Pancreas divisum: evaluation with secretin-enhanced magnetic resonance cholangiopancreatography

BACKGROUND: The clinical significance of pancreas divisum (PD) remains controversial. Secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) is a noninvasive diagnostic procedure that relies on the dynamic response of the main pancreatic duct (MPD) to secretin stimulation. The aim of this study was to determine the frequency of PD and to analyze the dynamic changes of the MPD by using S-MRCP in patients referred for suspected pancreatic diseases before ERCP. METHODS: MRCP was obtained before and at 30-second intervals over 10 minutes after secretin stimulation in consecutive patients with idiopathic acute pancreatitis (n = 67), persistent hydrolasemia (n = 42), recurrent abdominal pain thought to be of pancreatic origin (n = 48), severe chronic pancreatitis (n = 68), and in a control group (n = 54). RESULTS: Thirty patients (10.8%) had a PD at S-MRCP. Secretin stimulation improved the detection of PD in 23% (7/30). The frequency of PD was not significantly different (p > 0.2) between these groups. The occurrence of an abnormal response at S-MRCP (persistent dilatation of the MPD) did not significantly differ in patients with or without PD (p > 0.4). CONCLUSION: The frequency of PD did not differ between groups, and the dynamic changes of the MPD during S-MRCP were similar in patients with and without PD.     

Chronic alcoholism and evolution of pain and prognosis in chronic pancreatitis

To evaluate the influence of chronic alcoholism on clinical features of chronic pancreatitis in Japan, pain evolution, pancreatic insufficiency, and long-term prognosis were studied by comparing chronic alcoholic pancreatitis (N=88)with idiopathic pancreatitis (N=67).The 155 patients with known course of the disease over three years were followed-up further for five more years, and pain evolution was evaluated once at the start and once at the end of the follow-up period. At the time of diagnosis, severe pain (59 vs 33%, P < 0.001), pancreatic calcification (63 vs 31%, P<0.001), advanced exocrine pancreatic insufficiency (72 vs 60%, NS),and overt diabetes (48 vs 17%, P<0.007)were more common in alcoholic than in idiopathic pancreatitis, respectively. Pain evolution was similar in both pancreatitis, and the pain decreased with time. The rate of abstinence was higher in groups with pain relief than without in alcoholic pancreatitis. Cumulative mortality rate during the five years was higher in alcoholic than idiopathic pancreatitis (26 vs 10%, P<0.01).These results suggest more favorable evolution of the disease can be expected by abstinence from alcohol.This study was supported in part by a chronic pancreatitis research grant from the Welfare Ministry of Japan.     

Concurrent pancreatic ductal changes in alcoholic liver disease

BACKGROUND: Alcohol is a common etiological factor in both liver disease and chronic pancreatitis, but in a single individual it does not usually produce clinically significant disease in both organs. We assessed the prevalence of pancreatic ductal changes in patients presenting with alcoholic liver disease of different stages. METHODS: Forty-six patients with alcoholic liver disease were included in the present study. Liver biopsy was performed in patients with normal coagulogram. Endoscopic retrograde pancreatogram was performed in all patients and changes in chronic pancreatitis were noted. RESULTS: Of the 46 patients with alcoholic liver disease, 31 had cirrhosis of the liver, nine had fatty liver and two patients had alcoholic hepatitis. Twenty (43.47%) patients had features of chronic pancreatitis on endoscopic retrograde pancreatogram and these consisted of minimal pancreatitis changes in 10 patients, moderate changes in nine patients and advanced changes in one patient. There was no difference in the prevalence of pancreatitis changes in cirrhotics in comparison to non-cirrhotics. There was no correlation between the amount and length of alcohol intake and changes in pancreatitis. CONCLUSION: Pancreatic ductal changes on endoscopic retrograde pancreatogram are common in patients with alcoholic liver disease.     

