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1
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Malik S, Ullah H, Loganathan P, Singh Dahiya D, Chandan S, Mohan BP, Adler DG. Efficacy of Endoscopic Therapy in Symptomatic Pancreatic Divisum: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2025; 59:183-189. [PMID: 38457418 DOI: 10.1097/mcg.0000000000001986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/31/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND AND AIMS Pancreas divisum (PD) is a congenital malformation of the pancreas and is implicated as a cause of pancreatitis. The role of endotherapy has been variable in symptomatic PD indicated by recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic pancreatic-type abdominal pain (PP). The aim of this study was to analyze the pooled data to determine the success of endoscopic intervention for pancreas divisum. METHODS We conducted a comprehensive search of several databases (inception to July 2023) to identify studies reporting on the use of endoscopic therapy in symptomatic pancreatic divisum. The random-effects model was used to calculate the pooled rates and I2 % values were used to assess the heterogeneity. RESULTS A total of 27 studies were retrieved that reported endoscopic intervention in pancreatic divisum. The calculated pooled rate of technical success was 92% (95% CI: 87-95; I2 =63%). The calculated pooled rate of clinical success was 65% (95% CI: 60-70; I2 =60%). The rate of clinical success by PD subtypes was highest in RAP at 71% (95% CI: 65-76; I2 =24%). Available studies had significant heterogeneity in defining clinical success. The rate of adverse events was 71% (95% CI: 65-76; I2 =24%). CONCLUSIONS The role of endoscopic therapy in pancreatic divisum is variable with the highest success rate in recurrent acute pancreatitis. Endoscopic intervention is associated with a higher-than-usual rate of adverse events, including post-ERCP pancreatitis.
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Affiliation(s)
- Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Hamid Ullah
- Department of Internal Medicine, Hamid Ullah, West Virginia University Priyadarshini Loganathan, UT Health, San Antonio, TX
| | - Priyadarshini Loganathan
- Department of Internal Medicine, Hamid Ullah, West Virginia University Priyadarshini Loganathan, UT Health, San Antonio, TX
| | | | - Saurabh Chandan
- Department of Gastroenterology, CHI Creighton Medical Center, Omaha, NE
| | - Babu P Mohan
- Department of Gastroenterology, Orlando Gastroenterology PA, Orlando, FL
| | - Douglas G Adler
- Gastroenterology & Hepatology,Center for Advanced Therapeutic Endoscopy at Porter Adventist Hospital in Denver, CO
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Raut SS, Acharya S, Kumar S, Deolikar V, Kothari M. Recurrent Acute-on-Chronic Pancreatitis in a Chronic Alcoholic With Pancreatic Divisum: A Complex Case. Cureus 2024; 16:e53022. [PMID: 38410348 PMCID: PMC10895203 DOI: 10.7759/cureus.53022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/26/2024] [Indexed: 02/28/2024] Open
Abstract
Pancreatic divisum, a rare developmental anomaly of the pancreas, is infrequently observed in young individuals and is a recognized cause of recurrent acute pancreatitis, ultimately progressing to chronic pancreatitis. Chronic alcoholism is a prevalent and significant etiological factor contributing to both recurrent acute pancreatitis and chronic pancreatitis. This case report details the presentation of a 28-year-old patient with a history of chronic alcoholism, exhibiting recurrent acute pancreatitis evolving into chronic pancreatitis. Diagnostic evaluation revealed the presence of pancreatic divisum with associated pancreatic intraductal calculi, a common trigger for pancreatitis. The patient underwent successful management through endoscopic retrograde cholangiopancreatography, pancreatic lithotripsy, and pigtail pancreatic stent placement. This case highlights the complex interplay between chronic alcoholism leading to recurrent acute pancreatitis and pancreatic divisum, a rare congenital anomaly, which is found later in this case, complicating the disease.
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Affiliation(s)
- Sarang S Raut
- General Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sourya Acharya
- General Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sunil Kumar
- General Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Vinit Deolikar
- General Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Manjeet Kothari
- General Medicine, Jawaharlal Nehru Medical College, Wardha, IND
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3
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Umans DS, Timmerhuis HC, Anten MPGF, Bhalla A, Bijlsma RA, Boxhoorn L, Brink MA, Bruno MJ, Curvers WL, van Eijck BC, Erkelens GW, van Geenen EJM, Hazen WL, Hoge CV, Hol L, Inderson A, Kager LM, Kuiken SD, Perk LE, Quispel R, Römkens TEH, Sperna Weiland CJ, Thijssen AY, Venneman NG, Verdonk RC, van Wanrooij RLJ, Witteman BJ, Besselink MG, van Hooft JE. Prospective multicentre study of indications for surgery in patients with idiopathic acute pancreatitis following endoscopic ultrasonography (PICUS). Br J Surg 2023; 110:1877-1882. [PMID: 37811814 PMCID: PMC10638543 DOI: 10.1093/bjs/znad318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/21/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Cholecystectomy in patients with idiopathic acute pancreatitis (IAP) is controversial. A randomized trial found cholecystectomy to reduce the recurrence rate of IAP but did not include preoperative endoscopic ultrasonography (EUS). As EUS is effective in detecting gallstone disease, cholecystectomy may be indicated only in patients with gallstone disease. This study aimed to determine the diagnostic value of EUS in patients with IAP, and the rate of recurrent pancreatitis in patients in whom EUS could not determine the aetiology (EUS-negative IAP). METHODS This prospective multicentre cohort study included patients with a first episode of IAP who underwent outpatient EUS. The primary outcome was detection of aetiology by EUS. Secondary outcomes included adverse events after EUS, recurrence of pancreatitis, and quality of life during 1-year follow-up. RESULTS After screening 957 consecutive patients with acute pancreatitis from 24 centres, 105 patients with IAP were included and underwent EUS. In 34 patients (32 per cent), EUS detected an aetiology: (micro)lithiasis and biliary sludge (23.8 per cent), chronic pancreatitis (6.7 per cent), and neoplasms (2.9 per cent); 2 of the latter patients underwent pancreatoduodenectomy. During 1-year follow-up, the pancreatitis recurrence rate was 17 per cent (12 of 71) among patients with EUS-negative IAP versus 6 per cent (2 of 34) among those with positive EUS. Recurrent pancreatitis was associated with poorer quality of life. CONCLUSION EUS detected an aetiology in a one-third of patients with a first episode of IAP, requiring mostly cholecystectomy or pancreatoduodenectomy. The role of cholecystectomy in patients with EUS-negative IAP remains uncertain and warrants further study.
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Affiliation(s)
- Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Hester C Timmerhuis
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, Haga Hospital, The Hague, the Netherlands
| | - Rina A Bijlsma
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, the Netherlands
| | - Lotte Boxhoorn
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, the Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospital, Apeldoorn, the Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Chantal V Hoge
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Liesbeth M Kager
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, the Netherlands
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medical Centre Haaglanden, The Hague, the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Christina J Sperna Weiland
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Roy L J van Wanrooij
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, the Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, the Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
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Cammarata F, Rovati L, Fontana P, Gambitta P, Armellino A, Aseni P. Endoscopic Ultrasound to Identify the Actual Cause of Idiopathic Acute Pancreatitis: A Systematic Review. Diagnostics (Basel) 2023; 13:3256. [PMID: 37892077 PMCID: PMC10606009 DOI: 10.3390/diagnostics13203256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/24/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Idiopathic acute pancreatitis (IAP) presents a diagnostic challenge and refers to cases where the cause of acute pancreatitis remains uncertain despite a comprehensive diagnostic evaluation. Endoscopic ultrasound (EUS) has emerged as a valuable tool in the diagnostic workup of IAP. This review explores the pivotal role of EUS in detecting the actual cause of IAP and assessing its accuracy, timing, safety, and future technological improvement. In this review, we investigate the role of EUS in identifying the actual cause of IAP by examining the available literature. We aim to assess possible existing evidence regarding EUS accuracy, timing, and safety and explore potential trends of future technological improvements in EUS for diagnostic purposes. Following PRISMA guidelines, 60 pertinent studies were selected and analysed. EUS emerges as a crucial diagnostic tool, particularly when conventional imaging fails. It can offer intricate visualization of the pancreas, biliary system, and adjacent structures. Microlithiasis, biliary sludge, chronic pancreatitis, and small pancreatic tumors seem to be much more accurately identified with EUS in the setting of IAP. The optimal timing for EUS is post-resolution of the acute phase of the disease. With a low rate of complications, EUS poses minimal safety concerns. EUS-guided interventions, including fine-needle aspiration, collection drainage, and biopsies, aid in the cytological analysis. With high diagnostic accuracy, safety, and therapeutic potential, EUS is able to improve patient outcomes when managing IAP. Further refinement of EUS techniques and cost-effectiveness assessment of EUS-guided approaches need to be explored in multicentre prospective studies. This review underscores EUS as a transformative tool in unraveling IAP's enigma and advancing diagnostic and therapeutic strategies.
