The 501st case: elevated blood glucose, chronic pancreatitis, and post- pancreatoduodenectomy malnutrition / 中华内科杂志

A 50-year-old man with a 15-year history of elevated blood glucose and an approximately 2-year history of diarrhea was admitted to the Peking Union Medical College Hospital. The initial diagnosis was type 2 diabetes. After repeated pancreatitis and pancreatoduodenectomy, severe pancreatic endocrine and exocrine dysfunction including alternating high and low blood glucose and fat diarrhea occurred. Tests for type 1 diabetes-related antibodies were all negative, C-peptide levels were substantially reduced, fat-soluble vitamin levels were reduced, and there was no obvious insulin resistance. Therefore, a diagnosis of pancreatic diabetes was clear. The patient was given small doses of insulin and supplementary pancreatin and micronutrients. Diarrhea was relieved and blood glucose was controlled. The purpose of this article is to raise clinicians' awareness of the possibility of pancreatic diabetes after pancreatitis or pancreatic surgery. Timely intervention and monitoring may reduce the occurrence of complications.

Agenesia del páncreas dorsal: reporte de caso y revisión del tema / Agenesis of the dorsal pancreas: case report and topic review

Complete agenesis of the dorsal pancreas (ADP) is an exceedingly rare congenital anomaly, compatible with life. It may be asymptomatic and usually incidentally diagnosed. In symptomatic cases, the clinical manifestations vary from abdominal pain, pancreatitis and diabetes mellitus to exocrine insufficiency with steatorrhea. We present a case report of a 28 year old female with ADP, diagnosed incidentally during radiological evaluation for hyperglycemias in SARS COV2 concomitant affection. Magnetic resonance cholangiopancreatography confirmed the absence of, neck, body and tail of the pancreas. Knowing the pancreatic embryogenesis, the clinical presentation of their malformations and the main radiological characteristics is important for the proper diagnosis of these anomalies.

A pancreatic hemorrhagic pseudocyst with pseudoaneurysm and the role of doppler ultrasonography: a case report

SUMMARY Hemorrhagic pseudocysts with pseudoaneurysms are a rare and fatal complication of chronic pancreatitis due to the erosion of pancreatic to peripancreatic arteries. The timing of the rupture cannot be accurately predicted, but prompt diagnosis and management are essential to prevent further bleeding. We describe the case of a 68-year-old man who presented acute epigastric pain and anemia and had a history of chronic pancreatitis with a pseudocyst. A biliary and pancreas MRI showed an enlarged size of a known pancreatic pseudocyst with internal high signal intensity material. Color-Doppler ultrasonography showed pulsating signals in the pseudocyst, and our final diagnosis was a pseudoaneurysm in the pancreatic hemorrhagic pseudocyst. The pseudoaneurysm was successfully treated with coil embolization of the feeding artery. We report this case of a rare complication of chronic pancreatitis to show that color-Doppler ultrasound is a non-invasive and effective diagnostic tool for pseudoaneurysm, which enables early detection and prompt treatment without the need for invasive diagnostic modalities.

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.

Seudoquiste del páncreas. Experiencia quirúrgica en 50 casos / Pseudo cyst of the pancreas. Surgical experience in 50 cases

Se realizó un estudio prospectivo y descriptivo en 50 pacientes atendidos en el Servicio de Cirugía General del Hospital General Docente "Dr. Agostinho Neto" de Guantánamo, con el diagnóstico de seudoquiste del páncreas en el período 1997-2016, a los cuales se les efectuó alguna de las técnicas quirúrgicas para su solución. El dato primario fueextraído de las historias clínicas. Para el procesamiento de la información se emplearon como medida de tendencia central: la media aritmética; como medida de dispersión central la desviación estándar y el rango. Hubo prevalencia de la pancreatitis crónica y de pancreatitis aguda. La edad promedio es de 45 años, un rango de 19-72 años. El sexo predominante fue el masculino. El alcoholismo se observó en la mayoría de las pancreatitis. La pancreatitis crónica fue la primera causa del seudoquiste del páncreas. El diámetro promedio del seudoquiste es de 12 cm. Los drenajes internos ocuparon la mayoría de los procederes quirúrgicos realizados, además de la cistoyeyunostomía en Y Roux, la cistoduodenostomía y la cistogastrostomía. No hubo fallecidos y un seguimiento promedio de 71.4 meses sin recurrencia(AU)