Evaluation of pancreatic exocrine function by secretin-enhanced magnetic resonance cholangiopancreatography

AIM: To assess the feasibility and usefulness of secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) for evaluation of pancreatic exocrine function. METHODOLOGY: S-MRCP was performed in 20 patients with mild (n = 8) or severe (n = 12) chronic pancreatitis (according to the grade of exocrine pancreatic insufficiency indicated by the Lundh test) and in 10 volunteers without pancreatic disease. MRCP images were evaluated before and 10 minutes after the intravenous administration of 0.5 IU/kg secretin. The changes in pancreatic tissue T2 signal intensity and duodenal filling after the injection of secretin were determined by means of S-MRCP. The S-MRCP findings were then compared with those of the Lundh test. RESULTS: The pancreatic T2 signal intensity showed a significant elevation after secretin administration in the volunteers and in the patients with mild or severe chronic pancreatitis. This elevation was significantly lower in patients with mild and severe chronic pancreatitis than in the volunteers (66.85+/-15.77 and 24.45+/-5.85 vs. 200.0+/-45.07, respectively). After administration of secretin. the diameter of the duodenum was significantly increased in all three groups. This duodenal filling was significantly reduced in patients with mild or severe exocrine pancreatic insufficiency as compared with the volunteers (4.12+/-1.33 and 1.70+/-0.77 vs. 15.38+/-1.73, respectively). There was no significant difference in pancreatic T2 signal intensity changes or in duodenal filling in patients with mild or severe exocrine pancreatic insufficiency. There were significant correlations between the pancreatic T2 signal intensity changes and the duodenal filling and the results of the Lundh test (r = -0.616 and -0.78). CONCLUSION: These results demonstrate that the administration of secretin increases the T2 signal intensity of the pancreatic tissue and the diameter of the duodenum to different extents in normal subjects and in patients with chronic pancreatitis. This suggests that S-MRCP can provide information of value in the assessment of an exocrine pancreatic insufficiency.     

Increase in the incidence of alcoholic pancreatitis and alcoholic liver disease in Iceland: impact of per capita alcohol consumption

Abstract

Objective: To analyze the incidence of acute alcoholic pancreatitis and of severe alcoholic liver disease (ALD) and its association with per capita alcohol consumption with identification of both alcoholic cirrhosis (AC) and severe alcoholic hepatitis (AH), in a population-based setting.

Methods: A search was undertaken in diagnoses database for diagnostic codes in order to find patients hospitalized with incident acute alcoholic pancreatitis (AP) and alcoholic liver disease in Iceland in 2001–2015. Diagnoses were verified in all patients who were retrospectively reviewed. Those with ALD had either AC or AH. Alcohol sales during the study period were obtained from Statistics Iceland.

Results: Overall, 273 patients with acute AP, mean age at diagnosis 50 (14) years, 74% males and 159 patients with ALD, mean age 57 (11) years, 73% males, were identified. Mean per capita alcohol consumption was 6.95 (0.4) liters and increased by 21% over the study period. The annual incidence of AP increased from 4.2 per 100.000 to 9.5 and ALD from 1.6 to 6.1 per 100.000. Trend analysis showed a significant annual increase of 7% (RR 1.07, 95%CI 1.04–1.10) for AP and an annual increase of 10.5% (RR 1.10, 95%CI 1.06–1.15) for ALD. The increase was only significant in males.

Conclusions: Increase per capita alcohol consumption over a 15?year study period was associated with an increase in the incidence of severe alcoholic liver disease and alcohol-related acute pancreatitis in males but not in females.     

