Chronic pancreatitis: report from a multicenter Italian survey (PanCroInfAISP) on 893 patients.

BACKGROUND: No data on chronic pancreatitis in Italy are available yet. AIM: To evaluate demographic, clinical, diagnostic and therapeutic aspects in patients suffering from chronic pancreatitis. PATIENTS AND METHODS: Eligible patients were prospectively enrolled from 2000 to 2005. Information concerning demographic data, lifestyle risk factors, family and clinical history, associated factors (alcohol, autoimmunity, cystic dystrophy of the duodenal wall, obstruction, genetic mutations) concomitant diseases, diagnostic findings, and pharmacological, endoscopic and surgical therapy were gathered. RESULTS: 893 patients (74% males, mean age 53.7+/-15.2 years) were evaluated. 519/859 patients (60%) were drinkers and 555/840 (66%) were smokers. A strong positive correlation between drinking and cigarette consumption (R=0.53; p<0.0001) was found. Heavy alcohol consumption (>80g of alcohol/day for more than 5 years) was considered the most important risk factor in 300 patients (34%), obstruction in 238 (27%), alcohol and obstruction in 82 (9%), autoimmunity in 34 (4%), cystic dystrophy of the duodenal wall/groove pancreatitis in 55 (6%), gene mutations in 36 (4%), and none (idiopathic) in 148 (17%). Bile stones were diagnosed in 287 patients (33%) and cholecystectomy was performed in 329 patients (38%). Pancreatic calcifications were diagnosed in 547/879 patients (62%). Pancreatic surgery was performed in 273 patients (31%). Endoscopic sphincterotomy was performed in 371 patients (42%). Exocrine and endocrine insufficiency were found, respectively, in 373/834 (45%) and 275/885 patients (31%). CONCLUSIONS: An unexpected low frequency of alcohol abuse and new emerging associated risk factors for chronic pancreatitis were observed in Italy.

Treatment of small hepatocellular carcinoma with percutaneous ethanol injection: a validated prognostic model.

OBJECTIVE: Percutaneous ethanol injection may prolong the survival of patients with small hepatocellular carcinoma associated with cirrhosis. The aim was to identify prognostic factors of survival and of local recurrence, as well as separate new lesions. METHODS: We performed Cox regression analysis in 115 consecutive patients with hepatocellular carcinoma (81 Child-Pugh class A, 34 Child-Pugh class B) treated by percutaneous ethanol injection. The validity of the model was tested by comparing predicted and observed survival in 105 independent patients from an external series. RESULTS: Overall survival rates were 89%, 63%, and 43% at 1, 2, and 3 yr, respectively. The 1-, 2-, and 3-yr survival rates were 96%, 78%, and 63%, respectively, for Child-Pugh class A patients and were 73%, 35%, 12%, respectively, for Child-Pugh class B. The albumin level was the only independent variable significantly associated with survival (p < 0.0001). The 3-yr rate of appearance of separate new lesions and local recurrence were 41% and 23%, respectively. The survival predicted by the model agreed with that observed in the independent patients. CONCLUSIONS: Survival of patients with hepatocellular carcinoma treated by percutaneous ethanol injection is related to baseline albumin level. The high rate of recurrence (both local and distant) points out the palliative role of this therapy.

Acute pancreatitis in the postpartum period: a population-based case-control study.

OBJECTIVE: To determine relationships among pregnancy (during and postpartum), acute pancreatitis, and gallstones. PATIENTS AND METHODS: In this retrospective population-based case-control study, we identified all 12- to 50-year-old Rochester, Minn, females diagnosed between 1976 and 1991 as having acute pancreatitis (cases). For each case, we matched 4 women of the same age (+/- 6 years) with no history of acute pancreatitis (controls). Acute pancreatitis was defined as associated with pregnancy if it occurred from 10 months prior to delivery to delivery and with the postpartum period if it occurred within 10 months of the date of delivery. Logistic regression was used to assess associations between pregnancy-related acute pancreatitis, age, gallstone occurrence, and alcohol use. RESULTS: In a cohort of 61 women who developed acute pancreatitis and 244 controls, the relative risk for acute pancreatitis associated with pregnancy was 1.43 (95% confidence interval, 0.61-3.40). All 10 cases of acute pancreatitis associated with pregnancy occurred in the postpartum period. Gallstones were present in 6 of them compared with 13 of 51 women with non-pregnancy-related acute pancreatitis (P < .05). Women with postpartum-related pancreatitis were younger than those with non-pregnancy-related pancreatitis (mean, 28 vs 36 years; P < .05). Alcohol was not associated with pregnancy-related pancreatitis. CONCLUSIONS: Acute pancreatitis during the postpartum period is not directly related to pregnancy but is associated with gallstones and occurs in younger women.

