Investigating the value of dual-layer spectral detector CT in distinguishing resectable pancreatic ductal adenocarcinoma from mass-forming chronic pancreatitis / 中国癌症杂志

Background and Purpose:Accurate differentiation of pancreatic ductal adenocarcinoma(PDAC)from mass-forming chronic pancreatitis(MFCP)is clinically significant.The application of dual-layer spectral detector CT(DLCT)in pancreas has been explored.This study aimed to investigate the value of DLCT in distinguishing resectable PDAC from MFCP.Methods:We retrospectively collected data of 33 patients with resectable PDAC and 19 patients with MFCP admitted to Fudan University Shanghai Cancer Center from September 1,2021 to May 31,2023.Prior to surgery,patients underwent enhanced DLCT scans,including arterial phase(AP),parenchymal phase(PP)and venous phase(VP).DLCT quantitative parameters,including attenuation enhancement fraction(AEF),lesion-to-parenchyma ratio(LPR)and iodine enhancement fraction(IEF)were calculated.Difference analysis was conducted using independent sample t-test or chi-square test.Univariate and multivariate analyses were performed using binary logistic regression.Receiver operating characteristic(ROC)curves were used for performance evaluation.P＜0.05 was considered statistically significant.Results:Statistically significant differences were observed between PDAC and MFCP in AEF_AP/PP,LPR40_VP,IEF_PP/VP,carbohydrate antigen 19-9(CA19-9)and double-duct sign(all P＜0.05).The spectral combined model composed of LPR40_VP and IEF_PP/VP exhibited the best discriminatory efficacy,surpassing CA19-9,double-duct sign and AEF_AP/PP(all P＜0.05).The combined model demonstrated an area under curve(AUC)of 0.841,sensitivity of 90%,specificity of 73%,and accuracy of 79%.Conclusion:DLCT has certain potential in differentiating resectable PDAC from MFCP.Spectral quantitative parameters can complement CA19-9 and outcome shortcomings of conventional CT in distinguishing resectable PDAC from MFCP.

Clasificación de Rosemont para pancreatitis crónica / Rosemont classification for chronic pancreatitis

Chronic pancreatitis is a persistent fibroinflammatory disease of the pancreas, more common in smokers or alcoho- lics. Genetic predisposition with mutations in various genes has also been documented. It typically presents with recurrent abdominal pain and endocrine and exocrine dysfunction, potentially progressing to pancreatic cancer and severe complications in later stages. In Chile, an annual incidence of 0.8 cases per 100,000 inhabitants is estimated, with a prevalence of 6.1 cases per 100,000 inhabitants. Early diagnosis is a current challenge for which endosonography has emerged as a sensitive and specific diagnostic tool, especially with the implementation of the Rosemont classification. Various studies have validated the utility of this classification. However, the limited availability of endosonography in some countries, such as Chile, establishes challenges for generalizing its appli- cation. It is expected that in the future, the Rosemont classification will become a standard for the diagnosis of chronic pancreatitis.

La pancreatitis crónica es una enfermedad fibroinflamatoria persistente del páncreas, más común en fumadores o alcohólicos. De igual forma se ha documentado predisposición genética con mutaciones de distintos genes. Usualmente se manifiesta con dolor abdominal recurrente y disfunción endocrina y exocrina, pudiendo llegar a desarrollar cáncer de páncreas y graves complicaciones en fases tardías. En Chile, se estima una incidencia anual de 0,8 casos por 100.000 habitantes, con una prevalencia de 6,1 casos por cada 100.000 habitantes. El diagnóstico temprano es un desafío para el cual la endosonografía ha destacado como una herramienta diagnóstica sensible y específica, especialmente con la implementación de la clasificación de Rosemont. Distintos estudios han validado la utilidad de esta clasificación. Sin embargo, la limitada disponibilidad de endosonografía en algunos países, como Chile, plantea desafíos para generalizar su aplicación. Se espera que en un futuro la clasificación de Rosemont se convierta en un estándar para el diagnóstico de pancreatitis crónica.