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Affiliation(s)
- Francesco Cammarata
- Department of General Surgery, Ospedale Luigi Sacco, Università degli Studi di Milano, 20157 Milan, Italy;
| | - Lucrezia Rovati
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Paola Fontana
- Department of Gastroenterology, ASST Ovest Milanese, 20025 Legnano, Italy; (P.F.); (P.G.)
| | - Pietro Gambitta
- Department of Gastroenterology, ASST Ovest Milanese, 20025 Legnano, Italy; (P.F.); (P.G.)
| | - Antonio Armellino
- Endoscopy Division, Ospedale San Leopoldo Mandic di Merate, ASST Lecco, 23807 Lecco, Italy;
| | - Paolo Aseni
- Emergency Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy
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Inamdar S, Cote GA, Yadav D. Endotherapy for Pancreas Divisum. Gastrointest Endosc Clin N Am 2023; 33:789-805. [PMID: 37709411 DOI: 10.1016/j.giec.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.
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Affiliation(s)
- Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Shorey Building, 8th Floor, 4301 West Markham Street, Little Rock, AR 72205, USA.
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L461, Portland, OR, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, USA
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6
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Vitali F, Zundler S, Jesper D, Wildner D, Strobel D, Frulloni L, Neurath MF. Diagnostic Endoscopic Ultrasound in Pancreatology: Focus on Normal Variants and Pancreatic Masses. Visc Med 2023; 39:121-130. [PMID: 37899794 PMCID: PMC10601528 DOI: 10.1159/000533432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/03/2023] [Indexed: 10/31/2023] Open
Abstract
Background Endoscopic ultrasound (EUS) is a main tool in gastroenterology for both diagnosis and exclusion of pancreatic pathology. It allows minimally invasive assessment of various diseases or anatomic variations affecting the pancreas also with the help of new Doppler technologies, elastography, contrast-enhanced imaging including post hoc image processing with quantification analyses, three-dimensional reconstruction, and artificial intelligence. EUS also allows interventional direct access to the pancreatic parenchyma and the retroperitoneal space, to the pancreatic duct, pancreatic masses, cysts, and vascular structures. Summary This review aimed to summarize new developments of EUS in the field of pancreatology. We highlight the role of EUS in evaluating pancreatic pathology by describing normal anatomic variants like pancreas divisum, pancreatic lipomatosis, pancreatic fibrosis in the elderly and characterizing pancreatic masses, both in the context of chronic pancreatitis and within healthy pancreatic parenchyma. EUS is considered the optimal imaging modality for pancreatic masses of uncertain dignity and allows both cytological diagnosis and histology, which is essential not only for neoplastic conditions but also for tailoring therapy for benign inflammatory conditions. Key Messages EUS plays an indispensable role in pancreatology and the development of new diagnostic and interventional approaches to the retroperitoneal space and the pancreas exponentially increased over the last years. The development of computer-aided diagnosis and artificial intelligence algorithms hold the potential to overcome the obstacles associated with interobserver variability and will most likely support decision-making in the management of pancreatic disease.
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Affiliation(s)
- Francesco Vitali
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Zundler
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Daniel Jesper
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Dane Wildner
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Deike Strobel
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Luca Frulloni
- Department of Medicine, Gastroenterology Unit, Pancreas Center, University of Verona, Verona, Italy
| | - Markus F. Neurath
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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Baba T, Yamazaki T, Sakai M, Matshuda K, Amaya K, Takatsuki M, Okada Y. A possible manifestation of pancreas divisum-pancreatic pseudocyst in an infant with no apparent history of pancreatitis: a case report. Surg Case Rep 2023; 9:153. [PMID: 37665533 PMCID: PMC10477155 DOI: 10.1186/s40792-023-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Pancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can cause pancreatitis or epigastric pain. We report an unusual case of PD in an infant. CASE PRESENTATION The patient was a 9-month-old girl with no pertinent medical history. She had suffered vomiting and diarrhea for 1 week before transfer to our hospital. Her general condition was poor, and abdominal distention was noted. Blood tests revealed microcytic anemia with normal chemical markers. The parents reported no episode of pancreatitis. Ultrasonography revealed massive ascites, which was later found to be bloody. Enhanced computed tomography and magnetic resonance imaging depicted a cystic lesion, approximately 2 cm in size, anterior to the second portion of the duodenum. During exploratory laparotomy, a pinhole was identified on the cyst wall, which was mistakenly identified as a duodenal perforation, and direct closure was performed. Postoperative levels of serum amylase and inflammation markers were elevated, and the amount of ascites increased, impairing oral feeding. The level of pancreatic enzymes in the ascites was high. Imaging studies were repeated, but the cause of pancreatic fistula was not identified. Conservative therapy, including administration of total parenteral nutrition, antibiotics, and octreotide, was initiated, but the situation did not improve. Three months after admission, endoscopic retrograde cholangiopancreatography showed a thick dorsal pancreatic duct communicating with a hypoplastic ventral duct, which was indicative of PD. Contrast medium leaking from the dorsal duct near the minor ampulla revealed the presence of a pseudocyst. Stenting via the minor papilla was impossible because the minor papilla was obstructed. Instead, a stent was inserted into the ventral pancreatic duct. Endoscopic transgastric drainage of the cyst was effective, and the patient was discharged, 7 months after admission. The patient is healthy, but the gastric stent needs to be replaced regularly. CONCLUSION In children, PD can manifest with pancreatic pseudocyst that causes pancreatic ascites, even in the absence of pancreatitis. This may be a previously unrecognized manifestation of PD in children, and clinicians need to be aware of it.
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Affiliation(s)
- Tokuro Baba
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan.
- Department of Pediatric Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-Nagae, Toyama, 930-8550, Japan.
| | - Toru Yamazaki
- Department of Pediatric Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-Nagae, Toyama, 930-8550, Japan
| | - Masato Sakai
- Department of Pediatric Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-Nagae, Toyama, 930-8550, Japan
| | - Koichiro Matshuda
- Department of Internal Medicine, Toyama Prefectural Central Hospital, 2-2-78 Nishi-Nagae, Toyama, 930-8550, Japan
| | - Koji Amaya
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-Nagae, Toyama, 930-8550, Japan
| | - Mitsuhisa Takatsuki
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Yasuhiro Okada
- Department of Pediatric Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-Nagae, Toyama, 930-8550, Japan
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Kara S, Ozair S, Brzobohaty M, Nedd K. A Rare Case of Pancreatic Divisum Presentation. Cureus 2023; 15:e37580. [PMID: 37193449 PMCID: PMC10183217 DOI: 10.7759/cureus.37580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/18/2023] Open
Abstract
Pancreatic divisum (PD) is a malformation wherein the majority of affected patients remain asymptomatic or present with complications early in life. Some cases, however, may present in adulthood with recurrent pancreatitis, which makes the diagnosis clinically challenging. Here, we present a rare case of an elderly female with acute-on-chronic epigastric pain secondary to pancreatitis due to PD. During hospitalization, the patient was treated for acute pancreatitis and subsequently discharged with recommendations for corrective surgery. This case is unique particularly due to the older age of onset of symptoms, as well as the lack of exacerbating factors such as drug abuse, alcohol, or obesity. This case highlights the importance of considering PD as a differential diagnosis when managing patients with recurrent pancreatitis regardless of their age.
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Affiliation(s)
- Sam Kara
- Department of Neurology, Larkin Community Hospital Palm Springs Campus, Miami, USA
| | - Saleha Ozair
- Department of Internal Medicine, Larkin Community Hospital, Miami, USA
| | - Miro Brzobohaty
- Department of Internal Medicine, Larkin Community Hospital Palm Springs Campus, Miami, USA
| | - Kester Nedd
- Department of Neurology, Larkin Community Hospital Palm Springs Campus, Miami, USA
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9
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Correlation between Pancreatic Duct Variation and Related Diseases: An Effective Method Observing the Dual-Energy CT with Low-keV Monoenergetic Images. Diagnostics (Basel) 2023; 13:diagnostics13030520. [PMID: 36766625 PMCID: PMC9914045 DOI: 10.3390/diagnostics13030520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/18/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Pancreatic duct variation can affect the secretory function of the pancreas. We aimed to explore the pancreatic duct variation, observed using low-keV monoenergetic images [MEI (+)] of dual-energy CT (DECT), and its relationship with related diseases. We further sought to compare pancreatic duct imaging using low-keV MEI (+) of DECT and magnetic resonance cholangiopancreatography (MRCP). MATERIALS AND METHODS The DECT and MRCP images of 854 patients were evaluated retrospectively. The 808 patients' pancreatic duct types were classified according to the anatomy and the opening of the pancreatic ducts, and the correlation with related diseases was analyzed. The DECT and MRCP images of 852 patients were graded according to the sharpness of the pancreatic ducts for evaluation. RESULTS A higher prevalence of acute pancreatitis (AP), chronic pancreatitis (CP), and duodenal papillary carcinoma (DPC) was observed in the variant group. Of the 27 AP cases in the variant group, 9 patients (33.3%) were Type 3c. Additionally, Type 4a was significantly correlated with AP and CP (p < 0.05). Low-keV MEI (+) of DECT outperformed the MRCP images in the sharpness of the pancreatic ducts in 852 patients. CONCLUSIONS Pancreatic duct variation is associated with AP, CP, and DPC. Low-keV MEI (+) DECT is an effective method to observe the pancreatic duct system.
