RESUMO
Abstract Pseudoaneurysm secondary to chronic pancreatitis is a rare complication, but one with a high mortality rate. It is etiologically associated with chronic pancreatitis, and most diagnoses are made after rupture, which manifests with clinical signs of acute hemorrhage. Computed tomography plays an important role in diagnosis, but digital subtraction angiography remains the gold-standard method for diagnostic confirmation and for treatment planning. This article describes two cases of pseudoaneurysm in patients with chronic alcoholic pancreatitis; one involving the splenic artery and the other the gastroduodenal artery, complicated by thoracic and abdominal bleeding respectively. Both were successfully treated, using minimally invasive endovascular methods to implant coils and stent-grafts.
Resumo O pseudoaneurisma decorrente de pancreatite crônica consiste em complicação rara, porém com alta taxa de mortalidade. Está etiologicamente associado à pancreatite crônica, e seu diagnóstico é feito mais comumente após ruptura, manifestando-se através de sinais clínicos de hemorragia aguda. A tomografia computadorizada desempenha papel importante no diagnóstico; contudo, a angiografia por subtração digital mantém-se como método padrão-ouro para confirmação diagnóstica e direcionamento do tratamento. O presente artigo relata dois casos de pseudoaneurisma em pacientes com pancreatite crônica alcoólica, sendo um da artéria esplênica e outro da artéria gastroduodenal, complicados com sangramento torácico e abdominal respectivamente. Ambos foram submetidos a tratamento endovascular minimamente invasivo com sucesso, através de implante de molas e de stent-grafts.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Falso Aneurisma/etiologia , Pancreatite Crônica/complicações , Procedimentos Endovasculares , Artéria Esplênica , Angiografia Digital , Falso Aneurisma/diagnóstico por imagem , Pancreatite Alcoólica/complicações , Artéria Gástrica , HemorragiaRESUMO
ABSTRACT Objective: To compare the quality of life between patients with alcoholic chronic pancreatitis and controls, and between diabetic and non-diabetic patients, correlating clinical, sociodemographic, and nutritional factors with their quality of life scores. Methods: Forty-three outpatients of the pancreas and biliary tract clinic diagnosed with alcoholic chronic pancreatitis were assessed. Quality of life was measured by the Brazilian version of the Short Form-36. The control group consisted of 43 healthy companions. Nutritional status was classified according to body mass index and triceps, biceps, suprailiac, and subscapular skinfold thicknesses, using the appropriate methods. The percentage of body fat was given by adding the four skinfold thicknesses and by bioelectrical impedance analysis. The statistical tests included the Chi-square, Mann-Whitney, and Spearman's correlation tests, with the significance level set at p<0.05. Results: The sociodemographic variables of the case and control groups did not differ. Quality of life was lower in alcoholic chronic pancreatitis patients than in controls. The only quality of life domain that differed between diabetics and non-diabetics was functional capacity, lower in diabetics (p=0.022). Smoking duration, alcohol intake in grams, and time since pancreatic surgery correlated negatively with the quality of life of alcoholic chronic pancreatitis patients. Old age, skinfold thicknesses, and percentage of body fat correlated positively with quality of life. Conclusion: Quality of life is low in alcoholic chronic pancreatitis patients because of the negative influence of certain factors, such as smoking duration, amount of alcohol consumed, and time since pancreatic surgery.
