Bone mineral metabolism and bone mineral density in alcohol related and idiopathic chronic pancreatitis.

BACKGROUND: There is limited information on the bone mineral metabolism in patients with chronic pancreatitis (CP). METHODS: 103 patients with CP (all males: mean age 38.6 ± 20.64 yrs) and 40 age matched control males (mean age: 36.7 ± 20.70 yrs) were prospectively studied. Serum levels of 25 (OH) Vitamin D3, alkaline phosphatase (ALP), and parathyroid hormone (PTH) were measured. Bone mineral density (BMD) was measured using adual-energy X-ray absorptiometry (DEXA) scanner. RESULTS: Seventy two (70%) patients had alcohol related chronic pancreatitis (ACP), 30 (29.1%) patients had idiopathic chronic pancreatitis (ICP) and one patient had post-traumatic chronic pancreatitis. Fifty nine (59.8%) patients had chronic calcific pancreatitis (CCP) and 39 (37.8%) patients were diabetic. Steatorrhea was noted in 21 (20.4%) patients. On comparison with controls, patients with chronic pancreatitis had significantly lower 25 (OH) Vitamin D3 levels (p = 0.01). On evaluation of bone mineral density (BMD) at lumbar spine, 46% patients were osteopenic and 12% patients were osteoporotic. On evaluation of BMD of femur, 30.1% patients were osteoporotic and 39.8% patients were osteopenic. No significant difference was found in the frequency of metabolic osteopathy between alcoholic and idiopathic groups (p = 0.108), calcific and non-calcific groups (p = 0.410), diabetic and non-diabetic groups (p = 0.126). smokers and non-smokers (p = 0.198), and patients with and without history of steatorrhea (p = 0.265) and indifferent severity groups ofupancreatitis (p = 0.910) CONCLUSIONS: Majority of patients with both ACP and ICP had low BMD and similar frequency of bone changes between various groups suggests that systemic inflammation may play an important role in its pathogenesis. Further detailed metabolic studies are necssary to define the pathogenic mechanism of metabolic osteopathy associated with chronic pancreatitis.

Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis & disconnected pancreatic duct syndrome.

INTRODUCTION: There is limited data on the long term consequences and safety profile of long term indwelling transmural stents after successful treatment of walled off pancreatic necrosis (WOPN). AIM: To retrospectively evaluate consequences of long term indwelling transmural stents in patients with WOPN. METHODS: The records of patients who underwent endoscopic transmural drainage of WOPN and had disconnected pancreatic duct syndrome (DPDS) were analyzed. RESULTS: Thirty patients (26 M; mean age 37.1 ± 7.8 years) with long term indwelling transmural stents and DPDS were followed up for a mean of 20.4 ± 12.2 months (range: 3-38 months). The etiology of acute necrotizing pancreatitis was alcohol in 21, gall stones in 7 and idiopathic in 2 patients. In all patients two or three, 7 (17 patients) or 10 Fr (13 patients) 5 cm double pigtail stents were placed. ERCP revealed disconnected PD at the pancreatic head, body and tail region in 22, 7, and 1 patient respectively. Five patients (16.6%) had spontaneous migration of stents (both the stents in four patients and one stent in one patient; 7 Fr in four and 10 Fr in one patient respectively). Stent migration led to recurrence of pancreatic fluid collection (PFC) in one patient whereas in the remaining 4 patients it did not cause any symptoms. There was no recurrence of symptomatic PFC in remaining 25 patients. CONCLUSION: Long term indwelling transmural stents in patients with WOPN and DPDS seem to be safe and also appear to decrease the risk of PFC recurrence.

Non-surgical management of pancreatic pseudocysts associated with arterial pseudoaneurysm.

