Mucinous cystadenoma of the pancreas as a cause of acute pancreatitis

Acute pancreatitis is only rarely the first presentation of a cystic neoplasm of the pancreas. Mucinous cystadenomas have not been reported to be a cause of acute pancreatitis; however, we present two cases of mucinous cystadenoma of the pancreas which have caused acute pancreatitis. Both patients (female) presented acute abdominal pain, with serum amylase elevation and ultrasound scan (US) and computed tomography (CT) evidence of moderate pancreatitis, which resolved with medical treatment; fluid collection in the distal pancreas had been misinterpreted as a pseudocyst. There was no history of alcohol abuse or gallstone disease. After distal pancreatectomy the diagnosis of mucinous cystadenoma was confirmed; in one case a large pseudocyst was associated with this diagnosis. Pre-operative differential diagnosis between inflammatory and neoplastic cysts is difficult, especially when the patient's first presentation is due to an episode of acute pancreatitis. A neoplastic cyst should be considered when acute pancreatitis attacks occur in non-alcoholic women, who do not have gallstone disease.     

The clinical significance of hyperamylasemia in organophosphate poisoning

OBJECTIVE: Hyperamylasemia with a presumptive diagnosis of acute pancreatitis has been reported following organophosphate poisoning but there are no large-scale studies incorporating more specific diagnostic criteria. METHODS: Retrospective review of the medical records of 159 patients with a diagnosis of organophosphate poisoning over 3 years. Serum amylase, pancreatic amylase, salivary amylase, lipase and cholinesterase levels, and the clinical manifestations were analyzed. RESULTS: Serum amylase data was available for 121 of the 159 study patients. Hyperamylasemia (amylase > or = 360 U/L) was found in 44 patients (36%). Lipase was measured in 28 patients with hyperamylasemia; 9 of 28 had hyperlipasemia (lipase > or = 380 U/L). The finding of hyperamylasemia was closely related to clinical severity and presence of shock. A presumptive diagnosis of painless acute pancreatitis was diagnosed by hyperlipasemia associated with hyperamylasemia, clinical severity, serum LDH, and leukocyte counts. Two patients with presumptive pancreatitis died. Shock, coma, and hypoalbuminemia were the factors predicting fatality. CONCLUSIONS: Hyperamylasemia is frequent in severe organophosphate poisoning. However, hyperamylasemia is not synonymous with acute pancreatitis and pancreatic amylase is not a reliable parameter in the diagnosis of organophosphate-induced pancreatitis due to its low sensitivity and specificity. Lipase assay is indicated in patients with hyperamylasemia for early diagnosis of pancreatitis. Proper image studies and even pathological examination are also needed to confirm the extent of pancreatic injury. With prompt diagnosis and appropriate treatment, a complete recovery can be anticipated unless the patient has otherwise unrelated complications.     

Lessons learned from a complicated case of cephalic obstructive chronic pancreatitis

The authors report the complex case of a 51 year-old man admitted to his local hospital for gallbladder and common bile duct lithiasis, 1 year before admission to our hospital. There, he was treated by cholecystectomy and transduodenal biliary sphincteroplasty. He was readmitted after 3 months because of a painful episode and was discharged with the diagnosis of "relapsing acute pancreatitis in chronic pancreatitis." At our hospital, he underwent laparotomy and revision of the previous transduodenal biliary sphincteroplasty. Pancreatic sphincteroplasty and septectomy were also performed. The night after surgery, the patient suffered from acute post-operative pancreatitis complicated by severe hemorrhage due to erosion of the superior pancreaticoduodenal arteries, treated with gastroduodenal artery embolization by tungsten coils. Three months later, the patient suffered from another acute episode. An endoscopic retrograde colangio pancreatography (ERCP) showed the complete patency of the sphincteroplasties but clearly identified the persistence of a severe cephalic stricture. Therefore, the patient was readmitted to our hospital and underwent another laparotomy. A pylorus-preserving pancreaticoduodenectomy (PPPD) was performed. The post-operative course was uneventful and at 14 months follow-up the patient was in good health. The discussion focuses on the surgical treatment of chronic pancreatitis with cephalic Wirsung duct stenosis, stressing the increasing role of PPPD as a first-choice option.     

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.     