RESUMO Objetivo: Avaliar a qualidade de vida dos pacientes com pancreatite crônica alcoólica, comparando-os aos participantes de um grupo-controle e entre pacientes com e sem diabetes. Métodos: Avaliaram-se 43 pacientes do ambulatório de pâncreas e vias biliares diagnosticados com pancreatite crônica alcoólica. A qualidade de vida foi verificada por meio do Short Form-36, versão brasileira. O grupo-controle para a qualidade de vida foi composto por 43 acompanhantes sem doenças conhecidas. Para avaliação do estado nutricional, foi calculado o índice de massa corporal e dobras cutâneas do tríceps, bíceps, suprailíaca e subescapular, de acordo com a metodologia adequada. Para obtenção da porcentagem de gordura corporal, utilizou-se o somatório das quatro dobras e a medida obtida por meio da bioimpedância. Para análise estatística, foi utilizado teste de Qui-quadrado, Mann-Whitney e correlação de Spearmam, com p<0,05. Resultados: Não houve diferença entre o grupo-caso e o grupo-controle para as variáveis sociodemográficas. A qualidade de vida dos pacientes com pancreatite crônica alcoólica mostrou-se diminuída quando comparada aos membros do grupo-controle. Ao serem comparados os domínios de qualidade de vida dos pacientes com e sem diabetes, somente o quesito capacidade funcional apresentou diferença: menor para o grupo com diabetes (p=0,022). A correlação mostrou que o tempo de tabagismo, a quantidade de etanol em gramas e o tempo de cirurgia pancreática incidiram negativamente na qualidade de vida do grupo com pancreatite crônica alcoólica. Idade avançada, pregas cutâneas e porcentagem de gordura corporal se correlacionaram positivamente com qualidade de vida. Conclusão: A qualidade de vida está diminuída no grupo com pancreatite crônica alcoólica devido à influência negativa de fatores como tempo de tabagismo, quantidade de etanol e tempo de cirurgia pancreática.
Assuntos
Qualidade de Vida , Pancreatite Alcoólica/complicações , Pancreatite Crônica/complicações , Diabetes MellitusRESUMO
OBJECTIVES: Acute pancreatitis is a severe and frequently life-threatening disease, which can lead to pancreatic necrosis, acute lung injury, systemic inflammatory response syndrome, and other complications. In this study, we hypothesized that the expression of heme oxygenase-1 determined by the number of guanidinium thiocyanate (GT) repeats can influence the occurrence of acute pancreatitis. METHODS: Patients with acute pancreatitis (n = 131) and age- and sex-matched healthy controls (n = 108) were studied. The polymerase chain reaction products were analyzed by ABI 3130 genetic analyzer and the exact size of the polymerase chain reaction products was determined by GeneMapper software. A short allele was defined as containing 27 GT repeats or fewer, whereas a long allele was more than 27 repeats. RESULTS: The subjects were categorized into 3 groups on the basis of the genotype results: 1 short and 1 long, 2 short, and 2 long alleles (L/L). Patients with necrotizing disease more frequently were carriers of LL genotype compared with those who had edematous acute pancreatitis. Furthermore, logistic regression analysis revealed that the presence of L/L allele type doubles the risk for developing pancreatic necrosis in patients with acute pancreatitis. CONCLUSIONS: The polymorphism of the GT repeats in the heme oxygenase-1 promoter region may be a risk factor for developing severe and necrotizing acute pancreatitis.
Assuntos
Repetições de Dinucleotídeos , Heme Oxigenase-1/genética , Pancreatite Necrosante Aguda/genética , Polimorfismo Genético , Regiões Promotoras Genéticas/genética , Doença Aguda , Adulto , Idoso , Colelitíase/complicações , Gorduras na Dieta/efeitos adversos , Progressão da Doença , Edema/sangue , Edema/epidemiologia , Edema/genética , Feminino , Predisposição Genética para Doença , Genótipo , Heme Oxigenase-1/sangue , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pancreatite/sangue , Pancreatite/epidemiologia , Pancreatite/etiologia , Pancreatite/genética , Pancreatite Necrosante Aguda/sangue , Pancreatite Necrosante Aguda/epidemiologia , Pancreatite Necrosante Aguda/etiologia , Pancreatite Alcoólica/complicações , Estudos Prospectivos , Fatores de RiscoRESUMO
Although pseudoaneurysms are a rare complication of chronic pancreatitis, they are potentially serious both because of the events they can lead to and the diagnostic challenges they may pose. Historically, they used to be treated surgically, through ligation and/or resection; it was not until the last decade that scarcely invasive percutaneous endovascular procedures were introduced. This article reports the case of a patient with chronic pancreatitis presenting with severe upper digestive hemorrhage caused by the rupture of a pseudoaneurysm of the gastroduodenal artery. The patient was successfully treated using selective embolization.
