Diferentes sistemas de pontuação na pancreatite alcoólica aguda: qual a seguir? Um dilema em curso / Different scoring systems in acute alcoholic pancreatitis: which one to follow? an ongoing dilema

ABSTRACT BACKGROUND: Acute pancreatitis is a common disorder in medical practice. In recent times, management has changed drastically with majority of decisions like intravenous antibiotics, negative suction with Ryle's tube and surgical interventions like necrosectomy etc based on severity of the disease. There are different scores in use to assess severity of disease but the relative efficacy has remained a debatable subject. OBJECTIVE: The present study was thus done to investigate the predictive accuracy of different scoring systems in acute pancreatitis. METHODS: Fifty patients of acute pancreatitis admitted in medicine ward of Pt. B.D. Sharma PGIMS, Rohtak, India, were taken for study after fulfilling eligibility criteria. These patients were investigated at admission and followed up prospectively. The severity of pancreatitis was classified for each of these patients as per Revised Atlanta System of Classification. Commonly used scoring systems pertaining to acute pancreatitis, viz, BISAP, Ranson, APACHE II and modified computed tomography severity index (CTSI) were calculated. Subsequently these scores were then correlated with severity, presence of organ failure, occurrence of local complications and final outcome of the patients. RESULTS: Out of 50 patients, etiology was chronic alcohol intake in all but one with idiopathic pancreatitis. The mean age of the study population was 42.06±13.27 years. 32% of these patients had pancreatic necrosis, 40% had peripancreatic collections. 56% of them had mild acute pancreatitis, 24% had moderately severe acute pancreatitis, while 20% had severe acute pancreatitis. APACHE II had the highest accuracy in predicting severity, organ failure and fatal outcomes. As far as these parameters were concerned, the negative predictive values of BISAP score were also considerable. Modified CTSI score was accurate in predicting local complications but had limited accuracy in other predictions. CONCLUSION: APACHE II emerged as most reliable scoring system followed by BISAP and Ranson in management of the patients with acute pancreatitis. But in constraints of time and resources, even BISAP score with its significant negative predictive values served as a valuable tool for assessing and managing these patients.

RESUMO CONTEXTO: A pancreatite aguda é uma desordem comum na prática médica. Nos últimos tempos, sua gestão mudou drasticamente com a maioria das decisões tomadas baseadas na gravidade da doença, como administração de antibióticos intravenosos, sucção negativa com o tubo de Ryle ou intervenções cirúrgicas como necrosectomia, etc. Há diferentes escores em uso para avaliar a gravidade da doença, mas a eficácia relativa manteve-se um assunto discutível. OBJETIVO: O presente estudo foi assim realizado para investigar a acurácia preditiva de diferentes sistemas de pontuação na pancreatite aguda. MÉTODOS: Foram selecionados 50 pacientes com pancreatite aguda admitidos na enfermaria de medicina de Pt. B.D. Sharma PGIMS, Rohtak, Índia, e foram considerados para estudo após o cumprimento dos critérios de elegibilidade. Estes pacientes foram investigados na admissão e seguidos prospectivamente. A severidade da pancreatitie foi classificada para cada um destes pacientes pelo sistema de classificação Atlanta revisado. Os sistemas de pontuação comumente usados pertencentes à pancreatite aguda, ou seja, BISAP, Ranson, APACHE II e CTSI modificado foram calculados. Posteriormente, esses escores foram correlacionados com a severidade, presença de falência de órgãos, ocorrência de complicações locais e desfecho final dos pacientes. RESULTADOS: Dos 50 pacientes, a ingestão crônica de álcool foi a etiologia em todos, exceto em um com pancreatite idiopática. A média de idade da população estudada foi de 42,6±13,27 anos. Destes pacientes, 32% apresentavam necrose pancreática, 40% apresentavam coleções peripancreáticas, 56% apresentavam pancreatite aguda leve, 24% apresentavam pancreatite aguda moderadamente grave, enquanto 20% apresentavam pancreatite aguda grave. O APACHE II teve maior precisão em prever a severidade, a falha do órgão e resultados fatais. No que diz respeito a esses parâmetros, os valores preditivos negativos do escore BISAP também foram consideráveis. A contagem modificada de CTSI foi exata em prever complicações locais, mas teve a exatidão limitada em outras predições. CONCLUSÃO: O APACHE II emergiu como o sistema de pontuação mais confiável seguido por BISAP e Ranson na gestão dos pacientes com pancreatite aguda. Mas em condicionantes do tempo e dos recursos, mesmo a Pontuação do BISAP com seus valores preditivos negativos significativos, serviu como uma ferramenta valiosa para avaliar e administrar esses pacientes.

