[Spontaneous rupture of the spleen in chronic calcifying pancreatitis: report of three cases]. / Rupture spontanée de rate sur pancréatite chronique calcifiante.

Spontaneous rupture of the spleen is a rare complication of chronic calcifying pancreatitis. Anemia and hemorrhagic shock may not occur, making diagnosis more difficult. Favourable response to conservative treatment does not prevent the need for splenectomy, as calcifiying chronic pancreatitis may progress locally. We report three cases of spontaneous rupture of the spleen. In two cases, splenic rupture revealed calcifying chronic pancreatitis and both patients underwent urgent splenectomy. In the third case, the patient was known to have calcifying chronic pancreatitis, and splenectomy was performed because of unsuccessful conservative treatment. We discuss the role of distal pancreatectomy during splenectomy to reduce the rate of postoperative complications and additional surgery. We also discuss the role of arterial embolisation and laparoscopy in the management of this rare condition.

Diagnostic criteria in predicting a biliary origin of acute pancreatitis in the era of endoscopic ultrasound: multicentre prospective evaluation of 213 patients.

BACKGROUND: No study on bioclinical criteria predicting a biliary origin for acute pancreatitis has included endosonography as a reference examination. Re-examination of bioclinical parameters deserves consideration in the era where other causes are known (e.g. hereditary, autoimmune). AIM AND METHODS: To determine the performance of bioclinical markers in predicting a biliary origin of acute pancreatitis where the diagnosis of biliary lithiasis was established or ruled out using endosonography. Only patients with a first acute episode of pancreatitis were included. RESULTS: 213 patients (male: 55%; median age: 56 years) were prospectively included in 14 centres. Causes of acute pancreatitis were: biliary (62%), alcoholic (25%), other (13%). Delay between symptom-onset and admission was <48 h in 80%. Endosonography was the sole method establishing the diagnosis of biliary pancreatitis in 15% of patients. At univariate analysis, age, female sex, declared alcohol consumption, elevated aspartate and alanine transaminases on admission, gammaglutamyl transferase, alkaline phosphatase, total bilirubin, lipase, mean corpuscular volume were predictive of a biliary origin. Only age (p < 0.0001), sex (p < 0.0008) and alanine transaminase (p < 0.0004) remained significant at multivariate analysis. At age 50, the respective sensitivity and specificity were 73 and 65%. With an elevated alanine transaminase at 2 times the upper limit of normal range, the respective sensitivity and specificity were 74 and 84%. The probability of a biliary origin of acute pancreatitis could be estimated by the following formula: = 1/1 + exp(4.6967 - 0.0656 x age + 1.1208 x sex - 0.6909 x alanine transaminase). CONCLUSION: When endosonography is performed to confirm or exclude a biliary origin of acute pancreatitis, age, sex and alanine transaminase at admission are the only factors predictive of a biliary cause.

Serum fibrosis markers can detect large oesophageal varices with a high accuracy.

OBJECTIVES: The aim of this study was to determine the value of serum fibrosis markers for the diagnosis of oesophageal varices in alcoholic patients. METHODS: Fifty-four sets of clinical and biochemical data, including serum markers of fibrosis, obtained from 146 heavy alcohol drinkers (106 men, 40 women; mean age 49.2+/-9.0 years) without any history of variceal bleeding were analysed. Gastroscopy and liver biopsy were performed in all patients. Multivariate analysis was performed to identify the markers best correlated with oesophageal varices. RESULTS: Fifty-nine patients (40.4%) had severe fibrosis (3+) and 48 (32.9%) had oesophageal varices (all grades considered together). In multivariate analysis, a prothrombin index below 60%, alkaline phosphatase activity over 110 IU/l, and hyaluronate over 100 g/l were the best markers for the prediction of oesophageal varices. The diagnostic accuracy for medium to large oesophageal varices using these three factors was 86%. Eight patients (16.7%) with oesophageal varices presented no or moderate fibrosis (F<3): one patient (12.5%) had an alkaline phosphatase level >110 IU/l. However, all eight of these patients had small oesophageal varices. CONCLUSIONS: These three non-invasive markers correctly predict the presence or absence of medium to large oesophageal varices in 86% of alcoholic patients.

Efficacy of lanreotide 30 mg on prevention of pain relapse after oral refeeding in patients with necrotizing acute pancreatitis. A phase II prospective multicentre study.

