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Intramural gastric pseudocysts are extremely rare and are often associated with pancreatitis and pancreatic pseudocysts; they can lead to complex clinical presentations requiring careful diagnosis and management. We present a case of a 57-year-old man with a history of pancreatitis and pancreatic pseudocysts who was diagnosed with intramural gastric pseudocysts. The patient was diagnosed with multiple gastric intramural pseudocysts at different locations during separate admissions and imaging studies. This indicates a recurrence of gastric intramural pseudocysts. In these cases, studies rarely discuss recurrence and its underlying causes. This highlights a significant gap in the existing literature. To provide a broader understanding, we reviewed the literature by searching major databases (PubMed, Scopus, and Web of Science) and then extracted and analyzed data from 18 articles, reaching 24 similar cases. Of the 25 patients studied (including our case), 92% were male and 8% were female. Cases had a mean age of 47.68 ± 14.82 years. Additionally, 84% of the patients had a history of alcohol consumption, and 88% had a positive history of pancreatitis. Common symptoms were abdominal pain (especially in the epigastric region), vomiting, nausea, and weight loss. In conclusion, results showed that intramural gastric pseudocysts generally occur in middle-aged men with a history of chronic or heavy alcohol consumption and pancreatitis.

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Ampullary malignancies are extremely rare tumors that are usually diagnosed when they cause biliary obstruction. Rarely, any tumor or mass near or within the pancreas can cause acute pancreatitis and on even rarer occasions, these tumors can cause severe complications such as acute peripancreatic fluid collections, necrotizing pancreatitis, and infections. As a medical team, we must embrace these difficulties and these dreadful scenarios, as they are opportunities for growth for the medical team and opportunities to save even more patients. We present the case of a 59-year-old male who suddenly presented acute severe pancreatitis with necrosis and infection due to an ampullary mass. After recovery, he was referred to a tertiary center, where his cancer was successfully treated.

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PURPOSE: To explore the incidence, dynamic changes, prognostic factors and prognosis of late-onset vascular complications after discharge in patients with necrotizing pancreatitis (NP), and determine the relationship between the pancreatic necrosis volume (PNV) and late-onset vascular complications. METHODS: This was a retrospective cohort study that included NP patients who did not have any vascular complications during index hospitalization. Computed tomography (CT) examinations were performed, and the PNV was calculated based on the picture archiving and communication system. Multivariate logistic regression analysis was employed to determine the potential prognostic factors for late-onset vascular complications after discharge. RESULTS: A total of 35.6 % (37/104) of the patients had late-onset portal venous system involvement during the one-year follow-up period, including 35 patients with stenosis and 2 patients with occlusion. No venous thrombosis or arterial vascular complications were observed. PNV > 134 cm3 (OR, 7.08, 95 % CI 1.83-27.36; P = 0.005) and pancreatic necrosis involving the body and/or tail of the pancreas (OR, 10.05; 95 % CI, 2.66-38.02; P = 0.001) were prognostic factors for abnormal patency of the portal venous system. The abnormal patency of the portal venous system tended to persist during follow-up, and gastric varices were observed in 32.4 % (12/37) of the patients in the abnormal patency group without any symptoms. CONCLUSIONS: Late-onset vascular complications involving venous stenosis or occlusion were common in NP patients after discharge, approximately one third of whom developed gastric varices. PNV and the location of necrosis were closely associated with the development of these complications.

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Introduction and importance: Necrotizing pancreatitis is an uncommon diagnosis in pediatric patients. Early diagnosis is difficult as the presentation varies significantly. However, it should be in the differential diagnosis of abdominal pain in the pediatric age group. Case presentation: An 8-year-old girl arrived with a 1-day history of vomiting, constipation, and abrupt, increasing epigastric discomfort. She didn't have any noteworthy family or medical background. Upon examination, she seemed to be afebrile but also had discomfort in her stomach and symptoms of dehydration. An enlarged pancreas with necrotizing pancreatitis was seen in the first imaging. She received intravenous fluids, antibiotics, and analgesics as a treatment for her acute severe pancreatitis diagnosis. Since the patient continued to have fever, meropenem was prescribed in place of ceftriaxone at first. After 10 days of uncomplicated hospitalization, she was released from the hospital. Discussion: Once rare, pediatric pancreatitis now affects 3-13 out of every 100 000 people yearly. Although it is uncommon (<1% in children), necrotizing pancreatitis can happen. Its causes are similar to those of acute pancreatitis, involving genetic abnormalities and certain drugs. Abdominal discomfort, fever, vomiting, and nausea are among the symptoms. Imaging methods like contrast-enhanced CT are used in diagnosis. Surgery has given way to less intrusive techniques like catheter drainage as a form of treatment. Surgery is seldom required in pediatric instances, which are often handled conservatively. Conclusion: Childhood necrotizing pancreatitis is uncommon but dangerous; prompt diagnosis and prompt treatment are essential.