BACKGROUND: Pseudoaneurysms associated with pancreatic pseudocysts are different from simple, isolated pancreatic pseudoaneurysms and there is paucity of published data on their non surgical treatment. AIM: To retrospectively analyze results of combination of angioembolisation or thrombin injection followed by endoscopic transpapillary drainage for management of pseudoaneurysms associated with pancreatic pseudocysts. METHODS: Eight patients (all males; mean age ± SD: 31.2 ± 6.1 years; age range: 21-38 years) underwent radiological management of the pseudoaneurysm followed by endoscopic drainage of the pseudocysts. RESULTS: All patients had pseudocysts (median size 4 cm) with underlying chronic pancreatitis. All patients had abdominal pain on presentation and 7/8 (87.5%) patients had presented with overt gastrointestinal bleeding. The size of the pseudoaneurysms varied from 1 to 4 cm. Two patients were treated with percutaneous thrombin injection whereas six patients underwent digital subtraction angiography and angioembolisation. All patients underwent successful endoscopic transpapillary drainage through the major (5) or minor papilla (3) and resolution of pseudocysts was noted within 6 weeks (median 4 weeks). No significant complication of the procedure was noted in any of the patients. CONCLUSIONS: Pseudoaneurysms associated with pancreatic pseudocysts can be successfully and safely treated with a combination of radiological obliteration of the pseudoaneurysm followed by endoscopic transpapillary drainage.

Implications of culture positivity in acute pancreatitis: does the source matter?

BACKGROUND AND AIMS: Sepsis is an important complication and cause of morbidity and mortality in acute pancreatitis (AP). The source of sepsis may be infected pancreatic and peripancreatic collections and/or necrosis or extrapancreatic including infections in the bloodstream or respiratory and urinary tracts. We studied the implications of the source of sepsis on various outcome parameters in AP like persistent organ failure (POF), length of hospital (LOH) stay, and mortality. METHODS: A retrospective analysis of culture reports of AP patients was done, and the outcome parameters were recorded. RESULTS: Three hundred fifty-seven patients (229 M; age: 40.3 ± 14.04 years) of AP who had detailed culture reports were included. Eighty-four (23.5%) patients had pancreatic (or peripancreatic) source (group 1), 52 (14.6%) patients had other (extrapancreatic) sources (group 2), 20 (5.6%) patients were noted to have positive cultures from sources, which were both pancreatic and extrapancreatic (combined) sources (group 3), while 201 patients had sterile cultures. POF was seen in 147 (48%) patients (group 1: 67.8%; group 2: 65%; group 3: 90%; group 4: 34% [P < 0.001]). The mean LOH stay was 22.1 ± 20.26 days (group 1: 30.2 ± 20.64 days; group 2: 26.4 ± 26.82 days; group 3: 47.3 ± 32.60 days; group 4: 15.2 ± 11.34 days [P < 0.001]). Seventy (19.7%) patients succumbed to their illness (group 1 [22.9%]; group 2 [36.5%]; group 3 [40%]; group 4 [12%] [P < 0.001]). CONCLUSIONS: POF and LOH stay were more common in patients with combined pancreatic and extrapancreatic sources of sepsis. Mortality was significantly higher in patients with sepsis (groups 1, 2, 3) compared with sterile groups.

Non-fluoroscopic endoscopic ultrasound-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis.

BACKGROUND AND AIM: Endoscopic treatment of pancreatic necrosis is less invasive than surgery but is a technically demanding procedure. The aim of the present study was to retrospectively evaluate the safety and efficacy of endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis (WOPN) without the use of fluoroscopy. METHODS: Over the last 24 months, 20 patients (16 men) with symptomatic non-bulging WOPN were treated endoscopically at Department of Gastroenterology, PGIMER, Chandigarh, India.The WOPN was transmurally approached using a linear echoendoscope and the tract dilated over the wire and multiple stents and a nasocystic drain were placed. RESULTS: All 20 patients had acute severe pancreatitis and the etiology of pancreatitis was alcohol in 12, gallstones in six and idiopathic in two patients. All patients were symptomatic with pain and six patients had fever and presented 5 to 16 weeks after an acute episode.The size of WOPN ranged from 5 to 16 cm.All 20 patients had marked improvement with radiological resolution noted in 19 patients and only one patient required direct endoscopic necrosectomy. One patient with multiple WOPN had a large peripherally located WOPN that did not resolve after transmural drainage and required an additional percutaneous drainage. One to seven endoscopic sessions were required and all these patients had complete resolution within 6 weeks.There were no complications of the procedure.There has been no recurrence of symptoms in these patients over a median follow up of 14 months. CONCLUSION: EUS-guided transmural drainage of non-bulging WOPN without the use of fluoroscopy appears to be safe and effective.

