Familial chylomicronemia syndrome-induced acute necrotizing pancreatitis during pregnancy

Abstract Acute pancreatitis is a rare condition in pregnancy, associated with a high mortality rate. Hypertriglyceridemia represents its second most common cause.We present the case of a 38-year-old woman in the 24th week of gestation with a history of hypertriglyceridemia and recurrent episodes of pancreatitis. She was admitted to our hospital with acute pancreatitis due to severe hypertriglyceridemia. She was stabilized and treated with fibrates. Despite her favorable clinical course, she developed a second episode of acute pancreatitis complicated by multi-organ dysfunction and pancreatic necrosis, requiring a necrosectomy. The pregnancy was ended by cesarean section, after which three plasmapheresis sessions were performed. She is currently asymptomatic with stable triglyceride levels. Acute pancreatitis due to hypertriglyceridemia represents a diagnostic and therapeutic challenge in pregnant women, associated with serious maternal and fetal complications. When primary hypertriglyceridemia is suspected, such as familial chylomicronemia syndrome, the most important objective is preventing the onset of pancreatitis.

Management of infected pancreatic necrosis: state of the art / Necrose pancreática com infecção: estado atual do tratamento

ABSTRACT Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.

RESUMO A necrose pancreática ocorre em 15% das pancreatites agudas. A presença de infecção é o fator mais importante na evolução da pancreatite. Confirmar o diagnóstico de infecção ainda é um desafio. A mortalidade na necrose infectada é de 30% e na vigência de disfunção orgânica, chega a 70%. Nas últimas décadas, ocorreu uma verdadeira revolução no tratamento da necrose pancreática infectada. Mesmo assim, persiste o desafio e há múltiplas questões ainda não resolvidas: tratamento exclusivo com antibiótico, drenagem percutânea guiada por tomografia, drenagem por via endoscópica, desbridamento extra-peritoneal vídeo-assistido, acesso extra-peritoneal, necrosectomia por via aberta? Foi proposto o tratamento por etapas, "step up approach", iniciando-se com as medidas menos invasivas e reservando-se a intervenção operatória para os casos em que o procedimento anterior não resolver definitivamente o problema. A indicação e o momento da intervenção devem ser determinados pela evolução clínica. O ideal é que a intervenção seja feita apenas depois da quarta semana de evolução, quando já existe melhor delimitação da necrose. O tratamento deve ser individualizado. Não existe um procedimento que deva ser o primeiro e a melhor opção para todos os doentes. O objetivo deste trabalho é fazer uma análise crítica do estado atual do tratamento da necrose pancreática infectada.

Aspectos cirúrgicos da pancreatite aguda necrosante / Surgical implications of acute necrotizing pancreatitis

Objetivos: Sumarizar as recomendações da literatura atual quanto ao manejo da pancreatite aguda necrosante. Métodos: Foram selecionados artigos publicados nos últimos anos nas bibliotecas Cochrane e PubMed, pesquisados nos meses de maio e junho de 2017. Resultados: O diagnóstico de pancreatite aguda (PA) é estabelecido com a presença de pelo menos 2 dos 3 critérios a seguir: dor compatível com PA; elevação de amilase e lipase séricas 3 vezes ou mais do limite superior da normalidade; e alteração compatível com PA em Tomografia Computadorizada (TC) ou Ressonância Nuclear Magnética (RNM). O tratamento cirúrgico da PA está indicado na necrose pancreática infectada e na necrose estéril com sintomas (febre crônica, letargia, inapetência alimentar, náusea). Ele deve ser feito de imediato nos pacientes hemodinamicamente instáveis, enquanto que nos pacientes estáveis recomenda-se estabilizar o processo inflamatório por no mínimo 4 semanas antes do procedimento. Atualmente recomenda-se que se inicie a intervenção com técnicas minimamente invasivas, como drenagem endoscópica e drenagem percutânea, pois se sugere que tais técnicas resultam em menos efeitos adversos e morbidade. Na impossibilidade do uso dessas técnicas, podem ser realizadas cirurgia aberta ou por videolaparoscopia, devendo a indicação ser individualizada e dependente da experiência do cirurgião. Nos casos de pancreatite aguda biliar, a colecistectomia semieletiva é mandatória, pois o risco de recorrência de pancreatite é muito alto caso não seja feito o procedimento. Conclusões: Novos estudos são necessários para que seja possível definir com precisão o melhor tempo cirúrgico e a melhor técnica de necrosectomia/desbridamento no manejo da pancreatite aguda cirúrgica.