Endovascular treatment of pseudoaneurysms secondary to chronic pancreatitis: reports of two cases / Tratamento endovascular de pseudoaneurisma decorrente de pancreatite crônica: relato de dois casos

Abstract Pseudoaneurysm secondary to chronic pancreatitis is a rare complication, but one with a high mortality rate. It is etiologically associated with chronic pancreatitis, and most diagnoses are made after rupture, which manifests with clinical signs of acute hemorrhage. Computed tomography plays an important role in diagnosis, but digital subtraction angiography remains the gold-standard method for diagnostic confirmation and for treatment planning. This article describes two cases of pseudoaneurysm in patients with chronic alcoholic pancreatitis; one involving the splenic artery and the other the gastroduodenal artery, complicated by thoracic and abdominal bleeding respectively. Both were successfully treated, using minimally invasive endovascular methods to implant coils and stent-grafts.

Resumo O pseudoaneurisma decorrente de pancreatite crônica consiste em complicação rara, porém com alta taxa de mortalidade. Está etiologicamente associado à pancreatite crônica, e seu diagnóstico é feito mais comumente após ruptura, manifestando-se através de sinais clínicos de hemorragia aguda. A tomografia computadorizada desempenha papel importante no diagnóstico; contudo, a angiografia por subtração digital mantém-se como método padrão-ouro para confirmação diagnóstica e direcionamento do tratamento. O presente artigo relata dois casos de pseudoaneurisma em pacientes com pancreatite crônica alcoólica, sendo um da artéria esplênica e outro da artéria gastroduodenal, complicados com sangramento torácico e abdominal respectivamente. Ambos foram submetidos a tratamento endovascular minimamente invasivo com sucesso, através de implante de molas e de stent-grafts.

Alcoholic chronic pancreatitis: A quality of life study / Pancreatite crônica alcoólica: um estudo de qualidade de vida

ABSTRACT Objective: To compare the quality of life between patients with alcoholic chronic pancreatitis and controls, and between diabetic and non-diabetic patients, correlating clinical, sociodemographic, and nutritional factors with their quality of life scores. Methods: Forty-three outpatients of the pancreas and biliary tract clinic diagnosed with alcoholic chronic pancreatitis were assessed. Quality of life was measured by the Brazilian version of the Short Form-36. The control group consisted of 43 healthy companions. Nutritional status was classified according to body mass index and triceps, biceps, suprailiac, and subscapular skinfold thicknesses, using the appropriate methods. The percentage of body fat was given by adding the four skinfold thicknesses and by bioelectrical impedance analysis. The statistical tests included the Chi-square, Mann-Whitney, and Spearman's correlation tests, with the significance level set at p<0.05. Results: The sociodemographic variables of the case and control groups did not differ. Quality of life was lower in alcoholic chronic pancreatitis patients than in controls. The only quality of life domain that differed between diabetics and non-diabetics was functional capacity, lower in diabetics (p=0.022). Smoking duration, alcohol intake in grams, and time since pancreatic surgery correlated negatively with the quality of life of alcoholic chronic pancreatitis patients. Old age, skinfold thicknesses, and percentage of body fat correlated positively with quality of life. Conclusion: Quality of life is low in alcoholic chronic pancreatitis patients because of the negative influence of certain factors, such as smoking duration, amount of alcohol consumed, and time since pancreatic surgery.

RESUMO Objetivo: Avaliar a qualidade de vida dos pacientes com pancreatite crônica alcoólica, comparando-os aos participantes de um grupo-controle e entre pacientes com e sem diabetes. Métodos: Avaliaram-se 43 pacientes do ambulatório de pâncreas e vias biliares diagnosticados com pancreatite crônica alcoólica. A qualidade de vida foi verificada por meio do Short Form-36, versão brasileira. O grupo-controle para a qualidade de vida foi composto por 43 acompanhantes sem doenças conhecidas. Para avaliação do estado nutricional, foi calculado o índice de massa corporal e dobras cutâneas do tríceps, bíceps, suprailíaca e subescapular, de acordo com a metodologia adequada. Para obtenção da porcentagem de gordura corporal, utilizou-se o somatório das quatro dobras e a medida obtida por meio da bioimpedância. Para análise estatística, foi utilizado teste de Qui-quadrado, Mann-Whitney e correlação de Spearmam, com p<0,05. Resultados: Não houve diferença entre o grupo-caso e o grupo-controle para as variáveis sociodemográficas. A qualidade de vida dos pacientes com pancreatite crônica alcoólica mostrou-se diminuída quando comparada aos membros do grupo-controle. Ao serem comparados os domínios de qualidade de vida dos pacientes com e sem diabetes, somente o quesito capacidade funcional apresentou diferença: menor para o grupo com diabetes (p=0,022). A correlação mostrou que o tempo de tabagismo, a quantidade de etanol em gramas e o tempo de cirurgia pancreática incidiram negativamente na qualidade de vida do grupo com pancreatite crônica alcoólica. Idade avançada, pregas cutâneas e porcentagem de gordura corporal se correlacionaram positivamente com qualidade de vida. Conclusão: A qualidade de vida está diminuída no grupo com pancreatite crônica alcoólica devido à influência negativa de fatores como tempo de tabagismo, quantidade de etanol e tempo de cirurgia pancreática.