Assuntos
Falso Aneurisma/etiologia , Aneurisma Roto/etiologia , Duodeno/irrigação sanguínea , Pancreatite Alcoólica/complicações , Pancreatite Crônica/complicações , Estômago/irrigação sanguínea , Idoso , Falso Aneurisma/diagnóstico , Falso Aneurisma/terapia , Aneurisma Roto/diagnóstico , Aneurisma Roto/terapia , Artérias , Embolização Terapêutica , Endoscopia Gastrointestinal , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Alcohol is a common cause of hepatic and pancreatic damage. Despite the widespread alcohol consumption simultaneous presentation of acute alcoholic hepatitis and pancreatitis is uncomnon. We describe a case of a patient with alcoholic hepatitis in association acute pancreatitis, who developed multiorgan failure and died. The association of liver and pancreatic disease in clinical practice is discussed.
El alcohol es un factor etiológico común de daño hepático y pancreático. A pesar de su extenso consumo la presentación simultánea de hepatitis y pancreatitis aguda alcohólica es excepcional. Se presenta un caso de esta situación, que evolucionó hacia la falla orgánica múltiple con desenlace fatal. Se discute la asociación de daño hepático y pancreático agudo en la práctica Clínica.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Hepatite Alcoólica/complicações , Hepatite Alcoólica/diagnóstico , Pancreatite Alcoólica/complicações , Pancreatite Alcoólica/diagnóstico , Evolução FatalRESUMO
BACKGROUND: Patients with alcohol-related chronic pancreatitis (ARCP) may present with abnormal gastric emptying (GE), which has been ascribed mainly to nutrient maldigestion. Nevertheless, many patients also have diabetes with autonomic dysfunction and malnutrition and the role of these factors on abnormal GE has not been investigated. GOALS: To determine the influences of malabsorption, diabetes, malnutrition, and autonomic dysfunction on GE abnormalities in patients with ARCP. STUDY: Forty ARCP outpatients and 18 healthy controls were studied. GE was measured by scintigraphy after a standard, liquid, nutrient meal labeled with Technetium-phytate. Autonomic function was evaluated by cardiovascular tests. The influence of each factor on abnormal GE was assessed by Bayesian multiple regression analysis. RESULTS: In the ARCP group, GE was abnormal in 19 patients (47.5%), who showed either accelerated (N=12) or delayed emptying (N=7). Diabetes was highly prevalent (P<0.01) in ARCP patients with either rapid or delayed GE (18/19). Multiple regression analysis showed that not only diabetes, but also autonomic dysfunction has significant effects on abnormal GE, whereas malabsorption and malnutrition seemed not to be associated to abnormal emptying. CONCLUSIONS: A substantial proportion of patients with ARCP may have abnormal GE. Either delayed or accelerated GE seem to be related to underlying diabetes mellitus and autonomic neuropathy rather than to nutrient malabsorption and malnutrition.
Assuntos
Esvaziamento Gástrico , Pancreatite Alcoólica/fisiopatologia , Adulto , Doenças do Sistema Nervoso Autônomo/epidemiologia , Diabetes Mellitus/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite Alcoólica/complicações , Cintilografia , Fatores de Risco , Estômago/diagnóstico por imagem , TecnécioRESUMO
CONTEXTO: Retinopatia de Purtscher com redução da visão bilateral é uma rara e grave complicação da pancreatite aguda. RELATO DE CASO: O caso de um paciente de 35 anos com pancreatite alcoólica aguda que apresentou diminuição súbita da acuidade visual é descrito. Oftalmoscopia revelou pólo posterior esbranquiçado devido à presença de manchas algodonosas confluentes. Angiografia fluoresceínica mostrou oclusão arteriolar retiniana. Os achados eram compatíveis com retinopatia de Purtscher. Tomografia computadorizada do abdômen demonstrou fígado e pâncreas aumentados, com edema e inflamação. A patogênese desta forma de retinopatia ainda é incerta e não há tratamento específico disponível.