Acute intermittent porphyria with relapsing acute pancreatitis and unconjugated hyperbilirubinemia without overt hemolysis

A 36-year-old woman was admitted to hospital with a first attack of acute intermittent porphyria. At the same time increased serum levels of amylase and lipase as well as an increased amylase clearance to creatinine clearance ratio were observed, permitting the diagnosis of acute pancreatitis. The etiology of the latter could not be determined. In addition, elevation of indirect bilirubin without evidence of hemolysis was observed Gilbert's syndrome was suspected. 40 weeks after the first episode, a second attack of identical abdominal pain was noted, with elevation of pancreatic enzymes in the serum. There is evidence that acute intermittent porphyria and acute relapsing pancreatitis may have some etiological connection in this patient.     

Chylous cardiac tamponade in acute pancreatitis

A 47-year-old woman with acute necrotizing pancreatitis developed sudden cardiorespiratory arrest and needed resuscitation. A pericardial effusion was found, and 350 ml of a white nontransparent milky fluid was aspirated that contained 1020 mg triglycerides/100 ml. The diagnosis of chylous cardiac tamponade was made. Absence of amylase in the chylous effusion militates against the popular hypothesis that lymphatic transport of exocrine digestive enzymes from the inflamed pancreas produces the frequent intrathoracic serosal effusions in acute pancreatitis. The data of our patient rather suggest that these effusions result from the leakage of pancreatic inflammatory exudates through the diaphragm which, apparently, may even result in the loss of pericardial and adjacent thoracic lymph vessel integrity. Although pericardial tamponade is a rare complication, it should be considered if otherwise unexplained circulatory deterioration occurs in a patient with acute pancreatitis.     

Inferior vena caval thrombosis associated with acute pancreatitis: an unusual vascular complication--its presentation and management

Vascular thrombosis and systemic hypercoagulable states are known complications of acute pancreatitis. They are thought to be secondary to the release of proteolytic enzymes of the pancreas. Inferior vena caval thrombosis is an extremely rare complication of chronic pancreatitis and has, to the authors' knowledge, never been reported in acute pancreatitis. The clinical presentation and radiographic findings are reviewed to illustrate the disease spectrum. Early treatment with intravenous heparin appears to be an effective therapy. Familiarity with this complication will aid physicians in its early diagnosis. However, a high degree of suspicion for this complication is necessary to make a diagnosis.     

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.     

Multiple spurious laboratory results in a patient with hyperlipemic pancreatitis treated by plasmapheresis

Hyperlipidemia is a known cause for acute pancreatitis. Hyperlipidemia may also produce multiple spurious laboratory results that may complicate the diagnosis and management of pancreatitis. We encountered such a patient who had the following spurious laboratory results: normal serum amylase activity, hyponatremia, and high hemoglobin levels. These laboratory artifacts were previously described, mostly separately. In addition, our patient had artifactual thrombocytopenia. The patient improved dramatically following plasmapheresis, which enhanced reduction of serum lipids.     

Chronic recurrent pancreatitis in pregnancy

This report describes a case of chronic recurrent pancreatitis due to gallstones arising in the first trimester of pregnancy. Total parental nutrition produced a normalization of pancreatic enzymes and a rapid regression of symptoms. Following another relapse of acute pancreatitis, a laparoscopic cholecystectomy was performed. The pregnancy continued normally and the patient had a spontaneous delivery at the 37th week.     

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.     

Serum amylase determinations and amylase to creatinine clearance ratios in patients with chronic renal insufficiency

Patients with severe chronic renal failure may have significant hyperamylasemia in the absence of clinical symptoms or signs of acute pancreatitis. Amylase to creatinine clearance (CA/CC) ratios were usually elevated in patients with chronic renal failure and were not helpful in evaluating the possibility of acute pancreatitis. The mean amylase to creatinine clearance ratio for the controls with normal renal function was 1.24 +/- 0.13. In patients with chronic renal failure, it was 3.17 +/- 0.42 (P less than 0.001). Serum amylase isoenzyme patterns revealed no difference in salivary to pancreatic isoenzyme ratios between normals (1.04 +/- 0.12) and patients with severe renal insufficiency without evidence of pancreatic disease (1.07 +/- 0.13). The isoenzymes were helpful in excluding the diagnosis of pancreatic in 1 renal failure patient whose hyperamylasemia was primarily salivary in origin and in confirming the diagnosis in another who had only a pancreatic band.     

