RESUMO
We describe the case of a female patient with severe acute pancreatitis of biliary origin who presented with clinical deterioration. A thrombosis of the superior mesenteric artery and hepatic artery was identified as the cause, thus creating a rare vascular complication. She was taken for pharmacological and mechanical thrombectomy, with the subsequent death of the patient. Arterial vascular complications are an entity little recognized in the medical literature; they have a high mortality rate and pose a significant diagnostic and therapeutic challenge.
Se describe el caso de una paciente femenina con pancreatitis aguda grave de origen biliar quien presentó deterioro clínico, y como causa se identificó una trombosis de arteria mesentérica superior y arteria hepática, de modo que se configuró una complicación vascular poco frecuente. Fue llevada a trombectomía farmacológica y mecánica, con el posterior deceso de la paciente. Las complicaciones vasculares arteriales son una entidad poco reconocida en la literatura médica, tienen una alta tasa de mortalidad y suponen un reto diagnóstico y terapéutico importante.
RESUMO
BACKGROUND: Acute biliary pancreatitis (ABP) is often associated with persistent common bile duct (CBD) stones. The best strategy in terms of timing of surgery is still controversial. The aim of the current study is to describe the prevalence of persistent common bile duct (CBD) stones in ABP during the first week of symptoms at a high-volume referral center. STUDY DESIGN: Single-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of ABP who underwent laparoscopic cholecystectomy (LC) between January 2009 and December 2019 were extracted. RESULTS: Two hundred thirty-one patients were included. Cholecystectomy was performed laparoscopically in 230 (99.57%) patients. Intraoperative cholangiogram was performed in all patients. Two hundred nine (90%) patients had surgery within the first 7 days. Global prevalence of persistent CBD stones during IOC was 19.91% (95% CI 14.96-25.65). No significant association between timing to surgery and presence of CBD stones was found for the first week since the initial attack (p=0.28). Prevalence of CBD stones was significantly higher after day 7 (p=0.007 and 0.005). Positive findings in preoperative MRCP are significantly related to intraoperative CBD stones (p=0.0001). Mild postoperative complications (CD I/II) were present in 21 patients (9.09%). No difference was found in morbidity between CBD stones group and non-CBD stones group (p=0.48). We observed no severe complications nor mortality. CONCLUSIONS: In patients with mild acute biliary pancreatitis, the prevalence of persistent CBD stones does not change within the first 7 days since the onset of symptoms. This fact may have major clinical relevance when deciding the optimal therapeutic strategy in this population.
Assuntos
Colecistectomia Laparoscópica , Cálculos Biliares , Pancreatite , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica , Ducto Colédoco/diagnóstico por imagem , Ducto Colédoco/cirurgia , Cálculos Biliares/complicações , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/epidemiologia , Humanos , Pancreatite/epidemiologia , Pancreatite/etiologia , Prevalência , Estudos RetrospectivosRESUMO
ANTECEDENTES: La pancreatitis aguda leve es una inflamación local del páncreas sin complicaciones locales ni falla orgánica. Su manejo consiste en tres elementos básicos: hidratación, analgesia y ayuno. La realimentación se inicia cuando el paciente no tiene dolor y refiere apetito, pero el momento exacto para iniciarla no está previamente documentado. OBJETIVO: Determinar la tolerancia a la alimentación oral inmediata (8 horas posterior al inicio del manejo) en comparación con la alimentación temprana (48 horas) en los pacientes con pancreatitis aguda biliar leve. MÉTODO: Se incluyeron pacientes con pancreatitis aguda biliar leve y se aleatorizaron en dos grupos: A) alimentación temprana a las 48 horas (30 pacientes) y B) alimentación inmediata a las 8 horas de inicio del manejo (29 pacientes). Fueron evaluados por un tercer observador ciego (no involucrado en el estudio) para documentar síntomas como náusea, vómito, reactivación del dolor abdominal, síndrome de respuesta inflamatoria sistémica, tolerancia alimentaria y estancia hospitalaria. RESULTADOS: No se encontraron diferencias significativas