"Open abdomen" in the treatment of necrosis in acute pancreatitis]

Eleven cases of acute necrotic pancreatitis had been treated by "open abdomen" at the author's departments. Nine patients survived, but 2 patients had been lost in MOF. Indication, technics and complications are discussed. The author's opinion is, that--on the basis of a suitable indication--"open abdomen" is a good method in the treatment of the necrosis in acute pancreatitis.     

Computerized tomography versus nuclear magnetic resonance in acute pancreatitis

The aim of the study was to compare Computed Tomography (CT) and Nuclear Magnetic Resonance (MR) scan's diagnostic reliability in acute pancreatitis (AP). During a 44-month period 21 patients with a clinical and laboratory diagnosis of AP were submitted to CT and MR study. The scans were evaluated according to pancreatitis degree and presence and rate of necrosis. Pancreatitis degree was assessed using Balthazar's grading for CT scans; a similar classification was used for MR scans. Thirteen patients had oedematous pancreatitis and 8 necrotic pancreatitis. Necrosis was diagnosed intraoperatively or in non operated patients with CT scan. MR staging was identical to that of the CT ones except for 2 patients who were grade E at CT and grade D at MR. MR identified necrosis in all 8 patients with necrotic AP whereas CT diagnosed only 5 patients properly since 3 scans were performed without contrast medium infusion because of renal failure. MR proved to be a valid alternative in AP diagnosis: it provide the same diagnostic and prognostic information as CT and does not need contrast infusion, which makes it preferable to CT in the follow-up of severe AP evolution.     

The clinical picture and treatment of destructive pancreatitis

The results of treatment of 319 patients with acute pancreatitis are analyzed, 48 from them (15.1%)--with pancreanecrosis. Etiologic factors in destructive pancreatitis were alcohol addiction (41.67%), cholelithiasis (37.5%), hyperlipidemia (10.41%), hypercalcemia (4.17%), postoperative (4.17%). Location of the necrosis in parapancreatic fat cellular tissue was detected in 6 patients, in pancreatic head--in 8 and both in pancreatic head and corpus--in 11, in corpus and in tail--in 10; total pancreo-necrosis was observed in 5 patients. Therapeutic measures were conservative and only in cholelithiasis cholecystectomy was performed as well as drainage of the choledochus and abdominal cavity. Intensive care was aimed at blocking pancreatic and gastric secretion, inhibition of pancreatic enzymes ferments and suppressing mediators of inflammation, immunocorrection, prophylaxis of infection in the necrotic tissues. Desintoxication was carried out by combination of infusion therapy with forced diuresis, usage of extracorporeal methods and laparoscopic sanation of the abdominal cavity with subsequent lavage. Surgical interventions were carried out in far-off period only for complications of pancreanecrosis. Mortality rate in pancreanecrosis made up 20.85% and in total number of patients with acute pancreatitis--3.13%.     

One year results after extracorporeal shock wave lithotripsy of gallbladder stones

512 patients with gallbladder stones (393 females, mean age 52.7 years; 119 males, mean age 46.9 years) were treated by extracorporeal shock wave lithotripsy with an electrohydraulic Dornier MPL 9000 lithotripter. The Munich criteria were used for patients selection. Midazolam (15 mg im) and piritramid (mean 7.5 mg iv) were administered as analgetics. Stone fragmentation was achieved after an average of 1.92 treatment sessions. In 12 cases (2.3%) there was no fragmentation. Ursodeoxycholic acid (10 mg/kg/day) was administered as adjuvant litholytic therapy until 3 months after total fragment clearance. During a period of a year the patients returned for follow-up investigations in decreasing number. The total fragment clearance rate was 43.3%, for the I. group (single stone of 5 to 20 mm) was 58%, for the II. group (single stone of 21 to 30 mm) was 28.6%, for the III. group (2 or 3 stones of 30 mm maximum diameter) was 21.4%. In 12 cases (1.2%) vasovagal reactions, in 31 cases (3.1%) atrial and ventricular extrasystoles, in 27 cases (2.7%) transient gross hematuria were observed. During a period of a year 18 cholecystitis (3.5%), 8 pancreatitis (1.56%) and 5 obstructive jaundice (0.97%) developed. 28 cholecystectomies (5.4%), 1 necrectomy because of necrotic pancreatitis (0.19%) and 5 endoscopic sphincterotomies (0.97%) were required.     