Aims: Summarize the current recommendations in the set of necrotizing pancreatitis management. Methods: Publications on pancreatitis management published in the last years were reviewed and selected from May to June 2017 in Cochrane e PubMed database. Results: The diagnosis of acute pancreatitis (AP) is established with the presence of at least 2 of the following 3 criteria: AP compatible pain; Elevation of serum amylase and lipase 3 times or more of the upper limit of normal; And alteration compatible with AP in CT or Magnetic Nuclear Imaging (MRI). Surgical treatment of AP is indicated in infected pancreatic necrosis and in sterile necrosis with symptoms (chronic fever, lethargy, ingestion of food, nausea). It should be done immediately in hemodynamically unstable patients, whereas in stable patients it is recommended to stabilize the inflammatory process for at least 4 weeks before the procedure. It is now recommended that intervention be initiated with minimally invasive techniques, such as endoscopic drainage and percutaneous drainage, as it is suggested that such techniques result in fewer adverse effects and morbidity. In the impossibility of using these techniques, open surgery or laparoscopy may be performed, and the indication must be individualized and dependent on the experience of the surgeon. In cases of acute biliary pancreatitis, semi-elective cholecystectomy is mandatory because the risk of recurrence of pancreatitis is very high if the procedure is not performed. Conclusions: Further studies are needed to determine the best moment to intervene and the best necrosectomy technique with regard to surgical PA management.

Pancreatite aguda de etiologia desconhecida / Acute pancreatitis of unknown etiology

A pancreatite aguda (PA) é responsável por aproximadamente 210 mil hospitalizações por ano nos EUA, e cerca de 5% evoluem ao óbito. Após o primeiro episódio a conduta fundamental é identificar e tratar a causa, o que impedirá episódios recorrentes e mesmo a cronicidade da doença.

The acute pancreatitis (AP) is responsible for approximately 210,000 of hospitalizations in a year in USA, and about 5% lead to death. After the first episode, the mainly procedure to be adopted is to identify the cause of it and consequently treat it as well, which will block recurrent episodes and prevent that this ilness becomes chronic.

Early computerized tomographic scan in mild pancreatitis may be deceiving: an experience of tertiary care hospital

To assess the justification of Computerized Tomographic [CT] scan for the diagnosis of acute pancreatitis at early stage and its impact on mortality and morbidity of patients. It was a retrospective study conducted at Radiology Department Dow University of Health Sciences from April 2009 to August 2011. Patients were diagnosed as acute pancreatitis both clinically and radiologically. Severity of acute pancreatitis was clinically assessed by Ranson's criteria and radiologically by Balthazar CT Grading and CT Severity Index. Fourteen of the total 131 included patients underwent early CT scan at 4-12 hour after start of symptoms of abdominal pain and vomiting and were normal radiologically[10.68% out of total 131 patients presented with acute pancreatitis. These patients revisited at 24-36 hours, with severe epigastric pain and on follow-up CT scan on re-admission, two patients showed intra and peripancreatic collections, swollen pancreas with peripancreatic fat necrosis without necrotizing pancreatitis [Balthazar Grade-E] and moderate pancreatitis according to CT Severity Index[four points]; Three patients had 30% pancreatic necrosis with Balthazar grade-E changes and according to CT Severity Index moderate pancreatitis[2+4=6]; Two patients had 30-50% necrosis and rated as Balthazar Grade-E and labeled as severe necrotizing pancreatitis according to CT Severity Index[4+4=8]; while Seven patients showed severe necrotizing pancreatitis with >50% of pancreatic necrosis according to CT Severity Index[6+4] along with Balthazar Grade-E pancreatitis[6+4=10]. Patients with severity index of 10 had 100% mortality. Early CT scan has very little role in diagnosing and determining severity of disease or in predicting prognosis of patients.