A Case of Duodenal Intramural Hematoma Caused by Acute Alcoholic Pancreatitis / 대한췌담도학회지

Intramural duodenal hematoma (IDH) is a rare disease which defined a hematoma formation localized within the wall of the duodenum. The most common cause of IDH is due to blunt abdominal trauma while most of other cases of IDH are more related to the use of anticoagulants or coagulation disorders such as haemophilia and Von Willebrand disease. We report a very rare case of a large IDH caused by acute alcoholic pancreatitis without any kind of anticoagulation therapies nor coagulopathies. The patient was recovered by only medical treatment and observation without surgical intervention.

Efectos del ácido fólico sobre las características histológicas del páncreas en conejos alcohólicos adolescentes / Folic acid effects upon histological characteristics of pancreas in alcoholic adolescent rabbits

Introducción: la hepatitis y la pancreatitis constituyen las complicaciones más frecuentes del alcoholismo crónico. Objetivo: determinar el efecto del ácido fólico sobre las características histológicas del páncreas en la pancreatitis alcohólica de conejos machos adolescentes. Material y Métodos: se utilizaron 24 conejos adolescentes divididos en cuatro grupos experimentales: Grupo A (tratados con etanol), B (tratados con etanol y ácido fólico), C (tratados con ácido fólico) y D (control). A las 16 semanas de tratamiento se practicó eutanasia; se extrajeron fragmentos del páncreas de 1cm³ para estudio histológico. Resultados: el grupo tratado con etanol presentó zonas normales alternando con zonas que mostraron material hialino y acidófilo en la luz de los conductos intra e interlobulillares y epitelio aplanado en los conductos intralobulillares pequeños, así como signos de tumefacción en los acinos. El grupo control y el tratado con ácido fólico no mostraron alteraciones histológicas. El grupo tratado con etanol y ácido fólico presentó una apariencia bastante normal con sólo escasos conductos alterados. Conclusiones: el consumo de etanol provocó alteraciones histológicas en el páncreas a la dosis y tiempo utilizados, que pudieran catalogarse como una pancreatitis sub-aguda que fueron evitadas en gran medida con el tratamiento con ácido fólico.

Introduction: hepatitis and pancreatitis are the most frequents complications of chronic alcoholism. Objective: the purpose of this paper was to determine the effect of folic acid on histological features of alcoholic pancreatitis in male adolescent rabbits. Material y Methods: twenty four adolescent rabbits divided into 4 groups were used: Group A (treated with ethanol), group B (treated with ethanol and folic acid) group C (treated with folic acid), group D (untreated controls). The experiment lasted 16 weeks. At that moment, fragments of pancreatic tissue of one centimeter were obtained for histological study. Results: group D present areas with ducts intra and interlobulars ducts with acidofilic and hialinic material between areas with normal ducts. There were planed epithelial cells in small ducts, instead of cubic cells; and in acinars cells it was found tumefaction signal. Groups B and C did not present alterations at all. Group treated with ethanol and folic acid presented appearance almost normal with few ducts with alteration. Conclusions: ethanol provoked histological features alterations on pancreas and it was avoided with acid folic treatment.

Clinical characteristics of alcoholic severe acute pancreatitis / 中华胰腺病杂志

Objective To investigate the clinical characteristics of alcoholic severe acute pancreatitis (SAP). Methods Clinical data of 166 cases of SAP in Fujian Provincial Hospital from January 2001 to December 2008 were collected and analyzed retrospectively. Cases were divided into alcoholic SAP group (43cases) and control group ( 123 cases) depending on deoholic intake volue whithin 12～48 hours. Age, gender,CT scores, APACHE Ⅱ score, serum glucose, serum triglyceride (TG), serum calcium, serum albumin,morbidity, later infection rate and mortality rate of the two groups were compared. Results There was no significant difference in terms of age, but the proportion of male in alcoholic SAP group (39/43) was higher than that in control group (58/123, P<0.01 ). CT score, serum glucose and calcium were not significantly different between the two groups. The APACHEⅡ score and serum TG in alcoholic SAP group [19.16±5.38,(5.06±4.03)mmol/L] were significantly higher than those in control group [16.02±5.09, (3.12±2.95)mmol/L]. The albumenjolevel in alcoholic SAP group (25.23±7.12)g/L) was lower than that in control group [(30.68±8.35 ) g/L, P<0.01]. The incidences of ARDS and upper gastroenterologic bleeding were not significantly different between the two groups. But the incidences of acute kidney failure (44.2%), liver failure (41.9%), heart failure (37.2%), shock (39.5%), infection (27.9%) and mortality (30.2%) in alcoholic SAP were significantly higher than those in control group (26.0%,30.9%, 20.3%, 16.3%,16.3%, 7.3%, P<0.05 or<0.01). Conclusions Males predominates alcoholic SAP patients with high mortality and morbidity. Alcohol abstinence is effective to prevent alcoholic SAP ocurrence.