Small intestinal bacterial overgrowth is common both among patients with alcoholic and idiopathic chronic pancreatitis

BackgroundSmall intestinal bacterial overgrowth (SIBO) is known to occur in patients with chronic pancreatitis, particularly of alcoholic etiology. There are, however, scanty data on frequency of SIBO in patients with chronic idiopathic pancreatitis and factors associated with its occurrence.Methods68 patients with chronic pancreatitis and 74 age and gender-matched healthy subjects (HS) were evaluated for SIBO using glucose hydrogen breath test (GHBT). Persistent rise in breath hydrogen 12 ppm above basal (at least two recordings) was diagnostic of SIBO.ResultSIBO was diagnosed more often among patients with chronic pancreatitis than controls (10/68 [14.7%] vs. 1/74 controls [1.3%]; p = 0.003). Of 68 patients, 22 (32.3%) had alcoholic and 46 (67.6%) had idiopathic chronic pancreatitis. SIBO was as commonly detected among patients with alcoholic as idiopathic pancreatitis (3/22 [13.6%] vs. 7/46 [15.2%]; p = 0.86). Age, gender, body mass index (BMI), steatorrhoea, pain, analgesic use, pancreatic calcifications and use of pancreatic enzyme supplements had no relationship with the presence of SIBO. Diabetes mellitus tended to be commoner among patients with chronic pancreatitis with than without SIBO (6/10 [60%] vs. 18/58 [31%]; p = 0.07).ConclusionSIBO was commoner among patients with chronic pancreatitis, both alcoholic and idiopathic, than HS. Though presence of SIBO among patients with chronic pancreatitis tended to be commoner among those with diabetes mellitus, there was no relationship with age, gender, BMI, steatorrhoea, pain, analgesic use, pancreatic calcifications and use of pancreatic enzyme supplements.     

Role of Osteopontin in Calcification in Autoimmune Pancreatitis

Objectives The aim of the present study was to determine the potential for pancreatic calcification in autoimmune pancreatitis by investigating osteopontin and CD44 expression. Methods Human pancreatic tissues in normal pancreas, chronic pancreatitis, and autoimmune pancreatitis were obtained from the surgical specimens of 42 patients. Pancreatic tissues from male Wistar Bonn/Kobori rats were also used as an animal autoimmune pancreatitis model. Results The incidences of osteopontin expression in centroacinar cells in chronic pancreatitis with calcification and in autoimmune pancreatitis were significantly greater than that in normal pancreas (P < 0.05). Some cases of chronic pancreatitis and autoimmune pancreatitis expressed CD44 in centroacinar cells and ductal cells. In male Wistar Bonn/Kobori rats, the inflammatory area and percentage of osteopontin-CD44-positive cells increased with advancing age (P < 0.01 or 0.05). Conclusions These results suggest that autoimmune pancreatitis has the potential for pancreatic calcification over a long-term clinical course.     

Cholecystokinin in acute alcoholic and biliary pancreatitis

Summary Background. Recent studies have shown that cholecystokinin (CCK) agonist, cerulein can induce acute pancreatitis in animals. The role of CCK in the induction of acute pancreatitis in humans is unclear. We investigated plasma CCK levels in alcoholic and biliary pancreatitis on admission and during the episode of acute pancreatitis. Methods. Plasma CCK concentrations were determined by a specific and sensitive radioimmunoassay using CCK antiserum (Euro-Diagnostica, Malm?, Sweden) in 35 patients with acute alcoholic pancreatitis, in 27 patients with acute biliary pancreatitis, in 34 patients with nonpancreatic acute abdominal pain, and in 43 healthy subjects. The mean time from the first symptoms to the plasma sample was 31 (±3.7) h in alcoholic pancreatitis patients and 25 (±5.1) h in biliary pancreatitis patients. We also determined CCK levels in 20 patients during the episode of acute pancreatitis. Normal fasting level of CCK is ≤1.12 pmol/L according to manufacturer. Results. Basal plasma CCK concentrations were significantly lower both in alcoholic pancreatitis (mean ± SEM, 0.04±0.03 pmol/L, p<0.0001) and biliary pancreatitis patients (0.17±0.13 pmol/L, p<0.0001) than in nonpancreatic acute abdominal pain patients (1.23±0.32 pmol/L) or healthy subjects (1.18±0.20 pmol/L). Plasma CCK levels also remained low until the patient was well-recovering and had started oral diet. Conclusion. Basal plasma CCK concentrations are significantly decreased in acute alcoholic and biliary pancreatitis after the first day from the beginning of the symptoms until the patient was well-recovering.     