Identificando a la Pancreatitis aguda severa / Identifying the severe acute pancreatitis

OBJETIVOS: Comparar a pacientes con pancreatitis aguda con necrosis que no presentan complicaciones adicionales durante su hospitalización (Grupo A) versus aquellos pacientes con pancreatitis aguda con necrosis que presenten complicaciones adicionales durante su hospitalización (Grupo B). MÉTODOS: Se realizó el análisis sobre una base de datos preexistente de registros de pacientes hospitalizados con diagnóstico de pancreatitis aguda con necrosis de la Unidad de Pancreatitis Aguda Grave del Hospital Nacional Edgardo Rebagliati Martins entre 2000 y 2010. Se utilizaron los registros de todos los pacientes criterios diagnósticos de pancreatitis aguda severa con presencia de necrosis mayores de 18 años. RESULTADOS: Se incluyeron 215 registros de pacientes con PA con necrosis. Los pacientes del Grupo A representaron un 32% (68) y los del Grupo B el 68%(147). Grupo A tuvo un promedio de 39 días de hospitalización y el Grupo B tuvo un promedio de 56 días (p = 0.01). Del Grupo A 22% tuvieron más de 50% de necrosis mientras 43% del Grupo B tuvieron esta extensión de necrosis (p <0.05, OR 3.4, IC (1.12-10)). De los 14 casos fallecidos de toda la población, encontrándose todos ellos en el Grupo B, 12 de ellos tuvieron más de 50% de necrosis. CONCLUSIONES: No todos los casos clasificados como pancreatitis aguda severa, basados en la presencia de necrosis pancreática, se comportan de manera uniforme. Es la extensión de la necrosis pancreática (mayor a 50%) y no la sola presencia de la misma, la que determinaría una evolución con complicaciones adicionales y mayor mortalidad.

AIMS: To compare patients with acute necrotizing pancreatitis without any additional complications during their hospital stay (Group A) versus patients with Acute Necrotizing Pancreatitis with additional complications during their hospital stay (Group B) METHODS: Data obtained from a pre-existing base from hospitalized patients with diagnosis of acute necrotizing pancreatitis in the specialized unit of "Unidad de Pancreatitis Aguda Grave del Hospital Nacional Edgardo Rebagliati Martins" between 2000 and 2010. Data included patients with diagnosis of acute necrotizing pancreatitis, of ages 18 and over. RESULTS: Data from 215 patients with acute necrotizing pancreatitis was included. Patients from Group A represented 32% (68) and from Group B 68% (147). Group A had a average of 39 hospitalized days and Group B had an average of 56 days (p=0.01). From Group A 22% had more than 50% of necrosis while 43% of Group B had this extension of necrosis (p <0.05, OR 3.4, IC (1.12-10)). Of the 14 deaths of the population, all part of Group B, 12 of them had more than 50% of necrosis. CONCLUSIONS: Not every patient classified as severe acute pancreatitis, based on the presence of necrosis, behave likewise. It is an extended necrosis, described as more than 50% of pancreatic necrosis, and not the presence itself which will determine additional complications during the course of disease and a greater mortality.