Pseudocysts in acute nonalcoholic pancreatitis: incidence and natural history.

Epidemiological studies on pancreatic pseudocysts are retrospective analyses on alcoholic patients. The aims of this study were to investigate the incidence, natural history, and predictors of the appearance and disappearance of pancreatic fluid collections and pseudocysts after nonalcoholic acute pancreatitis. We carried out a prospective cohort study in a series of 926 patients with acute pancreatitis. Pancreatic fluid collections or pseudocysts were treated only after complications. We studied pancreatic fluid collections from 83 patients (8.9%): 48 of whom developed pseudocysts (5.1%). Both were less frequent after biliary pancreatitis (P < 0.0001). In the first 60 days of follow-up, patients with fluid collections or pseudocysts showed more complications than spontaneous disappearance; two of them died. After the 60th day, spontaneous disappearance was more frequent, and at one year the cumulative incidence of complications and spontaneous disappearance was 36% and 56%, respectively. A total of 33 patients with fluid collection needed interventional treatment (surgery or percutaneous or endoscopic drainage). Pseudocysts that were small (<5 cm) or developed in the tail had a higher incidence of spontaneous disappearance: 22/24 (91.7%) and 11/12 (91.7%), respectively. In conclusion, fluid collections and pseudocysts after non-alcoholic pancreatitis have a low incidence of complications and mortality with a high rate of spontaneous disappearance. We suggest treating them only after complications.

Treatment of small hepatocellular carcinoma associated with cirrhosis by percutaneous ethanol injection. A trial with a comparison group.

BACKGROUND: Ethanol injection has been reported to be effective in the treatment of hepatocellular carcinoma, but no controlled randomized trials have been performed. We therefore performed a trial comparing ethanol injection with an untreated, matched historical comparison group in the treatment of hepatocellular carcinoma. METHODS: From 1992 to 1993, 35 patients (14 Child's A and 21 Child's B cirrhosis) with small (< 4 cm) hepatocellular carcinoma associated with cirrhosis were treated by ethanol injection. Each patient was matched with an untreated case (followed up during the period 1984-89) for variables known to have independent prognostic value (age, Child's classification, number of lesions, alpha-fetoprotein, and modality of diagnosis). RESULTS: The 1-, 2-, and 3-year survival rates of ethanol-treated patients were 86% (95% confidence interval (CI), 69-94), 53% (95% CI, 34-68), and 33% (95% CI, 15-52), whereas the survival rates of the comparison group were 75% (95% CI, 56-85), 26% (95% CI, 13-41), and 14% (95% CI, 5-27) (P = 0.01). The 1-, 2-, and 3-year survival rates of Child's A were 100%. 87% (95% CI, 30-97), 71% (95 CI, 33-90), 71% (95% CI, 33-90) in the ethanol-treated patients and 92 (95% CI, 59-99), 43% (95% CI, 23-73), and 21% (95% CI, 23-72) in untreated patients. The 1-, 2-, and 3-year survival of Child's B patients were 76% (95% CI, 59-97), 32% (95% CI, 13-53), and 9% (95% CI, 0.8-33) in the treated group and 61% (95% CI, 40-83), 14% (95% CI, 3-32), and 9% (95% CI, 1-26) in the treated group. CONCLUSIONS: These data suggest that ethanol injection prolongs the life of patients with hepatocellular carcinoma associated with Child's A cirrhosis but seems not to influence the survival of Child's B patients.

Enalapril-associated acute pancreatitis: recurrence after rechallenge.

Three patients with acute pancreatitis diagnosed while they were taking enalapril are described. In two of these patients, enalapril was the only drug taken immediately before the symptoms began, and other etiologies were accurately excluded. In the third patient, the relationship between enalapril and acute pancreatitis was shown by a rechallenge with the drug that resulted in severe acute pancreatitis. This report is a definite demonstration of the relationship between enalapril and acute pancreatitis. We suggest stopping treatment with enalapril in patients suspected of having acute pancreatitis. We also recommend not rechallenging patients with the drug because of the risk of inducing severe acute pancreatitis.

