Introduction

This study aims to examine the extent of notable variations in recurrence rates, admissions to the intensive care unit (ICU), length of hospital stay (LoS), morphological characteristics, disease severity, and patient age between hypertriglyceridemia-induced acute pancreatitis (HTG-AP) and other causes of acute pancreatitis (OAP).

Aims & Methods

A retrospective, single-center cohort study was conducted using data from the BUC-API registry, which includes 1,855 consecutive cases of acute pancreatitis. We aim to seek if there are differences between cases with HTG-AP and OAP regarding demographical and clinical data.

Results

Our analysis reveals a modest association between HTG-AP and increased recurrence rates (χ²(1)=6.9, p<0.01, Cramer's V=0.07). Patients with HTG-AP had a median age of 44.5 years and experienced longer ICU stays (median=7.0 days) compared to those with OAP (median=3.0 days). Furthermore, patients with HTG-AP were more likely to develop acute peripancreatic fluid collections, require ICU admission, experience severe disease, and be treated in a gastroenterology ward (p=0.02, p<0.01, respectively).
Table 1 – Comparative analysis. Only findings with p-value <=0.01 presented.

Conclusion

HTG-AP is frequently linked with intensive care needs. The association between HTG-AP and recurrence may be linked to suboptimal adherence to lipid-lowering therapy. The typical profile of an HTG-AP patient is a middle-aged, mainly male individual with a history of acute pancreatitis, necessitating gastroenterology ward care, facing longer ICU and hospital stays, at a higher risk for severe acute pancreatitis (SAP), and with an increased likelihood of developing acute peripancreatic fluid collection (APFC).

References

1. A. L. Yang și J. McNabb-Baltar, „Hypertriglyceridemia and acute pancreatitis”, PANCREATOLOGY, vol. 20, nr. 5, pp. 795–800, iul. 2020, doi: 10.1016/j.pan.2020.06.005.
2. D. Mosztbacher et al., „Hypertriglyceridemia-induced acute pancreatitis: A prospective, multicenter, international cohort analysis of 716 acute pancreatitis cases”, PANCREATOLOGY, vol. 20, nr. 4, pp. 608–616, iun. 2020, doi: 10.1016/j.pan.2020.03.018.
3. V. P. Pulipati, E. A. Brinton, și B. Hatipoglu, „Management of Mild-to-Moderate Hypertriglyceridemia”, Endocr. Pract., vol. 28, nr. 11, pp. 1187–1195, nov. 2022, doi: 10.1016/j.eprac.2022.07.003.
4. R. A. Carr, B. J. Rejowski, G. A. Cote, H. A. Pitt, și N. J. Zyromski, „Systematic review of hypertriglyceridemia-induced acute pancreatitis: A more virulent etiology?”, PANCREATOLOGY, vol. 16, nr. 4, pp. 469–476, aug. 2016, doi: 10.1016/j.pan.2016.02.011.

Clinical Case Summary

Background and Aims: A 66-year-old woman was referred to our center for a recent diagnosis of type 2 achalasia non-responsive to endoscopic dilatation (up to 35 mm). She reported the onset of daily dysphagia 5 years before and 8 kg weight loss, daily regurgitation and occasional chest pain (Eckdart score 7/12). Barium swallow videofluoroscopy showed normal transit through esophageal-gastric junction and upper GI endoscopy was normal.
Methods: Due to the lack of clinical response to endoscopic dilatation, the patient was referred to our center to perform Per Oral Endoscopic Myotomy (POEM).
We repeated a radiologic study of the esophageal transit and the upper endoscopy with esophageal biopsies.
Results: The radiologic study of the esophageal transit showed mild dilation of the proximal tract associated with dyskinesia of the mid-distal portion and asynchronous tertiary contractions without closed stenosis of the lower esophageal sphincter (LES).
In the endoscopy, the esophagus was macroscopically normal. The histological examination of esophageal biopsies showed numerous intraepithelial CD3 positive T lymphocytes predominantly located in the lower-middle compartment of the epithelium (> 200/HPF). The histologic finding was highly suspected for lymphocytic esophagitis and we decided to start with topic steroid therapy with galenic budesonide (2 mg/die) with symptomatic improvement after two months. We will perform endoscopic and histologic evaluation 3 months after the start of therapy.
Conclusion: This case report is an example of lymphocytic esophagitis with a dysmotility-like onset. This condition generally affects old women and, the most common symptom is the dysphagia and food impaction. Therefore is fundamental to perform always upper GI endoscopy with esophageal biopsies to complete the diagnostic flowchart to exclude eosinophilic and non-eosinophilic esophagitis in patients complaining with symptoms of esophageal dysfunction.