Elevación de creatinina sérica como indicador de necrosis pancreática / Elevation of serum creatinine as an indicator of pancreatic necrosis

La Pancreatitis Aguda (PA) es una patología que se autolimita en el 80% de los casos; estos casos en general evolucionan hacia la recuperación total. Su evolución puede ser de leve a severa. La forma grave varía desde un 10% a un 25% y se asocia con falla orgánica y/o complicaciones locales como necrosis pancreática. En Venezuela, la PA Severa es un importante problema de salud pública, encontrándose entre las primeras 25 causas de muerte. Este estudio plantea la utilización de una prueba de laboratorio ampliamente disponible, de fácil uso e interpretación, para pronosticar la aparición de complicaciones como necrosis pancreática. Objetivo: Determinar la utilidad de la creatinina sérica como factor predictivo de necrosis pancreática en pancreatitis aguda. Materiales y Metodos: Estudio de tipo analítico, transversal y retrospectivo. Se revisaron las historias clínicas de los pacientes que ingresaron al hospital “Dr. Miguel Pérez Carreño”, con diagnóstico de pancreatitis aguda entre 2008 y 2009. Se registró creatinina sérica y se relacionó con la clasificación de severidad tomográfica según Balthazar. Resultados: La población estuvo conformada por 50 casos, de éstos se excluyeron 4, por embarazo o enfermedad renal crónica. Treinta de sexo femenino (65%) y 16 masculino (35%). Edades comprendidas entre 18 a 77 años, con media de 40,2. La estancia hospitalaria media fue de 8,74 días. Del total de 46 pacientes, presentó Balthazar A 63% (n=29), B 17,39% (n=8), C 14,04% (n= 6) y D 6,5% (n=3). No se obtuvo ningún E. Al aplicar un análisis de varianza se observó relación estadística significativa directamente proporcional de la creatinina sérica de ingreso (p=0,001) y de las 48 horas (p=0,001) con el Balthazar y el hematocrito. Conclusiones: La evaluación de los niveles y variaciones de creatinina sérica son de utilidad para predecir la aparición de necrosis pancreática en pacientes con pancreatitis aguda.

Acute Pancreatitis (AP) is a self-limited pathology in 80% of the cases; these cases generally evolve towards total recovery. Its evolution can be mild or severe. The severe form varies from a 10% to a 25%, and is associated with organ failure and/or local complications as pancreatic necrosis. In Venezuela severe AP is an important public health problem, being in the first 25 causes of death. The present study proposes the use of a widely available laboratory test, of easy use and interpretation, to predict the appearance of complications as pancreatic necrosis. Objective: To determine the usefulness of the serum creatinine as predictive factor of pancreatic necrosis in acute pancreatitis. Materials and Methods: An analytic, transversal and retrospective study. Clinical histories of patients admitted to the “Dr. Miguel Perez Carreño” hospital with a diagnosis of acute pancreatitis between years 2008 and 2009 were reviewed. Serum creatinine was registered and compared according to the Balthazar classification of tomographic severity. Results: The sample was comprised by 50 cases, from which 4 were excluded, due to pregnancy or chronic renal disease. Thirty were female (65%) and 16 male (35%). Between the ages of 18 and 77, with mean age of 40,2. The median hospital stay was 8,74 days. From total of 46 patients, 63% had Balthazar A (n=29); B 17.39% (n=8); C 14,04% (n= 6) and D 6.5% (n=3). No Balthazar E was obtained. When applying a variance analysis, a significant statistical relation was observed, directly proportional to the serum creatinine upon admission (p=0,001) and the 48 hours (p=0,001) with the Balthazar and hematocrit. Conclusions: The evaluation of the levels and variations of serum creatinine is a useful tool for predicting the appearance of pancreatic necrosis in patients with acute pancreatitis.

Pancreatitis aguda necrótica en la unidad de cuidados intensivos: Una comparación entre el tratamiento médico conservador y quirúrgico / Necrotic acute pancreatitis in the intensive care unit: A comparison between conservative and surgical medical treatment