Diastolic dysfunction, prolonged QTc interval and pericardial effusion as predictors of mortality in acute pancreatitis.

BACKGROUND AND AIM: The cardiac changes in acute pancreatitis have been earlier studied but the data on their prognostic significance is limited. This study was done to determine electrocardiographic (ECG) and echocardiographic changes in acute pancreatitis and determine their prognostic significance. METHODS: Fifty-two consecutive patients (mean age 36.5 ± 11 years (44 males)) with acute pancreatitis and without prior cardiovascular comorbidites were prospectively enrolled and subjected to clinical, laboratory and radiological investigation. ECG and echocardiography was done at admission and during follow up. RESULTS: Seventeen patients (32.7%) had mild pancreatitis and 35 (67.3%) patients had severe pancreatitis. Sinus tachycardia was the most common ECG abnormality. QTc prolongation was seen in 30/52 (57.7%) patients. On echocardiography, no patient had systolic dysfunction but 31/52 (59.6%) patients had diastolic dysfunction. All 22 patients with QTc interval < 440 ms survived compared with 8/30 patients with QTc interval ≥ 440 ms who died (P = 0.01). All eight patients who died had evidence of diastolic dysfunction (100%). None of the patients without diastolic dysfunction succumbed to illness (P = 0.02). Pericardial effusion was present in 6/52 (11.5%) patients. Of the eight patients who died, pericardial effusion was present in three (37.5%) patients and this frequency was significantly higher than that in patients who recovered (3/44 [6.8%]; P = 0.04). CONCLUSION: Electrocardiographic and echocardiographic changes are seen in more than 50% of patients with acute pancreatitis. Prolonged QTc interval, pericardial effusion and diastolic dysfunction are associated with higher mortality.

Endoscopic management of pancreatic injury due to abdominal trauma.

CONTEXT: There is limited experience with pancreatic endotherapy in patients with pancreatic injury due to trauma. OBJECTIVE: To retrospectively evaluate our experience of endoscopic management of pancreatic trauma. PATIENTS: Eleven patients (10 males and 1 female; mean age: 21.8±11.9 years) with pancreatic trauma. INTERVENTION: Endoscopic therapy. Patients with pseudocyst and a gastroduodenal bulge were treated with endoscopic transmural drainage. Pseudocysts without bulge or patients with external pancreatic fistula were treated with transpapillary drainage. RESULTS: Seven patients (6 males, 1 female) were treated for symptomatic pseudocyst and 4 patients (all males) were treated for persistent external pancreatic fistula. Three patients with external pancreatic fistula had partial disruption of pancreatic duct (head: 2 cases; tail: 1 case) and were successfully treated with bridging pancreatic stent (2 cases) or bridging nasopancreatic drain (1 case) with resolution of external pancreatic fistula in 4 to 6 weeks. Of seven patients presenting with symptomatic pseudocyst (size range: 4-14 cm), two patients were successfully treated with cystogastrostomy and there has been no recurrence over a follow up of 20 and 16 months, respectively. Five patients underwent transpapillary drainage. Three patients had partial disruption and two had complete disruption. In the former, a bridging nasopancreatic drain was placed in one patient and stent in two patients. All three patients had resolution of pseudocyst within 8 weeks and there has been no recurrence over a follow-up of 11 to 70 months. In two patients with complete disruption, non-bridging stent did not resolve the pseudocysts and required surgery. CONCLUSION: Pancreatic injury due to trauma can be effectively treated endoscopically.

