Indian Journal of Gastroenterology最新文献

Acute pancreatitis is an acute inflammatory disease, which may be associated with pancreatic and peri-pancreatic necrosis and development of (peri)pancreatic fluid collections (PFCs). Interventions in acute pancreatitis have evolved over the years with a paradigm shift from open surgical drainage and necrosectomy to minimally invasive approaches. Depending on the presence of necrosis, the PFCs may be acute necrotic collections or acute pancreatic fluid collections, which evolve over a period of three to four weeks to walled-off necrosis and pseudocysts, respectively. Patients with symptomatic and infected PFCs require drainage. In general, drainage should be delayed beyond three to four weeks when the collection wall has matured and the necrotic debris is liquefied. However, some patients may merit early drainage (within the first three to four weeks), if they have suspected infected pancreatic necrosis and worsening organ dysfunction despite antibiotics and supporting therapy. Endoscopic transmural drainage and necrosectomy have now emerged as the most favored treatment modality in suitable pancreatic collections located predominantly in the lesser sac. Being minimally invasive, per-oral endoscopic direct necrosectomy is as effective as surgical necrosectomy in patients with infected necrotic collections but with fewer adverse events. Percutaneous endoscopic necrosectomy is an important addition to our armamentarium for laterally placed collections as an effective alternative to surgical video-assisted retroperitoneal debridement. The current review provides an overview of the evolution, indications, approaches, techniques and outcomes of endoscopic interventions in the management of pancreatic fluid collections associated with acute pancreatitis. Future direction for better outcomes has been highlighted.

Acute pancreatitis (AP) is a burgeoning challenge. The first week of the disease is generally considered early AP. Events that occur during this phase can determine the magnitude of subsequent events. Even after decades of research, there is still no curative therapy for early AP. One of the earliest events of clinical AP is the co-localization of zymogen and trypsinogen within autophagolysosome which is followed by trypsin activation. The resulting acinar injury releases damaged-associated molecular patterns (DAMPs) that trigger cytokine production by the resident immune cells. Concurrently, there will be neutrophil infiltration, endothelial dysfunction and capillary leak. The local intra-pancreatic inflammation will activate the circulating mononuclear cells traversing the inflamed pancreas and in turn, get activated and perpetuate the systemic inflammatory response syndrome (SIRS). This eventually triggers organ damage. Concurrently, another phenomenon called compensatory anti-inflammatory response syndrome (CARS) ensues, that makes the patient susceptible to infections including infected necrosis. CARS is characterized by the downregulation of human leukocyte antigen (HLA)-DR and results in immunosuppression. The intestine also has a substantial role in determining the severity progression of systemic events in AP. The three components of the intestine that have been implicated include gut mucosal barrier, the microbiota and intestinal lymph. Intestinal inflammation occurs as a part of SIRS and results in the loss of tight junctions and apoptosis of the intestinal epithelial cells thereby increasing the mucosal permeability. Meanwhile, there will be gut microbial dysbiosis resulting in the translocation of pathogens and pathogen-associated molecular patterns (PAMPS) into the circulation. This would result in infections, which was already facilitated by CARS. In addition, the intestinal lymph could also result in translocation of intestinal toxins to the systemic circulation thereby contributing to the severity of AP. This narrative review discusses the current understanding of the mechanisms of early AP and the clinical implications.

Exocrine pancreatic insufficiency (EPI) frequently occurs following gastric resection, although it remains underdiagnosed and insufficiently managed. While pancreatic enzyme supplementation (PES) is the cornerstone of the management of EPI, substantial evidence endorsing its application post-gastric surgery is scarce. This scoping review assesses the occurrence of EPI following gastric resection and the influence of PES in managing these patient populations. All relevant studies related to EPI and PES in patients with gastric resection were reviewed until November 2024. Patient demographics, clinical profiles, method of assessment and prevalence of EPI and the effect of PES were analyzed. Total 14 studies reported EPI after gastric resection and three analyzed the outcome of PES after gastric resection. There was considerable variability in the methodologies employed to evaluate EPI following gastric resection. Earlier studies employed direct tests; however, newer studies have utilized indirect tests, predominantly the fecal elastase test. Both studies employing direct tests indicated an EPI prevalence rate of 100%, whereas those utilizing indirect tests revealed a prevalence rate between 26.8% and 100% (26.8% to 63.8% with fecal elastase). Only four studies reported on the severity of EPI following stomach resection, with significant variability. Lastly, there was a lack of high-quality evidence indicating the benefits of PES following gastric resection. Future studies are needed to develop criteria that facilitate the diagnosis of EPI in individuals who have undergone gastrectomy. Robust clinical trials are necessary to provide definitive proof of PES's efficacy in enhancing patient outcomes.