OBJETIVO: Determinar el pronostico del tratamiento medico y quirúrgico de pacientes con pancreatitis aguda necrótica. INTRODUCCION: El tratamiento de pancreatitis aguda severa es multidisciplinario y requiere la evaluación de los pacientes día a día, esto permite observar los cambios y dar terapia oportuna. El tratamiento incluye: admisión en UCI, fluidos, nutrición y antibióticos, así como otros soportes de vida para paciente critico. Con esto, los pacientes pueden ser tratados conservadoramente o si fuese necesario, con intervención quirúrgica. METODOS: Un estudio retrospectivo de pacientes con pancreatitis aguda necrótica, que ingresaron a la Unidad de Cuidados Intensivos, entre enero del 2004 a agosto del 2006. Los pacientes con pancreatitis aguda necrótica sin signos de sepsis fueron sometidos a tratamiento medico conservador. Se realizó una punción aspiración con aguja fina, a partir de la cuarta semana, a los pacientes con pancreatitis aguda necrótica y sepsis persistente. Previamente se descartó y erradicó todos los focos infecciosos no pancreáticos. Todos los pacientes con coloración Gram. ó cultivo positivo fueron sometidos a cirugía de inmediato. RESULTADOS: Setenta pacientes con pancreatitis aguda necrótica fueron incluidos, de los cuales 36 (51%) tuvieron pancreatitis aguda necrótica estéril con tratamiento medico conservador y 34 (49%) tuvieron pancreatitis aguda necrótica infectada con tratamiento quirúrgico. El promedio de edad fue 55.19 vs. 57.65 (p=0.57). El promedio de amilasas 1421.74 vs. 1402.45. (p=0.96). El índice de severidad tomográfica fue 8.47 vs. 8.79 (p=0.36). Apache II fue 8.22 vs. 9 (p=0.46). El promedio de órganos fallados 0.39 vs. 0.68. (p=0.19). La estancia en UCI fue de 10.75 vs. 26.5 días (p < 0.05). La estancia hospitalaria total fue 46.47 vs. 57.26 días (p < 0.05). La mortalidad (3/36) 8.3% vs. (9/34) 26.5% (p < 0.05) para el tratamiento medico...

OBJECTIVE: To determine the prognosis of patients with necrotic acute pancreatitis receiving medical and surgical treatments. SUMMARY: The severe acute pancreatitis treatment is multidisciplinary and requires a daily evaluation of the patient that will allow to observe changes and apply therapy indue time. The treatment includes: Admission in the ICU, fluids, nutrition and antibiotics, as well as other life supports for high-risk patients. Thus, patients undergo conservative treatment or, if it is necessary, surgery. METHODS: A retrospective study of patients with necrotic acute pancreatitis admitted to the ICU between January 2004 and August 2006. The patients with necrotic acute pancreatitis without signs of sepsis underwent a conservative medical treatment, while fine needle punction-aspiration was performed in all patients who were suffering from necrotic acute pancreatitis and persistent sepsis four weeks after their admission and after discarding and eradicating every non-pancreatic focus of infection. All Gram stain or culture positive patients underwent surgery immediately. RESULTS: Seventy patients with necrotic acute pancreatitis were included in the study. Thirty-six patients (51%) suffered acute pancreatitis with sterile necrosis and underwent a conservative treatment, while 34 patients (49%) developed acute pancreatic with infectednecrosis and underwent surgery. The average age was 55.19 vs. 57.65 (p=0.57). The average amylase was 1421.74 vs. 1402.45. (p=0.96). The tomography severity index was 8.47 vs. 8.79 (p=0.36). The Apache II was 8.22 vs. 9 (p=0.46). The average number of failed organs was 0.39 vs. 0.68. (p=0.19). The ICU stay was 10.75 vs. 26.5 days (p < 0.05) while the total hospital stay was 46.47 vs. 57.26 days (p < 0.05). The mortality rate was (3/36) 8.3% vs. (9/34) 26.5% (p < 0.05) for conservative medical treatment vs. surgical treatment, respectively...