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10
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Zdanowicz K, Uscinowicz M, Rakowska M, Wertheim-Tysarowska K, Rygiel AM, Oracz G, Lebensztejn DM. Chronic pancreatitis caused by a Homozygous SPINK1 c.194 + 2T > C variant and Pancreas Divisum in a 3-year-old child—case report. J Pediatr Genet 2022; 11:232-235. [DOI: 10.1055/s-0040-1717109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
AbstractChronic pancreatitis (CP) is a rare disease in children. We describe the first case of a 3-year-old Caucasian patient with CP with the presence of a homozygous pathogenic variant c.194 + 2T > C in serine protease inhibitor, Kazal type 1 (SPINK1) and pancreas divisum.
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Affiliation(s)
- Katarzyna Zdanowicz
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | - Miroslawa Uscinowicz
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | - Magdalena Rakowska
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, Children's Memorial Health Institute, Warsaw, Poland
| | | | | | - Grzegorz Oracz
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, Children's Memorial Health Institute, Warsaw, Poland
| | - Dariusz Marek Lebensztejn
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
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Pancreas Divisum Increases the Risk of Recurrent Acute Pancreatitis in Patients with rs12338 Polymorphism in the Cathepsin B Gene. Dig Dis Sci 2021; 66:2283-2290. [PMID: 32754840 DOI: 10.1007/s10620-020-06517-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/22/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Pancreas divisum (PD) as a cause of pancreatitis has been debated. In this study, we report the association of multiple gene polymorphisms on the risk of RAP in the presence of PD. DESIGN We enrolled 687 individuals (167 IRAP, 276 ICP, and 244 unrelated healthy controls) from May 2015 to September 2016. Patients were divided into those with/without PD. Associations between the significantly prevalent SNPs and IRAP/ICP in the presence of PD were evaluated. Clinical data were analyzed using Mann-Whitney U/Chi-square test. Effect size of association of SNPs with IRAP/ICP was expressed as odds ratio (OR) (95% CI). Gene-gene interaction was assessed by transheterozygosity analyses. Bonferroni-corrected two-tailed "p" value of ≤ 0.01 was considered statistically significant. RESULTS Thirty-three (19.8%) and 82 (29.7%) patients with IRAP and ICP, respectively, had PD. Among the patients with IRAP, duration of disease was significantly shorter in those with PD compared to those without (mean [95% CI] duration: 1.6 (1.3-1.9) vs 2.7 (2.3-3.1) years; p = 0.005). There were no differences in gender, race, and diabetes among patients with/without PD in IRAP/ICP groups. Mean (95% CI) pancreatic duct diameter (mm) was significantly higher in the presence of PD in patients with both IRAP [1.6 (1.4-1.9) v/s 1.29 (1.2-1.4); p = 0.03)] and ICP [5.2 (4.5-5.9) v/s 4.5 (3.9-5.1); p = 0.02]. CTSB (rs12338) polymorphisms were significantly associated with IRAP [OR (95% CI) 2.44 (1.41-4.22); p = 0.001] among patients with PD. No association was observed with ICP. Transheterozygosity analysis did not show any significant associations of combination of SNPs with IRAP in the presence of PD. CONCLUSION Risk of RAP due to PD increases in patients with rs12338 polymorphism in the cathepsin B gene.
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12
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Chronic pancreatitis for the clinician. Part 1: Etiology and diagnosis. Interdisciplinary position paper of the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:231-248. [PMID: 34157366 DOI: 10.1016/j.gastrohep.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/13/2021] [Accepted: 05/07/2021] [Indexed: 11/24/2022]
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13
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Sunnapwar A, Nagar A, Katre R, Khanna L, Sayana HP. Imaging of Ampullary and Periampullary Conditions. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2021. [DOI: 10.1055/s-0041-1726663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractThe ampulla of Vater is formed by the union of the pancreatic duct and the common bile duct and is also known as hepatopancreatic ampulla or hepatopancreatic duct. The ampulla is surrounded by a muscular valve known as the sphincter of Oddi, which controls the flow of bile and pancreatic juices into the duodenum in response to food. The ampulla is also an important embryological landmark as it marks the anatomical transition from foregut to the midgut. Because of this, it is a watershed zone where the blood supply changes from the celiac axis to the superior mesenteric artery. Radiologic evaluation of the ampulla and the periampullary region is challenging because it requires an understanding of the embryology, the normal appearance, and different anatomic variants. Also, a wide variety of pathologies can occur in this region. The purpose of this review is to present the normal anatomy of the ampulla and the periampullary region on different imaging modalities and to summarize the imaging features of the common variants, and benign and malignant ampullary and periampullary conditions. Understanding of the normal anatomical appearance and variants along with the knowledge of common pathologic conditions affecting the ampulla and periampullary conditions can help radiologists in making accurate diagnosis resulting in optimum patient care.
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Affiliation(s)
- Abhijit Sunnapwar
- Department of Radiology, University of Texas Health San Antonio, San Antonio, Texas, United States
| | - Arpit Nagar
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Rashmi Katre
- Department of Radiology, University of Texas Health San Antonio, San Antonio, Texas, United States
| | - Lokesh Khanna
- Department of Radiology, University of Texas Health San Antonio, San Antonio, Texas, United States
| | - Hari Prasad Sayana
- Department of Gastroenterology, University of Texas Health San Antonio, San Antonio, Texas, United States
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14
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Current State of Imaging of Pediatric Pancreatitis: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:265-277. [PMID: 33728974 DOI: 10.2214/ajr.21.25508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pancreatitis is as common in children as it is in adults, though causes and accepted imaging strategies differ in children. In this narrative review we discuss the epidemiology of childhood pancreatitis and key imaging features for pediatric acute, acute recurrent, and chronic pancreatitis. We rely heavily on our collective experience in discussing advantages and disadvantages of different imaging modalities; practical tips for optimization of ultrasound, CT, and MRI with MRCP in children; and image interpretation pearls. Challenges and considerations unique to imaging pediatric pancreatitis are discussed, including timing of imaging, role of secretin-enhanced MRCP, utility of urgent MRI, severity prediction, autoimmune pancreatitis, and best methods for serial imaging. We suggest a methodical approach to pancreatic MRI interpretation in children and have included a sample structured report, and we provide consensus statements according to our experience imaging children with pancreatitis.
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15
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Umans DS, Rangkuti CK, Sperna Weiland CJ, Timmerhuis HC, Bouwense SAW, Fockens P, Besselink MG, Verdonk RC, van Hooft JE. Endoscopic ultrasonography can detect a cause in the majority of patients with idiopathic acute pancreatitis: a systematic review and meta-analysis. Endoscopy 2020; 52:955-964. [PMID: 32557477 DOI: 10.1055/a-1183-3370] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Idiopathic acute pancreatitis (IAP) has a 25 % pancreatitis recurrence rate. Endoscopic ultrasonography (EUS) may diagnose treatable causes of IAP and hence prevent recurrence. The goal of this systematic review with meta-analysis is to determine the diagnostic yield of EUS and its impact on recurrence. METHODS PubMed, EMBASE and the Cochrane Library were systematically searched for English studies on EUS in adults with IAP. The primary outcome was diagnostic yield. Secondary outcomes included recurrence. Methodological quality was assessed using the QUADAS-2 score. Meta-analysis was performed to calculate the pooled diagnostic yield and risk ratio with 95 % confidence intervals (CI) using a random-effects model with inverse variance method. RESULTS 22 studies were included, with 1490 IAP patients who underwent EUS. Overall diagnostic yield was 59 % (874 /1490; 95 %CI 52 % - 66 %). The most common etiologies were biliary (429 /1490; 30 %, 95 %CI 21 % - 41 %) and chronic pancreatitis (271 /1490; 12 %, 95 %CI 8 % - 19 %). In 2 % of patients, neoplasms were detected (45 /1490; 95 %CI 1 % - 4 %). There was no difference in yield between patients with or without recurrent IAP before EUS (risk ratio 0.89, 95 %CI 0.71 - 1.11). CONCLUSIONS EUS is able to identify a potential etiology in the majority of patients with IAP, detecting mostly biliary origin or chronic pancreatitis, but also neoplasms in 2 % of patients. EUS may be associated with a reduction of recurrence rate. Future studies should include complete diagnostic work-up and preferably include patients with a first episode of IAP only.
