The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis).

Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment).

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

Antibodies to carbonic anhydrase and IgG4 levels in idiopathic chronic pancreatitis: relevance for diagnosis of autoimmune pancreatitis.

BACKGROUND: Increased serum antibodies against carbonic anhydrase II (CA-II Ab) or IgG4 levels have been reported in cases of autoimmune chronic pancreatitis (ACP). AIM: To assess the relevance of serum CA-II Ab and IgG4 levels for the diagnosis of ACP in idiopathic CP (ICP) versus alcoholic CP and Sjogren's syndrome (SS). SUBJECTS: This was a multicentre study involving 227 subjects divided into four groups: ICP (n = 54), normal controls (n = 54, paired by age and sex with ICP patients), alcoholic CP (n = 86), and SS (n = 33). METHODS: CA-II Ab was measured by ELISA and confirmed by western blotting. A score of easy clinical use with major clinical, morphological, and biochemical parameters for the diagnosis of ACP was applied. RESULTS: The percentage of patients with increased serum CA-II Ab was higher in the ICP group (28%) than in controls (1.9%) and in patients with alcoholic CP (10.5%), but lower than in patients with SS (64%). The proportion with elevated IgG4 levels was higher in the ICP group (15%) compared with controls (1.9%) and SS (0%) but not significantly different from alcoholic CP (8%). Most ICP patients (7/8) with high IgG4 levels exhibited increased CA-II Ab and a compatible ACP score. A definitive diagnosis of ACP by histological analysis was associated with other autoimmune disorders, an increase in both serum IgG4 and CA-II Ab levels, and IgG4 positive plasma cells. CONCLUSIONS: The increase in serum IgG4 levels was strongly associated with elevated CA-II Ab levels, manifestations compatible with ACP, and lymphoplasmacytic infiltration when surgical specimens were available.

[Selective intestinal bacterial decontamination in experimental acute pancreatitis]. / Descontaminación bacteriana selectiva intestinal en la pancreatitis aguda experimental.

BACKGROUND: Bacterial translocation implies the transit of viable gastric microflora from the intestinal lumen through the intestinal wall to the mesenteric ganglia and seems to be the mechanism by which microflora reach necrotic tissue in acute pancreatitis (AP). This occurs in 40-70% of necrotizing hemorrhagic AP and plays a major role in up to 80% of deaths from this cause. AIMS: To analyze the possible influence of bacterial decontamination in the gut on bacterial translocation in severe experimental AP. METHODS: Severe AP was induced in 43 male Sprague-Dawley rats by administration of 0.2 ml of 2.5% taurodeoxycholate sodium in NaOH glycyl-glycine buffer after cannulizing the bilio-pancreatic duct through the duodenum and clamping the common bile duct in the hepatic junction. The rats were divided into two groups: a) control group: 24 rats in which only AP was induced; b) problem group: 19 rats that underwent bacterial decontamination through the administration of 4 mg/ml gentamicin, bacitracin and neomycin in the drinking water during the 5 days prior to AP induction. Twenty-four hours after AP induction, laparotomy was performed and a sample for the culture of mesenteric lymphatic ganglia, pancreas, liver, spleen, peritoneum and cecum was obtained. RESULTS: Seven rats in the control group died. Of the 17 rats that survived 24 hours, positive cultures in the pancreas were obtained in nine. In the problem group, two rats died within 24 hours. Of the remaining 17 rats, positive pancreatic cultures were obtained in 2 while in 15 pancreatic cultures were negative. No microflora were cultured in the peritoneum. The microflora most frequently cultivated were Escherichia coli, enterococcus and proteus. No differences were found in the percentage of Gram-positive and Gram-negative bacteria between the two groups. CONCLUSIONS: a) The majority of the bacteria in AP tissue originate in the intestinal microflora, E. coli being the most prevalent. b) One of the main mechanisms in this process is bacterial translocation via the lymphatic pathway; transit directly through the transperitoneal pathway is not essential. c) Bacterial translocation already occurs in the earlier phases of AP. d) Bacterial decontamination prior to AP decreases the frequency of bacterial translocation and does not interfere in the Gram-positive/Gram negative balance, nor does it increase fungal infections.

[Prospective study of gastroesophageal reflux after esophageal variceal band ligation]. / Estudio prospectivo del reflujo gastroesofágico tras ligadura de varices esofágicas con bandas elásticas.