Assuntos
Humanos , Masculino , Adulto , Pancreatite Alcoólica/complicações , Doenças Retinianas/etiologia , Doença Aguda , Angiofluoresceinografia , Pancreatite Alcoólica , Doenças Retinianas/diagnóstico , Tomografia Computadorizada por Raios X , Acuidade VisualRESUMO
CONTEXT: Purtscher-like retinopathy with bilateral loss of vision is a rare and severe complication that may follow acute pancreatitis. CASE REPORT: The case of a 35-year-old patient with acute alcoholic pancreatitis who developed sudden loss of visual acuity is described. The ophthalmoscopic examination revealed diffuse retinal whitening of the posterior pole with confluent cotton-wool spots. Fluorescein angiogram showed retinal arteriolar occlusion. The findings were compatible with Purtscher-like retinopathy. Computed tomography of the abdomen demonstrated enlarged liver and pancreas with edema and inflammation. The pathogenesis of this form of retinopathy still remains uncertain and there is no specific treatment available.
Assuntos
Pancreatite Alcoólica/complicações , Doenças Retinianas/etiologia , Doença Aguda , Adulto , Angiofluoresceinografia , Humanos , Masculino , Pancreatite Alcoólica/diagnóstico por imagem , Doenças Retinianas/diagnóstico , Tomografia Computadorizada por Raios X , Acuidade VisualRESUMO
BACKGROUND AND AIMS: Internal pancreatic fistulas (IPF) are an uncommon but well-recognized complication of chronic pancreatitis (CP) that are associated with significant morbidity and mortality. Because of their low incidence, management is still controversial. The aims of this study are to report the 8-year experience with IPF management in a Brazil University-affiliated hospital and to propose a management algorithm. STUDY: A centralized diagnostic index was used to retrospectively identify all patients with IPF admitted to a teaching hospital from 1995 to 2003. The patient's medical records were reviewed for clinical features, diagnostic work-up, treatment strategies, response to therapy, and the length of hospital stay. All patients underwent contrast-enhanced computed tomography of the abdomen and endoscopic retrograde cholangiopancreatography, to guide the therapeutic modality to be offered. Conservative therapy included withholding of oral feedings in conjunction with total parenteral nutrition, octreotide subcutaneously, and multiple paracentesis or thoracentesis. Interventional therapy was either endoscopic or surgical. RESULTS: IPF was identified in 11 (7.3%) of 150 patients with CP. They ranged in age from 24 to 47 years (mean 36.1), with a male to female ratio of 10:1. All patients had underlying alcoholic CP. The presentation was pancreatic ascites in 9 patients and pleural effusion in 2 cases. Five patients were undergoing the conservative treatment, all presenting main pancreatic duct (MPD) dilatation; endoscopic placement of transpapillary pancreatic duct stent was performed in 4 patients who presented partial MPD stricture or disruption; surgical therapy was performed in 2 patients exhibiting complete MPD obstruction or disruption. Stents were removed 3 to 6 weeks after initial placement. IPF resolved in 10 of 11 patients (90.9%) within 6 weeks. The resolution of IPF was faster (13 +/- 5 vs. 25 +/- 13 days, P < 0.01) and the length of hospital stay was significantly shorter (17.2 +/- 5.6 vs. 31.2 +/- 4.4 days, P < 0.01) in patients subject to interventional treatment compared with those treated conservatively. There was 1 death due to sepsis in a patient managed conservatively; no death was recorded in the interventional therapy group. There was no recurrence of IPF at a mean follow-up of 38 months. CONCLUSIONS: Our results suggest that interventional therapy should be considered the best approach for the management of IPF in patients presenting MPD disruption or obstruction. Conservative therapy must be reserved for those showing MPD dilatation without ductal disruption or stricture. Early interventional therapy reduced hospital stay and convalescence, which likely resulted in lower healthcare overall costs.