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OBJECTIVE: Necrotizing pancreatitis (NP) is a severe form of pancreatitis that often necessitates intensive care and can result in significant morbidity and mortality. This study aimed to investigate racial and gender disparities in palliative care (PC) utilization among mechanically-ventilated patients with NP. METHODS: In this retrospective analysis using the National Inpatient Sample from 2016 to 2020, we investigated 84 335 patients with NP requiring invasive mechanical ventilation, and the utilization of PC services and their disparities based on gender and race. To adjust for potential confounding factors, we employed multivariable logistic regression, ensuring that our findings account for various influencing variables and provide a robust analysis of the data. RESULTS: Among the patients studied, 15.4% utilized PC consultations. Notably, female patients were 12% more likely to utilize PC than their male counterparts (OR 1.1, 95% CI: 1.003-1.2; P = .008). Racial disparities were pronounced: African Americans (OR 0.8, 95% CI 0.7-0.9, P < .001), Hispanic (OR 0.8, 95% CI 0.7-0.9, P = .001), and Asian or Pacific Islander patients (OR 0.74, 95% CI 0.57-0.97; P = .03) had significantly lower odds of utilizing PC compared to White patients. The cohort utilizing PC had a higher in-hospital mortality rate (74.7% vs 24.8%; OR 8.2, 95% CI 7.7-9.2) but a shorter mean hospital stays and lower associated costs. CONCLUSIONS: Our findings indicate significant racial and gender disparities in the utilization of PC for intubated patients with NP, with lower utilization among males and minority populations. These findings emphasize the urgent requirement for comprehensive changes in healthcare protocols.

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Liver embolization is a common procedure for management of liver lesions. Embolization can be performed using only an embolic material or along with chemotherapy agents. Infrequent complications seen postliver embolization include pulmonary thromboembolism, hepatic infarct, liver abscess, liver failure, ischemic biliary strictures, and less frequently pancreatic damage (incidence of 1.7%). We describe a case of necrotizing pancreatitis after bland embolization of a large hepatic hemangioma. The exact mechanisms of acute pancreatitis after liver embolization are uncertain, although direct ischemic mechanisms, toxic effects of antineoplastic agents, and volume of embospheres used are believed to play a role.

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BACKGROUND: Given the previously reported harmful effects of abdominal fat burden on kidney function, we aim to investigate the relationship between major adverse kidney events within 30 days (MAKE30) and abdominal obesity in acute necrotizing pancreatitis (ANP) patients and explore the underlying risk factors. METHODS: A retrospective cohort study of all patients admitted within 72 h after the first episode of ANP to a tertiary center between June 2015 and June 2019 was conducted. Automatic image analysis software was used to calculate the area of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT) and skeletal muscle from computed tomography scans at the umbilical level. The potential risk factors of MAKE30 were analyzed by logistic regression. RESULTS: A total of 208 eligible ANP patients were enrolled, with an incidence of 23% for MAKE30. VAT area was more closely associated with the development of MAKE30, with an area under the ROC curve of 0.69 (cutoff value 200 cm2, 63.8% sensitivity and 66.7% specificity). Multivariate logistic regression analysis demonstrated that VAT area [OR 1.01 (1.01-1.02); p < 0.001] was an independent risk factor in predicting MAKE30. Patients with a VAT area > 200 cm2 had more requirements of renal replacement therapy (32% vs. 12%, P < 0.001), and a significantly higher incidence of other poor clinical outcomes (all p < 0.05). CONCLUSION: Early assessment of the VAT area may help identify ANP patients at high risk of MAKE30, suggesting that it could be a potential indicator for adverse kidney events.