entre los grupos en cuanto a datos clínicos y bioquímicos. La estancia hospitalaria disminuyó significativamente en el grupo B (5.4 vs. 7.8 días; p < 0.003). CONCLUSIÓN: La alimentación inmediata en las primeras 8 horas del manejo de los pacientes con pancreatitis aguda biliar leve es bien tolerada y segura, y reduce la estancia hospitalaria. BACKGROUND: Mild acute pancreatitis is defined as pancreatic edema, without organic failure and without local complications. Its management consists in three basic elements: hydration, analgesia and fasting. Start refeeding when the patient haven´t pain and referring hungry, but exact time for this is not previously documented. OBJECTIVE: To determine the tolerance to immediate oral feeding (8 hours after the start of management) compared to early feeding (48 hours) in patients with mild acute biliary pancreatitis. METHOD: Included all patient with mild acute biliary pancreatitis, and they were randomized in to two groups: A) early oral feeding (n = 30) and B) immediate oral feeding (n = 29). They were evaluated by a third blind observer (not involved in the study) for documented symptoms like nausea, vomiting, reactivation of abdominal pain, systemic inflammatory response syndrome, food tolerance and hospital stay. RESULTS: There were no significant differences between both groups in the clinical data or in the biochemical studies. The hospital stay was significantly less in the group B (5.4 vs. 7.8 days; p < 0.003). CONCLUSION: Immediate oral feeding is well tolerated and secure in patients with mild acute biliary pancreatitis.
Assuntos
Pancreatite , Doença Aguda , Humanos , Tempo de Internação , Pancreatite/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND: The aim of the study was to compare the onset of oral feeding in the first 24 h after hospital admission with usual oral refeeding and determine whether the timing of the onset of oral feeding influences the recurrence of pain or alters the blood levels of pancreatic enzymes in patients with predicted mild acute biliary pancreatitis. METHODS: This non-inferiority randomized controlled trial was carried out between September 2018 and June 2019 after receiving authorization from the ethics committee for health research. Patients with a diagnosis of predicted mild acute biliary pancreatitis were divided into Group A (early oral refeeding, EOR) and Group B (usual oral refeeding, UOR). Outcome measures included pancreatic lipase levels, the systemic inflammatory response (concentrations of leukocytes), feasibility (evaluated by abdominal pain recurrence), the presence and recurrence of gastrointestinal symptoms and the length of hospital stay. RESULTS: Two patients in the EOR group experienced pain relapse (3.2%), and four patients in the UOR group experienced pain relapse (6.77%) after oral refeeding (p = 0.379). The presence of nausea or vomiting after the onset of oral refeeding was not different between the two groups (p = 0.293). The onset of oral refeeding was approximately 48 h later in the UOR group. The length of hospital stay was 5 days in the EOR group and 8 days in the UOR group (p = 0.042), and this difference was also manifested in higher hospital costs in the UOR group (p = 0.0235). CONCLUSION: Compared with usual oral refeeding, early oral refeeding is safe in predicted mild acute biliary pancreatitis patients, does not cause adverse gastrointestinal events, and reduces the length of hospital stay and costs. TRIAL REGISTRATION: Early oral refeeding in mild acute pancreatitis (EORVsUOR). NCT04168801 , retrospectively registered (November 19, 2019).
Assuntos
Pancreatite , Dor Abdominal/etiologia , Doença Aguda , Humanos , Pancreatite/etiologia , Pancreatite/terapia , Estudos Prospectivos , RecidivaRESUMO
La litiasis biliar está asociada desarrollo de pancreatitis aguda en el 40% de los casos, sin embargo la sensibilidad diagnóstica de la ecografía abdominal y la tomografía es limitada para hallar esta etiología. En el presente caso se ejemplifica el uso de las enzimas hepáticas aminotransferasas para la predicción del origen biliar en paciente con colecistectomía y ecografía abdominal negativa para colelitiasis y coledocolitiasis. Se presenta un paciente de 55 años, con un cuadro característico de pancreatitis aguda de origen biliar, a quien se hizo el diagnóstico y el tratamiento endoscópico recomendado.