Avaliação da lactoferrina e da calprotectina como marcadores de inflamação intestinal na pancreatite crônica / Evaluating lactoferrin and calprotectin as markers of intestinal inflammation inchronic pancreatitis

ABSTRACT Background: The treatment of chronic pancreatitis does not consistently solve intestinal abnormalities, and despite the implementation of various therapeutic measures, patients often continue to experience persistent diarrhea. Therefore, it is imperative to recognize that diarrhea may stem from factors beyond pancreatic insufficiency, and intestinal inflammation emerges as a potential contributing factor. Objective: The aim of this study was to assess fecal lactoferrin and calprotectin levels as indicators of intestinal inflammation in patients with chronic pancreatitis experiencing persistent diarrhea. Methods: In this study, 23 male patients with chronic pancreatitis primarily attributed to alcohol consumption and presenting with diarrhea (classified as Bristol stool scale type 6 or 7), underwent a comprehensive evaluation of their clinical and nutritional status. Fecal lactoferrin and calprotectin levels were mea­sured utilizing immunoassay techniques. Results: The average age of the participants was 54.8 years, 43.5% had diabetes, and 73.9% were smokers. Despite receiving enzyme replacement therapy and refraining from alcohol for over 4 years, all participants exhibited persistent diarrhea, accompanied by elevated calprotectin and lactoferrin levels indicative of ongoing intestinal inflammation. Conclusion: The findings of this study underscore that intestinal inflammation, as evidenced by elevated fecal biomarkers calprotectin and lactoferrin, may contribute to explaining the persistence of diarrhea in patients with chronic pancreatitis.

RESUMO Contexto: O tratamento da pancreatite crônica não resolve de forma consistente as anomalias intestinais e, apesar da implementação de várias medidas terapêuticas, os pacientes muitas vezes continuam a apresentar diarreia persistente. Portanto, é imperativo reconhecer que a diarreia pode resultar de fatores além da insuficiência pancreática, e a inflamação intestinal surge como um potencial fator contribuinte. Objetivo: O objetivo deste estudo foi avaliar os níveis fecais de lactoferrina e calprotectina como indicadores de inflamação intestinal em pacientes com pancreatite crônica com diarreia persistente. Métodos: Neste estudo, 23 pacientes do sexo masculino com pancreatite crônica atribuída principalmente ao consumo de álcool e apresentando diarreia (classificada na escala de fezes de Bristol tipo 6 ou 7), foram submetidos a uma avaliação abrangente de seu estado clínico e nutricional. Os níveis fecais de lactoferrina e calprotectina foram medidos utilizando técnicas de imunoensaio. Resultados: A idade média dos participantes foi de 54,8 anos, 43,5% tinham diabetes e 73,9% eram fumantes. Apesar de receber terapia de reposição enzimática e abster-se de álcool por mais de 4 anos, todos os participantes apresentaram diarreia persistente, acompanhada por níveis elevados de calprotectina e lactoferrina, indicativos de inflamação intestinal contínua. Conclusão: Os achados deste estudo ressaltam que a inflamação intestinal, evidenciada pelos biomarcadores fecais elevados calprotectina e lactoferrina, pode contribuir para explicar a persistência da diarreia em pacientes com pancreatite crônica.

Effectiveness of pancreatic stent placement in pediatric patients with acute recurrent and chronic pancreatitis / Eficacia de la prótesis pancreática en pacientes pediátricos con pancreatitis aguda recurrente y crónica

Abstract Background: The use of pancreatic prostheses in children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) has evolved. The main established indication is the treatment of persistent abdominal pain. This study aimed to evaluate the efficacy of pancreatic stenting for refractory abdominal pain in pediatric patients with ARP and CP. Methods: We conducted a retrospective case series study. We included patients under 16 years of age diagnosed with ARP and CP in the study. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with the insertion of one and later two pancreatic stents. We evaluated abdominal symptoms before and after treatment, number of changes, duration of treatment, and complications with follow-up at 24 months and after withdrawal. Results: Nine patients with ARP and CP were included in the study: six with undetermined etiology and three with pancreas divisum. The mean age was 12.4 years. Prosthesis placement relieved abdominal pain in 100% of cases, with 3.2 replacement sessions every 6.2 months for 27.4 months, and mild complications (15.7%). One patient experienced pain on removal of the prosthesis and required bypass surgery. Conclusion: Pancreatic stent placement in patients with refractory abdominal pain with ARP and CP proved to be effective and safe, providing medium-term symptom relief and minimal complications.