Clinical Case Summary

Background: Pancreatic Adenocarcinoma (PA) represents an aggressive disease affected by very poor prognosis worldwide. In the early phases, PA remains asymptomatic favoring delayed diagnosis and affecting the disease prognosis. Recently, Acute Pancreatitis (AP) has been described by some anecdotical cases as a potential early manifestation of PA, in particular if case of pancreatic head development.
Case presentation: An 80-year-old female patient affected by diabetes mellitus type 2 complaining of acute epigastric pain was admitted to the emergency room receiving an AP diagnosis. After 2 days she was hospitalized at Gastroenterology Department to receive medical treatment. On admission, the patient presented hyper-neutrophilia, elevated levels of pancreatic enzymes, cholestasis indexes, and phlogosis markers. Abdominal ultrasound revealed a hypoechoic nodular lesion of 40 mm located at the pancreas body, associated with ectasia of the upstream Wirsung duct. The contrast enhancement US (CEUS), evidenced a hypoenhancement pattern in the arterial phase suggesting the need for a second-level imaging examination. The abdominal CT scan revealed the lesion ventral to the splenic-portal confluence without signs of vascular infiltration, presenting a late contrast enhancement suggestive of a hetero-primitive lesion of the pancreatic body. Echo-endoscopy-guided sampling confirmed the adenocarcinoma diagnosis. After this, the patient received a distal pancreatectomy to achieve surgical radicality. No progression of disease was observed after surgery, and she is currently on stable oncological follow-up.
Conclusion: Even when the neoplasm is not located in the head of the organ, AP has herein been reported as a rare exordial manifestation of PA whose onset can help clinicians to achieve early diagnosis of this aggressive tumor.

References

1. Saluja A, Maitra A. Pancreatitis and Pancreatic Cancer. Gastroenterology. 2019 May;156(7):1937-1940. doi: 10.1053/j.gastro.2019.03.050. Epub 2019 Mar 30. PMID: 30940522.
2. Bezuidenhout AF, Wei PK, Burstein D, Brook A, Brook OR, Freedman SD, Tsai LL. Unexplained Acute Distal Pancreatitis: Association With Subsequent Diagnosis of Pancreatic Cancer. AJR Am J Roentgenol. 2023 Aug;221(2):196-205. doi: 10.2214/AJR.23.28999. Epub 2023 Mar 22. PMID: 36946899.
3. Walling A, Freelove R. Pancreatitis and Pancreatic Cancer. Prim Care. 2017 Dec;44(4):609-620. doi: 10.1016/j.pop.2017.07.004. Epub 2017 Oct 5. PMID: 29132523.

Clinical Case Summary

Patient of 71 years old with CP was admitted for painless jaundice with benign common bile duct (CBD) stricture. ERCP failed at her center due to duodenal edema that prevented seeing the papilla so the patient was transferred to our center for assisted EUS drainage.

After after a first attempt with an unsuccessful rendezvous ERCP due to guidewire loss in the exchange of devices, cholecystoduodenostomy was performed with a coaxial double pigtail after confirmation of cystic duct permeability in the cholangiogram (previously performed under EUS guidance with puncture of the CBD to perform de rendezvous). In a second attempt to treat the stricture, a rendezvous through the gallbladder was performed. After papilloplasty and dilating the stricture, a 10 x 60 mm FCMS was placed. The patient improved and the lumen apposing metal stent of the cholecystoduodenostomy was removed. In followup, proximal migration of the stent was observed, impossible to remove by ERCP at her center due to impossibility of accessing the papilla.

