Rectal diclofenac for prevention of post-endoscopic retrograde cholangiography pancreatitis.

BACKGROUND: Acute pancreatitis is an important complication of endoscopic retrograde cholangiography (ERC), occurring between 1-10% of patients. Several randomized controlled trials and meta-analyses have demonstrated the effectiveness of nonsteroidal anti-inflammatories (NSAIDs) such as diclofenac and indomethacin as a post-ERC pancreatitis (PEP) prophylaxis. The aim is to determine if the rectal diclofenac use reduces the PEP rate. METHODS: Retrospective cohort study. Subjects were included who underwent ERC for different indications in a tertiary center between January 2015 and June 2016. Two groups were analyzed: group A (without diclofenac use) and group B (with use of diclofenac as PEP prophylaxis). Biodemographic, technical and mortality variables were measured. RESULTS: The total cohort was 116 patients, 67 in group A and 49 in group B. The average age was 61.9±17.8 and 58.3±15.8 years, respectively (P=0.2606). Gender distribution showed a women predominance in both groups (P=0.933). Of the technical variables measured, the precut showed a statistically significant relationship to PEP (P=0.013). Of the total cohort, 8.6% developed acute pancreatitis after an ERC: four in group A and six in group B (P=0.196). In those who developed PEP (n=10), six patients developed severe acute pancreatitis (SAP). The average hospitalization for PEP was 32.2±34 days (P=0.881). No patients died, not were there any adverse reactions to the drug. CONCLUSIONS: Rectal diclofenac administered at the beginning of the ERC did not reduce the PEP rate in this patients cohort.

Microparticles and the hygiene hypothesis.

Departing from the functional parallelism that undoubtedly exists between the nervous and immune system, we suggest that the latter also counts with means for information exchange that may result in a mutual influence of immune processes between nearby individuals. Our concept relies on a molecular interface that is composed and, at the same time, interfered or modulated by the vast number of environmental agents from the surrounding milieu. We highlight the possibility that microparticles, previously shown to act as mediators of the transfer of receptors and other relevant immune molecules between distant cells, may represent a minor immune medium. In line with this argument, we envisage a potential role for the suggested interindividual immune link particularly in marginal conditions, such as those that shaped life in historical population centers or even in currently undeveloped countries. We speculate that overcrowding and unhygienic habits as dominant conditions may provide a suitable framework for the interconnection of individuals by means of their respective body wrapping microenvironments. As a corollary, we propose that collective means of defense may belong to the toolbox with which the immune system faces exceptional challenges. In the context, it seems highly suggestive to establish a link with the hygiene hypothesis. In this scenario, modern lifestyle appears as an interfering factor by dismantling the necessary conditions for the emergence of the immunological interface. Therefore, it is not implausible to confer to this modern 'immunological miscommunication' a role in current trends concerning the incidence of autoimmunity, allergy and chronic inflammation.

A propos time and autoimmunity.

The integrated defense system has been shaped over eons showing noteworthy robustness by surviving a million-year prehistory, a comparatively short evolving history and current transformation. Self-identification being part of it, so are deviations manifold expressed in autoimmunity. Epidemiological incidence and intensity, both being subject of change, are focused in the light of the time factor. Furthermore, it is stressed that there is no bi-univocal mutual relationship between immunity and defense and the origins of autoimmunity still remain mysterious. We question whether the present transforming events have occurred within too short a time to be attributed to genetic predisposition exclusively.

Autoimmunity and time entanglement.

Time is an important factor for every patient affected by chronic inflammatory autoimmune disease. More often than not we cannot predict the natural outcome of the process neither determine whether a remission depends on a particular treatment schedule or it does depend on the restoring capability by the "health drive." Autoimmune manifestations appear to be entangled with time in most complex ways.