Assuntos
Fístula Pancreática/terapia , Adulto , Algoritmos , Brasil , Endoscopia do Sistema Digestório , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pâncreas/patologia , Pâncreas/cirurgia , Fístula Pancreática/etiologia , Fístula Pancreática/cirurgia , Pancreatite Alcoólica/complicações , Cavidade Pleural/patologia , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
Patients with alcohol-related chronic pancreatitis (ARCP) often have peripheral neuropathy, but no data on the occurrence of autonomic neuropathy (AN) are available for this condition. To assess the autonomic function and the significance of its abnormalities for the prognosis of ARCP, 18 patients with ARCP and associated diabetes mellitus (P-DM group), 10 with ARCP without evidence of diabetes mellitus (P group), 17 patients with insulin-dependent diabetes mellitus (IDDM group), and 18 healthy controls answered a structured questionnaire and underwent three standardized cardiovascular (CV) tests that yielded six different parameters for autonomic nerve function. Patients with at least one symptom plus two abnormal results on CV tests were regarded as having AN. ARCP patients were followed up for 48 months and mortality rates were recorded. The proportions of patients with AN were 66.6% in the P-DM group, 30.0% in the P group, and 29.4% in IDDM patients. Seven of 15 ARCP patients with AN died during follow-up, compared with one of 13 of those without AN (p < 0.037). In conclusion, AN is commonly found in ARCP patients and carries an ominous prognosis.
Assuntos
Sistema Nervoso Autônomo/fisiopatologia , Pancreatite Alcoólica/fisiopatologia , Adolescente , Adulto , Arritmia Sinusal , Doenças do Sistema Nervoso Autônomo/complicações , Doenças do Sistema Nervoso Autônomo/diagnóstico , Doenças do Sistema Nervoso Autônomo/mortalidade , Doença Crônica , Diabetes Mellitus Tipo 1/etiologia , Diabetes Mellitus Tipo 1/fisiopatologia , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite Alcoólica/complicações , Pancreatite Alcoólica/mortalidade , Postura , Prognóstico , Reflexo , Taxa de Sobrevida , Manobra de ValsalvaRESUMO
Os autores apresentam um caso de paciente etilista, com pancreatite crönica, sem sintomatologia de agudizaçäo, amilase de 123 v/dl, no momento, com hematêmese e dor epigástrica. Foi solicitada gastroduodenoscopia e ultra-sonografia, que sugeriram pseudo-aneurisma da artéria esplênica, o que foi confirmado pela arteriografia. Um segundo ultra-som, realizado dois dias após o primeiro, mostrou alteraçäo do aspecto ultrasonográfico, com aumento do trombo e diminuiçäo da luz, indicando a variabilidade rápida da aparência ultra-sonográfica. Após, o paciente foi submetido a aneurismectomia, esplenectomia e pancreatectomia de cauda, com sucesso
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Falso Aneurisma/etiologia , Artéria Esplênica , Pancreatite Alcoólica/complicações , Falso Aneurisma , AngiografiaRESUMO
BACKGROUND: Chronic ethanol abuse is a common cause of chronic hepatic and pancreatic diseases in Western countries. The objectives of the present study were to determine the occurrence and the clinical evolution during follow-up of asymptomatic hepatic disease in Brazilian alcoholics with chronic pancreatitis whose most important beverage is cachaça, a beverage distilled from sugar cane. PATIENTS-METHODS: Thirty-two patients, mean age 35 years, with a mean daily ethanol intake of 204 g during a mean period of 16 years, presenting with chronic pancreatitis without clinical and laboratory features of hepatocellular failure, were followed up during 34 +/- 8 months after undergoing a percutaneous biopsy of the liver and histological examination. RESULTS: Hepatic injury was observed in 50% of the cases. During the follow-up, only one patient showed clinical or biochemical evidence of hepatic deterioration or complication. CONCLUSIONS: In subjects with a chronic intake of cachaça, the association between asymptomatic alcoholic hepatopathy and chronic alcoholic pancreatitis is frequent (50%). In chronic alcoholic pancreatitis, associated hepatic disease may remain asymptomatic in the majority of the cases and has little influence on the outcome of the patients, at least in a short-term follow-up.