Acute (nonprogressive) alcoholic pancreatitis: prospective longitudinal study of 144 patients with recurrent alcoholic pancreatitis

Over the last 10 years, a series of 144 consecutive patients with alcoholic recurrent pancreatitis have been studied prospectively at regular intervals with particular regard to exocrine function, calcifications, pancreatographic ductal changes, and histopathology of the pancreas. Based upon the long-term course, the patients were classified into two groups; group A (n = 95), those with chronic pancreatitis (78 of them with calcifications); and group B (n = 49), those with acute (nonprogressive) pancreatitis. The duration of disease from onset was 2-19 years (median, 9.7 and 8.3 years, respectively, in group A and B). The two groups were comparable at onset of the disease in age, sex, number of episodes of pancreatitis, and number of pseudocysts. In group A, all 95 cases fulfilled the strict diagnostic criteria of chronic pancreatitis within the period of observation (e.g., progressive exocrine insufficiency and/or typical morphological changes, particularly calcifications). In group B, the exocrine function remained normal over the entire period of observation. No histologic evidence of chronic pancreatitis was detected in five of seven large pancreatic specimens. Marked to moderate ductal changes were found in 10 of 16 patients in group B (despite normal exocrine function). Our data suggest that about one third of patients of the present series with alcoholic (recurrent) pancreatitis did not progress toward chronic (progressive) pancreatitis, although some demonstrated morphological alterations (except calcifications) in association with normally preserved exocrine function (residual scars?). The pathogenetic factor(s) responsible for progression (or nonprogression) of alcoholic (recurrent) pancreatitis to chronic pancreatitis remain(s) to be elucidated.     

Correlation between secretin-enhanced MRCP findings and histopathologic severity of chronic pancreatitis in a cat model

Background/objectivesTo evaluate the usefulness of secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) in chronic pancreatitis (CP), we compared the severity of disease determined histopathologically with that indicated by S-MRCP imaging parameters in an induced CP cat model.Materials and methodsAn experimental group of randomly chosen cats (n = 24) underwent ligation of the pancreatic duct to induce CP, and cats in a similarly chosen control group (n = 8) were sham-operated. MRCP was performed prior to secretin stimulation, and 5 and 15 min afterward, noting in particular the pancreatic duct caliber change (PDC) and the increasing degree of fluid volume (IDFV). Histopathological changes were observed in pancreatic samples processed for hematoxylin–eosin and Sirius red staining, and CP was classified as normal, minimal, moderate, or advanced. Correlations were investigated between these groups and the PDC at 5 min and the IDFV at 15 min.ResultsBetween cats with minimal CP and the controls, the differences in mean IDFV and PDC were not significant although diseased cats showed a downward trend in both parameters. However, compared with the control group both the mean IDFV and PDC were significantly lower in cats with moderate (IDFV, P = 0.001; PDC, P = 0.013) or advanced (IDFV, P = 0.013; PDC, P = 0.001) CP.ConclusionThe S-MRCP parameters IDFV and PDC correlated with the histopathological severity of induced CP. S-MRCP could be used to evaluate the severity of CP, although it is somewhat insensitive for depicting very early disease.     

Limited contribution of the SPINK1 N34S mutation to the risk and severity of alcoholic chronic pancreatitis: a report from the United States

Mutations in the SPINK1 gene (e.g. N34S) have been reported in patients with idiopathic, familial, tropical, and alcoholic pancreatitis. The prevalence of SPINK1 N34S differs between different patient populations, and its contribution to the risk and the severity of alcoholic chronic pancreatitis has not been defined in the United States. Mutational analysis of the exon 3 was performed in 32 patients with alcoholic chronic pancreatitis, 39 patients with nonalcoholic chronic pancreatitis or recurrent acute pancreatitis, and 190 previously studied healthy controls. The course of alcoholic chronic pancreatitis with and without N34S was compared in age of onset- and sex-matched patients. All SPINK1 gene sequence variations were heterozygous. SPINK1 N34S was present in 3/190 (1.6%) and P55S was found in 2/190 (1.1%) of controls. In alcoholics, the N34S mutation was identified in 2/32 patients (6.3%, P < 0.05). In nonalcoholics, N34S and P55S were identified in 6/39 patients (15.4%, P < 0.005, N34S N = 4, P55S N = 1, N34S/P55S N = 1). The clinical course of alcoholic chronic pancreatitis was similar between patients with and without the N34S mutation. The N34S mutation is uncommon in patients with alcoholic chronic pancreatitis in the United States; its prevalence is similar to other countries and appears not to alter the onset or the severity of alcoholic chronic pancreatitis.     

