Bacterial cholangitis causing secondary sclerosing cholangitis: a case report.
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BACKGROUND: Although bacterial cholangitis is frequently mentioned as a cause of secondary sclerosing cholangitis, it appears to be extremely rare, with only one documented case ever reported. CASE PRESENTATION: A 48-year-old woman presented with an episode of acute biliary pancreatitis that was complicated by pancreatic abcess formation. After 3 months she had an episode of severe pyogenic (E. Coli) cholangitis that recurred over the subsequent 7 months on a further two occasions. Initially, cholangiography suggested the presence of extra-biliary intrahepatic abcesses while repeated investigations demonstrated development of multiple segmental biliary duct strictures. After maintenance antibiotic treatment was started, no episodes of cholangitis occurred over a 14-month period. CONCLUSIONS: Sclerosing cholangitis can rapidly develop after an episode of bacterial cholangitis. Extra-biliary involvement of the hepatic parenchyma with abcess formation may be a risk factor for developing this rare but particularly severe complication. (+info)
Surgery for pancreas divisum.
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We present our experience of open surgical treatment in 5 patients with symptomatic pancreas divisum (PD). Choice of therapy was based on allocation of patients to one of five clinical presentation groups: (i) with minor symptoms (no operation); (ii) with recurrent acute pancreatitis or upper abdominal pain (RAP/RUAP)--3 patients; (iii) with radiological evidence of chronic pancreatitis (CP)--1 patient; (iv) chronic pancreatic pain without radiological evidence of chronic pancreatitis (CPP); and (v) other pancreatic complications--1 patient. This classification helps to decide management and predict possible outcome. Various types of operation were performed as indicated (open surgical accessory sphincteroplasty [2 also had distal pancreatectomy], n = 3; Puestow's operation, n = 1; or Beger's pancreatectomy, n = 1). All patients improved significantly and are now leading normal personal, professional, and social lives. We conclude that, with careful selection of patients and appropriate therapy, the response to surgical treatment is good. (+info)
Treatment of Shwachman syndrome by Japanese herbal medicine (Juzen-taiho-to): stimulatory effects of its fatty acids on hemopoiesis in patients.
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Juzen-taiho-to (a Japanese herbal medicine) has been traditionally administered to patients with anemia, neutropenia, or wasting syndrome. We previously attempted to isolate and purify the hemopoiesis-stimulatory components in Juzen-taiho-to extracts using an in vitro hemopoietic stem cell (HSC) assay method in which mouse HSCs can proliferate on a stromal cell line (MS-5). We have found that fatty acids (particularly oleic acid and linolenic acid) actively promote the proliferation of HSCs, and that the effect is mediated by stromal cells, rather than by any direct action on the HSCs. In the present study, we show, using human normal bone marrow cells (BMCs) and umbilical cord blood cells, that similar stimulatory effects are due to the presence of oleic acid and linolenic acid, which stimulate the proliferation of HSCs in stroma-based culture systems. Furthermore, a marked stimulatory effect was noted on BMCs from patients with Shwachman syndrome, which shows pancreatic and bone marrow dysfunctions. We also show the data on hemopoietic recovery after the administration of Juzen-taiho-to to a patient with Shwachman syndrome. These findings suggest that decreased fatty acid levels in the blood, caused by exocrine pancreatic insufficiency, induce bone marrow dysfunction in Shwachman syndrome. (+info)
Serum levels of procarboxypeptidase B and its activation peptide in patients with acute pancreatitis and non-pancreatic diseases.
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BACKGROUND: Carboxypeptidase B from the pancreatic gland may exist in three different molecular and immunoreactive forms: the proenzyme, the active enzyme, and the activation peptide. AIMS: To investigate levels of procarboxypeptidase B (proCAPB) and its activation peptide in serum in acute pancreatitis to test the accuracy of these two variables as markers for the diagnosis of acute pancreatitis and for prediction of pancreatic necrosis. To elucidate whether leakage of proenzymes and activation of proenzymes reflect two different pathophysiological events in acute pancreatitis. METHODS: Sera from patients with acute pancreatitis (n=85) and acute abdominal pain of non-pancreatic origin (n=53) were analysed for proCAPB and its activation peptide. Patients with pancreatitis were divided into necrotising (n=33) and oedematous attacks (n=52) using contrast enhanced computed tomography. Accuracy was determined using receiver operating characteristic curve analysis. RESULTS: Immunoreactive carboxypeptidase B activation peptide (ir-CAPAP) concentration in serum on admission was 0.7 nmol/l (0-18.1) in patients with oedematous pancreatitis compared with 5.8 nmol/l (1.9-34) in patients with later development of pancreatic necrosis. Elevated levels of the activation peptide on admission correlated with an accuracy of 92% to later development of pancreatic necrosis. Ir-proCAPB concentration in serum on admission was 16.0 nmol/l (1.4-50.5) in all patients with acute pancreatitis versus 0.3 nmol/l (0-3.6) in patients with non-pancreatic acute abdominal disorders. Cases with oedematous pancreatitis had ir-proCAPB levels of 15.4 nmol/l (1.4-50.5) versus 19.1 nmol/l (2.7-36.1) in cases with later development of pancreatic necrosis. Measurement of the proenzyme can thus be useful for the diagnosis of acute pancreatitis (accuracy 99%) but levels did not correlate with later development of pancreatic necrosis (accuracy 56%). CONCLUSION: Leakage of proenzymes occurs in acute pancreatitis, irrespective of severity, while development of pancreatic necrosis occurs only when there is activation of the proenzymes. (+info)
Evaluating ERCP is important but difficult.