Gallstones are associated with development of acute pancreatitis in 40% of cases, however the diagnostic sensitivities of abdominal ultrasound and CT scans for finding this etiology are limited. The case presented here exemplifies the predictive use of aminotransferase liver enzymes in patients with biliary cholecystectomy but abdominal ultrasound that is negative for cholelithiasis and choledocholithiasis. The case is a 55 year old patient whose clinical picture was consistent with acute biliary pancreatitis. The diagnosis was made and endoscopic treatment was recommended.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Endossonografia , Pancreatite , UltrassonografiaRESUMO
For over 20 years we have discussed the indication of early endoscopic retrograde cholangiopancreatography (ERCP) (72 h before the onset of symptoms) in acute biliary pancreatitis (ABP), seeking to stop the inflammatory process, reducing complications and mortality, taking into account that ERCP can cause pancreatitis and other complications such as perforation and hemorrhage. To elucidate this problem, there have been multiple meta-analyses based on the same 3 or 5 randomized controlled trials of early ERCP versus conventional treatment (including elective ERCP) in ABP, which have produced conflicting results. There is agreement regarding that it is not indicated in mild ABP, and it is indicated in ABP associated with cholangitis and persistent obstruction of the ampulla of Vater. There is controversy in severe presentation of ABP, since current evidence does not definitely show the usefulness of early ERCP. No more complications related to ERCP have been reported in this situation.
Desde hace más de 20 años se discute la indicación de la colangiopancreatografía retrógrada endoscópica (CPRE) precoz (antes de 72 h del inicio de los síntomas) en la pancreatitis aguda biliar (PAB), buscando detener el proceso inflamatorio, disminuyendo sus complicaciones y su mortalidad, tomando en cuenta que la CPRE puede ser causa de pancreatitis y otras complicaciones como perforación y hemorragia. Para dilucidar este problema se han realizado múltiples meta-análisis basados en los mismos 3 ó 5 estudios aleatorizados y controlados de CPRE precoz versus el tratamiento convencional (que incluye CPRE electiva) en PAB, los cuales han dado resultados discordantes. En lo que hay acuerdo es en que no está indicada en la PAB leve y sí está indicada en la PAB asociada a colangitis y a obstrucción persistente de la ampolla de Vater. En la PAB de presentación grave hay controversia; la evidencia actual no demuestra en forma definitiva la utilidad de una CPRE precoz. No se ha reportado mayor número de complicaciones relacionadas a la CPRE en esta situación.
Assuntos
Humanos , Colangiopancreatografia Retrógrada Endoscópica , Doenças Biliares/complicações , Pancreatite/diagnóstico , Doença Aguda , Diagnóstico Precoce , Seleção de PacientesRESUMO
The presence of cholestasis in both mild and severe forms of acute biliary pancreatitis (ABP) does not justify, of itself, early endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (ES). Clinical support treatment of acute pancreatitis for one to two weeks is usually accompanied by regression of pancreatic edema, of cholestasis and by stone migration to the duodenum in 60%-88% of cases. On the other hand, in cases with both cholestasis and fever, a condition usually characterized as ABP associated with cholangitis, early ES is normally indicated. However, in daily clinical practice, it is practically impossible to guarantee the coexistence of cholangitis and mild or severe acute pancreatitis. Pain, fever and cholestasis, as well as mental confusion and hypotension, may be attributed to inflammatory and necrotic events related to ABP. Under these circumstances, evaluation of the bile duct by endo-ultrasonography (EUS) or magnetic resonance cholangiography (MRC) before performing ERC and ES seems reasonable. Thus, it is necessary to assess the effects of the association between early and opportune access to the treatment of local and systemic inflammatory/infectious effects of ABP with cholestasis and fever, and to characterize the possible scenarios and the subsequent approaches to the common bile duct, directed by less invasive examinations such as MRC or EUS.