A prospective and descriptive study was carried out in 50 patients treated in the General Surgery Service of the General Teaching Hospital "Dr. Agostinho Neto" from Guantánamo, with the diagnosis of pseudocyst of the pancreas in the period 1997-2016, to which some of the surgical techniques for their solution were made. The primary data was extracted from the medical records. For the processing of information, the arithmetic mean was used as a measure of central tendency; as a measure of central dispersion the standard deviation and the range. There was a prevalence of chronic pancreatitis and acute pancreatitis. The average age is 45 years, a range of 19-72 years. The predominant sex was male. Alcoholism was observed in most pancreatitis. Chronic pancreatitis was the first cause of the pseudocyst of the pancreas. The average diameter of the pseudocyst is 12 cm. The internal drainages occupied most of the surgical procedures performed, in addition to the Roux-en-Y cystojejunostomy, the cystoduodenostomy and the cystogastrostomy. There were no deaths and an average followup of 71.4 months without recurrence(AU)

Management of pancreaticopleural fistulas secondary to chronic pancreatitis / Tratamento das fístulas pancreaticopleurais secundárias à pancreatite crônica

ABSTRACT Introduction: Pancreaticopleural fistula is a rare complication of chronic pancreatitis. Objective: To describe pancreaticopleural fistula due to chronic pancreatitis and perform an extensive review of literature on this topic. Methods: Comprehensive narrative review through online research on the databases Medline and Lilacs for articles published over the last 20 years. There were 22 case reports and four case series selected. Results: The main indication for surgical treatment is the failure of clinical and/or endoscopic treatments. Surgery is based on internal pancreatic drainage, especially by means of pancreaticojejunostomy, and/or pancreatic resections. Conclusion: Pancreaticopleural fistula is a rare complication of chronic pancreatitis and the Frey procedure may be an appropriate therapeutic option in selected cases when clinical and endoscopic treatments are unsuccessful.

RESUMO Introdução: A fístula pancreaticopleural é complicação rara da pancreatite crônica. Objetivo: Descrever a fístula pancreaticopleural consequente à pancreatite crônica e fazer revisão extensa da literatura sobre o tópico. Métodos: Revisão narrativa abrangente através de pesquisa online nas bases de dados Medline e Lilacs para artigos publicados nos últimos 20 anos. Resultados: Houve 22 relatos de casos e quatro séries de casos selecionadas. A principal indicação para o tratamento cirúrgico é a falha de tratamentos clínicos e/ou endoscópicos. A cirurgia é baseada na drenagem pancreática interna, especialmente por meio de pancreaticojejunostomias e/ou ressecções pancreáticas. Conclusão: A fístula pancreaticopleural é complicação rara da pancreatite crônica e o procedimento de Frey pode ser opção terapêutica apropriada em casos selecionados quando os tratamentos clínico e endoscópico não obtiverem êxito.

Pseudoaneurisma de aorta abdominal como complicação de pancreatite crônica: relato de caso / Abdominal aortic pseudoaneurysm as a complication of chronic pancreatitis: case report

A pancreatite crônica é uma enfermidade associada a diversas complicações vasculares, como pseudocisto hemorrágico, trombose do sistema venoso portal e formações varicosas e pseudoaneurismáticas. O pseudoaneurisma de aorta abdominal secundário à pancreatite crônica é uma complicação rara, de difícil suspeição clínica, que requer tratamento complexo. A fisiopatologia dessa condição envolve a corrosão enzimática tecidual após a liberação e ativação de enzimas exócrinas proteolíticas das células acinares do pâncreas. O presente estudo relata o caso de um paciente de 52 anos, etilista crônico, internado com dor abdominal difusa, cuja propedêutica revelou se tratar de um pseudoaneurisma em aorta infrarrenal. Optou-se pelo tratamento cirúrgico convencional, levando-se em consideração a idade, as condições clínicas do paciente e a disponibilidade de endopróteses compatíveis com o diâmetro da aorta