Ascites, pleural, and pericardial effusions in acute pancreatitis. A prospective study of incidence, natural history, and prognostic role.

Ascites and pleural and pericardial effusions can be observed during acute pancreatitis. The aims of this study were to evaluate their incidence, natural history, and prognostic role in patients with acute pancreatitis. One hundred patients consecutively admitted with a diagnosis of acute pancreatitis were prospectively submitted to abdominal, pleural, and cardiac ultrasonography at admission and during follow-up. Ascites was found in 18 patients, pleural effusion in 20, and pericardial effusion in 17. Twenty-four patients of this series had severe pancreatitis; three of them died. All effusions disappeared spontaneously in patients who survived pancreatitis up to two months after dismissal. At multivariate analysis ascites and pleural effusion were demonstrated to be accurate independent predictors of severity. The respective odds ratios were 5.9 [95% confidence interval (CI), 1.5-23.0%) and 8.6 (95% CI, 2.3-32.5%). Furthermore the presence of pleural effusion, ascites, and pericardial effusion were associated with an increased incidence of pseudocyst during follow-up. Ascites and pleural and pericardial effusions are frequent during acute pancreatitis. Pleural effusion and ascites are accurate predictors of severity in these patients.

Exocrine pancreatic insufficiency after allogeneic bone marrow transplantation.

Several reports suggest a relationship between bone marrow transplantation and pancreatic damage. The authors describe two patients with pancreatic insufficiency after bone marrow transplantation. The first patient had weight loss arising from steatorrhea secondary to severe pancreatic insufficiency (lipase output result <3% of normal) due to pancreatic atrophy. The second patient had steatorrhea secondary to intestinal bacterial overgrowth, but moderate pancreatic insufficiency was present (results of trypsin and lipase outputs were 50 and 30% of normal). Before the diagnosis of pancreatic insufficiency, both patients had acute graft vs host disease and the second patient had chronic graft vs host disease. We conclude that graft vs host disease after bone marrow transplantation may damage the pancreas. Patients with persistent malabsorption after bone marrow transplantation should be tested for exocrine pancreatic insufficiency.

Is the plasma amino acid consumption test an accurate test of exocrine pancreatic insufficiency?

BACKGROUND/AIMS: The amino acid consumption test has been proposed as an accurate test of exocrine pancreatic function. The diagnostic accuracy of this test was determined by simultaneously measuring plasma amino acids and enzyme secretion during stimulation of the pancreas with cholecystokinin octapeptide (CCK-OP) in 60 consecutive patients suspected of having pancreatic insufficiency. METHODS: All patients underwent duodenal intubation and intravenous infusion of CCK-OP (40 ng.kg-1.h-1). Pancreatic enzyme (lipase and trypsin) outputs and plasma amino acids were measured for a period of 1 hour. Total and individual plasma amino acids were quantitated by ion-exchange chromatography. The severity of pancreatic insufficiency was graded on the basis of enzyme output during CCK-OP infusion. RESULTS: There was no relationship between pancreatic enzyme output and plasma concentrations of individual or total amino acids before or during CCK-OP stimulation. Using a total amino acid decrease of 12% as the cutoff, the amino acid consumption test was 91% sensitive, but very nonspecific (21% specificity) for detection of pancreatic insufficiency. CONCLUSIONS: The amino acid consumption test with CCK-OP stimulation does not discriminate between patients with normal and impaired exocrine pancreatic secretion.

Biliary sludge and gallstones in pregnancy: incidence, risk factors, and natural history.