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ERCP is a valuable technique now practised widely throughout the world. It revolutionised the diagnosis and management of benign and malignant biliary and pancreatic diseases in the 1970s and 1980s. However, recent developments have highlighted the need for detailed evaluation of current ERCP practice. This review is based on a presentation to a recent NIH "state of the science" conference on ERCP, and refers to an article which appears in this issue of Gut from researchers in Hong Kong who report on a randomised controlled trial of endoscopic sphincterotomy in acute cholangitis. (+info)
Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis.
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OBJECTIVE: To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology. SUMMARY BACKGROUND DATA: Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate. METHODS: Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001. RESULTS: The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. CONCLUSIONS: Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen. (+info)
Therapeutic laparoscopy of the pancreas.
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OBJECTIVE: To communicate results of laparoscopic treatment of pancreatic pseudocyst (PP) and resection of benign lesions of the pancreas. Perioperative data, surgical outcomes, techniques and insights from 54 cases are presented. SUMMARY BACKGROUND DATA: Although laparoscopic therapy for other solid organs has been widely adopted, reports of therapeutic laparoscopy of the pancreas have been few and of limited numbers, and its role in pancreatic disease is still unclear. METHODS: Eighteen men and 11 women were selected for laparoscopic PP surgery. Four distinct laparoscopic approaches were used. An additional 9 men and 16 women underwent laparoscopic distal pancreatectomy (LDP) using a technique similar to the lesser sac approach. RESULTS: Laparoscopic PP surgery was completed successfully in 28 of 29 patients. The overall mean operative time was 2.8 hours and the mean postoperative length of stay was 4.4 days. Of the techniques described, the authors prefer cyst gastrostomy by the lesser sac approach or the minilaparoscopic cystic gastrostomy. LDP was attempted in 25 patients and completed successfully in 23. One underwent a successful hand-assisted enucleation of an insulinoma. In 12 cases the spleen was preserved. Mean operative time was 3.7 hours, and mean postoperative length of stay was 4.1 days. CONCLUSIONS: In the authors' experience, minimally invasive treatment of PP produces good results and avoids difficulties linked with percutaneous drainage or endoscopic internal procedures. However, combining upper endoscopy with intragastric laparoscopic surgery offers advantages of both. LDP compares well to open procedures and often allows preservation of the spleen. (+info)
Detection of K-ras point mutation at codon 12 in pancreatic diseases: a study in a Brazilian casuistic.
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OBJECTIVE: To clarify the sensitivity and the validity of K-ras point mutational analysis at codon 12 in Brazilian patients with pancreatic diseases, and the possible correlation between the presence of the mutation and the histopathological findings. PATIENTS: Ninety-seven Brazilian patients with pancreatic ductal adenocarcinoma, pancreatic neuroendocrine tumors and chronic pancreatitis were enrolled in this study. Forty-five patients (46%) were female and 52 patients (54%) were male, having an average age of 60.2+/-9.2 years for adenocarcinoma (n=52), 45.1+/-19.4 years for pancreatic neuroendocrine tumors (n=20), and 46.4+/-11.2 years for chronic pancreatitis (n=25). DNA extracted from 11 normal human peripheric lymphocytes was utilized as a control. RESULTS: The sensitivity of K-ras mutational analysis was 83.3% (25/30) in paraffin-embedded samples and 72.7% (16/22) in surgically resected specimens of the malignancy. On the other hand, no mutations were found in pancreatic neuroendocrine tumors or in chronic pancreatitis. Regarding the histopathological grading, the higher positivity rate was found in poorly-differentiated adenocarcinoma (100%), and progressively decreased in moderately-differentiated adenocarcinoma (72.2%), and well-differentiated adenocarcinoma (66.6%). The positivity rate in non-classified adenocarcinoma was 81.8%. CONCLUSION: K-ras point mutation, in our study, is notably prevalent in malignancies and is absent in chronic pancreatitis and pancreatic neuroendocrine tumors. These results encourage us to consider the possibility of treatment strategies for this oncogene in the future. (+info)