Role of surgery in the treatment of severe acute necrotic pancreatitis

Between May 1975 and December 1991, a total of 208 patients were operated upon for severe acute necrotic pancreatitis. The decision whether to operate on patients with clinical and biologic aggravation despite particularly sustained intensive care was taken after evaluation of ultrasound and CT scan images. Combining pancreatic body resections and necrotic tissue excision with laparostomy and staged lavage drainage reduced global mortality rate from 49.2 to 16.4 p. cent. The criteria used for determining the indication for surgical intervention, and the technical and tactical operative procedures applied allowing this improvement, are described and discussed.     

Is the association of serum lipase with beta2-microglobulin or C-reactive protein useful for establishing the diagnosis and prognosis of patients with acute pancreatitis?

In the Emergency Department it is mandatory to establish the diagnosis and the prognosis of acute pancreatitis as soon as possible. To evaluate whether the association of serum lipase either with serum beta2-microglobulin or with C-reactive protein allows simultaneously to establish the diagnosis and the prognosis of acute pancreatitis, 96 patients with acute abdomen were studied. Fifty-eight patients had non-pancreatic acute abdomen and the remaining 38 had acute pancreatitis: 23 mild acute pancreatitis, and 15 severe acute pancreatitis. Forty healthy subjects were studied as controls. Lipase, beta2-microglobulin and C-reactive protein were determined in the serum of all subjects, using commercial kits. One patient with acute pancreatitis was not correctly classified when lipase was used to discriminate between patients with non-pancreatic acute abdomen and those with acute pancreatitis. For the discrimination of patients with severe acute pancreatitis from those with the mild form of the disease in the remaining 37 acute pancreatitis patients, beta2-microglobulin had a sensitivity of 53.3 %, specificity of 81.8%, and prognostic accuracy of 70.3 % (27 of the 37 patients correctly classified); 87.5 % of the 96 cases were correctly classified. C-reactive protein showed a lower prognostic accuracy than beta2-microglobulin: sensitivity 86.7%, specificity 45.5%, accuracy 62.2 %; 84.4 % of the cases were correctly classified. Using the polychotomous logistic regression analysis we found the same accuracy in discriminating between patients with acute pancreatitis and those with non-pancreatic acute abdomen (99.0%) but a lower accuracy (54.1%) between patients with severe acute pancreatitis and those with the mild form of the disease. Our study shows that the association of serum lipase with beta2-microglobulin or with C-reactive protein is not useful in simultaneously establishing the diagnosis and prognosis of acute pancreatitis.     

Fecal elastase 1 determination in chronic pancreatitis

This study assessed the diagnostic accuracy of fecal elastase 1 in chronic pancreatitis. Fifty-three healthy subjects, 44 patients with chronic pancreatitis (22 severe, 13 moderate, and 9 mild), and 43 patients with nonpancreatic digestive disease were studied. Elastase 1 concentration was determined on a small sample of feces using a commercially available kit. Fecal chymotrypsin was also measured. With a cutoff level of 190 microg/g, all healthy controls except one (98.1%), and the majority of patients with nonpancreatic digestive diseases (40 of 43; 93.0%) had elastase values above this limit. Among the 44 patients with chronic pancreatitis, 34 (77.3%) had pathological values: all 22 (100%) with severe disease, 10 of 13 (76.9%) with moderate disease and 2 of 9 (22.2%) with mild disease. Chymotrypsin values were pathological in 25 of 44 (56.8%) patients with chronic pancreatitis: 17 of 22 (77.2%) with severe pancreatitis, 7 of 13 (53.8%) with moderate pancreatitis, and 1 of 9 (11.1%) with mild disease. The specificity was 95.8% for elastase 1 and 85.4% for chymotrypsin. The difference both in sensitivity and specificity of the two enzymes was statistically significant (P < 0.05). Fecal elastase 1 has a high sensitivity, superior to that of fecal chymotrypsin, in the diagnosis of chronic pancreatitis. For its simplicity and rapidity, it could represent the tubeless test of choice in chronic pancreatitis.     