RESUMO
For a long time, the aim of the endoscopist in acute pancreatitis has been cleaning up obstructed biliary tract through endoscopic retrograde cholangiopancreatography (ERCP) at the precise momentum, so the main factor causing biliary pancreatitis is treated, decreasing possibilities of complications and modifying the prognosis. However, in the last two decades, the role of the endoscopist has acquired new dimensions so it is possible to treat complications like pseudocysts and walled-of pancreatic necrosis with minimally invasive procedures. This review is focused on technique, indications, follow-up and result of ERCP in acute pancreatitis, drainage of pancreatic pseudocyst and endoscopic necrosectomy.
El rol del endoscopista en la pancreatitis aguda por largo tiempo estuvo abocado fundamentalmente a la posibilidad de desobstruir y limpiar la vía biliar a través de la realización de colangiopancreatografia retrograda endoscópica (CPRE), eliminando así un importante factor ligado el efecto de la coledocolitiasis en la patogénesis, gravedad y complicaciones de la pancreatitis aguda de origen biliar. Sin embargo, en las últimas dos décadas, el papel del endoscopista ha adquirido nuevas dimensiones, ampliándose al tratamiento de ciertas complicaciones de la pancreatitis aguda en general, como son los pseudoquistes pancreáticos y, últimamente, los secuestros de necrosis pancreática. En este artículo se revisan las indicaciones de la CPRE en la pancreatitis aguda, del drenaje de pseudoquiste pancreático y la necrosectomia endoscópica, así como aspectos de la técnica, seguimiento y resultados.
Assuntos
Humanos , Endoscopia do Sistema Digestório/métodos , Pancreatite/cirurgia , Pancreatite/complicações , Drenagem , Doença Aguda , Pancreatectomia/métodos , Pancreatite Necrosante Aguda/cirurgia , Colangiopancreatografia Retrógrada Endoscópica , Cisto Pancreático/cirurgia , Cisto Pancreático/etiologiaRESUMO
Background: An early decompression of the biliary tract can be useful in biliary pancreatitis. This can be accomplished with an ERCP. Aim: To analyze prospectively the outcomes of ERCP and eventual endoscopic management among patients with mild acute biliary pancreatitis with gallbladder in situ. Material and methods: We studied 90 consecutive patients aged between 15 and 92 years (71 females) with mild acute pancreatitis and gallbladder in situ, that were subjected to an ERCP and eventual sphincterotomy. Forty nine patients (54 percent) had jaundice and 12 (13 percent) had cholangitis. Results: In 67 patients (74 percent), ERCP detected an abnormal ampulla. The bile duct was successfully cannulated in 89 cases (99 percent). Of these, 42 (47 percent) had a dilated bile duct and 36 (40 percent) had choledocholithiasis. In two patients (2 percent) ERCP was only diagnostic. In the remaining patients, it was therapeutic. Endoscopic treatment was successful in 86 patients (99 percent). No complications arising from the endoscopic procedure were recorded. Follow-up was completed in 84 patients (94 percent). Of these, 10 (12 percent) were not subjected to a cholecystectomy, in eight due to a high surgical risk and in two due to refusal. In the remaining 74 patients, a cholecystectomy was performed during the same hospitalization in 57 (77 percent) and on a deferred basis in 17 (23 percent). Conclusions: In patients with mild acute biliary pancreatitis and gallbladder in situ, ERCP is a safe and effective method.