Resumen Introducción: El uso de prótesis pancreáticas en niños con pancreatitis aguda recurrente (PAR) y crónica (PC) ha evolucionado. La principal indicación establecida es el tratamiento del dolor abdominal persistente. El objetivo de este estudio fue evaluar la eficacia del uso prótesis pancreática para el dolor abdominal refractario en pacientes pediátricos con PAR y PC, sin respuesta a manejo conservador. Métodos: Se llevó a cabo un estudio retrospectivo de serie de casos. Se incluyeron pacientes menores de 16 años con diagnóstico de PAR y PC. Se realizó una colangio pancreatografía retrograda endoscópica (CPRE) para introducir inicialmente una y posteriormente dos prótesis pancreáticas. Se evaluaron síntomas abdominales antes y después del tratamiento, número de recambios, duración del tratamiento y complicaciones con seguimiento a 24 meses y posterior a su retiro. Resultados: Se incluyeron 9 pacientes con PAR y PC: seis de etiología no determinada y tres con páncreas divisum. La edad promedio fue de 12.4 años. La colocación de prótesis alivió el dolor abdominal en el 100%, con 3.2 sesiones de recambio cada 6.2 meses en 27.4 meses, y complicaciones leves (15.7%). Un paciente presentó dolor al retirar las prótesis y requirió cirugía derivativa. Conclusiones: El uso de prótesis pancreática en pacientes con dolor abdominal refractario con PAR y PC demostró ser eficaz y seguro al aliviar los síntomas a mediano plazo con mínimas complicaciones.

Clinical and paraclinical characteristics in pediatric patients with acute recurrent and chronic pancreatitis: a cohort in Mexico / Características clínicas y paraclínicas en pacientes pediátricos con pancreatitis aguda recurrente y crónica: una cohorte en México

Abstract Background: Acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) are infrequent clinical entities in pediatric patients, as less than 8% of the literature mentions this population. This study aimed to describe the clinical and paraclinical profile, and the etiology related to patients with ARP and CP attended at a tertiary-level healthcare institute in Mexico. Methods: We conducted a retrospective study from medical records of patients with ARP and CP attended between 2010 and 2020, analyzing the clinical characteristics, imaging studies, and the etiology associated with each patient. Results: We analyzed 25 patients: 17 were diagnosed with ARP, and eight with CP. The main etiology identified was an anatomical alteration of the pancreatic duct (32%); pancreas divisum was the most prevalent condition. In 48% of the population, the etiology was not identified. The group with CP was higher in frequency for calcifications and dilation of the pancreatic duct (p < 0.005) compared to the ARP group. Conclusions: The main etiology for ARP and CP was an anatomical alteration of the pancreatic duct; however, in almost half of the cases, no established cause was identified. Although comparing our results with those offered by large cohorts such as the INSPPIRE group can be complex, we found relevant similarities. Currently, the data obtained from this first descriptive study are the foundation for future research in the field of Mexican pediatric pancreatology.

Resumen Introducción: La pancreatitis aguda recurrente (PAR) y crónica (PC) son entidades poco frecuentes en la edad pediátrica; sin embargo, menos del 8% de la literatura hace referencia a esta población. El objetivo de este estudio fue describir el perfil clínico, paraclínico y etiologías vinculadas en los pacientes con PAR y PC atendidos en una institución de tercer nivel de atención en México. Métodos: Se realizó un estudio retrospectivo de los expedientes de los pacientes con PAR y PC atendidos entre 2010 a 2020, analizando las características clínicas, estudios de imagen y etiologías asociadas en cada uno de los pacientes. Resultados: Se analizaron 25 pacientes, 17 con diagnóstico de PAR y ocho con PC. La principal etiología identificada correspondió a las alteraciones anatómicas del conducto pancreático (32%); el páncreas divisum fue la entidad más prevalente. En el 48% de la población no se pudo identificar una etiología. El grupo con PC presentó mayor frecuencia de calcificaciones y dilatación ductal pancreática (p < 0.005) en comparación al grupo de PAR. Conclusiones: La principal etiología de PAR y PC identificada en nuestro estudio corresponde a las alteraciones anatómicas del conducto pancreático; sin embargo, en casi la mitad de los casos, no se tiene una causa establecida. Aunque es complicado comparar nuestros resultados con los ofrecidos por las grandes cohortes del grupo INSPPIRE, sí encontramos similitudes relevantes. Los datos obtenidos en este primer estudio descriptivo son la base para futuras investigaciones en el ámbito de la pancreatología pediátrica mexicana.

Progress on chronic pancreatitis and gut microbiota / 国际儿科学杂志

Gut microbiota plays an important role in digestive system diseases and has been paid more and more attention.Chronic pancreatitis is a common clinical disease of digestive system, its pathogenesis is not completely clear.Gastrointestinal microflora dysbiosis is associated with many pancreatic diseases.Similarly, the occurrence of chronic pancreatitis is related to the gut microbiota dysbiosis, and the intestinal microecological balance is broken, resulting in varying degrees of gastrointestinal microflora dysbiosis and bacterial translocation, which affects the occurrence and development of chronic pancreatitis.This review analyzes the changes of gut microbiota in chronic pancreatitis and the possible pathogenesis, so as to provide a reference for discussing the clinical value of gut microbiota in the diagnosis and treatment of chronic pancreatitis.