Chronic pancreatitis can be complicated by several vascular disorders, such as bleeding pseudocysts, thrombosis of the venous portal system, varicosities, and pseudoaneurysms. Pseudoaneurysm of the abdominal aorta secondary to chronic pancreatitis is a rare complication. It is a challenging clinical situation, demanding a high degree of clinical suspicion, and requires complex therapeutic procedures. The pathophysiology of this condition involves interstitial liberation and activation of enzymes from the exocrine pancreatic glands and subsequent digestion of the surrounding tissues. In the present case report, we describe a 52-year-old patient complaining of diffuse abdominal pains. Clinical investigation revealed chronic alcoholism and imaging examinations showed a pseudoaneurysm of the infrarenal aorta. We decided to perform conventional surgical treatment after considering the patient's age and clinical status and the endoprostheses available at our hospital with diameters compatible with the patient's aorta

Extracción endoscópica de cálculos pancreáticos en pancreatitis crónica para evitar reagudizaciones / Endoscopic extraction of pancreatic stones in chronic pancreatitis with the aim to prevent acute flares

Chronic pancreatitis (CP) is defined by chronic inflammation of the pancreas with progressive replacement by fibrosis that produces characteristic morphological changes. The clinical picture is variable, being the main problem the pain and relapses of pancreatitis with possible local complications. Over time, the result is the development of exocrine and endocrine failure. In the initial phase, flare-ups of CP can not be distinguished from recurrent acute pancreatitis (RAP). If there are intraductal stones in the duct of Wirsung, endoscopic extraction of obstructive stones may be the first step to prevent new relapses and complications. We present the case of a patient with five episodes of acute pancreatitis (AP), three of them in the past five months. The patient was referred for study and management of RAP. His recent imaging study already showed dilatation of the main pancreatic duct, calcifications and pancreatic stones, compatible with CP. Although the hypertriglyceridemia participated in the etiology of AP, the last two episodes already occurred with normal values of triglycerides. Another possible etiologic factor was not found. His laboratory results did not show endocrine or exocrine insufficiency. The patient was treated with papillotomy, pancreatic stone extraction and installation of terapeutic pancreatic stent. He has been asymptomatic, free from new episodes of AP in the past six months. In conclusion, the CP is one of the possible causes of RAP. Endoscopic treatment by obstructive stone extraction is an efficient therapy to avoid new relapse.

La pancreatitis crónica (PC) se define por la inflamación crónica del páncreas con reemplazo progresivo por fibrosis que produce cambios morfológicos característicos. El cuadro clínico es variable, siendo el principal problema el dolor, reagudizaciones de pancreatitis con eventuales complicaciones locales. Con el tiempo, el resultado final es el desarrollo de insuficiencia exocrina y endocrina. En la fase inicial, no se puede distinguir las reagudizaciones de la PC de una pancreatitis aguda recurrente (PAR). Si se encuentran cálculos intraductales en el conducto de Wirsung, la extracción endoscópica de cálculos obstructivos puede ser el primer paso para prevenir nuevas recaídas y complicaciones. Se presenta el caso de un paciente con cinco episodios de pancreatitis aguda (PA), tres de ellos en los últimos cinco meses. El paciente fue derivado para estudio y manejo de PAR. Su estudio imagenológico reciente ya demostró dilatación del conducto pancreático principal, calcificaciones y cálculos pancreáticos, compatible con PC. Aunque la hipertrigliceridemia participó en la etiología de las PA, los últimos dos episodios ocurrieron con valores normales de triglicéridos. No se encontró otro factor etiológico posible. Su estudio de laboratorio no mostró insuficiencia exocrina ni endocrina. El paciente fue tratado mediante papilotomía, extracción de cálculos pancreáticos e instalación de prótesis pancreática terapéutica. Ha estado asintomático, libre de nuevos episodios de PA en los seis meses transcurridos. En conclusión, la PC es una de las posibles causas de PAR. El tratamiento endoscópico mediante extracción de cálculos obstructivos es una terapia eficiente para evitar nuevas recaídas.

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.