Technology insight: applications of MRI for the evaluation of benign disease of the pancreas

This article reviews the role of MRI in the evaluation of benign pancreatic disease. Although MRI and magnetic resonance cholangiopancreatography (MRCP) are most often used to evaluate the liver and bile duct, technical advances such as the use of secretin stimulation also allow for high-quality imaging of the pancreas and pancreatic ductal system. Secretin-stimulated MRCP (S-MRCP) can aid the diagnosis of acute and chronic pancreatitis, and delineate ductal pathology such as benign strictures and duct leaks. There seems to be a role for S-MRCP in the assessment of pancreatic function and (possibly) sphincter of Oddi dysfunction. When endoscopic or surgical therapy is planned, S-MRCP can help to establish a diagnosis as well as offer a 'road map' to guide therapy. S-MRCP is noninvasive and almost entirely without risk to the patient, which gives it a distinct advantage over traditional endoscopic methods of diagnosis for conditions such as pancreas divisum and other ductal pathology. The information provided by S-MRCP, obtained before endoscopic or surgical therapy is attempted, can assist the patient and physician in making a fully informed decision with regard to the risks and probable benefits of any planned intervention.     

Pancreatographic findings in idiopathic acute pancreatitis

Background/purpose

Despite extensive evaluation based on clinical history, biochemical tests, and noninvasive imaging studies, the cause of acute pancreatitis cannot be determined in 10 to 30% of patients, and a diagnosis of idiopathic acute pancreatitis is made. The purpose of this study was to clarify the pancreatographic findings in patients with idiopathic acute pancreatitis.

Methods

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 34 patients with idiopathic acute pancreatitis, and the pancreatographic findings were examined. Patency of the accessory pancreatic duct was examined by dye-injection endoscopic retrograde pancreatography (ERP) in 16 of the 34 patients.

Results

In 11 patients (32%), the following anatomic abnormalities of the pancreatic or biliary system were demonstrated: complete pancreas divisum (n = 5), incomplete pancreas divisum (n = 2), high confluence of pancreaticobiliary ducts (n = 2), choledochocele (n = 1), and giant periampullary diverticulum (n = 1). Pancreatographic findings were normal in 17 patients. Eleven of these patients were examined by dye-injection ERP, and all were found to have nonpatent accessory pancreatic duct.

Conclusions

Anatomic abnormality of the pancreatic or biliary system is one of the major causes of idiopathic acute pancreatitis. Closure of the accessory pancreatic duct may play a role in the development of idiopathic acute pancreatitis in patients with a normal pancreaticobiliary ductal system.     

Sphincter of oddi manometry

Summary Conclusion. In chronic alcohol abusers with no pancreatic disease, secretin was found to induce a paradoxical spasmodic response in the sphincter of Oddi (SO) instead of the relaxation observed in controls. Cerulein, on the contrary, had a normal relaxing effect on the SO. Background. We previously reported SO dyskinesia in cases of chronic pancreatitis. Here we investigated whether chronic alcohol consumption may have contributed to the genesis of this dyskinesia. Methods. SO and main pancreatic duct pressures were recorded endoscopically with a dual electronic pressure sensor in 27 chronic alcohol abusers and compared with the values obtained in 15 normal controls. These pressures were recorded both in the basal state and after applying hormonal stimulation by injecting either secretin (1 CU/kg) or cerulein (75 ng/kg). Results. Cerulein relaxed the SO in both the controls and the chronic alcohol abusers, whereas it transiently enhanced the main pancreatic duct (MPD) pressure. Secretin induced a wave of MPD hyperpressure (+15.4±3.0 mm Hg) in both groups of subjects, but in the alcoholic group, instead of relaxing SO, it significantly enhanced the amplitude of phasic contractions (+32.6±8.4 mm Hg). The SO basal pressure was also paradoxically enhanced by secretin in the alcoholic patients (28.8±8.2 vs 10.1±2.4 mm Hg).     