The value and significance of gene sequencing in the diagnosis of pediatric pancreatitis / 中国小儿急救医学

Genetics has become one of the most important factors in the etiology of pediatric pancreatitis with advances in technology and clinical studies.Variations in these genes may increase the risk of acute recurrent and chronic pancreatitis in children, accelerate progression to endocrine and exocrine pancreatic insufficiency, and increase the risk of pancreatic cancer in adulthood.This review summarized the clinical research on the relationship between gene variations and pancreatitis, elaborated on the mechanisms, risks, and clinical phenotypes of pancreatitis caused by different gene variations, and analyzed the significance of related gene sequencing in children with pancreatitis.It aims to help pediatricians know the indications of gene sequencing in pediatric pancreatitis and do much better in relevant diagnosis, prognosis evaluation, and genetic counseling.

Application of endoscopic retrograde cholangiopancreatography on diagnosis and treatment of pediatric chronic pancreatitis / 中国小儿急救医学

Objective:To investigate the value of endoscopic retrograde cholangiopancreatography(ERCP)and related techniques in the diagnosis and treatment of chronic pancreatitis in children.Methods:The clinical data of 16 children with chronic pancreatitis diagnosed in the Department of Gastroenterology at Beijing Children′s Hospital from January 2021 to January 2022, who had ERCP indications were analyzed retrospectively, including age, sex, operation time, postoperative complications and follow-up data.Results:Thirty nine ERCP operations were performed in 16 children, with the age of (7.20±2.51) years old, and the minimum weight of 13 kg.There were 7 males and 9 females.The clinical manifestations were upper abdominal pain in all cases, 3 patients with dyspnea, 1 patient with gastrointestinal bleeding, and 1 patient with diabetes.In terms of etiology, 16 cases were diagnosed by ERCP including, 7 cases with pancreatic divisum, 1 case with abnormal pancreaticobile duct confluence.Among the 16 children, 11 had gene examination with 9 gene mutations (including 7 cases SPINK1 mutation, 1 case PRSS mutation, and 1 case CFTR mutation).The operation time was 30 to 65 minutes, and the median was 43 minutes.The operation time was negative correlation with age, while there was no correlation with the anatomical structure abnormality or the gene mutation.Among the 16 children, 15 were placed with pancreatic duct stents, with a success rate of 93.8%.Three children had postoperative pancreatitis, the rest had hyperamylasemia.Postoperative complications were not related with the age, the anatomical structure abnormality or the gene mutation.All children had been followed up for more than one year.All children have not suffered from pancreatitis again, and the body mass index had increased significantly after operation than before( P<0.05).The ERCP operation was performed 2 to 4 times in children after stent replacement, and the time of stent replacement ranged from 3 months to 12 months. Conclusion:The main causes of chronic pancreatitis in children are anatomical abnormalities or gene mutations.ERCP and related techniques are minimally invasive, safe and effective in the treatment of chronic pancreatitis.

Risk factors analysis and nomogram development for idiopathic chronic pancreatitis with common bile duct stricture / 中华胰腺病杂志

Objective:To identify the risk factors and develop nomogram for idiopathic chronic pancreatitis (ICP) patients with common bile duct stricture (CBDS).Methods:The clinical data of 1 633 ICP patients admitted to the Department of Gastroenterology of First Affiliated Hospital of Naval Medical University from January 2000 to December 2013 were collected retrospectively and prospectively. The patients were classified into CBDS group ( n=259) and non-CBDS group ( n=1 374) according to whether CBDS occurred. The cumulative incidence of CBDS after the onset and diagnosis of ICP were calculated by Kaplan-Meier method. After excluding patients who had developed CBDS before/or at the diagnosis of ICP, the remaining patients were randomly divided into the training set and the validation set. The univariate and multivariate Cox proportional hazards regression analysis were used to establish a risk predicting nomogram for CBDS after ICP onset. Its clinical application value was evaluated through the consistency index (C index). Results:15.9%(259/1 633) of patients developed CBDS after the onset of ICP. The cumulative incidence of CBDS at 3, 5, and 10 years after the onset of ICP was 9.6% (95% CI 0.082-0.111), 11.2% (95% CI 0.097-0.129) and 16.2% (95% CI 0.142-0.184), respectively. 9.4%(143/1 517) of patients developed CBDS after the diagnosis of ICP. The cumulative incidence of CBDS at 3, 5, and 10 years after the diagnosis of ICP was 8.3% (95% CI 0.069-0.099), 8.9% (95% CI 0.074-0.105) and 13.3% (95% CI 0.110-0.162), respectively. Univariate analysis found that factors including gender, age at onset of ICP, age at diagnosis of ICP, being adolescents at onset of ICP, smoking history, alcohol intake, initial manifestations, pancreatic duct stones, fatty steatorrhea, main pancreatic duct (MPD) morphology and pain type were significantly different between CBDS group and non-CBDS group. Multivariate analysis showed that male ( HR 2.134, 95% CI 1.336-3.408), age at diagnosis of ICP ( HR 1.038, 95% CI 1.024-1.052), first manifestation (pancreatic abdominal pain) and main duct morphology (complex lesion) were identified as independent risk factors for CBDS in ICP patients. A nomogram for predicting CBDS after ICP diagnosis was established based on the above four variables. The nomogram had a C-index of 0.740 (95% CI 0.700-0.790) for internal validation in the training set and 0.650 (95% CI 0.570-0.730) for external validation in the validation set. Conclusions:The nomogram established in this study can evaluate the risk of developing CBDS in ICP patients, benefit the early diagnosis and timely intervention of CBDS in clinical practice, and prevent potential related complications.