Pancreatite necro-hemorrágica: atualização e momento de operar / Necrotizing pancreatitis: update and when to operate

INTRODUÇÃO: A pancreatite necro-hemorrágica representa a variante mais grave do espectro de apresentações clínicas que podem compor o quadro da pancreatite aguda. Embora já conhecida há muitos séculos, inúmeras questões permanecem em aberto acerca dessa entidade e o número de trabalhos sobre o assunto publicados nos últimos anos tem sido muito expressivo. MÉTODO: Foi realizada ampla pesquisa na literatura, com especial atenção aos artigos publicados nos últimos três anos e indexados ao PubMed. Foram utilizados os seguintes descritores de forma cruzada: pancreatitis, surgical procedures; necrosis. A pesquisa inicial evidenciou cerca de 13.000 artigos, sendo avaliados os mais relevantes dos últimos três anos além de artigos mais antigos, considerados "clássicos" sobre o assunto e que, portanto, não poderiam deixar de ser citados. CONCLUSÃO: O tratamento da pancreatite aguda envolve um grande número de questões, dentre as quais as mais importantes estão relacionadas ao manejo da antibioticoterapia, tipo de dieta empregada e as questões relacionadas ao manejo da necrose infectada. Em especial, mudanças radicais foram implementadas nos últimos anos sobre todos esses tópicos, e uma atualização constante deve ser obrigatoriamente buscada pelos profissionais envolvidos no tratamento dessa doença.

BACKGROUND: Necrotizing pancreatitis represents the most severe form of presentation from the clinical spectra of acute pancreatitis. Although known for many centuries, many questions remain open about this entity and a great number of articles were published about this matter in the last few years. METHOD: A throughout research in the literature, with special attention to the articles published in the last three years and indexed to the PubMed was performed. The following headings were used: pancreatitis, surgical procedures, necrosis. The initial research rendered about 13 000 articles, and the ones published in the last three years were evaluated. Some older, but remarkable articles were also included given their importance to this matter. CONCLUSION: The treatment of acute pancreatitis involves a great number of questions, among which the most important are the ones related to the use of antibiotics, type of diet employed and the questions related to the manangement of the infected necrosis. There were many radical changes instituted in the last years on all these topics and a constant updating must be necessarily done by the ones involved on the treatment of this disease.

Diagnostic and prognostic value of CRP in post-ERCP pancreatitis

Acute pancreatitis [AP] is an inflammation of the pancreas secondary to a variety of causes. It is the most common serious complication of endoscopic retrograde cholangiopancreatography [ERCP]. As most ERCP is performed on an outpatient base, early evaluation can allow safe discharge of the majority of patients. The aim of this study was to identify the value of C-reactive protein [CRP] in the diagnosis and prognosis of post-ERCP pancreatitis [PEP]. One hundred patients who were candidate for ERCP examination either diagnostic or therapeutic included in the present study. All patients has been followed-up daily for at least 48 hours after ERCP for symptoms and signs suggestive of post-ERCP pancreatitis and follow-up of post ERCP pancreatitis patients has been done until pancreatic enzymes and CRP became normal. Serum amylase, lipase and CRP were done immediately after ERCP and on 2[nd] and 7[th] day after ERCP. CT abdomen was performed for patients who develop post-ERCP pancreatitis. Patients were divided into group A [GA] which developed post-ERCP pancreatitis [25 patients [25%]] and group B [GB] which had no pancreatitis [75 patients [75%]]. Serum amylase and lipase were significantly higher in GA relative to GB at T[0], T[2], T[7]. Additionally, at T[2] both serum amylase and lipase was more than 3 fold the upper limit of normal in GA. Also data concerned with CRP level at T[0], T[2], T7 revealed a significant increase in GA relative to GB. Data were highly significant at T[2] and T[7]. Out of the 25 cases of Post-ERCP pancreatitis, 17 cases showed CT findings consistent with acute pancreatitis, 13 of them had mild and moderate disease. The remaining 4 cases had severe acute pancreatitis. Since the mean value of CRP at T[7] in GA is still high above upper limit of normal, while serum amylase and lipase were not, and the significant rise in CRP level at T[0], T[2], T[7] in GA was directly correlated to the CT findings. Therefore, these data might suggest the importance of the CRP level as a diagnostic test and also in the assessment of the prognosis of Post-ERCP Pancreatitis, it is cheap, readily available but it is not an early marker

