp. According to international regulations and guidelines, serological surveillance can be used to demonstrate the absence of Trichinella spp. in a defined domestic pig population. Most enzyme-linked immunosorbent assay (ELISA) tests presently available do not yield 100% specificity, and therefore, a complementary test is needed to confirm the diagnosis of any initial ELISA seropositivity. The goal of the present study was to evaluate the sensitivity and specificity of a Western Blot assay based on somatic Trichinella spiralis muscle stage (L1) antigen using Bayesian modeling techniques. A total of 295 meat juice and serum samples from pigs negative for Trichinella larvae by artificial digestion, including 74 potentially cross-reactive sera of pigs with other nematode infections, and 93 meat juice samples from pigs infected with Trichinella larvae were included in the study. The diagnostic sensitivity and specificity of the Western Blot were ranged from 95.8% to 96.0% and from 99.5% to 99.6%, respectively. A sensitivity analysis showed that the model outcomes were hardly influenced by changes in the prior distributions, providing a high confidence in the outcomes of the models. This validation study demonstrated that the Western Blot is a suitable method to confirm samples that reacted positively in an initial ELISA.

[Cryptosporidiose (C. parvum) in a foal with diarrhea]. / Cryptosporidiose (C. parvum) bei einem Fohlen mit Durchfall.

The protozoon parasite Cryptosporidium parvum is an important cause of diarrhea in farm animals, but it can also infect other animals and humans. In this case report, oocysts of Cryptosporidium spp. were microscopically detected by modified Ziehl-Neelsen staining in the feces of a 9 day old Arabian colt presented with yellowish, foul smelling, diarrhea and fever of 40 degrees C. PCR and sequencing of the isolate revealed C. parvum (bovine genotype). Hemato-chemical analysis of the foals blood revealed a marked hypogammaglobulinaemia (IgG 108mg/dl). The colt responded well to a supportive therapy and administration of plasma (until a gammaglobulin-concentration of 620 mg/dl was reached) and was released in good health from the clinic after 10 days. Follow-up testing for Cryptosporidium oocycsts remained negative. Cryptosporidiosis with life-threatening diarrhea is a rare diagnosis in foals in Switzerland. Immunodeficiency increases the risk for cryptosporidiosis. We hypothesize that the low concentration of gammaglobulins together with the weak INF-gamma response normally observed in young foals may have favored the clinical manifestation with diarrhea. Foals with diarrhea should be screened for cryptosporidia with specific tests.

Apparent prevalence of and risk factors for infection with Ostertagia ostertagi, Fasciola hepatica and Dictyocaulus viviparus in Swiss dairy herds.

Infections with helminth parasites can negatively affect performance of dairy cows. Knowledge on infection intensity, spatial distributions and risk factors are key to develop targeted treatment strategies. Canada and most EU countries have conducted large investigations, but respective data for Switzerland were missing. We now performed a bulk tank milk serosurvey for Ostertagia ostertagi, Fasciola hepatica, and Dictyocaulus viviparus on a total of 1036 voluntarily participating dairy herds that were sampled at confinement periods, i.e. in winter 2014/15 or 2015/16, respectively. All samples were analyzed with commercial ELISAs for antibodies (AB) against O. ostertagi and F. hepatica, and those of the first sampling period additionally with an in-house ELISA for AB against D. viviparus. Testing for the latter parasite was not done in the second year of the study, as the sampling period might have missed infections due to the short lived nature of specific antibodies. The possible influence of geographic, climatic, and farm management variables on AB levels were assessed for each parasite using scanning cluster and multiple regression analysis. Overall seroprevalence for O. ostertagi was 95.5% (95% C.I.: 94.0-96.6), with a mean optical density ratio (ODR) of 0.83, for F. hepatica 41.3% (95% C.I.: 38.3-44.4), and for D. viviparus 2.9% (95% C.I.: 1.6-4.7). There were no significant differences between the two sampling periods. For all parasites, significant geographic clusters of higher AB levels could be established. Furthermore, AB levels against all three parasites were positively correlated with each other, indicating either cross-reactions or co-infections. For O. ostertagi, herd size and percentage of pasture in the ration were positively correlated with AB levels. For F. hepatica, altitude above sea level (a.s.l.) positively, and milk production per cow and year was negatively correlated with AB levels. This work provides baseline data for further studies performing in-depth risk factor analysis and investigating management as well as targeted treatment options to control the parasites.

Dogs as victims of their own worms: Serodiagnosis of canine alveolar echinococcosis.