Gut microbiota controls the development of chronic pancreatitis: A critical role of short-chain fatty acids-producing Gram-positive bacteria

Chronic pancreatitis (CP) is a progressive and irreversible fibroinflammatory disorder, accompanied by pancreatic exocrine insufficiency and dysregulated gut microbiota. Recently, accumulating evidence has supported a correlation between gut dysbiosis and CP development. However, whether gut microbiota dysbiosis contributes to CP pathogenesis remains unclear. Herein, an experimental CP was induced by repeated high-dose caerulein injections. The broad-spectrum antibiotics (ABX) and ABX targeting Gram-positive (G+) or Gram-negative bacteria (G-) were applied to explore the specific roles of these bacteria. Gut dysbiosis was observed in both mice and in CP patients, which was accompanied by a sharply reduced abundance for short-chain fatty acids (SCFAs)-producers, especially G+ bacteria. Broad-spectrum ABX exacerbated the severity of CP, as evidenced by aggravated pancreatic fibrosis and gut dysbiosis, especially the depletion of SCFAs-producing G+ bacteria. Additionally, depletion of SCFAs-producing G+ bacteria rather than G- bacteria intensified CP progression independent of TLR4, which was attenuated by supplementation with exogenous SCFAs. Finally, SCFAs modulated pancreatic fibrosis through inhibition of macrophage infiltration and M2 phenotype switching. The study supports a critical role for SCFAs-producing G+ bacteria in CP. Therefore, modulation of dietary-derived SCFAs or G+ SCFAs-producing bacteria may be considered a novel interventive approach for the management of CP.

LONG-TERM OUTCOMES FOLLOWING FREY'S PROCEDURE FOR CHRONIC PANCREATITIS – A TEN-YEARS OF SINGLE-CENTER EXPERIENCE FROM A TERTIARY CARE CENTER IN SOUTH INDIA

Background/Aim: Chronic pancreatitis (CP) is surgically treated in selected patient populations. Frey's procedure (FP) is the most commonly described procedure for CP with head mass. This study is being conducted to determine the long-term outcome and ef?cacy of FP in patients with CP in South India of various etiologies. Methods: This is a retrospective study of patients who underwent FP at our institution. Clinical features, perioperative ?ndings, and follow-up results were evaluated. A subgroup analysis of pain relief was performed between alcoholics and non-alcoholic groups and between patients receiving FP alone and FP with additional procedures. Of the 181 patients, alcohol was Results: the causative factor in 99 (54.69%), gallstones in 20 (11.04%), and idiopathic in 62 (34.25%). With a median follow-up of 43.49 months (range 12-72 months), 78 (43.09%) patients experienced complete pain relief. Due to persistent pain and the presence of preoperative diabetes mellitus (DM), pain relief in patients with postoperative complications was incomplete. New DM and exocrine dysfunction were reported in 25 years (13.81%) and 15 (8.28%) patients. Patients with a history of alcohol abuse, smoking, weight loss, and postoperative complications are associated with newly developed diabetes. FP is a Conclusion: safe surgical option for CP with acceptable perioperative complications and appropriate short-term and long-term pain management in properly selected patients. Continuous pain and preoperative DM were independent predictors of incomplete pain relief after FP. Symptoms associated with alcohol abuse, smoking, and weight loss were associated with the development of post-FP DM in the study population.