Evaluation of Severity in Acute Pancreatitis / 대한소화기학회지

Acute pancreatitis has a variable etiology and natural history, and some patients have severe complications with a significant risk of death. The prediction of severe disease should be achieved by careful ongoing clinical assessment coupled with the use of a multiple factor scoring system and imaging studies. Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis. However, there are no complete scoring index with high sensitivity and specificity till now. The interest in new biological markers and predictive models for identifying severe acute pancreatitis testifies to the continued clinical importance of early severity prediction. Among them, IL-6, IL-10, procalcitonin, and trypsinogen activation peptide are most likely to be used in clinical practice as predictors of severity. Even if contrast-enhanced CT has been considered the gold standard for diagnosing pancreatic necrosis, early scanning for the prediction of severity is limited because the full extent of pancreatic necrosis may not develop within the first 48 hour of presentation.

Hypertriglyceridemia-induced Pancreatitis / 대한소화기학회지

Hypertriglyceridemia (HTG) is a rare cause of pancreatitis. However, the relationship between acute pancreatitis and severe HTG is well recognized. We report a case of necrotizing pancreatitis due to severe HTG (type IV) in a patient with poorly controlled diabetes. It was of particular interest that serum pancreatic enzymes were normal even though the imaging studies indicated the presence of necrotizing pancreatitis. Our case clearly demonstrates the various indices of HTG-induced necrotizing pancreatitis with a normal pancreatic enzyme level despite there being a serum triglyceride level < or=1,000 mg/dL. We present this case with a review of literature for hyperlipidemic pancreatitis in Korea.

Morphological and functional outcome after pancreatic necrosectomy and lesser sac lavage for necrotizing pancreatitis.

BACKGROUND: Immediate outcomes after pancreatic necrosectomy have improved in recent years. This study reviews our short-term to medium-term experience of structural and functional changes in the pancreas after necrosectomy. METHODS: Ten patients (8 males, median age 35 years), discharged after pancreatic necrosectomy for acute necrotizing pancreatitis between 1996 and 1998 were reviewed after a median period of 22 months. Clinical evidence of pancreatic dysfunction was documented at follow-up interview. Patients underwent computed tomography of the abdomen, endoscopic retrograde pancreatography, oral glucose tolerance test, fecal fat estimation and fasting serum C-peptide estimation (CPE). RESULTS: No patient had repeat episodes of pancreatitis during the follow-up period. Three patients developed de-novo diabetes after discharge. No patient had symptoms of steatorrhea. Five patients showed severe changes on CECT. ERCP showed marked changes in six patients, the commonest being an abrupt cut-off of the main pancreatic duct. Glucose tolerance was abnormal in three patients and impaired in two patients while fecal fat excretion was abnormal in 8 patients. CONCLUSIONS: Severe acute pancreatitis and necrosectomy are associated with significant structural and functional changes on medium-term follow-up.

Perfil dos pacientes internados com pancreatite aguda nos serviços de gastroenterologia clínica e cirurgia geral do Hospital Santa Clara, do Complexo Hospitalar Santa Casa, Porto Alegre/RS, no período de 2000 a 2004 / Profile of patients with acute pancreatitis in the Service of Clinical Gastroenterology and Surgery of Santa Clara Hospital, Santa Casa, Porto Alegre/RS, South Brazil, 2000-2004