Isolated pancreatic tuberculosis mimicking focal pancreatitis and causing segmental portal hypertension.

CONTEXT: Isolated pancreatic tuberculosis is a common mimicker of pancreatic malignancy and a common presentation is abdominal pain. However, segmental portal hypertension is very uncommon. CASE REPORT: A case of isolated pancreatic tuberculosis mimicking focal pancreatitis and causing segmental portal hypertension is presented. CONCLUSION: A histological or microbiological diagnosis of the presence of pancreatic masses is necessary to detect potentially treatable diseases, such as tuberculosis, in endemic countries like India.

Comparative evaluation of structural and functional changes in pancreas after endoscopic and surgical management of pancreatic necrosis.

BACKGROUND: Patients with acute necrotizing pancreatitis may develop pancreatic insufficiency and this is commonly seen in patients who have undergone surgery for pancreatic necrosis. Owing to the paucity of relative data, we retrospectively evaluated the structural and functional changes in the pancreas after endoscopic and surgical management of pancreatic necrosis. METHODS: The records of patients who underwent endoscopic transmural drainage of walled off pancreatic necrosis (WOPN) over the last 3 years and who completed at least 6 months of follow up were analyzed. Structural and functional changes in these patients were compared with 25 historical surgical controls (operated in 2005-2006). RESULTS: Twenty six patients (21 M; mean age 35.4±8.1 years) who underwent endoscopic drainage for WOPN were followed up for 22.3±8.6 months. During the follow up, five (19.2%) patients developed diabetes with 3 patients requiring insulin and 1 patient with steatorrhea requiring pancreatic enzyme supplementation. The pancreatic fluid collection (PFC) recurred in 1 patient whose stents spontaneously migrated out. On follow up, in the surgery group, 2 (8%) patients developed steatorrhea and 11 (44%) developed diabetes. Five (20%) of these patients had recurrence of PFC. On comparison of follow up results of endoscopic drainage with surgery, recurrence rates as well as frequency of endocrine and exocrine insufficiency was lower in the endoscopic group but difference was not significant. CONCLUSION: Structural and functional impairment of pancreas is seen less frequently in patients with pancreatic necrosis treated endoscopically compared to patients undergoing surgery, although the difference was insignificant. Further studies with large sample size are needed to confirm these initial results.

Morphological features of fluid collections on endoscopic ultrasound in acute necrotizing pancreatitis: do they change over time?

BACKGROUND: There have been attempts to develop universally applicable nomenclature for pancreatic fluid collections (PFCs) in acute pancreatitis. But PFCs following acute necrotizing pancreatitis (ANP) has not been studied by sensitive imaging techniques like endoscopic ultrasound (EUS). The aim of the study was to prospectively study morphological structure of pancreatic fluid collections occurring after ANP by serial EUS. METHODS: Patients with ANP having PFC at ≥4 weeks of onset of symptoms seen at our center from October 2011 to November 2012 were prospectively followed up with EUS at 6 weeks, 3 months and 6 months respectively and the amount of solid content in the collection was quantified as percentage amount of echogenic material. The symptomatic patients undergoing EUS/percutaneous drainage also underwent EUS prior to drainage for assessment of solid content. RESULTS: Of the 54 patients enrolled, 7 patients were lost to follow up or refused EUS. Forty seven patients (34 males; mean age 36.7±11.6 years) were studied. Etiology of acute pancreatitis was alcohol (n=22), gallstones (n=10), idiopathic (10), gallstones+alcohol (n=3) and drug induced (n=2). Contrast enhanced computed tomography done after 3 days of onset of ANP had shown less than 30%, 30-50% and more than 50% necrosis in 6 (13%), 14 (30%) and 27 (57%) patients respectively. On EUS at 6 weeks, 41/47 (87%) patients had fluid collection with solid debris. Follow up EUS at 3 and 6 months revealed progressively decreasing solid content in PFCs. CONCLUSIONS: All PFCs following ANP may not have solid necrotic content and over a period of time necrotic content tends to liquefy. This may have therapeutic implications.