Clinico-radiological comparison and short-term prognosis of single acute pancreatitis and recurrent acute pancreatitis including pancreatic volumetry.

PURPOSE: The necrosis-fibrosis hypothesis describes a continuum between single attacks of acute pancreatitis (SAP), recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) with endocrine and exocrine pancreatic insufficiency. For prevention purposes we evaluated clinico-radiological parameters and pancreatic volumetry to compare SAP and RAP and provide prognostic relevance on short-term mortality, need for intervention and the hospitalization duration. MATERIALS AND METHODS: We retrospectively investigated 225 consecutive patients (150 males, range 19-97years) with acute pancreatitis (74%SAP, 26%RAP) according to the revised Atlanta classification. All patients received an intravenous contrast-enhanced CT after a median time of 5 (IQR 5-7) days after onset of symptoms. Two experienced observers rated the severity of AP by 3 CT scores (CTSI, mCTSI, EPIC). Moreover, total pancreatic volumes and additional parenchymal necrosis volumes were assessed, when appropriate. Clinical parameters were etiology of AP, lipase on admission, CRP 48 hours after admission (CRP48), and the presence of organ dysfunction, assessed by the modified Marshall score. The modified Marshall score included systolic blood pressure, serum creatinine, and the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio) and was assessed on admission and 48 hours after admission to find patients with persistent organ failure. Outcome parameters were total hospitalization duration, short-term mortality and need for intervention. RESULTS: Lipase, CRP48, etiology of AP, EPIC, PaO2/FiO2 ratio, and the presence of a pleural effusion differed significantly in both groups (p<0.05). In 109 patients with interstitial edematous AP, the total pancreatic volume was significantly smaller in patients with RAP compared to those with SAP (69±35cm3; (RAP) vs 106±45cm3; (SAP), p<0.001). All outcome parameters including the mortality rates (SAP vs. RAP: 15% vs. 7%) were comparable in both groups (p>0.05). In the necrotizing RAP group, only the necrotic volume correlated significantly with total hospitalization time (r = 0.72, p<0.001), whereas the systolic blood pressure was the only, but weak predictor for short-term mortality (ß-coefficient: -0.05, p = 0.03) and the need for intervention (ß-coefficient: -0.02, p = 0.048) in the total RAP group. In patients with SAP, the modified Marshall score was the strongest predictor of short-term mortality, followed by the mCTSI on multivariate logistic regression (Marshall score: ß-coefficient: 1.79, p<0.001; mCTSI: ß-coefficient: 0.40, p<0.001). CTSI was the best predictor for required intervention in necrotizing SAP (ß-coefficient: 0.46, p<0.001), followed by the volume of intrapancreatic necrosis (ß-coefficient: 0.17, p = 0.03). CONCLUSION: Total pancreatic volume differed significantly between interstitial RAP and SAP and intrapancreatic necrosis volume revealed prognostic value for the total hospitalization duration in necrotizing RAP. Although all outcome parameters were comparable between SAP and RAP, only systolic blood pressure and pancreatic volumetry were prognostic in RAP. In SAP, only the modified Marshall score and mCTSI revealed prognostic value for short-term mortality, whereas CTSI was predictive for the need for intervention.

[Treatment of pain in chronic pancreatitis]. / Tratamiento del dolor en la pancreatitis crónica.

Abdominal pain is the most frequent symptom in patients with chronic pancreatitis. Between 70 and 90% of patients experience pain at some point in the course of their disease. In patients with alcoholic pancreatitis, pain is usually experienced at disease onset. Two distinct forms of idiopathic chronic pancreatitis can be distinguished: in early-onset (juvenile) idiopathic chronic pancreatitis, pain occurs initially, while in late-onset (senile) idiopathic chronic pancreatitis, pain is delayed or may even be absent. According to several authors, between 27 and 67% of patients require surgery due to lack of response to medical treatment. Pain may reoccur in more than 30% of patients who have undergone surgery and consequently, reintervention is not uncommon. Several treatment options are currently available: medical, endoscopic and surgical. The most appropriate treatment for each patient should be chosen on an individualized basis.

Intravenous nitroglycerin for prevention of pancreatitis after therapeutic endoscopic retrograde cholangiography: a randomized, double-blind, placebo-controlled multicenter trial.

BACKGROUND AND STUDY AIMS: Several studies have suggested that nitroglycerin promotes pancreatic drainage and thereby helps to prevent pancreatitis occurring after endoscopic retrograde cholangiography (ERC). We performed a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of intravenous nitroglycerin for preventing acute pancreatitis in moderate- to high-risk patients undergoing ERC. PATIENTS AND METHODS: The patients underwent therapeutic ERC for gallstone removal, bile duct stenosis, or sphincter of Oddi dysfunction (SOD). They were randomly allocated to receive an intravenous nitroglycerin bolus of 0.1 mg, then 35 microg/kg per minute intravenously (maximum dose 9 mg) for 6 h, or an identical placebo regimen. Serum amylase and lipase levels were determined before and 24 h after ERC. RESULTS: The study was terminated after the interim analysis. The intention-to-treat population consisted of 208 patients enrolled in 20 centers, of whom 105 received nitroglycerin and 103 placebo therapy. Post-ERC pancreatitis (mild/moderate/severe) occurred in 25 patients, comprising 10 (3/5/2) in the nitroglycerin arm and 15 (5/6/4) in the placebo arm (OR 0.62, 95 % CI 0.26 - 1.45; P = 0.26). Pancreatitis-related hospital stays were similar in the two groups (median 4 days, range 2 - 13 days in the nitroglycerin group; median 5 days, range 2 - 20 days in the placebo group). The incidence of pancreatitis in patients with SOD did not differ between the groups (4/11 in the nitroglycerin arm, and 4/15 in the placebo arm). Adverse events were more frequent in the nitroglycerin group and led to cessation of drug infusion in 10 patients in the nitroglycerin arm and in 2 patients in the placebo arm ( P = 0.019). CONCLUSION: In this study, nitroglycerin offered a limited and clinically nonsignificant benefit for the prevention of post-ERC pancreatitis. Its use did not improve the technical success rate of ERC.

