Introduction

Updated population-based studies on acute pancreatitis (AP) in Romania are lacking. Our aim was to evaluate the current data for AP in a tertiary center in Bucharest.

Aims & Methods

We performed an electronic health care records (EHRs) search ICD-10 codes: K85, B25.2, B26.3) for AP cases treated at University Emergency Hospital of Bucharest between 2015 and 2022. Aim of this study was to estimate the daily cost of AP and its probable correlation in regard to: type of case (gastroenterological or surgical), sex, age, ICU, outcome, etiology, severity, morphology (assessed as stated in Revised Atlanta Classsification (RAC). All costs reported in EUR by conversion from RON at the date of submission (28 april 2023).

Results

1503 episodes of AP (942 gastroenterological, 561 surgical) in 1314 unique patients were analysed, data about costs being found in 1246 episodes. Median daily cost (MDC) estimated at 170.91. Higher MDC was related to surgical AP, F(1,1244)=7,05, p<0,01. The Kruskal-Wallis analysis showed significant diferences in regard to: severity H(2)=85,20, p<0,01 with the highest cost in severe AP (Md=229.23) and the lowest in mild AP (Md=162.26); outcome H(4)=105,22, p<0,01 the deceased having the highest MDC (Md=204.84) and the one healed the lowest (Md=118.57). Significant differences H(6)=17,22, p<0,01 were found between Acute Necrotic Collection (Md=123.29) and Interstitial AP (Md=84.80) and between the biliary H(15)=203,96, p<0,01 (Md=139.34), hypertrigliceridemic (Md=97.45) and alchoolic etiology (Md=79.31). Pearson Correlation found a weak and unsignificant correlation with older age, r(1244)=0,25, p=0,373. No significant differences were found regarding sex, F(1,1244)=2,73, p=0,09, and admission in ICU F(1,1229)=1,46, p=0,23.

Conclusion

In this large retrospective study higher costs of AP correlate to hospitalization in surgical wards, severity, developement of local complications and biliary etiology. No correlations were found to age or ICU admission. Median daily cost (MDC) estimated at 170.91. This is the first report of AP related costs in Romania.

References

1. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111. doi: 10.1136/gutjnl-2012-302779
2. Fagenholz PJ, Fernández-del Castillo C, Harris NS, et al. Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas. 2007;35(4):302-307. doi: 10.1097/mpa.0b013e3180603f3a
3. Kim MK, Han J, Lee SY, et al. The economic burden of acute pancreatitis in Korea: a national population-based study. PLoS One. 2018;13(4):e0195550. doi: 10.1371/journal.pone.0195550
4. Barkin JA, Barkin JS, Hupertz V, et al. Hospital length of stay and cost of acute pancreatitis in the United States: a systematic literature review. Pancreas. 2015;44(6):810-815. doi: 10.1097/MPA.0000000000000349
5. Martínez-Moneo E, Sánchez-Pobre P, Pérez-Martínez I, et al. Impact of a standardized protocol of clinical management and follow-up on healthcare costs in patients with acute pancreatitis. Rev Esp Enferm Dig. 2017;109(10):719-725. doi: 10.17235/reed.2017.4562/2017

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

Introduction: Superior mesenteric artery pseudoaneurysms (SMA) are rare vascular entities, but can potentially result in significant morbidity and mortality (up to 60%) if rupture occurs. Traditionally, SMA pseudoaneurysms are associated with arterial dissection, pancreatitis, infection, trauma, tumor invasion, or arise as post-operative and iatrogenic complication.^1-8
Case report: A 51-year-old man with a medical history of chronic alcohol consumption and chronic pancreatitis presented with multiple episodes of hematemesis and hematochezia, jaundice and severe abdominal pain with a supraumbilical pulsatile mass. The patient was haemodynamically unstable (BP: 79/45 mmHg, HR: 123/min) with inadequate resuscitation despite transfusions of blood products and intravenous fluids. Laboratory tests showed significant reduction in hematocrit (Hct: 23,9%, Hb: 7,7 g/dL) and abnormal liver function tests (TBL: 7,21 mg/dL, DBL: 4,88 mg/dL, SGOT: 156 U/l, SGPT: 92 U/l, γGT: 1822 U/l, ALP: 1577 U/l). An abdominal vascular lesion was suspected and an urgent CT angiography was performed. The CT scan confirmed the presence of a ruptured superior mesenteric artery pseudoaneurysm, 11.5cm in diameter, localized inside a giant pancreatic pseudocyst (Figure A). Ultimately, as the patient was a poor surgical candidate we decided to treat him using endovascular therapy. Arterial catheterization and angiographic evaluation of the superior mesenteric artery pseudoaneurysm was performed, showing active contrast agent extravasation treated by a fully covered stent placement (Figure B). The final angiogram confirmed the the success of the intervention. The postoperative course was uneventful and the patient was discharged on the 8^th postoperative day.
Conclusions: In conclusion, physicians should keep alert to this rare etiology of haemobilia. It is of utmost importance to urgently manage SMA pseudoaneurysms because of the high risk of rupture and potential life-threatening haemorrhage.