Objetivo: Analizar en forma prospectiva los resultados de la Colangio Pancreatografía Retrógrada Endoscópica (CPRE) y eventual manejo endoscópico en pacientes portadores de pancreatitis aguda biliar (PAB) leve con vesícula in situ. Material y Método: Se estudiaron 90 pacientes consecutivos con PAB leve y vesícula in situ. La edad promedio fue de 49,5 +/- 18,6 años (78,9 por ciento mujeres y 21,1 por ciento hombres). Del total, 49 pacientes (54,4 por ciento) presentaron ictericia y 12 (13,3 por ciento) colangitis. Resultados: La CPRE pesquisó pato-logia de la ampolla en 67/90 pacientes (74,4 por ciento). La canulación selectiva de la vía biliar resultó exitosa en 89/90 casos (98,9 por ciento). En estos, se demostró una vía biliar dilatada en 42 (47,2 por ciento) y coledocolitiasis en 36 (40,4 por ciento). La CPRE fue diagnóstica en 2 enfermos (2,2 por ciento) y hubo indicación de procedimiento terapéutico en los 87 restantes (97,7 por ciento), este resultó exitoso en 86 (98,9 por ciento). No se presentaron complicaciones derivadas de la cirugía endoscópica. Se completó el seguimiento en 84/89 pacientes (94,4 por ciento). De estos, 10 (11,9 por ciento) no fueron colecistectomizados (8 debido al riesgo quirúrgico y 2 por rechazo a la intervención). De los 74 restantes, 57 (77 por ciento) fueron sometidos a una colecistectomía dentro de la misma hospitalización y 17 (23 por ciento en forma diferida. El 91,9 por ciento de ellas (68/74) mediante laparoscopia. Conclusión: En pacientes con PAB leve y vesícula in situ, la CPRE es un método seguro y efectivo. Además, permite efectuar una colecistectomía por vía laparoscópica, durante la misma hospitalización en la gran mayoría de los pacientes y constituye una alternativa a la colecistectomía en pacientes de alto riesgo quirúrgico.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Ducto Colédoco/cirurgia , Ducto Colédoco/patologia , Vesícula Biliar , Pancreatite/cirurgia , Pancreatite/diagnóstico , Colangiopancreatografia Retrógrada Endoscópica/métodos , Doença Aguda , Seguimentos , Estudos ProspectivosRESUMO
PURPOSE: The influence of treatment access regulation and technological resources on the mortality profile of acute biliary pancreatitis (ABP) was evaluated. METHODS: The cases seen in a tertiary hospital were studied during two periods of time: 1995-1999 and 2000-2004, i.e., before and after the implementation of medical regulation. RESULTS: Among the 727 patients with acute pancreatitis, 267 had ABP and were classified according to APACHE II scores. The cases being referred to the tertiary hospital decreased from 441 to 286 (p < 0.001). The patients' profile regarding age, gender, severity, cholestasis incidence and mortality were similar during the first and second periods of study (n = 154 and n = 113, respectively). The number of patients with hematocrit > 44 percent was smaller during the second study period (p<0.002). The use of magnetic resonance cholangiography, videolaparoscopic cholecystectomy, and access to the ICU were found to be more frequent during the second study period. Regarding the deaths occurring within 14 days of hospitalisation, 73.4 percent and 81.3 percent were observed during the first and second study periods, respectively. CONCLUSION: Since the improvement in clinical and technological approach was not enough to modify the mortality profile of ABP, further studies on the treatment of inflammatory responses should be carried out.(AU)