The murine (H-2k) T-cell epitopes of bee venom phospholipase A2 Lie outside the active site of the enzyme. Implications with respect to a paracrine activation of Th2 cells for an IgE antibody response

A 51-year-old drunken male was carried to a hospital with acute abdominal pain and was suspected of acute pancreatitis. The patient was treated with fasting, electrolyte transfusion, and anodyne, but took a sudden turn for the worse and died in 16 hours. In the judicial autopsy, rupture of a small intestine was detected. As the police investigated, he had been kicked in the abdomen by an assailant before coming to the hospital. The cause of death was diagnosed to be acute peritonitis due to the rupture of a small intestine. Several problems were pointed out on medical examinations and treatments of this case.     

Gender differences in kappa-opioid modulation of cocaine-induced behavior and NMDA-evoked dopamine release

CASE REPORT: An 18-year-old female who accidentally ingested strychnine developed chemical pancreatitis in addition to the classical clinical picture of strychnine poisoning. Many drugs or chemicals have been reported to be associated with pancreatitis; however, this paper provides us with the first evidence that acute pancreatitis may follow strychnine poisoning. The patient survived despite the development of seizures, lactic acidosis, rhabdomyolysis, and pulmonary infiltrates. Toxicology testing confirmed the presence of strychnine in blood (2.17 mg/L), gastric aspirate, and urine. Attention is drawn to the fact that survival can follow the ingestion of large doses of strychnine providing there is no delay in diagnosis and treatment. The pathophysiologic mechanism of chemical pancreatitis is discussed.     

PCR-ribotyping and pyrolysis mass spectrometry fingerprinting of environmental and hospital isolates of Clostridium difficile

Pancreatic ischemia is a very rare etiology of clinical acute pancreatitis, complicating cardiac surgery, hemorrhagic shock, and transplantation of the pancreas. In this article, we present two patients with acute ischemic necrotizing pancreatitis, complicating a generalized atheromatous disease with extensive lesions in the splanchnic circulation (patient 1) and repair of a descending thoracic aortic aneurysm (patient 2). Diagnostic approach and management of ischemic necrotizing pancreatitis are discussed.     

Diagnosis and surgical management of pancreatic pseudocysts

Fifty-two patients with pancreatic pseudocysts were treated surgically between 1968 and 1994. Clinical symptoms were non-specific. Ten patients with acute pancreatitis were managed conservatively and resolution occurred in 3 patients. 42 patients underwent operation. Internal drainage was performed in 28 patients, external drainage in 8, others in 6. Pancreatic fistulas occurred in the external drainage group, 2 patients died and 1 patient had the of recurred pseudocyst. There were no complications in the internal drainage group. It was quite different in the external drainage group. The management should differ in that acute and chronic pancreatic pseudocysts. Patients with pseudocysts of chronic pancreatitis could undergo emergent surgery of internal drainage because waiting 6 weeks for maturation of the pseudocysts after diagnosis was unnecessary and even hazardous. However, if pseudocyst developed after acute pancreatitis, it should be watched for up to 6-8 weeks. During this period the pseudocyst perhap disappeared spontanously or matured for surgery.     

Surgical interventions in acute pancreatitis

Results of treatment of 240 patients with an acute pancreatitis are adduced. Of them 42 (17,5%) were operated on. In 6 patients an acute edema of pancreas was revealed (one patient have died), in 36--destructive forms of an acute pancreatitis, 8 (22%) died. Results of treatment of patients, operated on in one week after disease beginning, were the best.     

Postgastrectomy afferent loop obstruction due to efferent loop herniation simulating acute pancreatitis

A case of afferent loop obstruction due to efferent loop retro-anastomatic herniation following a Polya gastrectomy is presented. The clinical picture closely mimicked that of acute pancreatitis. The difficulty in diagnosis in this situation is discussed and the importance of operative techniques in its prevention emphasized.     

Afferent loop obstruction after total gastrectomy presenting as acute pancreatitis (clinical contribution to the etiopathogenesis)

Afferent loop obstruction presenting as acute pancreatitis is an uncommon pathology encountred after total gastrectomy or gastric resection. The authors refer about a case of afferent loop syndrom presenting as acute pancreatitis, and conclude that, since this disease is very rare, aggressive and variable, its diagnosis and therapy is still controversal.