Federico Bolado

Novedades en el manejo de la pancreatitis aguda

Resumen La pancreatitis aguda es una enfermedad potencialmente grave y con incidencia creciente. El pancreas divisum no cumple los criterios de causalidad necesarios para ser considerado como causa. La disfuncion del esfinter de Oddi podria ser causa de pancreatitis aguda idiopatica. No se dispone de alternativas menos invasivas a la manometria del esfinter de Oddi para su diagnostico. Casi la mitad de los pacientes con sindrome de respuesta inflamatoria sistemica desarrollan fallo organico. Los mecanismos implicados en este paso no estan claros. La obesidad es un predictor de gravedad en la pancreatitis aguda; la causa podria ser la presencia de acidos grasos libres insaturados que tienen actividad proinflamatoria. Los pacientes con necrosis extrapancreatica tienen mejor pronostico que los que tienen necrosis de la glandula o ambas. La mortalidad de los que tienen necrosis infectada es del 15-20%. La categoria “moderadamente grave” es muy heterogenea y podria requerir nuevas actualizaciones. El tratamiento laparoscopico de los seudoquistes es una alternativa al endoscopico y podria ser la primera opcion en pacientes que requieren colecistectomia. Las protesis metalicas de aproximacion luminal para el tratamiento de la necrosis pancreatica son coste-efectivas. La calidad de vida de algunos pacientes con pancreatitis aguda esta significativamente deteriorada incluso pasado un ano. La hidratacion energica no es superior a la estandar para prevenir la pancreatitis aguda post-CPRE. El papel de las estatinas para prevenir la pancreatitis aguda no esta claro. La fluidoterapia intensiva y el uso de Ringer lactato parecen beneficiosos en el tratamiento de la pancreatitis aguda.

EUS-guided transgastric drainage of a peripancreatic collection containing an arterial bypass graft

A 63-year-old man was admitted with aortic dissection and acute thrombosis of the superior mesenteric artery in May 2013. After urgent surgical arterial bypass, he experienced postoperative mesenteric ischemia, pancreatitis, and bleeding, requiring 2 additional surgical interventions. Subsequently, he experienced pancreaticocutaneous fistula and abdominal sepsis; after a lengthy hospital stay, he was discharged in September. One day after discharge he was readmitted for fever related to Pseudomona and Serratia spp infection of a peribypass collection, which was treated with percutaneous drainage twice, and 4 courses of antibiotics for recurrent bacteriemia until April 2014, when recurrence of the peribypass collection was diagnosed. Because of the patient’s unacceptable surgical risk, EUS-guided transgastric drainage of the collection with the arterial bypass floating inside (Fig. 1) was completed (Video 1, available online at www.giejournal. org). A double pigtail stent was inserted, followed by a nasocystic catheter for continuous lavage during 1 week. After 4 weeks, a CT scan confirmed resolution of the collection, and the transgastric double-pigtail stent was retrieved uneventfully. He has been asymptomatic except for an episode of fever, which resolved with antibiotics without recurrence of fluid collection during 9 months of follow-up.

Chronic Pancreatitis-Like Changes Detected by Endoscopic Ultrasound in Type 1 Diabetics Are Not Associated With Gastrointestinal Symptoms or Nutritional Deficiencies.

Objectives Previous studies have shown changes in the pancreas of type 1 diabetic (T1-DM) patients, similar to those present in patients with chronic pancreatitis. Our aim was to analyze the prevalence of endoscopic ultrasound (EUS) criteria for chronic pancreatitis in T1-DM, to determine the association with factors related to the diabetes and to define its clinical significance. Methods Eighty-six T1-DM patients were prospectively included. All of them underwent EUS. Standard criteria were used. Patients were divided into 3 groups according to the number of EUS criteria they met: group A, 0 to 2 criteria; group B, 3 to 4; and group C, more than 4. Association between EUS findings and demographic or clinical factors was studied as well as the relationship between EUS abnormalities and the presence of gastrointestinal symptoms or nutritional deficiencies. Results Fifty-three patients (61.6%) showed at least 1 morphologic abnormality. Fifty-eight patients were included in group A, 21 in group B, and 7 in Group C. No significant differences were found when comparing the 3 groups. Conclusions Chronic pancreatitis-like changes are frequent in the pancreas of T1-DM patients. These changes are not associated with demographic or clinical data. Therefore, the clinical relevance seems to be scarce.