OBJETIVO: Avaliou-se a influência do acesso aos recursos assistenciais e tecnológicos sobre a mortalidade na pancreatite aguda biliar (PAB). MÉTODOS: Os casos de PAB tratados num hospital universitário foram estudados em dois períodos: 1995 a 1999 e 2000 a 2004, antes e depois da implantação da Regulação Médica. RESULTADOS: Do total de 727 casos com pancreatite aguda atendidos, 267 apresentavam PAB e tiveram a gravidade avaliada pelo escore de APACHE II. Houve redução dos encaminhamentos de casos entre os períodos, de 441 para 286 (p < 0,001). O perfil dos pacientes com PAB no primeiro período (n = 154) e no segundo (n =113) foi semelhante quanto à idade, sexo, gravidade, incidência de colestase e mortalidade. A incidência de pacientes com hematócrito > 44 foi menor no segundo período (p < 0,002). O emprego de colangiografia por ressonância magnética, da colecistectomia por videolaparoscopia e do acesso à terapia intensiva foi significantemente maior no segundo período. A maioria dos óbitos ocorreu até os 14 dias de admissão, 73,4 por cento no primeiro período e 81,3 por cento no segundo. CONCLUSÃO:A melhora do suporte tecnológico e clínico não foi suficiente para modificar o perfil de mortalidade na PAB, o que indica a necessidade de avaliar terapêuticas para a sua resposta inflamatória.(AU)
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Colangiografia/métodos , Colecistectomia/métodos , Colelitíase/mortalidade , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Pancreatite/mortalidade , APACHE , Doença Aguda , Brasil/epidemiologia , Colangiografia/mortalidade , Colecistectomia/mortalidade , Colelitíase/terapia , Cuidados Críticos/estatística & dados numéricos , Reações Falso-Positivas , Acessibilidade aos Serviços de Saúde/organização & administração , Incidência , Pancreatite/terapia , Sensibilidade e EspecificidadeRESUMO
PURPOSE: The influence of treatment access regulation and technological resources on the mortality profile of acute biliary pancreatitis (ABP) was evaluated. METHODS: The cases seen in a tertiary hospital were studied during two periods of time: 1995-1999 and 2000-2004, i.e., before and after the implementation of medical regulation. RESULTS: Among the 727 patients with acute pancreatitis, 267 had ABP and were classified according to APACHE II scores. The cases being referred to the tertiary hospital decreased from 441 to 286 (p < 0.001). The patients' profile regarding age, gender, severity, cholestasis incidence and mortality were similar during the first and second periods of study (n = 154 and n = 113, respectively). The number of patients with hematocrit > 44 percent was smaller during the second study period (p<0.002). The use of magnetic resonance cholangiography, videolaparoscopic cholecystectomy, and access to the ICU were found to be more frequent during the second study period. Regarding the deaths occurring within 14 days of hospitalisation, 73.4 percent and 81.3 percent were observed during the first and second study periods, respectively. CONCLUSION: Since the improvement in clinical and technological approach was not enough to modify the mortality profile of ABP, further studies on the treatment of inflammatory responses should be carried out.
OBJETIVO: Avaliou-se a influência do acesso aos recursos assistenciais e tecnológicos sobre a mortalidade na pancreatite aguda biliar (PAB). MÉTODOS: Os casos de PAB tratados num hospital universitário foram estudados em dois períodos: 1995 a 1999 e 2000 a 2004, antes e depois da implantação da Regulação Médica. RESULTADOS: Do total de 727 casos com pancreatite aguda atendidos, 267 apresentavam PAB e tiveram a gravidade avaliada pelo escore de APACHE II. Houve redução dos encaminhamentos de casos entre os períodos, de 441 para 286 (p < 0,001). O perfil dos pacientes com PAB no primeiro período (n = 154) e no segundo (n =113) foi semelhante quanto à idade, sexo, gravidade, incidência de colestase e mortalidade. A incidência de pacientes com hematócrito > 44 foi menor no segundo período (p < 0,002). O emprego de colangiografia por ressonância magnética, da colecistectomia por videolaparoscopia e do acesso à terapia intensiva foi significantemente maior no segundo período. A maioria dos óbitos ocorreu até os 14 dias de admissão, 73,4 por cento no primeiro período e 81,3 por cento no segundo. CONCLUSÃO:A melhora do suporte tecnológico e clínico não foi suficiente para modificar o perfil de mortalidade na PAB, o que indica a necessidade de avaliar terapêuticas para a sua resposta inflamatória.