UNLABELLED: In recent years, variceal ligation has been introduced as an alternative treatment to endoscopic sclerotherapy. AIM: To evaluate the occurrence of excess gastroesophageal reflux in cirrhotic patients with esophageal varices eradicated by band ligation. PATIENTS AND METHODS: Twenty-six cirrhotic patients with esophageal varices underwent band ligation until variceal eradication. pH monitoring was carried out in all patients before inclusion in the eradication program and again at the end. The results were evaluated according to De Meester's criteria. RESULTS: Five patients presented excess gastroesophageal reflux before the beginning of treatment. A further six patients developed excess gastroesophageal reflux after endoscopic treatment. The only factor implicated in the development of excess gastroesophageal reflux was the use of sclerosant at the end of treatment to ensure complete eradication: five of the eight who needed sclerosant developed excess gastrophageal reflux, while only two of the 16 treated without sclerosant did so (p < 0.01). CONCLUSION: Esophageal variceal band ligation does not significantly provoke excess gastroesophageal reflux if sclerosant is not used in the endoscopic technique.

Alcoholic recidivism after liver transplantation for alcoholic cirrhosis.

Liver transplantation (LT) for alcoholic cirrhosis remains controversial. This controversy surrounding LT in alcoholics focuses on the risk of alcohol recidivism and on potential noncompliance with the immunosuppressive regimen, both of which result in graft failure. Our study examined alcohol recidivism after LT by measuring alcohol in urine and its repercussion on the allograft. Forty-four consecutive alcoholic patients and a comparison group of 17 patients receiving LT were included in this study and followed up for a mean of 39.5 +/- 19.6 months. Seven percent (3 of 44) of patients with alcoholic liver disease and 0% of patients in the comparison group admitted to having used alcohol after LT. Alcohol in urine, however, was detected in 18% (8 of 44) of the alcoholic group; therefore the true recidivism rate was higher than the rate admitted. All patients in both groups were compliant with the medications, because the cyclosporine levels were within the therapeutic range in all. On histologic examination the only alcohol-induced lesion found in three of the eight recidivistic patients was steatosis. Therefore, although alcoholic recidivism occurs, it does not seem to affect compliance to treatment profoundly or to compromise graft function. Therefore, LT seems justified for end-stage alcoholic cirrhosis.

Plasma adrenomedullin levels in patients with hepatic cirrhosis.

OBJECTIVE: The role of adrenomedullin in cirrhosis is at present unknown. The aim of this study was to investigate plasma levels of adrenomedullin in cirrhosis. METHODS: We measured plasma adrenomedullin concentrations using radioimmunoassay in 43 patients with cirrhosis (17 in Child-Pugh's class A, 13 in Child-Pugh's class B, and 13 in Child-Pugh's class C) and compared these values with those in 24 age-matched healthy subjects. Renal function, plasma cyclic adenosine monophosphate (cAMP) concentration, plasma renin activity, and plasma aldosterone concentration were measured in each patient. RESULTS: Plasma adrenomedullin levels were increased significantly in patients with cirrhosis compared with healthy subjects. In addition, plasma adrenomedullin values were higher in patients with cirrhosis and ascites than in those without ascites. Moreover, plasma adrenomedullin levels increased in relation to the severity of cirrhosis. Significant positive correlations also were found between adrenomedullin and cAMP concentrations and plasma renin activity or plasma aldosterone concentrations. CONCLUSIONS: Plasma adrenomedullin is increased in patients with cirrhosis compared with healthy subjects. The increase in plasma adrenomedullin levels is related at least in part to the severity of cirrhosis and may contribute to the arteriolar vasodilation in patients with cirrhosis. These effects are related in part to a cAMP-dependent pathway.

Value of endothelin in cellular rejection after liver transplantation.

Endothelin-1 is a vasoconstrictor peptide released by the vascular endothelium by various chemical and mechanical factors. Cellular rejection is one of the most common complications following orthotopic liver transplantation, endotheliitis being its most specific and consistent histological feature. To assess the role of endothelin in cellular hepatic rejection, we studied 21 cirrhotic patients undergoing elective liver transplantation. These patients were divided in two groups: Group I comprised 10 patients without cellular rejection, and Group II comprised 11 patients with cellular rejection. Endothelin was measured on day 7 after transplantation, on the day of liver biopsy, and after treatment for rejection. We found a significant increase in the plasma endothelin levels in the early postoperative period in the patients with moderate or severe cellular rejection compared with the non-rejection group. It remained significantly elevated until the clinical diagnosis of rejection was made. This value returned to baseline with successful treatment. So, the monitorization of this peptide may be of help in the diagnosis of rejection, its severity, and the evaluation of its resolution.