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INTRODUCTION: Inflammation-induced dysregulation of the coagulation cascade and vascular stasis in hospitalized patients with acute necrotizing pancreatitis (ANP) serve as a milieu for venous thromboembolism (VTE). Deep vein thrombosis (DVT) and pulmonary embolism (PE) are often underrecognized. We evaluated the incidence and risk factors for VTE in a cohort of patients with ANP. METHODS: All adult patients with ANP at our center between 2009 and 2022 were followed for three months after index hospitalization and categorized into cases and controls based on development of VTE. Demographic, clinical, and radiologic characteristics during admission were compared. A multivariable analysis was done to identify independent predictors for VTE. A p value of <0.05 was taken as significant. RESULTS: Among 643 ANP patients, 512 [males-350, median age-52 years] were eligible for inclusion. VTE developed in 64 (12.5 %) patients - 28 DVT (5 %), 22 PE (4 %) and both in 14 (3 %) after a median 16 days from the diagnosis of ANP. Significant independent predictors for VTE on multivariable analysis were age ≥60 years (OR 1.91; 95 % CI 1.04-3.53), peri-pancreatic extent of necrosis (OR 7.61; 95 % CI 3.94-14.70), infected necrosis (OR 2.26; 95 % CI 1.13-4.50) and total length of stay ≥14 days (OR 4.08; 95 % CI 1.75-9.50). CONCLUSIONS: The overall incidence of VTE in our cohort of patients with ANP was 12.5 %, which was usually diagnosed within one month of hospitalization. High-risk patients can be stratified based on clinical and imaging characteristics and may benefit from intensive DVT screening and prophylaxis during hospitalization and following discharge.

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Biliary complications are common after liver transplantation (LT). Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred method to treat biliary complications. Nevertheless, ERCP is not without complications and may have a greater complication rate in the LT population. Knowledge of the prevalence, severity, and possible risk factors for post-ERCP pancreatitis (PEP) in LT recipients is limited. Therefore, this study aims to determine the incidence and severity of PEP and identify potential risk factors in LT recipients. This retrospective cohort included patients ≥18 years who underwent ≥1 ERCP procedures after LT between January 2010 and October 2021. Two hundred thirty-two patients were included, who underwent 260 LTs and 1125 ERCPs. PEP occurred after 23 ERCP procedures (2%) with subsequent mortality in three (13%). Multivariate logistic regression identified wire cannulation of the pancreatic duct as a significant risk factor for PEP (OR, 3.21). The complication rate of PEP after LT in this study was shown to be low and is lower compared to patients without a history of LT. Nevertheless, the mortality rate of this group of patients was notably higher.

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Background/Aims: Coaxial placement of double pigtail plastic stents (DPPS) through lumen-apposing metal stents (LAMSs) is commonly performed to reduce the risk of LAMS obstruction, bleeding, and stent migration when used for the drainage of pancreatic fluid collections (PFCs). A systematic review and meta-analysis were performed to compare the outcomes of LAMS alone and LAMS with coaxial DPPS placement in the management of PFCs. Methods: A systematic review was conducted to identify studies comparing LAMS and LAMS/DPPS for PFC drainage. Primary outcomes included the rate of clinical success, overall adverse events (AEs), bleeding, infection, occlusion, and stent migration. The pooled effect size was summarized using a random-effects model and compared between LAMS and LAMS/DPPS by calculating odds ratios (ORs). Results: Nine studies involving 709 patients were identified (338 on LAMS and 371 on LAMS/DPPS). LAMS/DPPS was associated with a reduced risk of stent obstruction (OR, 0.59; p=0.004) and infection (OR, 0.55; p=0.001). No significant differences were observed in clinical success (OR, 0.96; p=0.440), overall AEs (OR, 0.57; p=0.060), bleeding (OR, 0.61; p=0.120), or stent migration (OR, 1.03; p=0.480). Conclusions: Coaxial DPPS for LAMS drainage of PFCs is associated with a reduced risk of stent occlusion and infection; however, no difference was observed in the overall AE rates or bleeding.

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PURPOSE: In patients with acute necrotizing pancreatitis (ANP), the site, size, and the number of acute necrotic collections (ANC) may determine the outcome of patients. The current study aimed to correlate the nature of ANC with the adverse outcomes in ANP patients. METHODS: This was a single-center, prospective study (August 2019-August 2022) recruiting patients with ANP, correlating the site, size, and number of ANC with the length of hospital stay, intensive care unit (ICU) stays, development of organ failure and infection, need for intervention, and mortality. RESULTS: A total of 114 patients (mean age: 37.3 ± 13.4 years, 85.1% males) with ANP were included in the study. The number and maximum diameter of collections significantly correlated with the length of the hospital and ICU stay and the need for intervention. Taking a cut-off size of 8 cm, the sensitivity and specificity for predicting the need for intervention were 82.7% and 74.2%, respectively. ANCs located in the perinephric, paracolic, subhepatic, and epigastric regions had a significant correlation with two or more adverse outcomes. Additional points were added to the modified CT severity index (mCTSI) based on the present study's findings. The new score had significantly higher AUROC than mCTSI for predicting infection, need for intervention, ICU stay > 1 week, and mortality. CONCLUSION: The site, size, and number of EPNs have a significant correlation with adverse clinical outcomes in patients with ANP. The inclusion of these parameters, along with present scoring systems, will help further improve the prognostication of patients.