Background and aims: In chronic pancreatitis, fully covered self-expanding metal stents (FCSEMS) are used to treat refractory pancreatic duct strictures. However, the FCSEMS design, effectiveness, safety, optimal stent indwelling time and patient selection remain unclear. This study aimed at evaluating technical success, clinical success and adverse events with FCSEMS in patients with symptomatic pancreatic duct stricture.

Methods: The prospective study was conducted between May 2017 and May 2021 at a tertiary care center for chronic pancreatitis with refractory pancreatic duct stricture using controlled radial expansion (CRE) endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS (Niti-S, Bumpy stent, Taewoong Medical, Gimpo-Si, South Korea).

Results: During the study period, a total of 11 patients underwent ERCP with FCSEMS for refractory pancreatic duct stricture. The mean age (± standard deviation, [SD]) was 32.36 ± 10.98 years and nine patients (81%) were male. Technical and clinical success rates were 100% and 90.9%, respectively. All patients had a history of prior pancreatic endotherapy. The median (inter quartile range, [IQR]) stent indwell time was seven (6-10) months. The median visual analogue scale (VAS) pain score pre and post-FCSEMS was 8 (5-8) and 1 (0-2), respectively (p-value 0.003). Median (IQR) follow-up after stent removal was 48 (40-60) months. One patient (9%) developed de novo main pancreatic duct (MPD) stricture, which was asymptomatic. None of the patients had cholangitis, pancreatitis, perforation, proximal migration or stent fracture.

Conclusion: The FCSEMS treatment appears to be safe, feasible and possibly an effective option for patients who have not responded to endoscopic plastic stenting.

Background: The incidence of acute pancreatitis is increasing globally. Gallstones (GS) and ascariasis are the major causes for acute pancreatitis in the Kashmiri population. In recent years, we have observed an increase in the admission rate of acute pancreatitis. Many patients who present first time as gallstone pancreatitis have asymptomatic gallstones. We aimed at studying the etiology and yearly admission rate of acute pancreatitis with main focus on gallstone pancreatitis and the contribution of asymptomatic gallstones.

Methods: This was a hospital-based, prospective, observational study from January 2015 to December 2019 for a period of five years. Patients of acute pancreatitis were evaluated for etiology and yearly admission rate. Patients of gallstone pancreatitis were evaluated in terms of clinical profile, risk factors, nature (symptomatic/asymptomatic, known/unknown gallstones), size of stones, treatment and outcome in terms of severity and mortality. The data was analyzed by Statistical Package for the Social Sciences (SPSS) version 20.0, as mean (SD), frequencies and percentages.

Results: As many as 702 (8.5%) patients of acute pancreatitis were admitted among 8245 gastrointestinal emergencies in five years. The yearly admission rate of acute pancreatitis was 5.6%, 7.3%, 8.7%, 9.5% and 10.3%, respectively (p = 0.013). Gallstones, Ascariasis, alcohol and idiopathic acute pancreatitis were 47.7%, 6.9%, 1.2% and 33.7%, respectively. Gallstone pancreatitis increased from 31% in 2015 to 52.4% in 2019 (p = 0.045) and ascariasis-related acute pancreatitis declined from 14.4% to 1.6% (p = 0.034). Asymptomatic gallstones constituted 87.7% of cases. Known/unknown asymptomatic gallstones and symptomatic gallstones were 24.4%, 63.2% and 12.2%, respectively. Gallstones < 5 mm and > 5 mm were76.1% and 23.8% respectively (p = 0.027). Cholecystectomy rate in index admission was 4.7%. Mild, moderate and severe gallstone pancreatitis was 60.2%, 18.8% and 20.8%, respectively. Mortality in gallstone pancreatitis was 10.4%.

Conclusion: The incidence of acute pancreatitis is increasing due to gallstone pancreatitis. Ascariasis-related acute pancreatitis has declined. There is significant contribution of asymptomatic gallstones in patients who present for the first time as acute pancreatitis. Small gallstones < 5 mm are likely to be the risk factors for gallstone pancreatitis.