Low Serum Levels of Prealbumin, Retinol Binding Protein, and Retinol Are Frequent in Adult Type 1 Diabetic Patients

Aim. To determine the serum prealbumin (PA), retinol binding protein (RBP), and retinol levels in adult patients with type 1 diabetes (T1D) and to analyze some factors related to those levels. Methods. A total of 93 patients (47 women) were studied. Age, gender, BMI, duration of diabetes, chronic complications, HbA1c, lipid profile, creatinine, albumin, PA, RBP, and retinol were recorded. High and low parameter groups were compared by Mann–Whitney U and χ 2 tests. Correlation between parameters was analyzed by Spearmans test. Odds of low levels were analyzed by univariate logistic regression and included in the multivariate analysis when significant. Results. 49.5%, 48.4%, and 30.1% of patients displayed serum PA, RBP, and retinol levels below normal values, respectively. A high correlation (Rho > 0.8) between PA, RBP, and retinol serum levels was found. Patients presenting low levels of any of them were predominantly women, normal-weighted, and with lower levels of triglycerides and serum creatinine. No differences in age, macrovascular complications, duration of diabetes, or HbA1c values were observed when comparing low and normal parameter groups. Conclusion. Low serum levels of PA, RBP, and retinol are frequent in T1D adult patients. This alteration is influenced by female sex and serum creatinine and triglyceride levels.

Acute recurrent pancreatitis secondary to hepatocellular carcinoma invading the biliary tree

Hepatocellular carcinoma rarely invades the biliary tree. Clots or tumor embolus passing though the bile duct can cause pancreatitis by a mechanism similar to gallstone pancreatitis. We present the case of a patient with recurrent acute pancreatitis, initially suspicious of biliary origin. Despite cholecystectomy he had new episodes of acute pancreatitis. Hepatocellular carcinoma was diagnosed after the third episode. ERCP findings suggested the presence of a fistula connecting the tumor and the biliary tree. The patient was operated and the hepatocellular carcinoma was resected. Its pathological analysis confirmed the communication between the tumor and the biliary duct.

918 Low Levels of Pancreatic Elastase-1 May Not Reflect Exocrine Pancreatic Insufficiency in Type 1 Diabetes Mellitus

Introduction: type 1 diabetes mellitus (T1DM) has been described as a cause of exocrine pancreatic exocrine (EPI). However, the value of Pancreatic Elastase-1 in stools (PE-1) in these patients has been discussed. Aim: to analyze the levels of PE-1 in a group of T1DM patients and to establish its clinical implications. Methods: cross-sectional study approved by de ethics committee of our centre. T1DM and LADA (Latent Autoimmune Diabetes in Adults) aged 18 or older were referred to our department from the Endocrinology Service. All participants signed an informed consent. We analyzed the levels of PE-1 (ELISA with monoclonal antibodies, normal value > 200 mcg/g) in all patients. Then, we tried to define the relationship between those levels with demographic variables and variables related to the diabetes evolution such as age at diagnosis, years since diagnosis was made, levels of HbA1c, presence of gastrointestinal symptoms or complications (nephropathy, neuropathy or retinopathy). Finally we compared the results of PE-1 with those of the mixed 13Ctriglyceride (13C-MTG) breath test (normal value > 29%). Data were analyzed using the independent-samples t-test, the Mann-Whitney U test and the chi-square test. Correlation between quantitative variables was made using the Pearsons correlation coefficient (r). To analyze the agreement between the categorical results of both test we used the kappa coefficient (κ). Results: 100 patients (50 male). Mean age: 45.8 + 11.75. T1DM/LADA: 93/ 7. 71 were smokers and 20 recognized alcohol consumption > 20 g/day. Mean PE-1 level: 249.5 + 158.3. In 43 cases its level was below the cutoff value. 22 of them had levels < 100. The PE-1 level was not correlated with age, years since diagnosis or C-Peptide levels. An inverse correlation was found between PE-1 and HbA1c levels (r: -0.30, p=0.003). No statistically significant differences were found in PE-1 levels comparing sex, type of diabetes, presence of symptoms, smoking or alcohol consumption. However PE-1 levels were 98.6 mcg/g (95% CI: 38.8-159.5, p=0.002) lower in patients diagnosed with diabetes-related complications. 13C-MTG breath test were performed in 86 patients. It was altered in 5 cases (5.8%). Only two of them had also a pathologic PE-1. There was no agreement between both tests (κ=0.005, p=0.93). The same way, no correlation was found (r=0.06, p=0.58). Conclusions: Low PE-1 levels are frequent (43%) in T1DM patients. PE-1 levels are lower in patients with diabetes-related complications and in those with poor glycemic control. Despite low PE-1 levels, fat absorption seems to be preserved in most cases. Therefore, low PE-1 levels in T1DM should be taken cautiously since they may not mean real EPI.

Mo1339 Nation-Wide Multicenter Prospective Validation of the New Severity Classifications of Acute Pancreatitis

G A A b st ra ct s Fig 1a: A summary of biochemicals seperated by those that reached statistical significance (p < 0.05) and those that were near significance (0.05 < p < 0.10) between cases (SAP) and controls (MAP) at each time point (1-3). Collectively, metabolites were more likely to be upregulated in cases, but normalized as the disease process resolved (T1: 209 upregulated, T3: 130 upregulated).{BR}Figure 1b: Summary of the time progression of metabolites within cases (SAP) compared to controls (MAP). Compared to controls, metabolites were more dysregulated with time in cases.