Clinical value of pancreatitis-associated protein in acute pancreatitis

OBJECTIVES: Pancreatitis-associated protein (PAP) is a secretory protein that is overexpressed by the pancreas during acute pancreatitis. This study was carried out to assess the clinical value of PAP in acute pancreatitis, particularly its ability to indicate the severity of the disease. METHODS: Twenty-one healthy subjects, 58 patients with acute pancreatitis, and 20 patients with nonpancreatic acute abdomen were studied. In addition to serum PAP concentration, serum concentrations of amylase, lipase, and C-reactive protein (CRP) were measured at admission and, in patients with acute pancreatitis, during the following 5 days. RESULTS: On admission, serum PAP concentrations were abnormally high in 46 of the 58 patients with acute pancreatitis (79%); serum amylase, in 57 patients (98%); serum lipase, in all patients (100%); and serum CRP, in 40 patients (69%). During the subsequent days of the study, PAP and CRP tended to increase, whereas amylase and lipase decreased. No significant differences in PAP or amylase and lipase concentrations were found between patients with mild pancreatitis and those with severe pancreatitis during the entire study period, whereas from the third day to the sixth day, CRP concentrations were significantly higher in patients with severe pancreatitis than in those with mild pancreatitis. Among the 20 patients with nonpancreatic acute abdomen, PAP concentrations were abnormally high in 10 (50%), whereas amylase concentrations were abnormally high in five (25%), and lipase concentrations were high in two (10%). CONCLUSIONS: Our results indicate that the clinical value of PAP in acute pancreatitis is quite limited and, in particular, that PAP is not a useful marker for determining the severity of the disease.     

Endoscopic retrograde cholangiopancreatography in the evaluation of pancreatic disease

Endoscopic retrograde cholangiopancreatography (ERCP) was carried out in 98 patients with unexplained abdominal pain or known pancreatitis with recurrent pain. Patients with jaundice were excluded from the study. In 38 patients with a clinical diagnosis of pancreatitis, the radiological findings on ERCP were graded according to the criteria of Kasugai et al. Advanced pancreatitis was found in 20 patients (52,5%), moderate changes in 7 (18,4%) and minimal-change pancreatitis in 6 (15,8%). ERCP had normal pancreatic function tests. In 35 patients investigated for unexplained abdominal pain, changes consistent with pancreatitis were found in 7, pancreatic carcinoma in 5, a duodenal ulcer in 2, gallstones in 1 and a duodenal tumour in 1. ERCP was normal in 19 patients. A comparison of the findings on ERCP and the standard secretin-cholecystokinin pancreatic function test was available in 52 patients. There was a good agreement between the two tests in the patients with advanced or moderate pancreatitis as revealed by ERCP, but less agreement in the patients with minimal-change pancreatitis. A few patients with clinical pancreatitis and abnormal ERCP had normal pancreatic function tests. ERCP increases the diagnostic yield in patients suspected of having pancreatitis and is at present the only reliable method of diagnosing pancreatic carcinoma which is not evident by other non-operative techniques. ERCP is also of value in the assessment of the severity of pancreatitis and is a necessary investigation before pancreatic surgery to confirm or exclude cyst formation or the site of duct obstruction. The finding of an unsuspected cyst at ERCP necessitates early operation because of the danger of introducing infection during the procedure.     