Assuntos
Hepatopatias Alcoólicas/complicações , Pancreatite Alcoólica/complicações , Adulto , Brasil/epidemiologia , Doença Crônica , Seguimentos , Humanos , Hepatopatias Alcoólicas/diagnóstico , Hepatopatias Alcoólicas/epidemiologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pancreatite Alcoólica/diagnóstico , Pancreatite Alcoólica/epidemiologia , Fatores de TempoRESUMO
Biliary and pancreatic stents are effective tools in the management of obstructive jaundice (both malignant and benign), pancreatic pseudocyst drainage, and as treatment for biliary and pancreatic fistulae. Unfortunately, stents may become blocked and require replacement in a number of patients. In the present study a blocked stent from a patient with transpapillary drainage of pancreatic pseudocyst and another from a patient with obstructive jaundice resulting from cancer of the head of the pancreas associated with Mirizzi syndrome were characterized by electron microscopy. Stent blockage was diagnosed by a pressure test and stent cultures were performed. Electron microscopy of the blocked stents revealed the sludge to consist of microcolonies of bacteria mixed with amorphous material, and cultures of both stents were positive for Klebsiella sp and E. coli.
Assuntos
Adulto , Feminino , Humanos , Colestase/complicações , Escherichia coli/patogenicidade , Klebsiella/patogenicidade , Pancreatite Alcoólica/complicações , Stents/efeitos adversosRESUMO
Aiming at establishing the prevalence of peptic ulcer in chronic alcoholic pancreatitis and an eventual correlation with gastric acid secretion and endoscopic and histopathologic alterations as well as the presence of Helicobacter pylori in the gastroduodenal mucosa, thirty patients with chronic alcoholic pancreatitis (Group I) and ten control subjects (Group II) were prospectively studied. After upper gastrointestinal endoscopy was performed. Group I was subdivided according to the lack (Subgroup Ia) or a presence (Subgroup Ib) of peptic ulcer. The prevalence of peptic ulcer in these patients was 23.33% clearly higher than that reported in the general population. Baseline and stimulated acid secretion as well as baseline gastrinemia among the subgroups and groups were similar. There was no statistically significant difference in the other parameters evaluated. Due to the increased prevalence of asymptomatic peptic ulcer in patients with chronic alcoholic pancreatitis. Upper gastrointestinal endoscopy is suggested as a diagnosis routine and follow-up of this group of patients.
Assuntos
Ácido Gástrico/metabolismo , Infecções por Helicobacter/microbiologia , Pancreatite Alcoólica/complicações , Pancreatite Alcoólica/epidemiologia , Adulto , Endoscopia Gastrointestinal , Feminino , Mucosa Gástrica/metabolismo , Mucosa Gástrica/microbiologia , Mucosa Gástrica/patologia , Helicobacter pylori/isolamento & purificação , Humanos , Mucosa Intestinal/metabolismo , Mucosa Intestinal/microbiologia , Mucosa Intestinal/patologia , Masculino , Pessoa de Meia-Idade , Úlcera Péptica/microbiologia , Prevalência , Estudos ProspectivosRESUMO
We report the case of a 27-year-old man with alcoholic acute pancreatitis, who developed an acute loss of visual acuity; a bilateral Purtscher's retinopathy, a rare complication of acute pancreatitis, was confirmed by ophthalmoscopy.