BACKGROUND: Besides acting as definitive hosts for Echinococcus multilocularis, dogs can become infected by the larval form of this parasite and thereby develop life-threatening alveolar echinococcosis (AE). Although AE is a zoonotic disease, most therapeutic and diagnostic approaches have been developed for human patients. In dogs, AE is typically diagnosed in the advanced stage of the disease when the parasitic mass has already caused abdominal distension. At that stage, complete resection of the parasitic mass is often impossible, leaving a guarded prognosis for the affected dogs. For humans, sensitive and specific diagnostic protocols relying on serology have been validated and are now widely used. In contrast, sensitive and specific laboratory diagnostic tools that would enable early diagnosis of canine AE are still lacking. The aim of the current study was to establish a serological protocol specifically adapted to dogs. METHODS: We tested several native and recombinant antigens (EmVF, Em2, recEm95, recEm18) in in-house ELISA, an in-house Western blot (WB), as well as a commercially available WB developed for serodiagnosing human AE (Anti-Echinococcus EUROLINE-WB®), using a panel of known status dog sera. RESULTS: RecEm95-antigen was revealed to be the most promising antigen for use in ELISA, demonstrating 100% (95% CI: 72-100%) sensitivity and 100% (95% CI: 93-100%) specificity in our study. The in-house WB using EmVF antigen performed as well as the recEm95-ELISA. The commercial WB also correctly identified all infected dogs, coupled with a specificity of 98% (95% CI: 91-100%). CONCLUSION: The recEm95-ELISA alone or in combination with either the in-house WB or the Anti-Echinococcus EUROLINE-WB® (IgG) with a minor modification should be considered as the best current approach for the serological diagnosis of dogs infected with the larval stage of E. multilocularis. However, larger studies with a focus on potentially cross-reacting sera should be undertaken to verify these findings.

Clinical presentation, diagnosis, therapy and outcome of alveolar echinococcosis in dogs.

Alveolar echinococcosis (AE), a parasitic disease primarily of the liver caused by the larval stage of Echinococcus multilocularis, is highly endemic in Switzerland. In contrast to well-established management protocols in people, little is known with regard to optimal treatment strategies in dogs. The objective of this study was to describe the clinical signs and diagnostic procedures in dogs with AE and to evaluate outcome following medical treatment alone or surgery and medical treatment. Of 23 putative AE cases between 2004 and 2014, 20 were classified as confirmed (n=18) or probable (n=2) AE, based on abdominal ultrasound, serology, cytology, histology and/or PCR. Most dogs presented with abdominal distension in an advanced stage of disease. Dogs receiving specific treatment (radical or debulking surgery together with medical treatment, or medical treatment alone) survived longer than dogs left untreated, but no difference was found between treatment types. Survival at one year was associated with absence of free abdominal fluid, absence of abdominal distension and treatment of any type. However, dogs treated with debulking surgery all faced relapse. Findings of this study suggest that in AE-affected dogs for which a therapeutic approach is regarded appropriate by owners and veterinarians, radical surgical resection and medical treatment or, if total resection is not possible, medical treatment alone should be considered. However, studies on larger numbers of dogs are necessary before definitive treatment recommendations can be made.

Effect of prostaglandin blockers on ascites fluid in pancreatitis.

UNLABELLED: Prostacyclin (PGI2), a potent vasodilator with complex effects on the mesenteric circulation, has been found to be elevated in the hemorrhagic ascitic fluid of pigs with hemorrhagic pancreatitis. This investigation was designed to determine if blockage of PGI2 significantly reduces the volume and/or toxicity of hemorrhagic ascitic fluid associated with hemorrhagic pancreatitis in pigs. Fifteen pigs were studied: five received corticosteroids, five received ibuprofen, and five were untreated. The relative toxicity of the hemorrhagic ascitic fluid was assessed by intraperitoneal injections of the fluid from pigs into mice. RESULTS: (1) hemorrhagic pancreatitis was associated with high levels of PGI2 in blood 15 times and in hemorrhagic ascitic fluid 25 times that of baseline; (2) steroids and ibuprofen blocked PGI2 production (p less than 0.05); (3) neither steroids nor ibuprofen, even when administered as pretreatment, decreased ascites formation; and (4) the mortality rate in mice was significantly reduced (p less than 0.05) in the ibuprofen-treated group as compared with the untreated and steroid-treated groups. CONCLUSION: PGI2 does not play a significant role in the volume of ascites formation. There was an absence of toxicity in the hemorrhagic ascitic fluid of the ibuprofen-treated group.

Gastrointestinal and pancreatic complications associated with severe pancreatitis.