Prevalence of Helicobacter pylori infection and gastric mucosal abnormalities in chronic pancreatitis

OBJECTIVE: Chronic pancreatitis is often associated with abnormal gastric acid secretion. However, previous studies have taken into consideration neither the potential role of Helicobacter pylori (H. pylori) infection nor histological features of the gastric mucosa in this context. The aim of this study was to analyze the prevalence of H. pylori infection as well as the pattern of gastritis in patients with chronic pancreatitis. METHODS: Forty patients with chronic alcoholic pancreatitis were included in the study: 40 patients with alcoholic liver cirrhosis and normal exocrine pancreatic function and 40 asymptomatic nonalcoholic subjects matched for age and sex used as control subjects. Endoscopy was performed in all patients, and five biopsy specimens from the antrum (three from the gastric body and two from the cardia) were taken for histological grading of gastritis and H. pylori assessment. RESULTS: Prevalence of H. pylori infection was similar in subjects with chronic pancreatitis (38%), asymptomatic subjects (28%) and liver cirrhosis (30%). Topography and expression of H. pylori-associated chronic gastritis was also not different among the three groups of subjects. In H. pylori-negative subjects, the presence of moderate to severe chronic antral gastritis was significantly more common in patients with chronic pancreatitis (40%) than in subjects with liver cirrhosis (18%) and in asymptomatic subjects (14%) (p < 0.05). No difference was found among the three groups of patients with regard to gastritis activity, atrophy, and intestinal metaplasia in the various gastric regions. The chronicity grade of gastritis did not correlate with the severity of pancreatic insufficiency. CONCLUSION: Prevalence of H. pylori infection is not different in patients with chronic pancreatitis as compared with subjects alcoholic liver cirrhosis and asymptomatic subjects. A severe H. pylori-negative chronic gastritis is more common in patients with chronic pancreatitis. This chronic inflammation of the gastric mucosa could contribute to determining the changes in gastric physiology described in patients with chronic pancreatitis.     

Diagnosis of chronic pancreatitis: presenting features and diagnostic delay

The diagnosis of chronic pancreatitis continues to present difficulties. The nonspecific nature of the symptomatology, its low prevalence and the limited value of morphological and functional tests in the early stages are the most common causes of delay in diagnosis. Our aim was to analyze the most significant clinical manifestations and the diagnostic features of chronic pancreatitis, distinguishing between alcoholic and nonalcoholic etiologies. We studied 158 patients, 136 (86.1%) with alcoholic and 22 (13.9%) with nonalcoholic chronic pancreatitis. The initial symptomatology, the age at diagnosis, the delay in diagnosis from the onset of the clinical signs and the type of diagnosis (incidental or suspected) were considered for each patient. Men predominated in both the alcoholic and the nonalcoholic pancreatitis groups (97.8% and 68.2%, respectively). The mean ages at onset and diagnosis were 38 and 50.6 years, respectively, in alcoholic chronic pancreatitis and 44 and 55 years in the nonalcoholic group; the differences between the two parameters were statistically significant. The most common clinical signs in alcoholic chronic pancreatitis were abdominal pain (81.6%) and episodes of acute pancreatitis (64%), while patients with nonalcoholic pancreatitis presented abdominal pain (59%), diarrhea (40.9%) and weight loss (36.4%). The delay in diagnosis from the onset of the clinical manifestations was 5.8 years (6.1 years in alcoholic and 4.3 years in nonalcoholic pancreatitis. The diagnosis was incidental in 34% of cases of alcoholic chronic pancreatitis and in 50% of cases in the nonalcoholic group.     

Seizure control after stimulation of the vagus nerve: clinical outcome measures

Our objective was to determine whether pleural effusion is a predictor of severity in acute pancreatitis and, if so, whether it is an independent predictor. One hundred ninety-six consecutive cases of acute pancreatitis from October 1, 1994, to September 30, 1995, were reviewed. Medical records were analyzed for evidence of pleural effusion by chest radiograph and severe acute pancreatitis by identification of pancreatic necrosis or organ system dysfunction. Data were analyzed to determine if identification of pleural effusion provided an early sign of severity. Among 135 patients who underwent chest radiography, pleural effusion was seen in 16 of 19 (84.2%) with severe pancreatitis and 10 of 116 (8.6%) of patients with mild pancreatitis (p < 0.001). Pleural effusion was noted in severe pancreatitis prior to clinical or computed tomography evidence of severity in only 20% of cases. Pleural effusion is strongly associated with severity in acute pancreatitis but provides independent information on severity in only a minority of cases.     