Is acute recurrent pancreatitis a chronic disease？

Whether acute recurrent pancreatitis is a chronic disease is still debated and a consensus is not still reached as demonstrated by differences in the classification of acute recurrent pancreatitis. There is major evidence for considering alcoholic pancreatitis as a chronic disease ab initio while chronic pancreatitis lesions detectable in biliary acute recurrent pancreatitis （ARP） seem a casual association. Cystic fibrosis transmembrane con-ductance regulator （CFTR） gene mutation, hereditary and obstructive pancreatitis seem an acute disease that progress to chronic pancreatitis, likely as a consequence of the activation and proliferation of pancreatic stellate cells that produce and activate collagen and therefore fibrosis. From the diagnostic point of view, in patients with acute recurrent pancreatitis Endoscopic ultrasound （EUS） seems the more reliable technique for an accurate evaluation and follow-up of some ductal and parenchymal abnormalities suspected for early chronic pancreatitis.     

Comparison of Endoscopic Ultrasound and Endoscopic Retrograde Pancreatography for the Prediction of Pancreatic Exocrine Insufficiency

Endoscopic retrograde pancreatography (ERP) is a sensitive test for the early ductal changes of chronic pancreatitis. More recently, endoscopic ultrasound (EUS) has also been proposed as a sensitive structural test for chronic pancreatitis. Few studies have compared EUS and ERP using an external reference standard. Direct pancreatic function tests (PFT) are an acceptable reference standard for chronic pancreatitis since they detect mild exocrine insufficiency. Our aim was to compare structural abnormalities as revealed by ERP and EUS for the prediction of exocrine insufficiency. Eight-three patients who underwent EUS, ERP, and secretin PFT for the evaluation of pancreatitis were identified from our database. Exocrine insufficiency was defined as a secretin PFT peak bicarbonate concentration <80 mEq/l. Based on the number of abnormal sonographic criteria observed, EUS findings were categorized as normal (<2 criteria), mild (3–5 criteria) or severe (6–9 criteria or calcifications). ERP findings were categorized based on the Cambridge classification. ERP and EUS did not differ significantly in either sensitivity (72% vs 68%, P = 0.52) or specificity (76% vs 79%, P = 0.40). ERP and EUS were similarly associated with exocrine insufficiency both in the presence of minimal (OR 3.4 and 4.9, respectively) and severe structural changes (OR 12 and 24, respectively). We consider EUS to have a diagnostic accuracy for the structural diagnosis of early- and late-stage chronic pancreatitis similar to that of ERP.     

Determination of Plasma Trypsin-Like Activity in Healthy Subjects, Patients With Mild to Moderate Alcoholic Chronic Pancreatitis, and Patients With Nonjaundice Pancreatic Cancer

Trypsin-like activity is released after stimulation of the exocrine pancreas. We investigated under basal conditions and after stimulation by a meal whether patients suffering from pancreatic disorders differ with respect to plasma trypsin-like activity (PTLA). In 45 subjects (healthy volunteers: n = 18, mild/moderate alcoholic chronic pancreatitis: n = 16, nonjaundice pancreatic cancer n = 7, and calcifying chronic pancreatitis: n = 4), basal and postprandial levels of PTLA were measured over a period of 2 hours. Basal plasma levels were similar in the first 3 groups. After stimulation, healthy volunteers and patients with pancreatic cancer showed significant decreases in trypsin-like activity; however, plasma levels did not decrease in patients with mild/moderate chronic pancreatitis (P < .001). Healthy individuals demonstrate a consistent decrease in postprandial trypsin-like plasma activity. This response is not altered in patients with pancreatic cancer, and it is not seen in patients with mild/moderate alcoholic chronic pancreatitis.     