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Affiliation(s)
- Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Carlos K Rangkuti
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christa J Sperna Weiland
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hester C Timmerhuis
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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16
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Umans DS, Timmerhuis HC, Hallensleben ND, Bouwense SA, Anten MPG, Bhalla A, Bijlsma RA, Boermeester MA, Brink MA, Hol L, Bruno MJ, Curvers WL, van Dullemen HM, van Eijck BC, Erkelens GW, Fockens P, van Geenen EJM, Hazen WL, Hoge CV, Inderson A, Kager LM, Kuiken SD, Perk LE, Poley JW, Quispel R, Römkens TE, van Santvoort HC, Tan AC, Thijssen AY, Venneman NG, Vleggaar FP, Voorburg AM, van Wanrooij RL, Witteman BJ, Verdonk RC, Besselink MG, van Hooft JE. Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study. BMJ Open 2020; 10:e035504. [PMID: 32819938 PMCID: PMC7440829 DOI: 10.1136/bmjopen-2019-035504] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/10/2020] [Accepted: 07/15/2020] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Idiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional diagnostic modalities such as endoscopic ultrasonography (EUS) are warranted after a first episode of IAP in order to uncover this aetiology. Failure to timely determine treatable aetiologies delays appropriate treatment and might subsequently cause recurrence of acute pancreatitis. Therefore, the aim of the Pancreatitis of Idiopathic origin: Clinical added value of endoscopic UltraSonography (PICUS) Study is to determine the value of routine EUS in determining the aetiology of pancreatitis in patients with a first episode of IAP. METHODS AND ANALYSIS PICUS is designed as a multicentre prospective cohort study of 106 patients with a first episode of IAP after complete standard diagnostic work-up, in whom a diagnostic EUS will be performed. Standard diagnostic work-up will include a complete personal and family history, laboratory tests including serum alanine aminotransferase, calcium and triglyceride levels and imaging by transabdominal ultrasound, magnetic resonance imaging or magnetic resonance cholangiopancreaticography after clinical recovery from the acute pancreatitis episode. The primary outcome measure is detection of aetiology by EUS. Secondary outcome measures include pancreatitis recurrence rate, severity of recurrent pancreatitis, readmission, additional interventions, complications, length of hospital stay, quality of life, mortality and costs, during a follow-up period of 12 months. ETHICS AND DISSEMINATION PICUS is conducted according to the Declaration of Helsinki and Guideline for Good Clinical Practice. Five medical ethics review committees assessed PICUS (Medical Ethics Review Committee of Academic Medical Center, University Medical Center Utrecht, Radboud University Medical Center, Erasmus Medical Center and Maastricht University Medical Center). The results will be submitted for publication in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER Netherlands Trial Registry (NL7066). Prospectively registered.
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Affiliation(s)
- Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Hester C Timmerhuis
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Nora D Hallensleben
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Marie-Paule Gf Anten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HagaZiekenhuis, Den Haag, Zuid-Holland, The Netherlands
| | - Rina A Bijlsma
- Department of Gastroenterology and Hepatology, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander MC, Amersfoort, Utrecht, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, North Brabant, The Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, UMCG, Groningen, Groningen, The Netherlands
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Ziekenhuizen, Apeldoorn, Gelderland, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud university medical center, Nijmegen, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
| | - Chantal V Hoge
- Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, LUMC, Leiden, Zuid-Holland, The Netherlands
| | - Liesbeth M Kager
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, Noord-Holland, The Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, Zuid-Holland, The Netherlands
| | - Tessa Eh Römkens
- Department of Gastroenteroloy and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, Noord-Brabant, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Adriaan Citl Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Gelderland, The Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, Zuid-Holland, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Overijssel, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Annet McJ Voorburg
- Department of Gastroenterology and Hepatology, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, Utrecht, The Netherlands
| | - Roy Lj van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
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17
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Identifying Factors Predicting Response to Endoscopic Management of Chronic Pancreatitis Secondary to Pancreas Divisum. J Gastrointest Surg 2020; 24:585-589. [PMID: 30887289 DOI: 10.1007/s11605-019-04122-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/13/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Appropriately selecting patients with chronic pancreatitis associated with pancreas divisum (PD) for endoscopic retrograde cholangiopancreatography (ERCP)-based therapy versus surgery remains difficult. The objective of this study was to identify factors that predict success or failure of ERCP for treatment of chronic pancreatitis in PD. METHODS Patients undergoing ERCP for a diagnosis of PD and pancreatitis between 2008 and 2016 were identified and grouped according to whether they required one or two ERCPs or three or more ERCPs. Groups were compared along demographic, diagnostic, laboratory, ERCP-related, and outcome variables. RESULTS Patients requiring 1-2 ERCPs were less likely to have back pain on initial presentation (4 vs. 24%, p = 0.02) and less likely to have a dilated bile duct on imaging prior to their first ERCP (8 vs. 30%, p = 0.04) than those requiring 3+ ERCPs. Patients requiring 1-2 ERCPs were also less likely to eventually require operative intervention for treatment of their chronic pancreatitis than those requiring 3+ ERCPs (24 vs. 44%, p = 0.047). On multivariable analysis, a dilated bile duct (odds ratio (OR) = 6.0, 95% confidence interval (CI) = 1.01-36.0, p = 0.048) was independently associated with requiring 3+ ERCPs. Back pain (OR = 6.3, 95% CI = 0.73-54.2, p = 0.09) trended toward but did not reach statistical significance for being independently associated with requiring 3+ ERCPs. CONCLUSIONS The success of endoscopic treatment of chronic pancreatitis in patients with PD is dependent on proper patient selection. Patients with a dilated bile duct and back pain upon presentation may not respond well to endoscopic treatment alone and are more likely to eventually require operative intervention. Consideration should be given to early operative intervention in these patients.
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18
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Umans DS, Hallensleben ND, Verdonk RC, Bouwense SAW, Fockens P, van Santvoort HC, Voermans RP, Besselink MG, Bruno MJ, van Hooft JE. Recurrence of idiopathic acute pancreatitis after cholecystectomy: systematic review and meta-analysis. Br J Surg 2019; 107:191-199. [PMID: 31875953 PMCID: PMC7003758 DOI: 10.1002/bjs.11429] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022]
Abstract
Background Occult biliary disease has been suggested as a frequent underlying cause of idiopathic acute pancreatitis (IAP). Cholecystectomy has been proposed as a strategy to prevent recurrent IAP. The aim of this systematic review was to determine the efficacy of cholecystectomy in reducing the risk of recurrent IAP. Methods PubMed, Embase and Cochrane Library databases were searched systematically for studies including patients with IAP treated by cholecystectomy, with data on recurrence of pancreatitis. Studies published before 1980 or including chronic pancreatitis and case reports were excluded. The primary outcome was recurrence rate. Quality was assessed using the Newcastle–Ottawa Scale. Meta‐analyses were undertaken to calculate risk ratios using a random‐effects model with the inverse‐variance method. Results Overall, ten studies were included, of which nine were used in pooled analyses. The study population consisted of 524 patients with 126 cholecystectomies. Of these 524 patients, 154 (29·4 (95 per cent c.i. 25·5 to 33·3) per cent) had recurrent disease. The recurrence rate was significantly lower after cholecystectomy than after conservative management (14 of 126 (11·1 per cent) versus 140 of 398 (35·2 per cent); risk ratio 0·44, 95 per cent c.i. 0·27 to 0·71). Even in patients in whom IAP was diagnosed after more extensive diagnostic testing, including endoscopic ultrasonography or magnetic resonance cholangiopancreatography, the recurrence rate appeared to be lower after cholecystectomy (4 of 36 (11 per cent) versus 42 of 108 (38·9 per cent); risk ratio 0·41, 0·16 to 1·07). Conclusion Cholecystectomy after an episode of IAP reduces the risk of recurrent pancreatitis. This implies that current diagnostics are insufficient to exclude a biliary cause.
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Affiliation(s)
- D S Umans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - N D Hallensleben
- Department of Gastroenterology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.,Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
| | - R C Verdonk
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - S A W Bouwense
- Department of Surgery, MUMC+, Maastricht, the Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - H C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.,Department of Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - R P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M J Bruno
- Department of Gastroenterology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - J E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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19
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Jalal M, Campbell JA, Hopper AD. Practical guide to the management of chronic pancreatitis. Frontline Gastroenterol 2019; 10:253-260. [PMID: 31288255 PMCID: PMC6583580 DOI: 10.1136/flgastro-2018-101071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/19/2018] [Indexed: 02/04/2023] Open
Abstract
Chronic pancreatitis (CP) is an irreversible fibroinflammatory disorder of the pancreas. It presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption due to pancreatic exocrine insufficiency and endocrine deficiency with the development of diabetes mellitus. The associated increased hospitalisation and high economic burden are related to CP often presenting at advanced stage with irreversible consequences. Diagnosing CP at an early stage is still challenging and therefore CP is believed to be under-reported. Our understanding of this disease has evolved over the last few years with attempts to redesign the definition of CP. Better recognition of the risk factors and conditions associated with CP can lead to an earlier diagnosis and coupled with a multidisciplinary approach to treatment, ultimately reduce complications. This article reviews the epidemiology, risk factors, diagnosis and management of CP.
