Laura Castoldi

Intraluminal Duodenal Diverticulum Causing Acute Pancreatitis: CT Scan Diagnosis and Review of the Literature

Background: Intraluminal duodenal diverticulum is a rare congenital anomaly. First described by Boyd in 1845, no more than 100 cases have been reported up to now: only 17 are associated with acute pancreatitis. Methods: A new case of intraluminal duodenal diverticulum with acute pancreatitis is reported and the literature about this association reviewed. Results: The diagnosis was made by helical CT scan. The pathogenesis of pancreatitis was possibly due to a pure duodenal content reflux through the papilla of Vater. The patient was successfully treated by surgery. Conclusions: Intraluminal duodenal diverticulum is a rare but curable cause of pancreatitis, usually affecting young people. We describe, for the first time, its unusual helical CT imaging with two-dimensional reformations.

Surgical management of acute pancreatitis in Italy: lessons from a prospective multicentre study

OBJECTIVEnThis study aimed to evaluate the surgical treatment of acute pancreatitis in Italy and to assess compliance with international guidelines.nnnMETHODSnA series of 1173 patients in 56 hospitals were prospectively enrolled and their data analysed.nnnRESULTSnTwenty-nine patients with severe pancreatitis underwent surgical intervention. Necrosectomy was performed in 26 patients, associated with postoperative lavage in 70% of cases. A feeding jejunostomy was added in 37% of cases. Mortality was 21%. Of the patients with mild pancreatitis, 714 patients with a biliary aetiology were evaluated. Prophylactic treatment of relapses was carried out in 212 patients (36%) by cholecystectomy and in 161 using a laparoscopic approach. Preoperative endoscopic retrograde cholangiopancreatography was associated with cholecystectomy in 83 patients (39%). Forty-seven patients (22%) were treated at a second admission, with a median delay of 31 days from the onset of pancreatitis. Eighteen patients with severe pancreatitis underwent cholecystectomy 37.9 days after the first admission. There were no deaths.nnnDISCUSSIONnThe results indicate poor compliance with published guidelines. In severe pancreatitis, early surgical intervention is frequently performed and enteral feeding is seldom used. Only a small number of patients with mild biliary pancreatitis undergo definitive treatment (i.e. cholecystectomy) within 4 weeks of the onset of pancreatitis.

A follow-up study of patients with Zollinger-Ellison syndrome in the period 1966-2002: Effects of surgical and medical treatments on long-term survival

Aim: To evaluate the clinical history of a series of patients with Zollinger-Ellison syndrome (ZES) in the period 1966 to 2002, before and after the introduction of the current antisecretive H2 receptor antagonists and proton pump inhibitors into clinical practice. Patients and Methods: The study involved 18 ZES patients (9 males; mean age, 43 years; range, 12-70 years), 8 with Type 1 multiple endocrine neoplasia (MEN-1), diagnosed on the basis of standard criteria. We considered the type, number and effectiveness of surgical interventions before and after appropriate treatment, the localization of the gastrinoma, the presence of associated diseases, the causes of death, and the duration of survival. Results: Total gastrectomy (but not antrectomy and vagotomy) and full compliance to antisecretory treatment reduced the number of operations from 29 to 9. One patient was cured (5.5%), whereas relapsing gastrinomas occurred in 4 patients and associated diseases or complications in ten. Death was related to ZES in 5 patients and to other causes in 4. Conclusions: Curing gastrinoma or appropriately inhibiting gastric acid hypersecretion in ZES patients prevent death and favors long-term survival, regardless of gastrin levels and the size or number of tumors.

Long term outcome of acute pancreatitis in Italy: Results of a multicentre study

BACKGROUNDnIn Italy, no long-term studies regarding the natural history of acute pancreatitis have been carried out.nnnAIMnTo report the results of a follow-up on a large series of patients hospitalised for pancreatitis.nnnMETHODSnData of 631 patients admitted to 35 Italian hospitals were retrospectively evaluated 51.7±8.4 months after discharge.nnnRESULTSnThe average recovery time after mild or severe pancreatitis was 28.2 and 53.4 days respectively. Fourteen sequelae were not resolved and 9 cases required late surgical intervention. Eighty patients (12.7%) had a second hospital admission. Of the patients with mild biliary pancreatitis, 67.9% underwent a cholecystectomy. The overall incidence of relapse was 12.7%. Mortality was 9.8% and no death was related to pancreatitis. Three patients died from carcinoma of the pancreas.nnnCONCLUSIONnReported recovery time after an attack of pancreatitis was longer than expected in the mild forms. The treatment of sequelae was delayed beyond one year after discharge. The incidence of relapse of biliary pancreatitis in patients not undergoing a cholecystectomy was low, due to endoscopic treatment. Mortality from pancreatic-related causes is low, but there is an association with malignant pancreatic or ampullary tumours not diagnosed during the acute phase of the illness.

ERCP in acute pancreatitis: What takes place in routine clinical practice?

AIMnTo evaluate the data from a survey carried out in Italy regarding the endoscopic approach to acute pancreatitis in order to obtain a picture of what takes place after the release of an educational project on acute pancreatitis sponsored by the Italian Association for the Study of the Pancreas.nnnMETHODSnOf the 1 173 patients enrolled in our survey, the most frequent etiological category was biliary forms (69.3%) and most patients had mild pancreatitis (85.8%).nnnRESULTSn344/1 173 (29.3%) underwent endoscopic retrograde cholangiopancreatography (ERCP). The mean interval between the onset of symptoms and ERCP was 6.7 ± 5.0 d; only 89 examinations (25.9%) were performed within 72 h from the onset of symptoms. The main indications for ERCP were suspicion of common bile duct stones (90.3%), jaundice (44.5%), clinical worsening of acute pancreatitis (14.2%) and cholangitis (6.1%). Biliary and pancreatic ducts were visualized in 305 patients (88.7%) and in 93 patients (27.0%) respectively. The success rate in obtaining a cholangiogram was statistically higher (P = 0.003) in patients with mild acute pancreatitis (90.6%) than in patients with severe disease (72.2%). Biliary endoscopic sphincterotomy was performed in 295 of the 305 patients (96.7%) with no difference between mild and severe disease (P = 0.985). ERCP morbidity was 6.1% and mortality was 1.7%; the mortality was due to the complications of acute pancreatitis and not the endoscopic procedure.nnnCONCLUSIONnThe results of this survey, as with those carried out in other countries, indicate a lack of compliance with the guidelines for the indications for interventional endoscopy.

Malakoplakia of the pancreas with diffuse lymph-node involvement

Abstract. We report a case of malakoplakia involving the pancreas in a 74-year-old man with associated regional lymphoadenopathy. Histological examination of both pancreas and lymph nodes revealed a diffuse histiocytic infiltrate containing numerous Michaelis-Gutmann bodies. Electron microscopy supported the diagnosis of malakoplakia and showed bacterial-like structures. Differential diagnosis includes myofibroblastic inflammatory tumor and histiocytic neoplasms. Lymph-node involvement during malakoplakia is extremely rare and it has never been documented microscopically. Lymphohematogenous spread of bacteria may be the cause of the nodal involvement, which, however, does not appear to influence the clinical course of the disease.