Drinking habits and pain in chronic pancreatitis.

To study the role that continuous drinking plays in the pain of chronic pancreatitis, we have examined 67 patients with alcoholic chronic pancreatitis with pain and 29 patients without pain, and we report on their alcoholic habits. Drinking habits played a part 92 (67.6%) of 136 times in patients with pain; in 185 without pain, 86 (46.5%) had continued their drinking habit (p < 0.001). Advanced pancreatic exocrine insufficiency was seen in 27 patients; 11 of them had pain during follow-up, whereas 16 did not. The nondrinker rate was similar in patients with and without pain, whereas among 69 patients with better pancreatic exocrine function, 56 had pain episodes and 13 did not. Alcoholic consumers were significantly more in number in the pain group: 70.4% versus 35% of the no pain group (p < 0.002). Our study shows that drinking alcohol in patients with chronic pancreatitis increased the frequency of painful episodes when there was relatively good pancreatic function, whereas in severe pancreatic insufficiency drinking had less influence on the development of pain.

[Duodenal diverticula associated with acute pancreatitis]. / Asociación de divertículos duodenales y pancreatitis aguda.

UNLABELLED: The purpose of this study was to assess the role of duodenal diverticula as an etiologic factor in acute pancreatitis. METHODS AND PATIENTS: We have reviewed the records of patients with diverticulum of the second portion of the duodenum diagnosed by gastroduodenal radiology or endoscopy during the period 1991-1992 in our hospital. As a control group we studied patients without duodenal diverticulum. All subjects underwent biliary-pancreatic ultrasonography. Thirty-eight patients had a duodenal diverticulum and gallstones 36 had a duodenal diverticulum but no gallstones; 21 had gallstones alone; and, finally, 42 patients were free of duodenal diverticulum and gallstones. RESULTS: Patients with duodenal diverticula had a greater prevalence of gallstones than those without (51.3% VS 33.3%, p < 0.005). Of the thirty-eight patients with duodenal diverticula and gallstones 23.7% had acute pancreatitis. None of the 21 patients without duodenal diverticulum and with gallstones had acute pancreatitis, p < 0.05. The median age of patients with duodenal diverticulum without gallstones was 64.25 years, range 34-85, and the age of those with duodenal diverticulum and gallstones was 70.4 years, range 37-87, p < 0.05. CONCLUSIONS: 1) Gallstones may cause acute pancreatitis in patients with D2 duodenal diverticula. 2) Patients with a D2 duodenal diverticulum frequently have gallstones. 3) The fact that the age of patients with duodenal diverticulum was lower than that of patients with both duodenal diverticulum and gallstones suggests that duodenal diverticula may play a role in the pathogenesis of gallstones.

[Prospective study of the prognostic value of C reactive protein, alpha 1-antitrypsin and alpha 1-acid glycoprotein in acute pancreatitis]. / Estudio prospectivo del valor pronóstico de la proteína C reactiva, alpha 1-antitripsina y alpha 1-glicoproteína ácida en la pancreatitis aguda.

Early recognition of severity of acute pancreatitis is very uncertain. For this reason it is necessary to have objective criteria to predict with accuracy the course of the disease. The aim of this study was to examine the value of the determination of the acute phase reactants: C reactive protein (CRP), alpha 1-antitrypsin (alpha-AT) and alpha 1-glycoprotein acid (alpha-GA) as prognostic indicators of acute pancreatitis on admission and on the third day. We have studied 40 patients with acute pancreatitis and serum concentrations of CRP, alpha-AT and alpha-GP were related to the Ranson Index. On admission the median levels of CRP: 74 mg/L, alpha-AT: 208 mg% and alpha-GA: 303 mg% were significantly higher (p less than 0.001) in patients with Ranson Index greater than or equal to 3 than in those with Ranson Index less than or equal to 2 (CRP: 166 mg/L, alpha-AT: 303 mg% and alpha-GA: 121 mg%). The values which differentiated patients with better and worse prognosis were: CRP 100 mg/L (sensitivity 100% and specificity 86%); alpha--AT 275 mg% (sensitivity 71% and specificity 85%); and alpha-GA 90 mg% (sensitivity 87.5% and specificity 57.9%). CRP, and to a lesser degree the alpha-AT and alpha-GA, were related to the duration of the ileus, and to the severe complications of the acute pancreatitis.