In our center, a new endoscopy was performed. CBD was punctured by EUS with a 22 G needle through the biliary stent to perform a rendezvous and a novagold guidewire was advanced to the duodenum. The CBD was accessed with a monorail sphincterotome over the guidewire and rigid guidewire was advanced to the biliary tract. Papilloplasty was performed againd and the migrated stent was removed with rat tooth forceps. A new FCMS was placed successfully.

To conclude, endoscopic management of patients with CP can be very complex and several advanced combined bile duct access techniques are sometimes required. So, these patients should ideally be managed in referral centers.

Introduction

EUS-guided drainage using lumen-apposing metal stents (LAMS) has become standard treatment of symptomatic walled-off necrosis (WON). The development of these fully covered self-expanding metal stents with special design of the flanges and large diameter, improved the drainage of debris and facilitated further direct endoscopic necrosectomy. Delivery systems with integrated electro-cautery (EC) enable direct access and stent deployment whilst the conventional stent insertion technique requires several steps including access using a needle or cystotome, wire insertion and enlargement of the created tract before the stent placement.

Aims & Methods

In this single center study, we aimed to compare the practicality of EUS-guided procedures and their outcome between conventional LAMS (cLAMS) and those with integrated EC (LAMS-EC).
From our prospectively maintained database, we included consecutive patients undergoing EUS-guided LAMS insertion with or without integrated electro-cautery for drainage of walled-off necrosis. Infection of the walled-off pancreatic necrosis, biliary compression with cholestasis or gastric outlet obstruction were accepted indications for intervention. Data on procedure time, sedation, hospital stay, technical and clinical success as well as adverse events were analysed.

Results

We analysed 107 consecutive procedures of transmural EUS-stenting for drainage of walled-off necrosis. 39 cLAMS and 68 LAMS-EC were placed successfully. Mean size of the walled-off necrosis was 12.9 ± 4.2 cm with mean 30% ± 15% solid necrosis.
Procedure times were shorter with LAMS-EC (18 .0 ± 6.6 min vs. 39.7 ± 8.3 min; p<0.05). All EUS-guided procedures with cLAMS drainage were performed under propofol sedation administered by an anaesthetic team. In the LAMS-EC group, 36 patients tolerated the procedure under iv sedation (fentanyl/midazolam) in left lateral position and 17 interventions were performed as daycase procedures. None of the patients developed sedation related adverse events such as aspiration.
Adverse events, technical success and clinical outcome did not differ between both groups.

Conclusion

The findings of this study suggest that cLAMS and EC-LAMS achieve similar rates of technical and clinical success without difference in the rate of adverse events. Compared to cLAMS, deplayment of EC-LAMS is faster and technically less demanding. This might allow to perform the procedure under conventional intravenous sedation and as daycase procedure in carefully selected patients.

Clinical Case Summary

A 90-year-old woman was referred to our endoscopy unit from another hospital for urgent rescue therapy because of impacted Dormia basket during ERCP performed for symptomatic recurrent choledochal lithiasis. In attempt to perform extracanalar lithotripsy Dormia basket was broken near the handle. Another ERCP was performed, and the contrast cholangiography showed dilated common bile duct (up to 13mm) with a constriction in the middle part and impacted Dormia basket with multiple gallstones, confirmed by Spyglass single-operator per-oral cholangioscopy with direct visualization. Electrohydraulics lithotripsy with Autolith EHL system (2437 pulses, medium-high power) was performed with stones fragmentation but Dormia basket entrapped stone fragments. Dormia basket distal margin was caught with a biopsy forceps and passed in duodenoscope working channel. Then biliary clearance was completed with ballon catheter and the following cholangiography confirmed successful biliary drainage and optimal bile outflow without contrast biliary or duodenal spreading. Postprocedural course was regular, and the patient was discharged after three days of hospitalization.