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Affiliation(s)
- Mustafa Jalal
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Andrew D Hopper
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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20
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Olson E, Perelman A, Birk JW. Acute management of pancreatitis: the key to best outcomes. Postgrad Med J 2019; 95:328-333. [PMID: 31123175 DOI: 10.1136/postgradmedj-2018-136034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/11/2018] [Accepted: 04/25/2019] [Indexed: 12/17/2022]
Abstract
Acute pancreatitis (AP) accounts for over 230 000 US and 28 000 UK hospital admissions annually. Abdominal pain is the most common presenting symptom in AP but may not reflect severity. The clinical challenge is identifying the 20% of patients in whom AP will be severe. We summarise the common aetiologies, the risk stratification strategies including the simplified Bedside Index for Severity in Acute Pancreatitis, acute management approaches in the initial presentation setting, conditions for using advance imaging and opinions on antibiotic use. Some warning signs of impending complications are also discussed.
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Affiliation(s)
- Erik Olson
- Department of Gastroenterology and Hepatology, Rochester General Hospital, Rochester, New York, USA
| | | | - John W Birk
- Gastroenterology-Hepatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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21
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Sitaraman LM, Sachdev AH, Gonda TA, Sethi A, Poneros JM, Gress FG. The Utility of Endoscopic Ultrasound in Patients with Isolated Elevations in Serum Amylase and/or Lipase. Clin Endosc 2019; 52:175-181. [PMID: 30646674 PMCID: PMC6453845 DOI: 10.5946/ce.2018.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/02/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to describe the diagnostic yield of endoscopic ultrasound (EUS) in patients with isolated elevated levels of amylase and/or lipase. METHODS A retrospective chart review was conducted at a large academic medical center from 2000 to 2016. Patients were selected based on having elevated amylase, lipase, or both, but without a diagnosis of pancreatitis or known pancreatobiliary disease. Patients were excluded if they had abnormal liver function tests or abnormal imaging of the pancreas. RESULTS Of 299 EUS procedures performed, 38 met inclusion criteria. Symptoms were present in 31 patients, most frequently abdominal pain (87%). In 20 patients (53%), initial EUS most commonly found chronic pancreatitis (n=7; 18%), sludge (5; 13%), or new diagnosis of pancreas divisum (3; 8%). In the asymptomatic patients (7), 3 had a finding on EUS, most importantly sludge (2), stone (1), and pancreas divisum (1). No patients were diagnosed with a mass or pancreatic cyst. During the follow up period, 6 patients (22%) had cholecystectomy. CONCLUSION In our study of patients with isolated elevations in amylase and/or lipase without acute pancreatitis who underwent EUS, approximately 50% had a pancreatobiliary finding, most commonly chronic pancreatitis or biliary sludge.
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Affiliation(s)
- Lalitha M Sitaraman
- Division of Digestive Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Amit H Sachdev
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Tamas A Gonda
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - John M Poneros
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Frank G Gress
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
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22
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Bizzarri B, Nervi G, Ghiselli A, Manzali E, Di Mario F, Leandro G, Gaiani F, Kayali S, De' Angelis GL. Endoscopic ultrasound in pediatric population: a comprehensive review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:33-39. [PMID: 30561393 PMCID: PMC6502188 DOI: 10.23750/abm.v89i9-s.7876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Endoscopic ultrasonography (EUS) with or without fine needle aspiration/biopsy (FNA/B) is a well-established diagnostic tool in adults for the evaluation and management of gastrointestinal (GI) tract disorders. Its use in children is still limited as well as literature in pediatric age is limited, although the application of EUS is now increasing. The present article aims to review the current literature about EUS indication, accuracy and safety in pediatric age. METHODS Electronic literature searches were conducted using Pubmed, Medline, Embase, and the Cochrane Central Register of Controlled Trials using the word pediatric endoscopic ultrasound, pediatric pancreaticobiliary AND/OR EUS, pediatric EUS technique. Main patients and procedures characteristics were analyzed. The primary endpoint was the indication of EUS. Secondary endpoints were the accuracy of the technique and the incidence of complications. RESULTS Data were extracted from 19 articles. A total of 571 patients were investigated, with a median age of 12,7 years. A total of 634 EUS procedures were performed. The majority of EUS procedures investigated the pancreaticobiliary tract (77,7%). Most studies showed a high positive impact on management with a median value of 81,7%. No major complications were reported. Five studies reported minor complications with a median value of 2%. CONCLUSIONS EUS is safe and has a significant role in the diagnosis of pancreaticobiliary and GI diseases even in children, with a high therapeutic success. An increasing EUS utilization by pediatric gastroenterologists is expected and offering dedicated EUS training to some selected pediatric gastroenterologists might be indicated.
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Affiliation(s)
- Barbara Bizzarri
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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Abstract
Acute pancreatitis is among the most common gastrointestinal disorders requiring hospitalization worldwide. Establishing the cause of acute pancreatitis ensures appropriate management and proper health care resource utilization. Causes of acute pancreatitis include biliary, alcohol use, hypertriglyceridemia, hypercalcemia, drug-induced, autoimmune, hereditary/genetic, and anatomic abnormalities. Fluid therapy remains the cornerstone of managing acute pancreatitis. This article provides a brief summary of current evidence-based practices in the diagnosis and management of uncomplicated acute pancreatitis.
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Abstract
Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.
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Abstract
Systemic inflammatory response syndrome (SIRS) prevention is key to severe acute pancreatitis (SAP) treatment and the assessment of high-volume hemofiltration (HVHF) for treating SAP accompanying multiple organ dysfunction syndromes.In this prospective controlled study, 40 SAP patients were divided into 2 groups: control (n = 22, treated with fasting, decompression, and intravenous somatostatin) and HVHF (n = 18, HVHF administration in addition to the treatment in the control group) groups; and were assessed for serum and urine amylase, WBC, C-reactive protein (CRP), and hepatic and renal functions. Vital signs and abdominal symptoms were recorded, and complications and mortality were analyzed.APACHE II scores in the HVHF group were significantly lower than in the control group at 3 and 7 days (6.3 ± 1.7 vs 9.2 ± 2.1 and 3.3 ± 0.8 vs 6.2 ± 1.7, respectively). Compared with controls, serum, and urine amylase, WBC, CRP, and organ functions significantly improved after HVHF treatment. Meanwhile, mortality (16.7% vs 31.8%) and complication (11.1% vs 40.9%) rates were significantly reduced.The other clinical parameters were significantly ameliorated by HVHF. HVHF rapidly reduces abdominal symptoms and improves prognosis, reducing mortality in SAP patients; and is likely through systemic inflammatory response syndrome attenuation in the early disease stage.
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27
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Patel S, Marshak J, Daum F, Iqbal S. The emerging role of endoscopic ultrasound for pancreaticobiliary diseases in the pediatric population. World J Pediatr 2017; 13:300-306. [PMID: 28393319 DOI: 10.1007/s12519-017-0020-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 07/14/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is a useful diagnostic and therapeutic tool in the pediatric population. Given the high accuracy and sensitivity of EUS, it is particularly effective in evaluating pancreaticobiliary disease. Published literature in the use of pediatric EUS is limited. Therefore we aimed to review the current literature for EUS indications, safety, and effectiveness for the pediatric population. DATA SOURCES English language articles on the use of pediatric endoscopic ultrasound in evaluating pancreaticobiliary diseases were retrieved from PubMed/ MEDLINE. RESULTS We analyzed various retrospective studies and case series publications. Data were extrapolated for pediatric patients with pancreaticobiliary diseases. CONCLUSIONS EUS offers superior imaging. It is comparible to magnetic resonance imaging and/or pancreatic-protocol computed tomography. In the current literature, there are a variety of pancreaticobiliary conditions where EUS was utilized to make a diagnosis. These include recurrent pancreatitis, congenital anomalies, microlithiasis, pancreatic pseudocysts, and pancreatic mass lesions. EUS was shown to be a safe and cost-effective modality with both diagnostic and therapeutic capabilities in the pediatric population. EUS is now increasingly being recognized as a standard of care when evaluating pancreaticobiliary conditions in children.