OBJECTIVE: To evaluate the incidence and symptoms of and risk factors for biliary sludge and gallstones during pregnancy and to assess the natural history of these conditions in the first year after delivery. DESIGN: Cohort study. PATIENTS: A total of 272 pregnant women recruited in the first trimester. MEASUREMENTS: Biliary sludge and gallstones were diagnosed using ultrasonography, both during pregnancy and after delivery. Predictors of the presence or disappearance of sludge and stones were examined. MAIN RESULTS: Overall, from the first trimester of pregnancy until the immediate postpartum period, 67 women were newly diagnosed with biliary sludge, and 6 women were newly diagnosed with gallstones. The respective incidence rates were 31% (95% Cl, 25% to 37%) and 2% (95% Cl, 0.2% to 4%). During pregnancy, 28% of women experienced biliary pain, which was associated only with presence of stones. After delivery, 92 women had sludge and 23 had stones. Sludge disappeared in 61% of these women (Cl, 50% to 73%) after a mean follow-up of 5 months, and stones disappeared in 28% of women (Cl, 10% to 46%) after 9.7 months of follow-up. CONCLUSIONS: Biliary sludge occurred frequently during pregnancy but was generally asymptomatic and often disappeared spontaneously after delivery. Gallstones were much less frequent and were more likely to be associated with biliary pain.

Clinical presentation and ultrasonography in the diagnosis of pancreatic cancer.

One thousand twenty patients consecutively admitted because of a clinical suspicion of pancreatic cancer were investigated to evaluate the accuracy of simple clinical, laboratory, and ultrasonographic data in the diagnosis of pancreatic cancer. Age, weight loss, recent-onset diabetes mellitus, palpable abdominal mass or gallbladder, elevated serum bilirubin or alkaline phosphatase levels, and ultrasonography were significant criteria in discriminating 80 pancreatic cancers from 940 controls. The most sensitive criteria were ultrasonography (83%), weight loss (66%), and bilirubin level of > 3 mg/dl (61%); the most specific were ultrasonography (99%), recent-onset diabetes (97%), and a distended palpable gallbladder (94%). Only ultrasonography demonstrated an elevated positive predictive value (86%), while weight loss, elevated bilirubin and alkaline phosphatase, besides ultrasonography had an elevated negative predictive value (95%). These results show that advanced pancreatic cancer may be excluded with simple clinical and laboratory data; ultrasonography can confirm the diagnosis with a high degree of accuracy. We suggest that the results of any new diagnostic tests for pancreatic cancer be compared with these clinical findings.

Ultrasound changes in abdominal echinococcosis treated with albendazole.

Fifty patients with 81 abdominal hydatid cysts were followed with ultrasound during and after treatment with albendazole. In 61 cysts (75%), regressive changes were observed after treatment. Detachment of the membrane and change to a solid pattern in anechoic cysts were observed. Disappearance of septa or change to a solid pattern in anechoic cysts with intracystic septation were also found. There was an increase of hyperechoic structures in cysts with a mixed pattern. Follow-up ultrasound examination showed disappearance of 7 cysts, while anechoic structures reappeared in five cases. In anechoic cysts, regressive changes due to albendazole seem to be permanent, but in cysts with a mixed pattern recurrences are sometimes observed.

Abdominal ultrasonography in the diagnosis of extrinsic endoscopic compressions of stomach and duodenum.

Extrinsic compressions of stomach or duodenum (ECSD) are occasionally found during endoscopic examination. Ultrasonography is usually performed in order to explain the significance of this feature. We have prospectively assessed the prevalence of ECSD and the diagnostic role of US in this context. ECSD were found in 37 out of 6604 gastroduodenoscopies. An abdominal US was performed after endoscopy in all these patients. The extrinsic compressions were in the gastric anterior wall in 7 patients in the gastric posterior wall in 10 patients, and in the lesser curvature in 9 patients and in the duodenum in 11 patients. In 20 patients the compression was due to neoplastic lesions, in another 15 non neoplastic conditions were found (hepatomegaly, splenomegaly, gallbladder hydrops, pancreatic pseudocyst, vascular malformations). Ultrasonography was demonstrated to have an elevated sensitivity (87.5%) and an elevated specificity (100%) when technically adequate. We conclude that extrinsic compressions of stomach and duodenum detected at endoscopy are frequently associated to neoplastic lesions. Abdominal ultrasonography is an accurate tool, when technically adequate, as an initial screening test for such lesions. Endosonography, CT scan or other invasive tests must be performed in doubtful cases.

Asymptomatic hepatocellular carcinoma in Child's A cirrhosis. A comparison of natural history and surgical treatment.

