Indian Journal of Gastroenterology最新文献

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.

Chronic pancreatitis (CP) is an irreversible disease of varied etiology characterized by destruction of pancreatic tissue and loss of both exocrine and endocrine function. Pain is the dominant and most common presenting symptom. The common cause for pain in CP is ductal hypertension due to obstruction of the flow of pancreatic juice in the main pancreatic duct either due to stones or stricture or a combination of both. With advances in technology and techniques, endoscopic retrograde cholangiography (ERCP) and stenting should be the first line of therapy for strictures of the main pancreatic duct (MPD). Small calculi in the MPD can be extracted by ERCP and balloon trawl. Extracorporeal shockwave lithotripsy (ESWL) remains the standard of care for large pancreatic calculi and aims to fragment the stones 3 mm or less that can easily be extracted by a subsequent ERCP. Single operator pancreatoscopy with intraductal lithotripsy is a technique in evolution and can be tried when ESWL is not available or is unsuccessful in producing stone fragmentation.

Background and objective: Early-onset pancreatic cancer (EOPC) is associated with poor prognosis and high disease burden. Metabolic risk factors such as diabetes and obesity are considered risk factors of EOPC. Recently, there has been an increasing number of EOPCs worldwide. However, the analysis of EOPC, including its metabolic risk factors, in the Middle East and North Africa (MENA) region has not been fully addressed.

Methods: Data from the Global Burden of Disease Study between 2000 and 2019 was used to analyze the prevalence, incidence, deaths and disability-adjusted life years (DALYs) associated with EOPC and its metabolic risk factors. The analysis further categorized the data based on countries, income status and sex and examined the annual percentage change (APC).

Results: Approximately 2800 cases, 2400 deaths and 114,000 DALYs were attributable to EOPC in the MENA region. The incidence (APC + 3.42%), death (APC + 0.73%) and DALYs (APC + 3.23%) rates of EOPC increased. In addition, the death and DALY rates of EOPC attributable to obesity and diabetes increased. High and upper-middle-income countries exhibited a higher burden of EOPC than lower-income countries.

Conclusion: Over the past two decades, the burden of EOPC and its associated metabolic risk factors has increased. There is an urgent need for region-wide policy development, including screening methods and risk factor reduction, to mitigate the high and rising burden of EOPC in the MENA region.

Background and objectives: The ageing population is increasing in India and there is hardly any information on outcomes of acute pancreatitis (AP) in the elderly in India. Hence we studied the comprehensive clinical characteristics and outcomes of AP in elderly patients.

Methods: This study included patients admitted with AP to a tertiary care centre from October 2018 to October 2022. Patients with the first episode of AP presenting within 14 days of disease onset were eligible for inclusion. The elderly population was defined as age ≥ 60 years. Recurrent AP, chronic pancreatitis and AP presenting after 14 days of disease onset were excluded. Propensity score matching was performed based on etiology and severity to compare elderly and non-elderly groups. Primary outcome was serious adverse outcome (SAO: in-hospital mortality or discharge in critical state). Secondary outcomes included organ failures, local complications, necrosis, mesenteric vascular thrombosis (MVT), length of hospital stay, intensive care unit (ICU) admission and infections.

Results: Of 630 eligible patients, 120 were > 60 years of age. Among the elderly, 72 (60%) were males. The median age was 68 (IQR 63-74) years. The most common etiology was biliary 76 (63.3%) followed by idiopathic 25 (20.8%) and alcohol eight (6.7%). Mild AP was seen in 72 (60%), while 21 (17.5%) had moderately severe and 27 (22.5%) had severe AP. Organ failures occurred in 27.5%, necrotizing pancreatitis in 15.2%, local complications in 27.6% and MVT in 3.3%. Infections affected 28.3%. Median hospital stay was four days (IQR 1-28), with 12.5% requiring ICU admission. SAO occurred in 8.3% of elderly patients, comparable to 11.4% in the non-elderly (p = 0.334). Bedside index for severity in acute pancreatitis (BISAP) score (adjusted OR 2.7, 95% CI 1.05-6.96, p = 0.04) and Charlson comorbidity index (without age) (adjusted OR 1.94, 95% CI 1.07-3.51, p = 0.03) independently predicted SAO in the elderly.

Conclusion: The outcomes of AP in the elderly in India are similar to patients < 60 years. Charlson comorbidity index and BISAP score predicted serious adverse outcomes in the elderly.

Infected pancreatic necrosis (IPN) is a serious and critical complication of acute pancreatitis (AP), often arising in the later stages of the disease. Early detection of high-risk individuals with IPN is essential because it may enable clinicians to implement more efficient management strategies. This review explores the key biomarkers currently used to predict and diagnose IPN. Established markers such as procalcitonin (PCT), C-reactive protein (CRP) and interleukin-6 (IL-6) play a vital role in detecting infection and inflammation. Non-invasive markers, including corticosteroid-binding globulin (CBG), neutrophil CD64 index (nCD64), soluble PD-L1 (sPD-L1) and human leukocytes antigen-DR (HLA-DR), further contribute to identifying immune suppression and infection risks. While these tools show promise, no single biomarker has proven to be sufficiently accurate. A combination of clinical assessment, imaging and multiple biomarkers is essential for a comprehensive diagnosis. This review emphasizes the need for further research to refine and validate these markers, making them more accessible and reliable for routine clinical use. By advancing our ability to identify IPN early, we can improve patient outcomes and reduce the severe impacts of this complication in individuals suffering from AP.