Outcome of Longitudinal Pancreatico-Jejunostomy on Pain Control and Pancreatic Function in Chronic Pancreatitis

Background: Outcome of drainage operation for chronic pancreatitis are variable. The present study is taken to observe effect of longitudinal pancreatico-jejunostomy (LPJ) on pain control and pancreatic function in chronic pancreatitis in our setting.Material & Methods:Thirty-three patients who underwent LPJ for symptomatic chronic pancreatitis for one year period presented with abdominal pain (100%), steatorrhoea (30.3%), diabetes (66.7%) and weight loss (78.8%). Definitive diagnosis was made on the basis of ultrasonography and MRCP findings. LPJ (Partingtong-Rochelle) operation was done in all patients. Pain (using visual analoge scale), glycemic status (using FBS, 2hABF, HbA1c), body weight, serum zinc levels (as a marker of exocrine function), and serum insulin level (as a marker of endocrine function) were measured immediately after admission and 3 months after operation.Results:Three months after operation pain was completely disappeared in 23 (69.7%) patients, it persisted in different grade in 10 (30.3%) patients and the pain reduction rate was significant. Twenty two patients who had diabetes prior to surgery, their glycemic status significantly decreased and serum insulin level significantly increased (preoperative; 7.1�1 礥/L, postoperative; 14.3�礥/L) in 22 patients with DM after surgery. Serum zinc level increased (preoperative; 80.8�.5 礸/dl, postoperative; 85.3�.7 礸/dl) 3 months after surgery but the difference was not significant (p=0.571). However the body weight of all patients were significantly increased after operation.Conclusions:LPJ reduces abdominal pain and improves both exocrine and endocrine function in patient with chronic pancreatitis. Serum zinc levels can be considered as a tool of exocrine function.

Diagnóstico diferencial en el paciente con calcificaciones pancreáticas / Differential diagnosis of pancreatic calcifications

La pancreatitis crónica (PC) es una enfermedad de incidencia creciente en la población pediátrica, aunque desconocida, y conlleva una importante comorbilidad. La clínica inicial suele ser la propia de un episodio de pancreatitis aguda pero la importancia recae en el desarrollo, al cabo de meses o años, de insuficiencia pancreática. Para su diagnóstico será necesario tener un alto índice de sospecha clínica y realizar pruebas de imagen que demuestren cambios propios de la PC. El manejo de esta entidad deberá ser multidisciplinar y consistirá en controlar de forma adecuada el dolor e iniciar tratamiento sustitutivo cuando se constate la presencia de insuficiencia pancreática exocrina y endocrina. El caso que se reporta a continuación es un buen ejemplo de un caso de PC con presencia de insuficiencia exocrina y endocrina. Se documenta el proceso diagnóstico de la PC, en cuanto a pruebas de imagen y pruebas que demuestren la presencia de insuficiencia pancreática. Se exponen también las diferentes pruebas que se realizan para llegar a la etiología del cuadro. Se intenta reflejar el manejo que se debe llevar a cabo en estos pacientes y el seguimiento estricto que requieren.

Chronic pancreatitis (CP) is a disease with increasing incidence, though unknown, in the last years in the pediatric population which entails important comorbidities. The initial symptomatology is similar to the clinical scenario of acute pancreatitis, but its importance relies on the development, in months to years, of pancreatic insufficiency. For its diagnosis a high clinical suspicion and typical image findings are necessary. The management of this entity is held by a multidisciplinary team and the main goal is to assure an optimal pain control and start substitutive treatment once the pancreatic insufficiency is diagnosed. The clinical case that follows is a good example of CP with stablished pancreatic exocrine and endocrine insufficiency. It documents the diagnostic process of CP, regarding the imaging tools used and other laboratory test that manifested the pancreatic insufficiency. We expose the different etiologic tests that were performed in order to get to the etiologic diagnosis. It intends to reflect on the management needed for these patients and the strict follow-up that must be done.