References

1. Guirgis M, Xu JH, Kaard A, Mwipatayi BP. Spontaneous Superior Mesenteric Artery Branch Pseudoaneurysm: A Rare Case Report. EJVES Short Rep. 2017 Oct 12;37:1-4.
2. Patelis N, Doukas P, Dodos I, Karampelas T, Kanellopoulos I, Kyriakopoulou K, Bisdas T. Endovascular Repair of a Complex Isolated Dissecting Aneurysm of the Superior Mesenteric Artery. EJVES Short Rep. 2019 Jun 17;44:5-8.
3. Kochar S, Sharparis Y, Banerjee B, Karasek M, Brennan S. Endovascular Coil Embolization of Superior Mesenteric Artery Branch Pseudoaneurysm. Cureus. 2021 Sep 16;13(9):e18014.
4. Camarasa Pérez Á, Soto Sánchez A, Pérez Sánchez E, Hernández Barroso M, Hernández Hernández G, Barrera Gómez M. Obstructive jaundice secondary to a pseudoaneurysm of the superior mesenteric artery. Rev Esp Enferm Dig. 2022 Dec;114(12):756.
5. Kimbara Y, Sato Y, Hasegawa T, Morinaga H, Murata S, Imai Y, Hara K, Okuno N, Inaba Y. Covered stent placement for emergency repair of a ruptured superior mesenteric artery pseudoaneurysm in advanced pancreatic head cancer. Radiol Case Rep. 2018 Oct 29;14(1):133-135.
6. Dávila Arias C, Ruiz-Rodríguez AJ, Cabrera Peña Á. Hematochezia secondary to hemosuccus pancreaticus due to a pseudoaneurysm associated with a pancreatic pseudocyst. Rev Esp Enferm Dig. 2021 Aug;113(8):618.

Clinical Case Summary

Pancreas divisum is the most frequent pancreatic congenital malformation and results from the failure of fusion of the dorsal and ventral pancreatic ducts during embryogenesis. In these cases, most of the pancreatic exocrine secretion is drained into the duodenum predominantly by the Santorini duct through the minor papilla. It is estimated that 5% of patients with pancreas divisum may present with symptoms, due to raised intrapancreatic dorsal ductal pressure from ductal anomalies.
The authors report a case of a 73-year-old male patient with a history of 6 admissions for acute pancreatitis in the last 12 months. These episodes were of mild severity, without cholestasis or alterations in lipid panel or serum calcium. He had no history of alcohol consumption, neither medication, nor herbal products or drug use. He denied a family history of pancreatic diseases. Between episodes of acute pancreatitis, he was asymptomatic. Magnetic Resonance Cholangiopancreatography showed a tortuous pancreatic duct with prominent caliber, with preferential drainage through the minor papilla (confirming pancreas divisum). Endoscopic ultrasound showed a diffusely dilated and tortuouspancreatic duct. Endoscopic retrograde cholangiopancreatography was performed, with successful sphincterotomy of the minor papilla and placement a pancreatic plastic stent in the Santorini duct. No complications were recorded during the procedure or the subsequent 24-hour clinical monitoring period. Two weeks after the procedure, radiographic control was performed to rule out migration of the pancreatic stent, and its endoscopic removal was accomplished. At 6 months of follow-up, the patient remained asymptomatic, without new episodes of acute pancreatitis.
This case report aims to emphasize that endotherapy for pancreas divisum, including minor papilla sphincterotomy and stenting of dorsal pancreatic duct, allows for improvement of pancreatic ductal drainage and prevention of acute pancreatitis episodes

References

Image list:

1. A tortuous pancreatic duct with prominent caliber (6mm diameter in the cephalic region), with preferential drainage through the minor papilla (Magnetic Resonance Cholangiopancreatography).
2. A diffusely dilated and tortuous Wirsung duct (Endoscopic ultrasound).
3. Successful sphincterotomy of the minor papilla and placement of a 5 Fr x 5 cm pancreatic platic stent in the Santorini duct (Endoscopic retrograde cholangiopancreatography).

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.