Pancreatite crônica / Chronic pancreatitis

A pancreatite crônica se caracteriza pela inflamação sustentada e substituição progressiva do parênquima pancreático por fibrose e calcificações. Clinicamente se manifesta por episódios de dor abdominal intensa, síndrome de má absorção e diabetes mellitus secundário. Em nosso país, o alcoolismo persiste como principal causa, porém a contribuição de outras formas de pancreatite crônica, particularmente as de causa genética, é reconhecida cada vez mais. O diagnóstico é, por vezes, difícil e requer a combinação de uma série de exames laboratoriais, radiológicos e endoscópicos, cuja sensibilidade e a especificidade variam amplamente de acordo com o estágio clínico em que se encontra a doença, sendo fundamental a formulação de adequadas hipóteses diagnósticas. O tratamento da insuficiência exócrina se baseia na reposição de enzimas pancreáticas exógenas, descartando-se doenças associadas que possam agravar a má absorção. O tratamento da dor é difícil, envolvendo profissionais da área clínica, endoscopistas, radiologistas e cirurgiões, uma vez que as decisões terapêuticas trazem importantes repercussões para a vida do paciente. Os pseudocistos, complicações habituais da pancreatite crônica, também são de tratamento multimodal, sendo importante conhecer a melhor forma de tratá-los de acordo com as características do paciente e as características da própria lesão no contexto da história natural da pancreatite crônica de cada indivíduo.

Wernicke's encephalopathy in a patient with acute alcoholic pancreatitis / 대한내과학회지

Wernicke's encephalopathy is a serious neurological disorder caused by thiamine deficiency that is characterized by the triad of ocular abnormalities, ataxia, and global confusional state. It is most often seen in alcoholics, but it can be seen in disorders associated with malnutrition and with prolonged intravenous feeding without appropriate vitamin supplementation. We report the case of a 51-year-old man with acute alcoholic pancreatitis and chronic alcoholism with an intraperitoneal abscess, who presented with Wernicke's encephalopathy. He was initially treated by fasting, intravenous fluid replacement, and intermittent vitamin infusion for 3 weeks. After subsequently starting a high carbohydrate oral diet, the patient developed diplopia, orientation disturbance, ataxia, a confusional state, and nystagmus. His neurologic signs and symptoms normalized gradually after intravenous thiamine supplementation.

The LDH to AST ratio as an indicator of pancreatic necrosis in acute biliary and alcoholic pancreatitis / 대한내과학회지

BACKGROUND: Lactate dehydrogenase (LDH) has been reported to be a sensitive indicator of pancreatic necrosis (PN), and some studies suggested that an elevation of the ratio of LDH to AST (LDH/AST ratio) woud be more accurate indicator of PN in acute biliary pncreatitis (BP). However, there were no studies in alcoholic pancreatitis (AP). The aim of this study was to assess the clinical usefulness of LDH/AST ratio in alcoholic pancreatitis (AP) as a indicator of PN. METHODS: On the basis of CT scan findings, the patients were categorized into two groups as having PN or non-PN. The plasma levels of the LDH, AST and LDH/AST ratio over two weeks postadmission period were evaluated and compared with in two groups of patients with BP (consiting of 12 PN and 34 non-PN patients), and with AP (consisting of 14 PN and 38 non-PN patients). RESULTS: In acute BP, on post-admission days 1 and 2, the LDH/AST ratio were low in both groups without significant difference. In the group with PN, thereafter, the LDH/AST ratio increased gradually, reached peak values at the 7th days and decreased. In the non-PN patients, the LDH/AST ratio increased gradually, but remained below the control range. The LDH/AST ratios were significantly higher from post-admission day 3 in the group with PN than in the non-PN group. In acute AP, the LDH levels were significantly higher over two weeks from admission day in the PN patients. The LDH/AST ratios were remained within or below the control range in both groups, though with statistically significnat difference. CONCLUSION: The LDH/AST ratio could be used as an indicator of PN in acute BP. In acute AP, however, LDH was a more useful indicator from the early stage in the course.