Anterior Cingulate Cortex Mediates Hyperalgesia and Anxiety Induced by Chronic Pancreatitis in Rats / 神经科学通报·英文版

Central sensitization is essential in maintaining chronic pain induced by chronic pancreatitis (CP), but cortical modulation of painful CP remains elusive. Here, we examined the role of the anterior cingulate cortex (ACC) in the pathogenesis of abdominal hyperalgesia in a rat model of CP induced by intraductal administration of trinitrobenzene sulfonic acid (TNBS). TNBS treatment resulted in long-term abdominal hyperalgesia and anxiety in rats. Morphological data indicated that painful CP induced a significant increase in FOS-expressing neurons in the nucleus tractus solitarii (NTS) and ACC, and some FOS-expressing neurons in the NTS projected to the ACC. In addition, a larger portion of ascending fibers from the NTS innervated pyramidal neurons, the neural subpopulation primarily expressing FOS under the condition of painful CP, rather than GABAergic neurons within the ACC. CP rats showed increased expression of vesicular glutamate transporter 1, and increased membrane trafficking and phosphorylation of the N-methyl-D-aspartate receptor (NMDAR) subunit NR2B and the α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor (AMPAR) subunit GluR1 within the ACC. Microinjection of NMDAR and AMPAR antagonists into the ACC to block excitatory synaptic transmission significantly attenuated abdominal hyperalgesia in CP rats, which was similar to the analgesic effect of endomorphins injected into the ACC. Specifically inhibiting the excitability of ACC pyramidal cells via chemogenetics reduced both hyperalgesia and comorbid anxiety, whereas activating these neurons via optogenetics failed to aggravate hyperalgesia and anxiety in CP rats. Taken together, these findings provide neurocircuit, biochemical, and behavioral evidence for involvement of the ACC in hyperalgesia and anxiety in CP rats, as well as novel insights into the cortical modulation of painful CP, and highlights the ACC as a potential target for neuromodulatory interventions in the treatment of painful CP.

Clinical progress on acute recurrent pancreatitis and chronic pancreatitis in children / 国际儿科学杂志

Pancreatitis is one of the common diseases of digestive system in children, especially acute recurrent pancreatitis(ARP)and chronic pancreatitis(CP)which can seriously affect the life quality of children and increase the burden of the family.With the application of gene detection technology in recent years, the awareness of etiology and risk factors on ARP and CP is inhenced.And also the application of endoscopic retrograde cholangiopancreatography(ERCP)offers hope for patients′ treatment.Therefore, this article will review the risk factors, clinical manifestation, auxiliary examination, diagnosis and treatment of ARP and CP to make patients obtain better assessment and reasonable treatment.

Clinical features of pancreatitis in children: a single center retrospective study / 中国小儿急救医学

Objective:To explore the clinical characteristics of children with pancreatitis, aiming to analyze the clinical differences of acute pancreatitis(AP), recurrent acute pancreatitis(RAP)and chronic pancreatitis(CP)in children.Methods:The clinical characteristics of AP, RAP, CP in children admitted to the Department of Gastroenterology at Children′s Hospital Affiliated to Capital Institute of Pediatrics from January 2015 to December 2020 were analyzed.Results:One hundred and nine cases were included in this study, including 69 cases of AP(63.3%), 22 cases of RAP(20.2%)and 18 cases of CP(16.5%). The proportion of school-age and adolescent children was 48.6% and 29.4%, and there was statistical difference between the composition of children at different ages( P<0.001). Idiopathic was the main cause of AP, RAP and CP.The other causes included biliary, viral infection, structural abnormalities, drug-induced, hypercholesterolemia and heredity.97.2%(106 cases)of the children were accompanied by abdominal pain, mainly in middle and upper abdomen(75 cases, 70.8%)and around umbilical cord(22 cases, 20.8%). The pancreatic enlargement in preschool children was mainly diffuse enlargement(11/12), while the older children with local enlargement and diffuse enlargement accounted for the same proportion, the difference was statistically significant( P=0.037). The height score of CP children was lower than the overall average of the population(0 score), and lower than those of AP and RAP children, with statistically significant difference[-0.65(-1.57, 0.25) vs.0.36(-1.03, 1.05) and -0.09(-0.30, 0.41), H=6.021, P=0.044]. Eight (11.6%) cases with AP progressed to RAP, and six (8.7%) cases with AP progressed to CP. Conclusion:Pancreatitis tends to occur in school-age and adolescent children, and idiopathic is the first cause of all types of pancreatitis.AP, RAP, and CP share common features of pancreatitis in terms of etiology composition and clinical manifestations.Compared with AP and RAP, CP is more likely to affect the growth and development of children.Some children with AP could progress to RAP or CP, so we should pay more attention to the etiological investigation of AP and eliminate the etiological factors in time to avoid the disease progression.