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Affiliation(s)
- Suril Patel
- Department of Internal Medicine, Winthrop University Hospital, 180 Hilton Ave, Apt #D1, Hempstead, NY, 11550, USA.
| | - Jarred Marshak
- Department of Internal Medicine, Winthrop University Hospital, 180 Hilton Ave, Apt #D1, Hempstead, NY, 11550, USA
| | - Fredric Daum
- Department of Pediatrics, Winthrop University Hospital, Hempstead, NY, USA
| | - Shahzad Iqbal
- Department of Internal Medicine, Winthrop University Hospital, 180 Hilton Ave, Apt #D1, Hempstead, NY, 11550, USA
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Husain SZ, Srinath AI. What's unique about acute pancreatitis in children: risk factors, diagnosis and management. Nat Rev Gastroenterol Hepatol 2017; 14:366-372. [PMID: 28293024 DOI: 10.1038/nrgastro.2017.13] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pancreatitis in children is an appreciable problem that has become increasingly prevalent. This Review covers the principles related to the definitions, epidemiology, risk factors, diagnosis and management of acute pancreatitis in children and identifies features that are unique among children. Additionally, knowledge gaps related to management principles are identified.
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Affiliation(s)
- Sohail Z Husain
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pediatrics, 4401 Penn Avenue, Pittsburgh, Pennsylvania 15224, USA
| | - Arvind I Srinath
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pediatrics, 4401 Penn Avenue, Pittsburgh, Pennsylvania 15224, USA
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29
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Pai CG, Kamath MG, Shetty MV, Kurien A. Continuing episodes of pain in recurrent acute pancreatitis: Prospective follow up on a standardised protocol with drugs and pancreatic endotherapy. World J Gastroenterol 2017; 23:3538-3545. [PMID: 28596690 PMCID: PMC5442090 DOI: 10.3748/wjg.v23.i19.3538] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/13/2017] [Accepted: 04/21/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the outcomes of drug therapy (DT) followed by pancreatic endotherapy for continuing painful episodes in recurrent acute pancreatitis.
METHODS DT comprised of pancreatic enzymes and anti-oxidants failing which, endotherapy (ET; pancreatic sphincterotomy and stent placement) was done. The frequency of pain, its visual analogue score (VAS), quality of life (QoL), serum C peptide and faecal elastase were compared between baseline and after 1 year of follow up in all patients and in the two subgroups on DT and ET. Response was defined as at least 50% reduction in the severity of pain to below a score of 5.
RESULTS Of the thirty nine patients analysed, 21 (53.9%) responded to DT and 18 (46.1%) underwent ET. The VAS for pain (7.0 ± 2.0 vs 1.3 ± 2.5, P < 0.001) and the number of days with pain per month decreased [1.0 (1.0, 2.0) vs 1.0 (0.0, 1.0), P < 0.001], and the QoL scores [55.0 (44.0, 66.0) vs 38.0 (32.00, 51.00), P < 0.01] improved significantly during follow up. Similar significant improvements were seen in patients in the subgroups of DT and ET except for QoL in ET. The serum C-peptide (P = 0.001) and FE (P < 0.001) levels improved significantly in the entire group and in the two subgroups of patients except for the C peptide levels in patients on DT.
CONCLUSION A standardised protocol of DT, followed by ET decreased the intensity and frequency of pain in recurrent acute pancreatitis, enhanced QoL and improved pancreatic function.
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30
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Michailidis L, Aslam B, Grigorian A, Mardini H. The efficacy of endoscopic therapy for pancreas divisum: a meta-analysis. Ann Gastroenterol 2017; 30:550-558. [PMID: 28845111 PMCID: PMC5566776 DOI: 10.20524/aog.2017.0159] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/24/2017] [Indexed: 12/16/2022] Open
Abstract
Background The purpose of this study was to perform a meta-analysis assessing the efficacy and predictors of success of endoscopic therapy in the management of patients with pancreas divisum. Methods An electronic database search (PubMed and ScienceDirect) was performed for relevant studies. Studies were selected based on predefined criteria and data were extracted on patient population, follow up, endotherapy methods, success rates and complication rates. A random-effect model was used to pool the effect size across studies. Heterogeneity testing and publication bias assessment were performed. Multivariate regression analysis was performed to identify predictors of successful endoscopic therapy. Results Of 381 articles reviewed, 23 studies with 874 patients met the inclusion criteria. All were case series with suboptimal quality. Endoscopic therapy included minor papilla sphincterotomy, minor papilla sphincteroplasty and dorsal duct stenting. Mean follow-up duration was 37 months. The rate of “improvement” as defined by authors after endoscopic therapy varied significantly across studies, ranging from 31-96%: 589/874 patients were reported to have improved, corresponding to a pooled efficacy rate of 67.5% (95% confidence interval [CI] 0.610-0.734; P=0.0001). The pooled rate of pancreatitis after endoscopic retrograde cholangiopancreatography was 10.1% (95%CI 0.084-0.124; 2-sided P=0.0001). On subgroup analysis, patients with recurrent acute pancreatitis had better endoscopic outcomes (pooled efficacy rate 76%, 95%CI 0.712-0.803, P=0.0001). Dorsal duct stenting and longer follow up were the only parameters predictive of successful endotherapy. Significant heterogeneity was observed within and across studies. Conclusions Endoscopic efficacy in pancreas divisum is estimated at 67.5%. Available studies are of poor quality with significant heterogeneity. Comparative studies with rigorous methodology are needed.
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Affiliation(s)
- Lamprinos Michailidis
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Bilal Aslam
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Alla Grigorian
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Houssam Mardini
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
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Adibelli Z, Adatepe M, Isayeva L, Esen O, Yildirim M. Pancreas divisum: A risk factor for pancreaticobiliary tumors – an analysis of 1628 MR cholangiography examinations. Diagn Interv Imaging 2017; 98:141-147. [DOI: 10.1016/j.diii.2016.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/07/2016] [Accepted: 08/07/2016] [Indexed: 02/07/2023]
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Chorioretinal Coloboma in a Patient with Pancreas Divisum: Clinical and Imaging Features. Eur J Ophthalmol 2016; 26:e158-e160. [DOI: 10.5301/ejo.5000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2016] [Indexed: 11/20/2022]
Abstract
Purpose To report the case of a 61-year-old woman with pancreas divisum and an asymptomatic chorioretinal coloboma in its 2 forms: complete and partial. Methods Case report. Results Dilated fundus examination and photograph revealed a complete and partial coloboma in the right eye. Swept-source optical coherence tomography and swept-source optical coherence tomography angiography (SS-OCTA) were performed. Swept-source optical coherence tomography angiography disclosed the complete coloboma as a black, round, avascular area surrounded by normal vascular tissue in every plexus (i.e., superficial, deep, and choriocapillary). Although irregular and attenuated, the vascular network of the partial coloboma was appreciable in each layer, indicating some degree of vascular preservation. Conclusions Chorioretinal coloboma has been linked to several ocular and systemic conditions. To our knowledge, no association between coloboma and pancreas divisum has been reported. In addition, chorioretinal coloboma has not been previously characterized by means of SS-OCTA.
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Abstract
Chronic pancreatitis is a debilitating condition often associated with severe abdominal pain and exocrine and endocrine dysfunction. The underlying cause is multifactorial and involves complex interaction of environmental, genetic, and/or other risk factors. The pathology is dependent on the underlying pathogenesis of the disease. This review describes the clinical, gross, and microscopic findings of the main subtypes of chronic pancreatitis: alcoholic chronic pancreatitis, obstructive chronic pancreatitis, paraduodenal ("groove") pancreatitis, pancreatic divisum, autoimmune pancreatitis, and genetic factors associated with chronic pancreatitis. As pancreatic ductal adenocarcinoma may be confused with chronic pancreatitis, the main distinguishing features between these 2 diseases are discussed.
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34
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Gupta A, Rai P, Singh V, Gupta RK, Saraswat VA. Intrahepatic biliary duct branching patterns, cystic duct anomalies, and pancreas divisum in a tertiary referral center: A magnetic resonance cholangiopancreaticographic study. Indian J Gastroenterol 2016; 35:379-384. [PMID: 27660206 DOI: 10.1007/s12664-016-0693-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 09/01/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Knowledge about anatomic variations in intrahepatic biliary ducts (IHBD) is relevant for performing biliary drainage and for avoiding bile duct injury during cholecystectomy and liver resections. Low insertion of cystic duct (LICD) is a common anatomic variant. Pancreas divisum is the commonest congenital anomaly of pancreas; it has been causally linked with recurrent acute pancreatitis (RAP). METHODS Magnetic resonance cholangiopancreaticography (MRCP) images of 500 consecutive patients were reviewed for anatomic variants of IHBD, cystic duct, and pancreatic duct. RESULTS Anatomy of IHBD could be evaluated in 458 MRCP's, of these 301 (65.72 %) had 'typical' anatomy. The variant in 157 persons included 'triple confluence' in 56 (12.23 %), 'right posterior segmental duct (RPSD) draining to left hepatic duct (LHD)' in 64 (14 %), 'RPSD to common hepatic duct (CHD)' in 20 (4.4 %), 'RPSD to cystic duct' in 2 (0.4 %), 'accessory duct to CHD' in 3 (0.7 %), 'accessory duct to right hepatic duct (RHD)' in 1 (0.2 %), 'segment 2 and 3 separately to CHD' in 1 (0.2 %), and complex variants in 10 (2.2 %). Cystic duct could be evaluated in 338 patients; of these, 15 (4.4 %) had LICD. Patients with RAP had pancreas divisum more often than those without any pancreatic disease, (-/-,10 % and -/-, 0.8 %; p = 0.004). CONCLUSIONS Nearly one third of MRCPs showed atypical IHBD pattern with RPSD draining to LHD being the commonest. LICD was the most common cystic duct variant. Pancreas divisum was more frequent in patients with RAP than in persons without pancreatic disease.