BACKGROUND: Pain relapse after oral refeeding occurs in 21% of the patients with acute pancreatitis, and in 35% of those with CT Balthazar's score > or =D [Gut 1997;40:262]. Somatostatin analogues may decrease the pain relapse rate by inhibiting exocrine pancreatic secretion. AIMS, PATIENTS AND METHODS: To assess the frequency of pain relapse in patients with acute necrotizing pancreatitis after treatment with one intramuscular injection of lanreotide 30 mg on the day before refeeding. The refeeding procedure was standardized and progressive. RESULTS: 23 patients were included in 4 centres. Acute pancreatitis was alcoholic (n = 11), biliary (n = 7), other (n = 5). Twelve patients had > or =3 Ranson's criteria. Balthazar's score (1985) was D or E in 7 and 16 patients, respectively. Median duration of pain and of interruption of oral feeding were 11 (3-23) and 16 (5-34) days, respectively. Median hospital stay was 22 (9-41) days. Only 1 patient (4.3 %) had pain occurring 3 days after refeeding. CONCLUSION: Pain relapse occurred in 4.3% of patients pretreated with the somatostatin analogue lanreotide, and this figure is lower than the expected 35% rate which was previously reported without preventive treatment. This suggests that one intramuscular injection of lanreotide 30 mg on the day before refeeding could decrease pain relapse in patients with acute necrotizing pancreatitis, but has to be confirmed in a phase III study.

Diagnostic accuracy of a rapid urine-screening test (Multistix8SG) in cirrhotic patients with spontaneous bacterial peritonitis.

OBJECTIVE: To assess the diagnostic accuracy of a rapid urine-screening test (Multistix8SG) for spontaneous bacterial peritonitis (SBP) in cirrhotic patients. METHODS: Seventy-two consecutive patients (44 males, 28 females; mean age 61.6 years) with cirrhosis and ascites were included in the study. A diagnostic paracentesis was performed on hospital admission in all patients and 2 days after antibiotic treatment in the case of SBP (polymorphonuclear [PMN] count over 250/mm in ascitic fluid). Each fresh sample of ascitic fluid was also tested using the Multistix8SG urine test, and the results were scored as negative, trace or positive. RESULTS: Nine of the 72 patients had SBP and the Multistix8SG urine test was positive. After 48 h of antibiotic therapy, the PMN count of three of these nine patients was still above 250/mm and the Multistix8SG test remained positive. In three other patients with SBP, the PMN count dropped below 250/mm and the Multistix8SG test result had become negative. Two of the nine SBP patients died before 48 h, and paracentesis was not performed in the ninth case. In the other 63 patients, the PMN count in ascitic fluid was below 250/mm; the Multistix8SG test revealed 17 trace results and 46 negative results. At the threshold of 250 PMN/mm in ascitic fluid, this test had a sensitivity and a specificity of 100%. CONCLUSION: A positive Multistix8SG urine test result in ascitic fluid appears to be an indication for antibiotic treatment.

Serum measurements of pancreatitis associated protein in active Crohn's disease with ileal location.

BACKGROUND AND AIMS: Pancreatitis-associated protein (PAP) is a pancreatic stress protein also expressed in the ileum but not in the colon. Its serum concentration is increased in patients with small bowel inflammation due to untreated celiac disease. We searched to determine whether PAP could be a serum marker for ileal location of active Crohn's disease (CD). METHODS: A multicenter prospective study was conducted, including 54 healthy controls and 124 patients with CD of whom 38 had quiescent ileal or ileocolonic disease (group A), 45 had active ileal or ileocolonic disease (group B), 18 had quiescent colon-only CD (group C), and 28 had active colonic disease (group D). Active disease was defined by a Crohn's disease activity index > 150 and serum C-reactive protein (CRP) > 10 mg/mL. Location of lesions was assessed by endoscopy. PAP was assayed in serum, the upper threshold for normal values being 50 ng/mL. RESULTS: In group B, 27 patients (60%) had elevated serum PAP, compared to one in group A (2.5%), one in group C (5.3%), three in group D (10.7%) and none in the control group (P<0.01). By contrast, serum levels of C-reactive protein did not differ between patients with active CD and either ileal location (group B) or pure colonic location (group D) (38 +/-10.5 vs 41.6 +/- 6.4 mg/mL, NS). Within group B, serum PAP concentration was correlated with none of the epidemiological, clinical or biological data available. Increased serum level of PAP diagnosed ileal location in active CD with a sensitivity of 60%, a specificity of 94%, a positive predictive value of 84% and a negative predictive value of 81%. CONCLUSION: Elevated serum PAP (> 50 ng/mL ) is significantly associated with disease activity and ileal location