Tratamiento endoscópico en la pancreatitis crónica: seguimiento a largo plazo / Endoscopic treatment in chronic pancreatitis: long-term results in 18 patients

Background: Intraductal stones, ductal abnormalities and pancreatic pseudocysts are part of chronic pancreatitis (CP). The goal of treatment is pain relief, resolution of local complications and relapse prevention. Endoscopic therapy (ET) can be considered in those who do not respond to medical treatment. Aim: To evaluate the indication, immediate and long-term results of ET in CP patients. Patients and Methods: Review of a database of patients with CP analyzing results of ET in 18 patients aged 16 to 60 years (13 males). Demographics, etiology, endoscopic technique, indication for treatment, pain relief, relapses and complications were recorded. Results: The etiology of CP was alcohol consumption in 5, idiopathic in 11, hereditary in one and autoimmune in one case. The follow-up period was 6 months to 14 years. Seven patients had diabetes mellitus type 3c and eight had moderate to severe exocrine pancreatic insufficiency. Pancreatic papillotomy was performed in all patients, with removal of some stones, without attempting a complete clearance of the pancreatic duct. In addition, a 7-10 French stent was placed in the main pancreatic duct in 15 patients with varying permanence (months to years). The stent was changed guided by recurrence of clinical symptoms. During the follow-up period, 10 patients remained asymptomatic and in three, pain or relapse were significantly reduced. Stenting failed in one patient for technical reasons. Two patients were operated. There were neither immediate nor late complications from ET. Conclusions: Long-lasting improvement of CP was observed in 13 of 18 patients treated with ET, without complications associated with the procedure.

Comparison of fccal elastase 1 for exocrine panreatic insufficiency evaluationn between ex-alcoholics and chronic pancreatitis patietts / Comparação da elastase fecal 1 para avaliação de insuficiência pancreática exócrina entre ex-alcoólatras e pacientes com pancreatite crônica

Context Fecal elastase is a noninvasive test for pancreatic insufficiency diagnosis. Objectives Evaluate the usefulness of fecal elastase 1 for the indication of exocrine pancreatic insufficiency among former alcohol addicts and patients with chronic pancreatitis. Methods Forty-three patients with chronic pancreatitis and thirty-three asymptomatic former alcohol addicts entered the study. The levels of fecal elastase 1 were measured using a commercial kit. Pancreatic imaging findings were used to categorize the groups. Results The levels of fecal elastase 1 were significantly lower in the patients than in the former alcohol addicts and in the group with tissue calcifications, duct alterations, or atrophy. With a cutoff level of 100 μg/g, the sensitivity of fecal elastase 1 in chronic pancreatitis was 46.51% and its specificity was 87.88% with a positive predictive value of 83.33% and a negative predictive value of 55.77%. When patients were stratified according to the severity of their pancreatitis, the sensitivity was 6.25% for mild pancreatitis and 70.37% for marked pancreatitis. Conclusion Low level of fecal elastase 1 was associated with marked rather than mild chronic pancreatitis; however, it may be useful to indicate pancreatic exocrine insufficiency in asymptomatic former alcohol addicts. .

Contexto O teste de elastase fecal é um teste não invasivo para diagnosticar insuficiência pancreática. Objetivos Avaliar a utilidade da elastase fecal 1 como indicador de insuficiência pancreática entre ex alcoólatras e pacientes com pancreatite crônica. Métodos Quarenta e três pacientes com pancreatite crônica e 33 ex alcoólatras assintomáticos entraram no estudo. Os níveis de elastase fecal 1 foram medidos usando kit comercial. Os achados de imagem pancreática foram usados para categorizar os grupos. Resultados Os níveis de elastase fecal 1 foram significantemente menores nos pacientes que nos ex alcoólatras e no grupo com calcificações teciduais, alterações de ductos, ou atrofia. A sensibilidade da elastase fecal 1 na pancreatite crônica foi de 46,51% e a especificidade foi de 87,88%, com valor preditivo positivo de 83,33% e valor preditivo negativo de 55,77%. Quando os pacientes foram estratificados segundo a severidade da pancreatite, a sensibilidade foi de 6,25% para pancreatite crônica leve e 70,37% para pancreatite crônica severa. Conclusão Baixo nível de elastase fecal foi associado com pancreatite crônica severa mais do que com a leve; entretanto, pode ser útil para indicar insuficiência pancreática exócrina entre os ex alcoólatras. .