Serum lipase and amylase ratio in acute alcoholic and nonalcoholic pancreatitis by using Dupont ACA discrete clinical analyzer

This work involves a retrospective analysis of serum amylase, lipase, and lipase/amylase ratio in alcoholic and nonalcoholic patients diagnosed with acute pancreatitis. The purpose of this study was to test the reliability of the Dupont ACA method with respect to the lipase/amylase ratio as a discriminator, for the etiology of pancreatitis. Thirty-six consecutive patients with the diagnosis of acute pancreatitis were studied. These patients were divided in two groups. Group I consisted of 11 patients who had presumed acute alcoholic pancreatitis. In group II, 19 patients had acute biliary pancreatitis, including two with necrotizing pancreatitis and abscess formation secondary to cholilathiasis, five cases were idiopathic in nature, and one was thought to be medication induced (hydrochlorothiazide). In all cases, the Dupont ACA discrete clinical analyzer was used to determine serum levels of amylase and lipase. Concerning the lipase/amylase ratio, the geometric mean ratio for group I was 0.32 (range: 0.11–0.86) and for group II the mean ratio was 0.22 (range: 0.04–0.93). WithP>0.1, the difference between geometric mean ratios was not statistically significant. This study reveals that the lipase/amylase ratio would not have been a good indicator of alcoholic vs nonalcoholic acute pancreatitis. Although there was no significant statistical difference between geometric means, this study does show a significant difference in the number of individuals with serum amylase >2000 IU/dl in nonalcoholic acute pancreatitis patients (8/25 showed levels above 2000 IU/dl) when compared to alcoholic acute pancreatitis patients (0/11 showed levels above 2000 IU/dl). Chi-square analysis between <2000 IU/dl and >2000 IU/dl for the nonalcoholic vs the alcoholic groups yielded aP value of 0.03.     

Factors and outcomes associated with pancreatic duct disruption in patients with acute necrotizing pancreatitis

Background and aimsAcute necrotizing pancreatitis (ANP) can affect main pancreatic duct (MPD) as well as parenchyma. However, the incidence and outcomes of MPD disruption has not been well studied in the setting of ANP.MethodsThis retrospective study investigated 84 of 465 patients with ANP who underwent magnetic resonance cholangiopancreatography and/or endoscopic retrograde cholangiopancreatography. The MPD disruption group was subclassified into complete and partial disruption.ResultsMPD disruption was documented in 38% (32/84) of the ANP patients. Extensive necrosis, enlarging/refractory pancreatic fluid collections (PFCs), persistence of amylase-rich output from percutaneous drainage, and amylase-rich ascites/pleural effusion were more frequently associated with MPD disruption. Hospital stay was prolonged (mean 55 vs. 29 days) and recurrence of PFCs (41% vs. 14%) was more frequent in the MPD disruption group, although mortality did not differ between ANP patients with and without MPD disruption. Subgroup analysis between complete disruption (n = 14) and partial disruption (n = 18) revealed a more frequent association of extensive necrosis and full-thickness glandular necrosis with complete disruption. The success rate of endoscopic transpapillary pancreatic stenting across the stricture site was lower in complete disruption (20% vs. 92%). Patients with complete MPD disruption also showed a high rate of PFC recurrence (71% vs. 17%) and required surgery more often (43% vs. 6%).ConclusionsMPD disruption is not uncommon in patients with ANP with clinical suspicion on ductal disruption. Associated MPD disruption may influence morbidity, but not mortality of patients with ANP. Complete MPD disruption is often treated by surgery, whereas partial MPD disruption can be managed successfully with endoscopic transpapillary stenting and/or transmural drainage. Further prospective studies are needed to study these items.