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Affiliation(s)
- Ankur Gupta
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India.
| | - Vivek Singh
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Rakesh Kumar Gupta
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Vivek Anand Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
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Somani P, Navaneethan U. Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis. ACTA ACUST UNITED AC 2016; 14:327-39. [PMID: 27371265 DOI: 10.1007/s11938-016-0096-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30 % of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.
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Affiliation(s)
- Piyush Somani
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
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Nishi T, Kawabata Y, Ishikawa N, Araki A, Yano S, Maruyama R, Tajima Y. Intraductal papillary mucinous carcinoma of the pancreas associated with pancreas divisum: a case report and review of the literature. BMC Gastroenterol 2015; 15:78. [PMID: 26152300 PMCID: PMC4495851 DOI: 10.1186/s12876-015-0313-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 06/30/2015] [Indexed: 01/15/2023] Open
Abstract
Background Pancreas divisum, the most common congenital anomaly of the pancreas, is caused by failure of the fusion of the ventral and dorsal pancreatic duct systems during embryological development. Although various pancreatic tumors can occur in patients with pancreas divisum, intraductal papillary mucinous neoplasm is rare. Case presentation A 77-year-old woman was referred to our hospital because she was incidentally found to have a cystic tumor in her pancreas at a regular health checkup. Contrast-enhanced abdominal computed tomography images demonstrated a cystic tumor in the head of the pancreas measuring 40 mm in diameter with slightly enhancing mural nodules within the cyst. Endoscopic retrograde pancreatography via the major duodenal papilla revealed a cystic tumor and a slightly dilated main pancreatic duct with an abrupt interruption at the head of the pancreas. The orifice of the major duodenal papilla was remarkably dilated and filled with an abundant extrusion of mucin, and the diagnosis based on pancreatic juice cytology was “highly suspicious for adenocarcinoma”. Magnetic resonance cholangiopancreatography depicted a normal, non-dilated dorsal pancreatic duct throughout the pancreas. The patient underwent a pylorus-preserving pancreaticoduodenectomy under the diagnosis of intraductal papillary mucinous neoplasm with suspicion of malignancy arising in the ventral part of the pancreas divisum. A pancreatography via the major and minor duodenal papillae on the surgical specimen revealed that the ventral and dorsal pancreatic ducts were not connected, and the tumor originated in the ventral duct, i.e., the Wirsung’s duct. Microscopically, the tumor was diagnosed as intraductal papillary mucinous carcinoma with microinvasion. In addition, marked fibrosis with acinar cell depletion was evident in the ventral pancreas, whereas no fibrotic change was noted in the dorsal pancreas. Conclusion Invasive ductal carcinomas of the pancreas associated with pancreas divisum usually arise from the dorsal pancreas, in which the occurrence of pancreatic cancer may link to underlying longstanding chronic pancreatitis in the dorsal pancreas; however, the histopathogenesis of intraductal papillary mucinous neoplasm in this anomaly is a critical issue that warrants further investigation in future.
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Affiliation(s)
- Takeshi Nishi
- Deparment of Surgery, Matsue Red Cross Hospital, 200 Horo-machi, Matsue, Shimane, 690-8506, Japan. .,Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Noriyoshi Ishikawa
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Asuka Araki
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Seiji Yano
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Riruke Maruyama
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
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37
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Cavestro GM, Leandro G, Di Leo M, Zuppardo RA, Morrow OB, Notaristefano C, Rossi G, Testoni SGG, Mazzoleni G, Alessandri M, Goni E, Singh SK, Giliberti A, Bianco M, Fanti L, Viale E, Arcidiacono PG, Mariani A, Petrone MC, Testoni PA. A single-centre prospective, cohort study of the natural history of acute pancreatitis. Dig Liver Dis 2015; 47:205-210. [PMID: 25475611 DOI: 10.1016/j.dld.2014.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 10/28/2014] [Accepted: 11/04/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND The natural history of acute pancreatitis is based on clinical studies that aim to elucidate the course of disease on the basis of predicted risk factors. AIMS To evaluate the long-term occurrence of recurrent acute pancreatitis and chronic pancreatitis in a cohort of patients following an initial episode of acute pancreatitis. METHODS 196 patients were enrolled consecutively and studied prospectively. Clinical characteristics, exogenously/endogenously-associated factors, and evolution to recurrent acute pancreatitis and chronic pancreatitis were analyzed. RESULTS 40 patients developed recurrent acute pancreatitis 13 of whom developed chronic pancreatitis. In a univariate analysis, recurrent acute pancreatitis was associated with an idiopathic aetiology (p<0.001), pancreas divisum (p=0.001), and higher usage of cigarettes and alcohol (p<0.001; p=0.023). Chronic pancreatitis was associated with a severe first episode of acute pancreatitis (p=0.048), PD (p=0.03), and cigarette smoking (p=0.038). By multivariate analysis, pancreas divisum was an independent risk factor for recurrent acute pancreatitis (OR 11.5, 95% CI 1.6-83.3). A severe first-episode of acute pancreatitis increased the risk of progressing to chronic pancreatitis by nine-fold. CONCLUSIONS Special attention should be given to patients who experience a severe first attack of acute pancreatitis as there appears to be an increased risk of developing chronic pancreatitis over the long term.
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Affiliation(s)
- Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy.
| | - Gioacchino Leandro
- Gastroenterology Unit 1, Gastroenterological Hospital 'S. De Bellis' IRCCS, Castellana Grotte, Italy
| | - Milena Di Leo
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaella Alessia Zuppardo
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Olivia B Morrow
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Chiara Notaristefano
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gemma Rossi
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Sabrina Gloria Giulia Testoni
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Giorgia Mazzoleni
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Matteo Alessandri
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Elisabetta Goni
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
| | - Satish K Singh
- Boston University School of Medicine and Boston Medical Center, Section of Gastroenterology, United States
| | - Aurore Giliberti
- Gastroenterology Unit 1, Gastroenterological Hospital 'S. De Bellis' IRCCS, Castellana Grotte, Italy
| | - Margherita Bianco
- Gastroenterology Unit 1, Gastroenterological Hospital 'S. De Bellis' IRCCS, Castellana Grotte, Italy
| | - Lorella Fanti
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edi Viale
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Mariani
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Chiara Petrone
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pier Alberto Testoni
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, Milan, Italy
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Boninsegna E, Manfredi R, Ventriglia A, Negrelli R, Pedrinolla B, Mehrabi S, Gabbrielli A, Pozzi Mucelli R. Santorinicele: secretin-enhanced magnetic resonance cholangiopancreatography findings before and after minor papilla sphincterotomy. Eur Radiol 2015; 25:2437-44. [DOI: 10.1007/s00330-015-3644-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/27/2014] [Accepted: 01/30/2015] [Indexed: 01/31/2023]
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Shirkhoda A, Borghei P, Gore RM. Anomalies and Anatomic Variants of the Pancreas. TEXTBOOK OF GASTROINTESTINAL RADIOLOGY, 2-VOLUME SET 2015:1797-1808. [DOI: 10.1016/b978-1-4557-5117-4.00096-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Mariani A, Di Leo M, Petrone MC, Arcidiacono PG, Giussani A, Zuppardo RA, Cavestro GM, Testoni PA. Outcome of endotherapy for pancreas divisum in patients with acute recurrent pancreatitis. World J Gastroenterol 2014; 20:17468-17475. [PMID: 25516660 PMCID: PMC4265607 DOI: 10.3748/wjg.v20.i46.17468] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/09/2014] [Accepted: 07/24/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the rate of relapses of acute pancreatitis (AP), recurrent AP (RAP) and the evolution of endosonographic signs of chronic pancreatitis (CP) in patients with pancreas divisum (PDiv) and RAP. METHODS Over a five-year period, patients with PDiv and RAP prospectively enrolled were divided into two groups: (1) those with relapses of AP in the year before enrollment were assigned to have endoscopic therapy (recent RAP group); and (2) those free of recurrences were conservatively managed, unless they relapsed during follow-up (previous RAP group). All patients in both groups entered a follow-up protocol that included clinical and biochemical evaluation, pancreatic endoscopic ultrasonography (EUS) every year and after every recurrence of AP, at the same time as endoscopic retrograde cholangiopancreatography (ERCP). RESULTS Twenty-two were treated by ERCP and 14 were conservatively managed during a mean follow-up of 4.5 ± 1.2 years. In the recent RAP group in whom dorsal duct drainage was achieved, AP still recurred in 11 (57.9%) after the first ERCP, in 6 after the second ERCP (31.6%) and in 5 after the third ERCP (26.3%). Overall, endotherapy was successful 73.7%. There were no cases of recurrences in the previous RAP group. EUS signs of CP developed in 57.9% of treated and 64.3% of untreated patients. EUS signs of CP occurred in 42.8% of patients whose ERCPs were successful and in all those in whom it was unsuccessful (P = 0.04). There were no significant differences in the rate of AP recurrences after endotherapy and in the prevalence of EUS signs suggesting CP when comparing patients with dilated and non-dilated dorsal pancreatic ducts within each group. CONCLUSION Patients with PDiv and recent episodes of AP can benefit from endoscopic therapy. Effective endotherapy may reduce the risk of developing EUS signs of CP at a rate similar to that seen in patients of previous RAP group, managed conservatively. However, in a subset of patients, endotherapy, although successful, did not prevent the evolution of endosonographic signs of CP.