Manejo endoscópico de las complicaciones de la pancreatitis / Endoscopic management of the complications of pancreatitis

Tanto la pancreatitis aguda como crónica causan diferentes complicaciones que antes del advenimiento de la terapéutica endoscópica tenían que ser tratadas con cirugía convencional. El avance de la endoscopía intervencionista nos ha permitido acceder al páncreas y tratar estas complicaciones efectivamente y con menor morbilidad para nuestros pacientes. Aproximadamente el 90% de las pancreatitis aguda son edematosas, tienen una resolución clínica temprana y sin complicaciones. Los pacientes que son admitidos con pancreatitis necrotizante están predispuestos a tener diferentes tipos de complicaciones tanto locales como sistémicas particularmente si hay falla orgánica. Por otro lado la pancreatitis crónica es un proceso inflamatorio crónico del páncreas en donde se ha establecido la fibrosis de la glándula con posible disfunción exocrina y/o endocrina. El objetivo principal de la terapéutica endoscópica en la pancreatitis crónica es aliviar la obstrucción y disminuir la presión del conducto pancreático con la intención de aliviar el dolor abdominal. En esta revisión vamos a hablar acerca de las indicaciones y técnica endoscópica para tratar las diferentes complicaciones de la pancreatitis como, drenaje de pseudoquistes, necrosectomía pancreática, manejo del síndrome de conducto desconectado y terapia endoscópica en pancreatitis crónica.

Acute and chronic pancreatitis may lead to complications that prior the recent advancement of therapeutic endoscopy had to be treated with conventional surgery. The current techniques in interventional endoscopy allow us to access the pancreas and treat some of the complications in a minimally invasive way leading to less morbidity in our patients. Approximately 90% of acute pancreatitis episodes are edematous with early resolution of clinical symptoms and rarely leading to major complications. Patients with necrotizing pancreatitis are susceptible to local and systemic complications particularly in the setting of organ failure. On the other hand chronic pancreatitis is as a chronic inflammatory process that leads to fibrosis of the gland and in occasions to exocrine and/or endocrine insufficiency. The main objective of therapeutic endoscopy in chronic pancreatitis is to relief the obstruction and decreases the pressure in the pancreatic duct with the intention to alleviate abdominal pain. In this review we will address the indications and endoscopic techniques to treat the different complications of pancreatitis such as pseudo cyst drainage, walled off necrosis debridement, disconnected duct syndrome and different options for endoscopic therapy in chronic pancreatitis.

Insuficiência exócrina do pâncreas: etiologias / Exocrine pancreatic insufficiency: etiology

Insuficiência exócrina do pâncreas tem sido revisitada em vários compêndios médicos internacionais e suas novas etiologias avaliadas e reconfirmadas. Neste artigo abordamos as causas mais comuns e tradicionais, pancreatite crônica e fibrose cística, bem como as recentemente mais enfatizadas como doença celíaca e diabetes mellitus. Comentamos a clínica e o diagnóstico precoce e o tratamento com reposição enzimática

Pancreatic exocrine insufficiency has been broadly discussed in international medical literature. New aetiologies have been studied and reaffirmed. In this paper we describe common and traditional causes such as chronic pancreatitis and cystic fibrosis as well as the most recently emphasised celiac disease and diabetes. We also review clinical features, early diagnosis and pancreatic enzyme replacement therapy

Manejo nutricional en un paciente adulto con Absceso Pancreático y complicaciones / Nutritional Management of a patient with pancreatic abscess and complications

Paciente de sexo masculino de 42 años de edad. Inicia cuadro de 5 días antes de la intervención nutricional con dolor abdominal, náuseas y vómitos; estos síntomas son controlados con antieméticos y analgésicos. Paciente ingresa al hospital por presentar insuficiencia respiratoria; ingresa a la unidad de trauma shock y es referido, luego, a la Unidad de Cuidados Intensivos Intermedios (UCIN) para recibir nutrición enteral total y control de la glicemia; se le realiza una tomografía axial computarizada (TAC) donde se evidencia necrosis del 50% de páncreas. Sala: Cirugía A. Fecha de nacimiento: 11-05-1970. Edad: 42 años. Sexo: Masculino. Fecha de ingreso a servicio: 30-04-12. Diagnóstico médico: Absceso pancreático, Diabetes Mellitus tipo 2 y Trastorno de la coagulación.