Hemoconcentration as an early risk factor for necrotizing pancreatitis

OBJECTIVE: The aim of our study was to determine whether measurement of serum hematocrit during the first 24 h helps in distinguishing necrotizing from mild pancreatitis. METHODS: From May 1992 to June 1996, a case-control study was performed with cases of patients with necrotizing pancreatitis. We selected as a control the next patient admitted with mild pancreatitis. RESULTS: There were 32 patients in each group. Logistic regression identified an admission hematocrit of > or = 47% and a failure of admission hematocrit to decrease at 24 h as the best binary risk factors for necrotizing pancreatitis. At admission, more patients with necrotizing pancreatitis than with mild pancreatitis had a hematocrit > or = 47% (11/32 vs 3/32; p = 0.03). At 24 h, 15 additional patients with necrotizing pancreatitis versus only one with mild pancreatitis showed no decrease in admission hematocrit (p < 0.01). Thus, by 24 h, 26 of 32 patients with necrotizing pancreatitis versus only four of 32 patients with mild pancreatitis met one or the other criterion (p < 0.01). The sensitivity and specificity at admission were 34% and 91%; at 24 h, 81% and 88%. CONCLUSIONS: Hemoconcentration with an admission hematocrit > or = 47% or failure of admission hematocrit to decrease at approximately 24 h were strong risk factors for the development of pancreatic necrosis.     

Chronic pancreatitis, acute pancreatitis

MRCP has been recognized as a safe and noninvasive diagnostic method. In the present study we evaluated the usefulness of MRCP in diagnosis of chronic and acute pancreatitis. Two-dimensional fast asymmetric spin-echo (FASE) MRCP was performed in 40 patients with chronic pancreatitis and 13 with acute pancreatitis. In 29 patients (72.5%) with chronic pancreatitis and 9 (66.7%) with acute pancreatitis, main pancreatic duct (MPD) was visualized entirely. MRCP could demonstrate the characteristic findings of chronic pancreatitis such as dilatation and irregularity of MPD in most cases. In acute pancreatitis, MRCP indicated that MPD was normal in diameter, but irregular in configuration compared with that of the control group. MRCP may facilitate the diagnosis of chronic and acute pancreatitis.     

Postoperative changes in the coagulation and fibrinolytic systems in endoluminal stent-graft treatment of thoracic aortic aneurysms

Length of stay (LOS) predictions in acute pancreatitis could be used to stratify patients with severe acute pancreatitis, make treatment and resource allocation decisions, and for quality assurance. Artificial neural networks have been used to predict LOS in other conditions but not acute pancreatitis. The hypothesis of this study was that a neural network could predict LOS in patients with acute pancreatitis. The medical records of 195 patients admitted with acute pancreatitis were reviewed. A backpropagation neural network was developed to predict LOS >7 days. The network was trained on 156 randomly selected cases and tested on the remaining 39 cases. The neural network had the highest sensitivity (75%) for predicting LOS >7 days. Ranson criteria had the highest specificity (94%) for making this prediction. All methods incorrectly predicted LOS in two patients with severe acute pancreatitis who died early in their hospital course. An artificial neural network can predict LOS >7 days. The network and traditional prognostic indices were least accurate for predicting LOS in patients with severe acute pancreatitis who died early in their hospital course. The neural network has the advantage of making this prediction using admission data.     

Diagnostic features of chronic pancreatitis distal to benign and to malignant pancreatic duct obstruction

Differentiation between diffuse chronic pancreatitis and pancreatitis distal to a malignant or benign stenosis has important prognostic and therapeutic implications. We examined the retrograde pancreatograms of 64 patients with histologically confirmed diagnosis of diffuse chronic pancreatitis, chronic pancreatitis distal to a benign tumor and chronic pancreatitis distal to a malignant tumor. The nature of the stenosis was often difficult to determine from the shape of the pancreatic duct only. By using discriminant analysis it was possible to determine an allocation rule based on 8 criteria mainly derived from changes in the pancreatic ductuli. This allocation rule allowed the correct diagnosis to be made in 24 out of 26 patients with diffuse chronic pancreatitis (92%), 19 out of 20 patients with pancreatitis distal to a benign tumor (95%) and all 18 patients (100%) with pancreatitis distal to a malignancy.     