The present study deals with the natural history of 37 asymptomatic patients with cirrhosis and hepatocellular carcinoma, 25 with 2-9-cm tumors who were not surgically treated (first group) and 12 with tumors smaller than 4 cm who underwent resection (second group). All patients were in Child's A class. Two-year survival (according to life-table analysis by the Kaplan-Meier method) was 50% in the first group and 39% in the second group. This difference was not significant. In the first group no relation was found between survival and initial tumor size or alpha-fetoprotein levels. Ultrasound examinations at 3-mo intervals revealed the following patterns of tumor growth: (a) no significant growth during the follow-up (9 patients); (b) significant growth (tumor size at least doubling) only in the final stage of the disease (11 patients); (c) initial significant growth followed by a period of no increase in size (5 patients). These findings show that in our geographical area (a) 2-yr survival of untreated asymptomatic patients with hepatocellular carcinoma associated with cirrhosis does not differ from that of similar patients undergoing resection and (b) the tumor can exhibit long periods of no growth alternating with periods of exponential growth.

Early detection of hepatocellular carcinoma associated with cirrhosis by ultrasound and alfafetoprotein: a prospective study.

A prospective surveillance of hepatocellular carcinoma (HCC) associated with cirrhosis, using alfafetoprotein (AFP) and real-time ultrasonography (US) was carried out in 157 patients with histologically proven cirrhosis. During a two-year follow-up, 15 asymptomatic HCCs were identified. HCCs detected by these methods were at a relatively early stage, as most tumors were small (13 out of 15 less than 5 cm). US was more sensitive than AFP in the diagnosis of HCC when values greater than 400 ng/ml were considered. Patients with initial AFP values greater than 20 ng/ml developed HCC within two years more frequently than patients with values less than 20 ng/ml. A combined approach using US and AFP is suggested in our geographical area.

Ultrasonography and alpha-fetoprotein in diagnosis of hepatocellular carcinoma in cirrhosis.

The accuracy of ultrasound (US) and alpha-fetoprotein (AFP) in the diagnosis of hepatocellular carcinoma (HCC) in 363 patients with cirrhosis (C) and a clinical suspicion of HCC was assessed. The ultrasonographic patterns of HCC and their relationship with AFP values were analyzed. Echographic patterns were distributed as follows: 47 patients had sonodense lesions; 30 patients had hypoechoic lesions; 47 had mixed-pattern lesions, and in four patients focal dilated intrahepatic bile ducts were demonstrated. The sensitivity of US was 90%; specificity was 93.3%. Serum AFP level greater than or equal to 500 ng/ml (RIA) was the first clue to the diagnosis in 71 patients (48.6%); specificity was 100%. In 28 patients AFP levels became significantly elevated during follow-up after US detection of HCC. No relationship between echo pattern and serum AFP levels was demonstrated. An algorithm for diagnosis of HCC is proposed.

Sludge and stones in gallbladder after pregnancy. Prevalence and risk factors.

The prevalence of sludge and stones in the gallbladder of 298 women in the immediate post-partum period was ultrasonographically assessed. We have investigated some risk factors for the development of sludge or stones in these patients and followed up most of these patients by ultrasonography to detect the presence of sludge and/or stones in the year following their discovery. We found sludge in 80 (26.2%) and gallstones in 16 (5.2%) of these patients. Age, obesity and months of oral contraceptive use were risk factors only for the presence of gallstones. After 1 year of follow-up only 2 out of 45 patients with sludge but 13 out of 15 patients with gallstones still had abnormal ultrasonographic findings.

Gallstones, gallbladder cancer, and other gastrointestinal malignancies. An epidemiologic study in Rochester, Minnesota.

All 2583 residents of Rochester, Minnesota, who had gallstones initially diagnosed during the years 1950 to 1970 were followed for the development of gastrointestinal malignancies. Although 69 members of the cohort subsequently developed 72 gastrointestinal malignancies, this number of cases did not exceed the 76 cases expected (relative risk, 1.0). The risk for gallbladder cancer was increased threefold, but the increase was significant only in men (p = 0.05; 95% confidence interval, 1.0 to 30.0). The absolute incidence and the total number of men and women who developed gallbladder cancer was low (n = 5). The actual incidence of other gastrointestinal malignancies in our cohort with gallstones did not exceed the expected incidence in the general population of Rochester, Minnesota. Specifically, the risk for colon cancer was not increased, even after cholecystectomy. These data support an association between cholelithiasis and gallbladder cancer. We found, however, no association between cholelithiasis or cholecystectomy and any other gastrointestinal malignancy.