42 year old man with onset of symptoms five days before our nutritional intervention. The symptoms were abdominal pain, nausea and vomiting, these symptoms were controlled with antiemetics and analgesics. Patient was admitted to shock trauma unit with respiratory failure; then, he was referred to Intensive Care Unit (ICU) to receive mechanical ventilation. Later, patient was referred to the Intermediate Care Unit (IMCU) to receive full enteral nutrition and glycemic control. Patient underwent a computed tomography (CT) which showed a 50% necrosis of pancreas. Ward: Surgery. Date of Birth: 11-05-1970. Age: 42 years. Sex: Male. Date of joining service: 30-04-12. Medical Diagnosis: Nutrition, Pancreatic abscess, diabetes mellitus type 2 and coagulation disorder.

Update on Endoscopic Management of Main Pancreatic Duct Stones in Chronic Calcific Pancreatitis

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed.

Cambios endosonográficos en la glándula pancreática proximales y distales a una lesión tumoral de cabeza, cuello y cuerpo / Eus changes on the pancreatic gland proximal and distal to a tumor

El ultrasonido endoscópico es uno de los métodos con mayor sensibilidad para detectar cambios en el parénquima pancreático. No se han publicado estudios donde se describan los cambios pancreáticos observados proximales al tumor, los cuales podrían estar en relación al origen del mismo; sin embargo, los cambios post-tumorales por obstrucción del conducto de Wirsung si están descritos en la literatura. Objetivo: Describir los cambios observados por ecoendoscopia en el páncreas antes y después de la lesión tumoral. Metodología: Se evaluaron retrospectivamente videos de 36 pacientes a quienes se les realizó eco endoscopia superior con diagnóstico de cáncer de páncreas, los cuales acudieron entre Enero a Diciembre 2009, fueron excluidos pacientes con lesiones en proceso uncinado y cola del páncreas por no mostrar cambios pre y post tumorales. Las imágenes fueron interpretadas de acuerdo a patrones ya establecidos. Los datos fueron vaciados en tablas y analizados en porcentajes. Resultados: 18 pacientes presentaron cáncer en la cabeza del páncreas, 12 en el cuello y 6 en el cuerpo. De los cambios evidenciados proximales al tumor, una mayoría presentó pancreatopatía areolar 58%, (21): leve 4, moderada 10 y severa 7; seguidos de esteatosis pancreática 33% (12): homogénea 2, heterogénea 10; y con páncreas normal 9% (3). Los cambios post-tumorales observados fueron 94% pancreatitis obstructiva tumoral, y 6% tenían un páncreas normal. Conclusión: Es posible que la presencia de pancreatopatia areolar crónica y esteatosis pudiesen estar en relación con el desarrollo del cáncer pancreático. Se confirmó la presencia de pancreatitis obstructiva tumoral distal a las lesiones en la mayoría de los pacientes.

Endoscopic ultrasound is one of the most sensitive methods to detect changes in the pancreatic parenchyma. There have been no publish studies that describe changes observed proximal to the pancreatic tumor, which could be related to the origin of it, unlike the post-tumor changes by pancreatic duct obstruction, which are described in the literature. Objective: To describe the observed changes in the pancreas by EUS before and after the tumor. Methodology: We retrospectively evaluated videos of 36 patients who underwent upper endoscopy eco diagnosed with pancreatic cancer, they were received between January and December 2009, there were excluded patients with lesions in the uncinate process and tail of the pancreas, because they did not show change pre and post tumor. The images were interpreted according to established patterns. The data were emptied in tables and analyzed by percentages. Results: 18 patients had cancer of the head of the pancreas, 12 in the neck and 6 in the body. Evidenced changes proximal to the tumor, a majority showed areolar pancreatopathy 58% (21): 4 mild, 10 moderate and 7 severe; followed by pancreatic steatosis 33% (12): 2 homogeneous,10 heterogeneous, and 9% (3) normal pancreas. The observed post-tumor changes were obstructive tumoral pancreatitis 94% and 6% had a normal pancreas. Conclusion: It is possible that the presence of chronic areolar pancreatopathy could be related to the development of pancreatic cancer. We confirmed the presence of malignant obstructive pancreatitis distal to lesion in most patients.