A pancreatite aguda é uma doença inflamatória aguda do pâncreas, que pode acometer tecidos peripancreáticos, levar à necrose e até mesmo falência múltipla de órgãos. Sua fisiopatologia, ainda que não totalmente elucidada parece ser desencadeada por um fenômeno comum central, a ativação intrapancreática das enzimas digestivas que levam à autodigestão pancreática, com uma evolução imprevisível. É reconhecido apenas que a primeira fase da pancreatite aguda severa é a SIRS (Síndrome da Resposta Inflamatória Sistêmica). Por ser conhecida desde a antigüidade e ter altos níveis de morbimortalidade, decidiuse estudar a prevalência de pancreatite aguda nos pacientes atendidos no Complexo Hospitalar Santa Casa de Porto Alegre/RS. Sessenta pacientes foram incluídos no estudo. Os dados foram coletados de prontuários médicos e preenchendo-se um protocolo que analisou fatores como sexo, idade, etiologia, morbidade, necessidade ou não de unidade de terapia intensiva, exames de imagem, exames de laboratório, uso de antimicrobianos, cirurgia e tempo de internação. Apesar das controvérsias ainda hoje existentes na literatura, todos os pacientes foram manejados e receberam alta, provavelmente porque na amostra trataram-se de pancreatites leves, mesmo que não se tenha usado nenhum critério de gravidade e/ou prognóstico para classificá-los...

Acute pancreatitis is a severe inflammation of the pancreas which may damage the peripancreatic tissues, cause necrosis or even multiple organ failure. Its physiopathology, still not totally explained, it seems to be started by a central commom phenomenon, the intrapancreatic activation of digestive enzymes which lead to pancreatic self-digestion with unpredictable evolution. ItÆs only known the first stage of severe pancreatitis, Systemic Inflammatory Response Syndrome (SIRS). For being known since ancientness and having high levels of morbi-mortality, it was decided to study the prevalence of severe ancreatitis in pacients attended at Santa Casa Hospital, in Porto Alegre, RS. Sixty pacients were included in this study, the data was collected from medical records and filling a protocol that analyzed factors like gender, age, aetiology, morbity, necessity or not of an intensive care unit, image exams, laboratory exams, use of antimicrobial, surgery and time of internment. In spite of controversies present today in the books, all pacients were treated and released, probably because the group case study showed acute pancreatitis, even though it was not used any criteria of seriousness and/or prognostic to classify them...

Pancreatitis aguda: experiencia en el Hospital Jesús Yerena: Lídice / Acute pancreatitis: Hospital Jesús Yerena experience: Lídice

Presentar la experiencia en el diagnóstico y manejo de la pancreatitis aguda en el servicio de cirugía del Hospital Jesús Yerena de Lídice, en Caracas, al igual que los aspectos epidemiológicos relacionados con esta enfermedad y comparar los resultados con la bibliografía mundial. Se realizó un estudio de tipo retrospectivo, revisándose 106 historias clínicas de pacientes que ingresaron a la emergencia del hospital por presentar un cuadro de pancreatitis aguda, en un período de 10 años, desde enero de 1993 hasta enero de 2003. De un total de 106 pacientes con pancreatitis aguda, 83 fueron de sexo masculino (78,30 por ciento) y 39 de sexo femenino (21,70 por ciento). El grupo etario más afectado fue el comprendido entre los 27 y 37 años de edad (49 por ciento). Las causas de la pancreatitis fueron: litiasis biliar en 42,45 por ciento de los casos, trauma abdominal en 23,58 por ciento e ingesta excesiva de alcohol en 18,86 por ciento de los pacientes. Los principales síntomas presentados por estos pacientes fueron: dolor abdominal, náuseas, vómitos, ictericia y en algunos casos rigidez abdominal. Del total de pacientes, 44 fueron sometidos a intervención quirúrgica, realizándose diferentes procedimientos como: desbridamento pancreático, colecistostomía y coledocostomía, lavado peritoneal, irrigación de la cavidad abdominal. Las complicaciones más frecuentes fueron las fístulas pancreáticas (22,72 por ciento), absceso intraabdominal (13,63 por ciento), diabetes (4,54 por ciento), y pseudoquistes pancreáticos (2,72 por ciento). En total fallecieron 9 pacientes (8,49 por ciento). Preocupa el considerable número de personas jóvenes afectas por esta patología, ya que se consideran una población en edad productiva o económicamente activa. Dentro de los antecedentes patológicos de importancia presentados por estos pacientes, no difieren de manera significativa, en comparación con los descritos en la bibliografía mundial, pero se destaca que una población importante.