Progress in Clinical Research on Chronic Pancreatitis During Pregnancy / 胃肠病学

Chronic pancreatitis (CP) during pregnancy is rare but complicated in clinic, and its pathophysiology, clinical manifestations, diagnosis and treatment are special, which may seriously harm the health of mother and fetus if not properly treated. During pregnancy, physiological changes such as insulin resistance, mechanical pressure caused by the enlarged uterus and increased secretion of estrogen and progesterone will affect patients with CP. CP may increase the risk of pregnancy⁃related complications and adverse perinatal outcomes. The management of pregnant patients with CP mainly includes the improvement of lifestyle, symptomatic treatment and obstetric management. This article mainly reviewed the pancreatic physiology, clinical manifestations and management of pregnant patients with CP.

Chinese Consensus for Pancreatic Cancer Screening and Surveillance in High ⁃ risk Individuals (2021, Nanjing) / 胃肠病学

Pancreatic cancer is highly malignant with low 5‑year survival rate because it is hard to be diagnosed in early stage. So far, a standardized screening strategy of early pancreatic cancer has not been achieved in China. Based on updated research evidence, a total of 26 recommendations are proposed for screening aims, high ‑ risk individuals, initial screening age, follow ‑ up interval, monitoring methods and timing of operation. Chinese consensus for early pancreatic cancer screening and surveillance is finally formulated.

Pancreatitis recurrente en pediatría: serie de casos / Recurrent pancreatitis in children: Case series

La pancreatitis recurrente (PR) ocurre en el 15-36 % de las pancreatitis agudas, en la edad pediátrica. Se realizó un estudio descriptivo y transversal, para determinar la etiología y la evolución en menores de 18 años con diagnóstico de PR entre 2008-2016 en el Hospital Garrahan. Se incluyeron 10 pacientes, el 90 % de sexo femenino. La mediana de edad fue de 11 años. La mediana del número de episodios fue de nueve. La ecografía abdominal y/o la colangioresonancia iniciales mostraron hallazgos patológicos en cuatro pacientes. De los seis pacientes con estudios iniciales normales, tres desarrollaron signos de pancreatitis crónica (PC), uno con estenosis del Wirsung sugestiva de pancreatitis autoinmune. El 40 % de los pacientes tuvo diagnóstico etiológico. En el seguimiento, tres pacientes con pancreatitis idiopática desarrollaron PC. Los factores genéticos podrían jugar un papel en los casos considerados idiopáticos.

Recurrent pancreatitis (RP) occurs in children between 15-35 % of the cases. To determine the etiology and outcome of RP in children a descriptive, cross-sectional cohort study was conducted in children under 18 years of age with RP seen at Hospital Garrahan between 2008-2016. Of 10 patients with RP, 90 % were girls. Median age of the diagnoses of RP was 11. Median number of episodes was 9. Initial abdominal ultrasonography and/or magnetic resonance cholangiopancreatography were abnormal in four patients. Of six patients with normal studies at onset, three developed signs of chronic pancreatitis (CP) and one stenosis of the duct of Wirsung suggestive of autoimmune pancreatitis. In 40 % of our patients, the etiology was determined. On follow-up, three patients with idiopathic pancreatitis developed CP. Genetic factors may play a role in patients considered to have idiopathic pancreatitis.

Pancreatitis autoinmune en pediatría. Caso clínico / Autoimmune pancreatitis in children. Clinical case

La pancreatitis recurrente ocurre en el 15-35% en la edad pediátrica. Se define como 2 o más episodios distintos de pancreatitis aguda con normalización de enzimas pancreáticas entre cada episodio. Una de sus causas es la pancreatitis autoinmune. En los últimos 10 años se controlaron, en el Hospital Garrahan, 10 pacientes con diagnóstico de pancreatitis recurrente, de los cuales solo uno tuvo diagnóstico de pancreatitis autoinmune. Se describe el caso clínico de una paciente, que, inicialmente, tenía estudios normales de función y anatomía pancreática y, en la evolución, luego de un episodio de pancreatitis aguda, desarrolló estenosis del conducto de Wirsung sugestiva de pancreatitis autoinmune. Se considera importante describir esta patología infrecuente en pediatría, pero que se encuentra en auge.

Introduction. Recurrent pancreatitis occurs in children between 15 and 35% of the cases. It is defined as two or more separate episodes of acute pancreatitis with normalization of the pancreatic enzymes between episodes. One of the causes is autoimmune pancreatitis. Over the last 10 years, 10 patients with recurrent pancreatitis were sent at our center. Only one was considered to have autoimmune pancreatitis. We described a clinical case about a patient, who had, at the beginning, normal functional and anatomical studies, and then was finally diagnosed with autoimmune disease based on findings on the magnetic resonance cholangiopancreatography with a duct of Wirsung abnormality. We considered important to describe this uncommon disorder in childhood, in spite of having an increasing incidence.