[Radiation therapy of chronic pancreatitis. Case report]. / Strahlentherapie bei chronischer Pankreatitis. Fallbericht.

BACKGROUND: Chronic pancreatitis is a severe inflammatory process leading to destruction of exocrine tissue, fibrosis and a sometimes fatal pancreatic necrosis. Therapeutic options are poor and restricted to an exclusively symptomatic treatment. In this situation any additional treatment option is welcome. CASE REPORT: The present paper reports the successful irradiation of a patient with severe chronic pancreatitis resistant to any pretreatment. Pain relief was stated one week after beginning of the irradiation. Total dose was 7 Gy, applied with opposing ap/pa fields using 8 MV photons. Three years after treatment the patient has remained free from symptoms. He has gained 14 kg of weight and is working regularly.

Resolution of pancreatic ascites after low-dose radiation.

We have reported a case of pancreatic ascites that responded to low-dose radiation. Our review of the literature and of the limitations of various treatment methods available suggests that low-dose radiation may have a role in the treatment of patients who are at high risk for surgery.

[Changes in acid-base equilibrium of blood after intravenous laser irradiation (experimental study)]. / Izmenenie kislotno-osnovnogo sostoianiia krovi pri vnutri- vennom obluchenii lazernym svetom (éksperimental'noe issledovanie).

Experiments were conducted to study the acid-base equilibrium of blood in pancreatitis and in combination with laser irradiation of venous blood by the intravascular method through a light guide. Irradiation of blood was attended by inhibition of metabolic acidosis development, which was evidently linked with improved blood oxygen transport function in response to exposure to the laser beam.

[Effect of intravenous laser irradiation of blood on the homeostasis in patients with hemorrhagic pancreatitis]. / Vliianie vnutrivennogo lazernogo oblucheniia krovi na gomeostaz bo'lnykh gemorragicheskim pankreatitom.

After intravenous blood exposure to low-intensity radiation of Helium-Neon laser patients with haemorrhagic pancreatitis exhibited inhibition of the blood proteolytic activity; enhancement of free-radical oxidation, kallikrein-kinin system activity, blood oxygen transport, correction of endotoxic pancreatogenic syndrome. In addition, the positive shifts were also observed in the immunological status, morphofunctional characteristics of the red blood cells and hemoglobin, hepatic and renal functions. In severe pancreatogenic endotoxicosis the highest response was achieved with combined use of hemosorption and intravenous laser irradiation.

[Effect of intravascular laser irradiation of the blood on blood cells in pancreatitis]. / Vliianie vnutrisosudistogo oblucheniia krovi lazernym svetom na kletki krovi pri pankreatite.

Inpatient examinations included 17 patients with necrosis of the pancreas (4 patients had hemorrhagic and 14 fat necrosis): synthetic lymphocyte activity was studied by the luminescent method and the erythrocyte content of adenyl nucleotides by thin-layer chromatography in the toxic phase of pancreatitis. Synthetic lymphocyte activity was found to be decreased and the ATP pool of erythrocytes exhausted in the toxic phase of pancreatitis. Intravascular laser irradiation of the blood caused recovery of lymphocyte activity and increase in the ATP content in erythrocytes.

[The use of endovascular laser irradiation of the blood in the complex treatment of acute pancreatitis and peritonitis in experimental and clinical conditions]. / Primenenie éndovaskuliarnogo lazernogo oblucheniia krovi v kompleksnoi terapii ostrogo pankreatita i peritonita v éksperimente i klinike.

Experimental (118 experiments) and clinical (30 patients) investigations have shown a positive effect of endovascular irradiation of blood with the helium-neon and ultraviolet lasers on recovery of homeostasis in pancreatitis and peritonitis. The procedure stimulates the erythrocyte bioenergetics, reduces the degree of haemic hypoxia and increases nonspecific immunological reactivity.

Evaluation of gamma radiation therapy in experimentally induced hemorrhagic pancreatitis in dogs.

Acute bile-trypsin pancreatitis was induced in two groups of six dogs each. One group was given supportive treatment only; the second group was treated with irradiation of the pancreas (400 rad). A third group of six dogs was irradiated, but pancreatitis was not induced. A 13-fold increase in survival time was observed in the dogs with pancreatitis which had been irradiated. Irradiation alone was found to reduce the volume of pancreatic secretion with a relative increase in trypsin content. Modification of the inflammatory reaction by irradiation and reduction in pancreatic secretion probably account for the therapeutic effect.