Chronic pancreatitis is a progressive inflammatory disorder characterized by recurrent or persistent abdominal pain. Traditionally, pain in chronic pancreatitis has been linked to anatomical factors such as ductal hypertension, parenchymal pressure and disease-related complications, including pseudocysts and biliary obstruction. However, emerging evidence supports a neurobiological model of pancreatic pain, emphasizing neuropathic mechanisms and central sensitization as key contributors. Pain management in chronic pancreatitis requires a personalized, step-wise approach that combines pharmacologic titration, endoscopic decompression and, when necessary, surgical intervention. While the World Health Organization pain ladder, originally developed for cancer-related pain, offers a conceptual framework, its applicability to chronic pancreatitis remains insufficiently validated across diverse patient populations. In difficult cases, opioids are often prescribed despite increasing global concerns about opioid use disorder. The opioid epidemic highlights the importance of adopting responsible prescribing practices, employing validated screening tools and promoting interdisciplinary collaboration to balance effective pain relief with risk reduction. Recent advances such as neuromodulators (e.g. tricyclic antidepressants, pregabalin), celiac plexus blocks, pancreatic enzyme replacement therapy and antioxidant therapy, have improved outcomes in specific patients. Nonetheless, there is a significant need for innovative strategies that tailor pain management, lessen dependence on opioids and address the psycho-social aspects of chronic pain. This review emphasizes the burden of pain in chronic pancreatitis, assesses current treatment approaches and examines the relationship between opioid stewardship and quality of life. A paradigm shift-grounded in mechanistic understanding, multidisciplinary care and adaptable therapies-is vital to enhance long-term outcomes while minimizing opioid-related risks and harm.

Introduction: Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) presents a therapeutic challenge with no currently definitive treatment, including therapeutic plasma exchange (TPE) and insulin. TPE aims to quickly reduce serum triglyceride (TG); however, its efficacy lacks convincing evidence. Intravenous insulin is a promising and convenient alternative, while comparative data is limited.

Methods: This retrospective, single-center study compared TPE and insulin treatment in HTG-AP patients. The primary outcome measured was the percentage of TG reduction within 48 hours of admission.

Results: The study included 33 TPE-treated and 56 insulin-treated patients. The TPE groups were more severe than those with medical therapy at baseline characteristics. A trend towards higher TG reduction within 24 hours was observed in the TPE group (62.5% [IQR 51.7-83.3] vs. 55.7% [IQR 34.2-74.7], p = 0.038). However, no significant difference in TG reduction at 48 hours was found between insulin and TPE groups (83.6% and 81.9%, respectively, p = 0.715). The TPE group exhibited extended hospital stays (10.0 [IQR 7.0-13.5] days vs. 6.0 [4.0-8.7] days, p = 0.001) without any difference in in-hospital mortality or time needed to lower TG below < 11.3 mmol/L.

Conclusion: In patients with HTG-AP, TPE decreased plasma triglyceride levels faster in the first 24 hours than insulin therapy. However, there was no significant advantage after 48 hours. Therefore, insulin may be a promising alternative and convenient treatment in carefully selected patients with HTG-AP.

Background: Endoscopic ultrasound (EUS)-guided drainage is the standard of care for drainage of pancreatic necrosis. Though initially it was mainly used for drainage of only walled-off necrosis, recently, a few studies have also shown its safety in the management of acute necrotic collections. We did a retrospective study to evaluate the safety and efficacy of EUS-guided drainage in the early phase of pancreatitis as compared to interventions in the late phase.

Methods: We retrieved baseline disease-related, procedure-related and outcome-related details of patients who underwent EUS-guided drainage of pancreatic necrosis. Patients were divided into early (≤ 28 days from onset of pancreatitis) or delayed (> 28 days) drainage groups. Both groups were compared for disease-related characteristics and outcomes.

Results: Total 101 patients were included in the study. The mean age of included patients was 35.54 ± 13.58 years and 75 were male. Thirty-five patients (34.7%) underwent early drainage. In the early group, a majority of patients underwent intervention due to infected collection (88.6% vs. 18.2%; p < 0.001). More patients in the early group had < 30% wall formation (28.6% vs. 0%; p < 0.001) and > 30% solid debris within the collection (42.9% vs. 15.2%; p = 0.005). Patients in the early group were also more likely to require endoscopic necrosectomy (57.1% vs. 27.3%; p = 0.003) and additional percutaneous drainage (31.4% vs. 12.1%; p = 0.018). Overall, three patients in the early group and one patient in the delayed group had procedure-related complications. Four patients in the early group and one patient in the delayed group succumbed to illness (p = 0.029).