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Walled-off necrosis (WON) develops as local complications after acute necrotizing pancreatitis. Although less invasive interventions such as endoscopic ultrasonography (EUS)-guided drainage and endoscopic necrosectomy are selected over surgical interventions, delayed and step-up interventions are still preferred to avoid procedure-related adverse events. However, there is a controversy about the appropriate timing of drainage and subsequent necrosectomy. The advent of large-caliber lumen-apposing metal stents has also brought about potential advantages of proactive interventions, which still needs investigation in future trials. When step-up interventions of necrosectomy and additional drainage are necessary, a structured or protocoled approach for WON has been reported to improve safety and effectiveness of endoscopic and/or percutaneous treatment, but has not been standardized yet. Finally, long-term outcomes such as recurrence of WON, pancreatic endocrine, and exocrine function are increasingly investigated in association with disconnected pancreatic duct syndrome. In this review we discuss current evidence and controversy on EUS-guided management of WON.

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Objective: To describe the return to work of patients with severe acute pancreatitis within 6 months after discharge, and to explore the influence of demographic, clinical, and psychosocial factors on their return to work. Research design: Prospective 6 months follow-up study. Setting: A third class hospital in Guizhou Province. Adult of severe acute pancreatitis(18-60years), with a job before admission, in the intensive care unit ≥ 24 h, were included. Main outcome measures: To study return to work and influencing factors one, three and six months severe acute pancreatitis patients discharge. several measurements were used, including General Health Questionnaire (Demographic, disease-related, job-related and health behavior data), Readiness for Return-To-Work Scale and the Hospital Anxiety and Depression Scale. Results: Forty-three severe acute pancreatitis patients were included in our study, with mean age 41.53 years. Twenty-nine (67.44%) patients returned to work within 6 months, and fourteen patients did not return to work. The status of Readiness for Return-To-Work Scale: fourteen severe acute pancreatitis patients who did not return to work were mainly in the precontemplation dimension and prepared for action-self-evaluative dimension both 5 cases (35.71%), and the 29 patients who had returned to work were in the Proactive maintenance stage. The study showed that the independent risk factors for returning to work in SAP patients were chronic disease (OR, 0.095; 95% CI [0.011-0.822]; p=0.008), sepsis (OR, 0.071; 95% CI [0.015-0.339]; p=0.009), low education level (OR, 2.905; 95% CI [0.969-8.710]; p<0.001), and anxiety and depression at 6 months (OR, 1.418; 95% CI [0.996-2.019]; p=0.004). Conclusions: In conclusion, the return to work of patients with severe acute pancreatitis needs to be improved. Chronic diseases, sepsis, low level of education and higher degree of anxiety and depression at 6 months were important factors leading to their failure to return to work.

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We present a case of prophylactic endovascular embolization in a 51-year-old man with necrotizing pancreatitis (NP) before undergoing endoscopic necrosectomy (EN). Contrast-enhanced CT imaging revealed the presence of a walled-off necrosis (WON) surrounding the pancreas, with the splenic artery coursing through the cavity. The splenic artery was embolized using n-butyl-2-cyanoacrylate (NBCA) and coils to mitigate the risk of massive bleeding in EN. A newly developed polytetrafluoroethylene (PTFE)-coated microcatheter was used to inject NBCA, enabling embolization of a long segment of the splenic artery without adhering to the vessel wall. Coils were placed distal and proximal to the embolized segment to optimize control. Over 5 sessions of EN, no massive bleeding was encountered. This report demonstrates the benefits of utilizing PTFE-coated microcatheters for enhanced safety and maneuverability during embolization with NBCA. Furthermore, it highlights the importance of prophylactic embolization during EN for managing NP.