OBJECTIVE: To study the outcomes of gastrointestinal fistulas and pancreatic ductal disruption in severe pancreatitis. SETTING: University tertiary referral center. PATIENTS: One hundred thirty-six patients from 1982 to 1994. INTERVENTION: Diversion followed by resection and ostomy closure for gastrointestinal fistulas, pancreaticojejunostomy for pancreatic fistulas, and excision, external drainage, or internal drainage for pseudocysts. RESULTS: The incidence of infection was 24% (8/33) for peripancreatic fluid collections and 59% (61/103) for patients with necrosis plus fluid collections or necrosis without fluid. Sixty-nine patients developed 25 gastrointestinal fistulas and 51 complications caused by pancreatic ductal disruption. Necrosis and infection but not the open packing technique were associated with increased risk of gastrointestinal fistulas. In patients with pancreatic ductal disruption, pancreatic fistulas developed following necrosectomy and external drainage, while pancreatic pseudocysts evolved from undrained peripancreatic fluid collections. Gastrointestinal fistulas required prompt operative intervention, whereas pancreatic ductal disruption was treated nonoperatively initially. The mortality rate was 13% (3/23) in patients with gastrointestinal fistulas, similar to the overall mortality rate of 10.3% (14/136). There was no mortality in patients with pancreatic fistulas or pseudocysts. Length of hospital stay was prolonged by the presence of necrosis and infection, not by gastrointestinal fistulas or ductal disruption. Thirty-eight of the 69 patients with these complications required readmission for operative management of their complications. To date, only 18 (13.2%) of 136 patients with severe pancreatitis have not required surgical intervention. CONCLUSIONS: Gastrointestinal fistulas and pancreatic ductal disruption are common in severe pancreatitis. Although these complications are not associated with increased mortality or prolonged initial length of stay, readmission for elective surgical correction is necessary in most patients. Severe pancreatitis is a surgical disease, requiring both acute and long-term surgical care.

The role of antibiotic prophylaxis in severe acute pancreatitis.

OBJECTIVE: To assess the impact of intravenous (IV) antibiotic prophylaxis on the incidence of pancreatic infection and the mortality rate in severe acute pancreatitis. DESIGN: Restropective review of a cohort of 180 patients with severe acute pancreatitis. SETTING: A tertiary referral center in Sacramento, Calif. INTERVENTION: The use of IV antibiotic prophylaxis evolved during 3 periods from no antibiotics in 50 patients (1982-1989), to nonprotocol use in 55 patients (1990-1992), to a 4-week course of imipenem-cilastatin sodium (1993-1996) given to 75 patients having Acute Physiology and Chronic Health Evaluation (APACHE) II scores greater than 6 and pancreatic necrosis (> 15% of the gland), peripancreatic necrosis, or peripancreatic collection. MAIN OUTCOME MEASURES: Pancreatic infection and mortality. RESULTS: Without antibiotic prophylaxis, the incidence of pancreatic infection was 76% (38/50). Intravenous antibiotic prophylaxis reduced the infection rate of 45% (25/55) (P = .03). The imipenem-cilastatin protocol further reduced the infection rate to 27% (20/75) (P = .04). The mortality rates showed only a decreasing trend, from 16% (1982-1989) to 7% (1990-1992) to 5% (1993-1996) (P = .11). Patients with sterile severe acute pancreatitis had a mortality rate of 2% (2/97); whereas 17% (14/83) of patients with infection succumbed to the disease. Patients developing infection within the first 4 weeks from the onset of illness had mortality rates ranging from 19% to 40%, compared with 0% to 8% for those who became infected after 4 weeks. No patient with pancreatic infection developing after 4 weeks died with the imipenem-cilastatin protocol. CONCLUSIONS: Intravenous antibiotic prophylaxis significantly reduced the infection rate in severe acute pancreatitis, with only a trend toward improved survival. A prospective, randomized, double-blind multicenter trial comparing the efficacy of different types and/or combinations of antibiotic prophylaxis in severe acute pancreatitis is indicated.

Comprehensive management of acute necrotizing pancreatitis and pancreatic abscess.

Achieving reduced mortality rates in patients with necrotizing pancreatitis and pancreatic abscess is possible by employing a comprehensive management plan. Components of the plan include (1) rapid evaluation and assessment of the degree of physiologic and anatomic derangement, the latter by the prompt use of vascular enhanced computed tomographic scan; (2) adequate fluid resuscitation determined by early institution of advanced hemodynamic monitoring; (3) attempts to identify and document septic foci via computed tomography-guided percutaneous aspiration; and (4) aggressive surgical debridement. Close adherence to these policies allowed us to keep mortality in this seriously ill group of patients to 14%. Most deaths occurred in patients who were referred to this service late in the course of their disease. The Acute Physiology and Chronic Health Enquiry (APACHE) II severity of illness index applied at the time of admission proved an accurate predictor of mortality. A score of 25 or greater was highly predictive of death, and a lesser score, of survival.

Pancreatitis after endoscopic retrograde cholangiopancreatography. An underreported disease whose severity is often unappreciated.

We describe our experience between 1985 and 1989 with 24 patients with clinically significant pancreatitis after endoscopic retrograde cholangiopancreatography. The resulting pancreatitis was categorized into three groups, all requiring hospitalization: (1) mild pancreatitis (n = 12); (2) moderate pancreatitis requiring aggressive evaluation, treatment, and follow-up (n = 6); and (3) severe pancreatitis requiring surgical therapy (n = 6). The average length of hospitalization for the entire group was 12.8 days. Surgical intervention was required in 5 patients, and 3 patients died of acute necrotizing pancreatitis with sepsis, adult respiratory distress syndrome, and intractable hemodynamic failure. Our experience with this entity suggests that this form of pancreatitis includes severe and even lethal outcomes. It was associated with a mortality of 13%.