Paniculite pancreática como a primeira manifestação de doença visceral: relato de caso / Pancreatic panniculitis as the first manifestation of visceral disease: case report

A paniculite pancreática, condição patológica rara, acomete 2-3 por cento dos pacientes com doença do pâncreas. Em 40 por cento dos casos, precede manifestações de doença pancreática. Relata-se caso de paciente feminina, 71 anos, surgimento há 1 mês de nódulos eritematosos nas pernas que evoluíram para ulceração e saída de conteúdo amarelado. Sem sintomas abdominais. A biópsia revelou macrófagos vacuolizados e necrose gordurosa representada por áreas anfofílicas, de material amorfo. Exame laboratorial e TAC demonstraram pancreatite crônica. Presume-se que a liberação de enzimas pancreáticas, tais como a tripsina, pode aumentar a permeabilidade da microcirculação e, então, a lípase e a amilase causariam a necrose de gordura subcutânea observada nas lesões. Na histologia, observam-se "células fantasmas" e paniculite septal de início e posteriormente lobular. O tratamento direciona-se a resolução da doença base.

Pancreatic panniculitis is a rare pathological condition affecting 2-3 percent of patients with pancreatic disease. In 40 percent of cases the condition precedes manifestations of pancreatic disease. We report the case of a 71-year-old female who presented with an erythematous tender node which had appeared one month previously, progressing to ulceration and yellowish exudation. No abdominal symptoms. Biopsy revealed fat necrosis and vacuolated macrophages represented by amorphous amphophilic areas. Laboratory examination and CT scan revealed chronic pancreatitis. It is assumed that release of pancreatic enzymes such as trypsin may enhance the permeability of the microcirculation leading to lipase and amylase causing the subcutaneous fat necrosis observed in the lesions. Histology showed "ghost cells" and, firstly, septal panniculitis, followed later by lobular panniculitis. Treatment focused on resolution of the underlying pancreatic disease.

Pancreatitis crónica: nuevas terapias / Chronic pancreatitis: new therapies

Chronic pancreatitis occurs by the prolonged inflammation of pancreatic tissue that induces the irreversible destruction of the organ, leading to a global pancreatic insufficiency. The most common manifestations are abdominal pain, diarrhea, malabsorption, and possibly diabetes mellitus. Chronic pancreatitis treatment includes dietary restrictions, enzymatic supplementation, vitamins, and endoscopic or surgical methods depending on the degree of ductal involvement. In addition to the known therapies, new therapies are under development and research.

La pancreatitis crónica se desarrolla por la inflamación prolongada del tejido pancreático que induce la destrucción irreversible del órgano, llevando a una insuficiencia pancreática global. Las manifestaciones más frecuentes son dolor abdominal, diarrea, malabsorción y eventualmente diabetes mellitus. El tratamiento en pancreatitis crónica incluye restricciones dietarias, suplementación enzimática, vitamínica, y métodos endoscópicos o quirúrgicos, dependiendo del grado de compromiso ductal. Además de lo descrito, están en desarrollo y experimentación nuevas terapias.

Pancreatic carcinogenesis: The impact of chronic pancreatitis and its clinical relevance.

Pancreatic cancer is a devastating disease with a dismal prognosis and early detection remains a challenge. On the background that inflammation is one of the key steps in the development of cancer, it is natural that chronic pancreatitis is considered as one of the etiological factors for the development of pancreatic cancer. However, the process of pancreatic carcinogenesis is a multifactorial phenomenon rather than a process that evolves solely via inflammation. This review attempts to put into perspective the association between different etiological forms of chronic pancreatitis and pancreatic cancer, and the diverse mechanisms operational in the process of pancreatic carcinogenesis. Furthermore, the clinical relevance of the current understanding of the relationship between chronic pancreatitis and pancreatic cancer, especially with regard to the pancreatic head mass of uncertain etiology, is discussed in this review.

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.