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White JJ, Roberts ZN, Gest TR, Beale EG. Pancreas divisum: a common developmental variant that deserves attention in preclinical medical education. Clin Anat 2014; 27:1038-45. [PMID: 25092806 DOI: 10.1002/ca.22446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/03/2014] [Accepted: 07/03/2014] [Indexed: 12/16/2022]
Abstract
Clinical literature indicates that pancreas divisum (PD) is present in 3-22% of the population and may be associated with an increased risk of pancreatitis. PD is a developmental variant wherein the duct systems derived from the dorsal and ventral pancreatic buds are not fused. Hence secretions from the head, neck, body, and tail, which develop from the dorsal bud, must pass through the minor duodenal papilla. The smaller uncinate process, derived from the ventral bud, drains through the major duodenal papilla. The purpose of this study was: (1) to do a cadaveric dissection to confirm whether PD is common in donors who had not been selected because they had pancreatitis and (2) to determine the frequency of PD descriptions in anatomy, embryology, pathology, and surgery books in our libraries. For our anatomical study, pancreata of eight human donors were dissected. Dye was injected into the ducts so that any communications between main and accessory ducts could be easily located. For our literature review, 22 anatomy, 14 embryology, 11 pathology, and 26 surgery books were examined for mention of PD. PD was unambiguously identified in two donor cadavers. However, only 14% of the anatomy plus embryology books compared to 70% of the surgery plus pathology books describe PD. Cadaveric dissection confirms that PD is indeed prevalent. The prevalence of PD with its increased risk of pancreatitis merits inclusion of this topic in textbooks of anatomy and embryology.
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Affiliation(s)
- Jessica J White
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas
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Nikolaidis P, Hammond NA, Day K, Yaghmai V, Wood CG, Mosbach DS, Harmath CB, Taffel MT, Horowitz JM, Berggruen SM, Miller FH. Imaging Features of Benign and Malignant Ampullary and Periampullary Lesions. Radiographics 2014; 34:624-41. [DOI: 10.1148/rg.343125191] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Wathle GK, Tjora E, Ersland L, Dimcevski G, Salvesen ØO, Molven A, Njølstad PR, Haldorsen IS. Assessment of exocrine pancreatic function by secretin-stimulated magnetic resonance cholangiopancreaticography and diffusion-weighted imaging in healthy controls. J Magn Reson Imaging 2013; 39:448-54. [PMID: 23649590 DOI: 10.1002/jmri.24167] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 03/13/2013] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To characterize and quantify exocrine pancreatic function by secretin-stimulated magnetic resonance cholangiopancreaticography (s-MRCP) and diffusion-weighted imaging (DWI) in healthy subjects and compare these findings to morphological features, ie, pancreatic volume and secretin-stimulated peak bicarbonate concentration measured in pancreatic juice. MATERIALS AND METHODS Pancreatic magnetic resonance imaging (MRI) (1.5 T) was performed in 20 healthy volunteers among which 10 underwent gastroscopy with duodenal intubation. MRI included T2-weighted imaging and DWI acquired before and 1, 5, 9, and 13 minutes after secretin administration. Secreted pancreatic juice volumes were calculated based on the sequential T2-weighted images and pancreatic volumes and apparent diffusion coefficient (ADC) values were estimated. RESULTS The mean pancreatic secretion rate declined from 9.5 mL/min at 1-5 minutes (postsecretin) to 2.9 mL/min at 9-13 minutes. Pancreatic head ADC values significantly increased from baseline (1.29 × 10(-3) mm(2) /s) to 1 minute postsecretin (1.48 × 10(-3) mm(2) /s) (P = 0.003). Secreted pancreatic juice volume at 1 minute after secretin correlated positively with peak bicarbonate concentration (n = 10, P = 0.05). CONCLUSION Secretin-stimulated MRCP and DWI can characterize and quantify exocrine pancreatic function in healthy subjects. These imaging methods may prove relevant for patients with exocrine pancreatic dysfunction.
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Affiliation(s)
- Gaute K Wathle
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
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Antaki N, Abboud D, Lemmers A, Antaki F, Devière J. Acute recurrent pancreatitis secondary to the rare association of a duodenal duplication cyst and a pancreas divisum. Clin Res Hepatol Gastroenterol 2013; 37:e32-6. [PMID: 22749085 DOI: 10.1016/j.clinre.2012.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 04/27/2012] [Accepted: 05/15/2012] [Indexed: 02/04/2023]
Abstract
Duodenal duplication cysts are rare congenital anomalies that can cause acute pancreatitis. Pancreas divisum is also a congenital anomaly, often discovered incidentally, but is considered a possible cause of acute pancreatitis. We report the case of the combination of both anomalies causing recurrent episodes of acute pancreatitis in a young man. Endoscopic treatment by partial excision of the cyst with a polypectomy snare and sphincterotomy of the minor papilla was successful.
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Affiliation(s)
- Nabil Antaki
- Department of Gastroenterology, Saint-Louis Hospital, PO Box 6448, Aleppo, Syria.
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Rana SS, Bhasin DK, Sharma V, Rao C, Singh K. Role of endoscopic ultrasound in the diagnosis of pancreas divisum. Endosc Ultrasound 2013; 2:7-10. [PMID: 24949360 PMCID: PMC4062234 DOI: 10.7178/eus.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 01/03/2013] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The published data on the accuracy of the detection of pancreas divisum by endoscopic ultrasound (EUS) is limited. In this study, we evaluate the accuracy of detection of pancreas divisum by radial EUS in patients with chronic pancreatitis. METHODS We retrospectively evaluated patients with chronic pancreatitis who underwent EUS followed by endoscopic retrograde cholangiopancreatography (ERCP) in the last four years to identify patients with complete pancreas divisum. RESULTS One hundred and forty six patients with chronic pancreatitis underwent EUS examination and 20 patients (13.6%) had pancreas divisum. The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of absence of stack sign on EUS for the diagnosis of pancreas divisum were 50%, 97%, 73%, 93% and 91%, respectively and for the inability to trace pancreatic duct from the head to the body were 100%, 96%, 80%, 100% and 96%, respectively. CONCLUSION EUS can diagnose pancreas divisum in a majority of patients. Pancreas divisum can be reliably excluded if pancreatic duct could be tracked backwards from the head to the body around the genu.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Deepak Kumar Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Chalapathi Rao
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Kartar Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
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DiMagno MJ, Dimagno EP. Pancreas divisum does not cause pancreatitis, but associates with CFTR mutations. Am J Gastroenterol 2012; 107:318-20. [PMID: 22306946 PMCID: PMC3458421 DOI: 10.1038/ajg.2011.430] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Bertin et al. partially dispel arguments that pancreas divisum (PD) causes pancreatitis, but fascinatingly indicate that PD associates with CFTR gene mutations predisposing to pancreatitis. This association, however, does not definitely confer a pathophysiological role for PD in pancreatitis but may denote that PD co-mingles with CFTR mutations without influencing pancreatitis or CFTR mutations influence pancreatic duct embryogenesis. We advise "idiopathic pancreatitis" patients with PD to undergo genetic testing. In lieu of CFTR mutations undertake no endoscopic/surgical procedure; if CFTR mutations are found, then refer patients for genetic counseling and withhold endoscopic/surgical therapy unless randomized studies show benefit.
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