Surgical management of pancreatic necrosis presenting with locoregional complications

BACKGROUND: Local complications of pancreatic necrosis may occur after surgery, but when they occur spontaneously render surgical treatment more hazardous and impair prognosis. METHODS: A retrospective review was carried out of 83 patients who underwent surgery for pancreatic necrosis from 1988 to 1995, to determine the incidence, type, treatment and outcome of locoregional complications caused by pancreatic necrosis associated with acute pancreatitis. RESULTS: Seventeen patients (20 per cent) were identified to have intra-abdominal complications with pancreatic necrosis either before operation or at the time of surgery. The majority of patients had a delay in intervention (mean 46 days). At presentation ten of the 17 patients had one or more organ system failures. Fourteen patients had gastrointestinal tract involvement, two had involvement of the biliary tract and one patient had a splenic rupture. Six patients died. CONCLUSIONS: In patients with pancreatic necrosis, development of locoregional complications is associated with a high mortality rate. The presence of gastrointestinal bleeding, peritonitis, jaundice or pneumoperitoneum in such patients suggests the presence of a complication of the necrotic process and should prompt early intervention. Early referral of patients with severe acute pancreatitis to specialized units may reduce the risk of locoregional complications.     

Ascites, pleural, and pericardial effusions in acute pancreatitis. A prospective study of incidence, natural history, and prognostic role

Ascites and pleural and pericardial effusions can be observed during acute pancreatitis. The aims of this study were to evaluate their incidence, natural history, and prognostic role in patients with acute pancreatitis. One hundred patients consecutively admitted with a diagnosis of acute pancreatitis were prospectively submitted to abdominal, pleural, and cardiac ultrasonography at admission and during follow-up. Ascites was found in 18 patients, pleural effusion in 20, and pericardial effusion in 17. Twenty-four patients of this series had severe pancreatitis; three of them died. All effusions disappeared spontaneously in patients who survived pancreatitis up to two months after dismissal. At multivariate analysis ascites and pleural effusion were demonstrated to be accurate independent predictors of severity. The respective odds ratios were 5.9 [95% confidence interval (CI), 1.5-23.0%) and 8.6 (95% CI, 2.3-32.5%). Furthermore the presence of pleural effusion, ascites, and pericardial effusion were associated with an increased incidence of pseudocyst during follow-up. Ascites and pleural and pericardial effusions are frequent during acute pancreatitis. Pleural effusion and ascites are accurate predictors of severity in these patients.     

What place for endoscopic sphincterotomy in treatment of acute pancreatitis?

STUDY AIM: A prospective study was undertaken in order to evaluate the effects of endoscopic sphincterotomy on the evolution of biliary and idiopathic acute pancreatitis. PATIENTS AND METHODS: Among 320 patients with acute pancreatitis observed from 1986 to 1996, 118 were excluded from the study for etiological reasons and 137 were included for an endoscopic sphincterotomy within 72 hours from their admission. There were nine technical failures and 128 endoscopic sphincterotomies were performed. Sixty-five eligible patients were not included for logistic problems or patients' refusal; they can be considered as a "control group". RESULTS: The mortality rate of endoscopic sphincterotomy was 0 and the morbidity rate 2.1%. The mortality rate of acute pancreatitis was 3.1% in the sphincterotomy group vs 7.6% in the control group (P = 0.1) (NS) and the morbidity rate 25% versus 32% (P > or = 0.1) (NS). CONCLUSION: These results suggest that endoscopic sphincterotomy could be beneficial in acute biliary or idiopathic pancreatitis but they are not statistically significant. Endoscopic sphincterotomy does not increase the severity of acute pancreatitis and can be considered particularly in cases of gallstone pancreatitis but it should be performed less than 48 hours after the onset of acute pancreatitis.