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INTRODUCTION AND IMPORTANCE: The incidence of acute pancreatitis varies globally, and its rates are increasing. Timely intervention in cases of infected necrosis is crucial to effective management. The landscape of acute pancreatitis management has undergone transformation through adopting a "step-up" strategy, accentuating the shift towards minimally invasive techniques. CASE PRESENTATION: A 63-year-old patient with acute pancreatitis and infected pancreatic necrosis underwent a challenging yet successful treatment using video-assisted retroperitoneal debridement employing a two-port approach facilitated access for an intricate area. The procedure, performed 45 days after admission, effectively reduced peripancreatic collections, demonstrating the efficacy of this approach in managing complex cases of infected pancreatic necrosis. CLINICAL DISCUSSION: The management of acute pancreatitis has evolved towards a comprehensive strategy involving early hydration, nutritional support, effective pain management, and interventions. Infected pancreatic necrosis poses a serious complication, with minimally invasive techniques such as video-assisted retroperitoneal debridement (VARD) emerging as preferred options. The efficacy and safety of VARD in complex cases are highlighted, although challenges persist, especially in extensive necrosis. CONCLUSION: The VARD procedure, a key component of the step-up approach, exhibits a remarkable safety profile, substantially reducing postoperative complications and mortality compared to open surgical counterparts. However, challenges persist in managing cases of infected Walled-Off Necrosis with deep extension, necessitating carefully considering a minimal-access approach. We report our experience using the VARD in a two-port approach.

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We present a life-threatening case of postpartum acute necrotizing pancreatitis. The patient is a 37-year-old female with no past medical history who delivered a healthy baby boy via cesarean section. Twenty days later, she presented to the emergency department with acute onset of nausea, non-bloody vomiting, abdominal bloating, and epigastric pain radiating to the back. Less than 24 hours later, she progressed into septic shock despite aggressive resuscitation, requiring vasopressor support in the ICU. Initial CT imaging showed multiple patchy hypodensities throughout the pancreas consistent with severe necrotizing pancreatitis. Her hospitalization was further complicated by difficulty obtaining source control of her infection, Clostridium difficile, and nutritional deficiencies that resulted in gross anasarca. She was discharged from the hospital on day 59 after undergoing multiple percutaneous drain placements, IV antibiotics, and endoscopic gastrocystostomy with four pancreatic necrosectomies. Since discharge, the patient has required readmission twice for complications from her pancreatitis.

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Aeromonas is well-recognized for causing diarrhea and post-traumatic wound infections. The most common Aeromonas species include Aeromonas hydrophila, Aeromonas caviae, and Aeromonas sobria. In cases of immunocompromise and malignancy, Aeromonas infections can prove fatal. Instances of deadly necrotizing fasciitis in the extremities due to Aeromonas infection have been documented. Herein, a case of previously unreported fatal retroperitoneal necrotizing fasciitis involving Aeromonas caviae in a patient with a history of gastric cancer is presented.

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Acute pancreatitis (AP) is an acute inflammatory reaction of the pancreatic tissue, which involves auto-digestion, edema, hemorrhage, and necrosis. AP can be categorized into mild, moderately severe, and severe AP, with severe pancreatitis also referred to as acute necrotizing pancreatitis (ANP). ANP is characterized by the accumulation of necrotic material in the peritoneal cavity. This can result in intestinal injury. However, the mechanism of ANP-associated intestinal injury remains unclear. We established an ANP-associated intestinal injury rat model (ANP-IR model) by injecting pancreatitis-associated ascites fluid (PAAF) and necrotic pancreatic tissue at various proportions into the triangular area formed by the left renal artery and ureter. The feasibility of the ANP-IR model was verified by comparing the similar changes in indicators of intestinal inflammation and barrier function between the two rat models. In addition, we detected changes in apoptosis levels and YAP protein expression in the ileal tissues of rats in each group and validated them in vitro in rat epithelial crypt cells (IEC-6) to further explore the potential injury mechanisms of ANP-associated intestinal injury. We also collected clinical data from patients with ANP to validate the effects of PAAF and pancreatic necrosis on intestinal injury. Our findings offer a theoretical basis for restricting the buildup of peritoneal necrosis in individuals with ANP, thus promoting the restoration of intestinal function and enhancing treatment efficacy. The use of the ANP-IR model in further studies can help us better understand the mechanism and treatment of ANP-associated intestinal injury.NEW & NOTEWORTHY We constructed a rat model of acute necrotizing pancreatitis-associated intestinal injury and verified its feasibility. In addition, we identified the mechanism by which necrotic pancreatic tissue and pancreatitis-associated ascites fluid (PAAF) cause intestinal injury through the HIPPO signaling pathway.

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This report presents a unique case of acute necrotizing pancreatitis(ANP) concomitant with paroxysmal nocturnal hemoglobinuria(PNH), a combination that has not been documented in existing literature. The impact of PNH on ANP and its treatment remains uncertain due to the lack of consensus. The case described herein involves a patient who exhibited both ANP and PNH, subsequently experiencing splanchnic vein thrombosis (SVT), resulting in substantial intra-abdominal and gastrointestinal hemorrhaging. We attempted to analyze the role of PNH in the formation of SVT in ANP and propose some new insights and hypotheses for the treatment of such patients.