Conclusion: Though delayed interventions remain standard of care in the management of acute pancreatitis, some patients may require early intervention due to infected collection with deteriorating clinical status. Early EUS-guided interventions in such carefully selected patients have in similar clinical outcomes and complication rates compared to delayed intervention. However, such patients are more likely to require additional endoscopic or percutaneous interventions.

Background: Endoscopic ultrasound guided fine-needle aspiration (EUS FNA) is the first-line modality to diagnose suspected solid pancreatic malignant lesions. Elastography-guided FNA has been shown to improve the diagnostic yield of EUS FNA but prospective studies are limited. The aim of the study was to compare diagnostic accuracy, sensitivity and specificity of conventional and elastography-guided EUS FNA in patients with suspected malignant pancreatic solid masses.

Methods: Patients with suspected malignant solid pancreatic lesions presenting to our institute from July 2021 to January 2023 were recruited and randomized to conventional and elastography-guided EUS FNA using a 22-G EUS FNA needle. Diagnostic accuracy, sensitivity, specificity and positive and negative predictive values were calculated.

Results: Total 48 patients were initially screened for inclusion in the study, of which six were excluded and 42 patients underwent randomization. Finally, 20 patients in each group underwent the assigned intervention and were analyzed further. Baseline patient characteristics were similar in conventional FNA and elastography-guided FNA group with median age 52 (range 29-74) years and 51.8 (range 31-72) years, respectively, males being 70% and 75%, respectively. Median size of the lesion was 34 mm (range 14-48 mm) and 37 (range 18 to 50 mm), respectively, for both conventional and elastography arm. The average size of the lesion was 35.7 mm. Overall, the diagnosis of adenocarcinoma was made in 65% of cases. In the remaining cases, diagnoses were inflammatory mass, Castleman's disease, solid pseudopapillary epithelial neoplasm (SPEN), diffuse large B-cell lymphoma (DLBCL), pancreatic gastrointestinal stromal tumor (GIST) and metastasis. Conventional EUS FNA had diagnostic accuracy, sensitivity, specificity and positive and negative predictive values of 90%, 87.5%, 100%, 100% and 62.92%, respectively, and elastography-guided EUS FNA had diagnostic accuracy, sensitivity, specificity and positive and negative predictive values of 85%, 100%, 100% and 54.59%, respectively. No severe adverse events were noted.

Conclusion: There is no significant difference between conventional and elastography-guided EUS FNA in terms of diagnostic accuracy, sensitivity, specificity and positive and negative predictive values. Both techniques appear safe and effective for characterizing solid pancreatic masses and elastography did not score numerically over the conventional arm.

Autoimmune pancreatitis (AIP) is a rare inflammatory disorder of the pancreas, often mistaken for pancreatic cancer. Despite definitive diagnostic criteria such as histology, imaging, serology, other organ involvement and response to therapy (HISORt), International Consensus Diagnostic Criteria (ICDC) and Japan Pancreas Society (JPS) criteria being available for AIP, making a diagnosis of AIP remain a rarity in the evaluation of a pancreatic mass or distal bile duct obstruction. A significant proportion of patients are diagnosed only after surgical resection. Endoscopic ultrasound (EUS) is the main modality for establishing diagnosis of AIP. Considering the rarity of the disease, there are no classical findings on EUS associated with AIP. Histopathology remains the crux for diagnosing AIP with need for EUS-guided sampling. Both focal and diffuse forms of AIP are described with different EUS findings in both. The focal form mimics pancreatic cancer closely. The disease is also known to have extra-pancreatic involvement with cholangiopathy also seen often in association. Diffuse involvement of the pancreas is unusual and may be rarely seen with diffuse pancreatic infiltrative diseases. The primary consideration remains differentiating AIP from carcinoma of pancreas, where EUS plays a significant role. Adjunct techniques such as EUS-guided elastography and contrast harmonic EUS can add value in diagnosing AIP. Advances in tissue sampling, including availability of better needles for core biopsy, have aided in improving the diagnostic yield of AIP. In this narrative review, we aim to highlight the increasing role of EUS for establishing diagnosis of AIP while elaborating its role in evaluation, sampling and therapeutic monitoring.