Search

In an 18 year hospital experience of over 500 patients with primary acute pancreatitis, 20 developed the disease either while pregnant (7 patients) or within five months of pregnancy (13 patients). Eighteen of the 20 patients had gallstones and adequate biliary surgery abolished further attacks of pancreatitis. Only two patients had surgery during the acute phase of their illness. The single fetal death was associated with early surgical intervention and there were no maternal deaths. We found no evidence of a specific link between pregnancy and pancreatitis but there is a marked association between pancreatitis and gallstones.

Among 100 consecutive patients with pancreatic pseudocysts, a biliary cause for the preceding acute pancreatitis was found in 27, for a mortality rate of 22 percent. Patients with alcohol abuse as the cause had a more favorable prognosis, with a 5 percent mortality rate among 59 patients (p less than 0.05, chi-square test). Despite an age difference between the two groups, we consider that this feature of patients with pancreatic pseudocyst warrants attention and we make recommendations herein with respect to therapy. Pseudocysts developed in 86 patients consequent to an episode of acute pancreatitis, and all 12 deaths (14 percent) were in this group. None of the remaining 14 patients whose pseudocysts were a feature of chronic pancreatitis died. Of the 81 patients in whom amylase levels were measured, 76 percent had an increased level.

Twenty-six patients with acute pancreatitis and normal chest radiographs on admission were studied. Twelve (46%) developed abnormalities in the first five days of illness. Twenty-four of the 25 patients tested developed an arterial pO2 of less than 10.6 kPa (80 mmHg) but severe hypoxia was present in a greater percentage of patients whose chest radiology became abnormal. Blood gases and chest radiographs should be checked on a regular basis in patients with acute pancreatitis.

Early differentiation of gallstone from nongallstone associated acute pancreatitis by imaging methods is often difficult. Timing of surgery in gallstone pancreatitis is controversial, but early surgery requires early demonstration of gallstones. This study assesses the value of easily available clinical and laboratory data in establishing gallstones as the etiology of pancreatitis. In 405 consecutive episodes of acute pancreatitis, data were collected prospectively on 14 clinical and laboratory variables. Gallstones caused 177 episodes and alcohol 135, 93 were due to other or unknown causes. Age, sex, and within 48 hours of admission, serum alkaline phosphatase, aminotransferases, amylase, and bilirubin were all significantly different (all p less than 0.001, chi square) in gallstone and alcohol groups. Multivariate analysis based on five of these variables enabled correct prediction of the presence or absence of gallstones in 50 of a further 56 episodes. This method may help in planning early interventional treatment of gallstone associated acute pancreatitis.

We have analysed the effects of 'curative' and palliative surgery and adjuvant therapy on actuarial 5 and 10 year survival in 97 local patients with primary small bowel malignancies presenting to five Glasgow teaching hospitals over a 15 year period. The 5 year survival rates in 18 patients with lymphoma undergoing 'curative' surgery was 48 per cent while in patients whose surgery was considered palliative the figure was 12 per cent (P less than 0.001). In the 29 patients with carcinoma, 17 had 'curative' surgery and 12 a palliative procedure with respective 5 year survival rates of 38 per cent and 0 per cent (P less than 0.01). In 16 patients with carcinoid tumours the surgeons' assessment of curative or palliative surgery was of little consequence with 51 per cent of the palliative group alive at 10 years. Mean survivals were increased in lymphoma patients in both 'curative' and palliative groups receiving adjuvant therapy but not significantly so. We suggest that all detectable macroscopic tumour, where possible, should be removed and that adjuvant therapy may be of benefit in all patients with lymphoma, even when surgery is considered 'curative'.

Twenty-five patients with acute pancreatitis were studied prospectively in the first week of their admission using haematological and coagulation tests. Platelet counts initially fell and later returned to admission levels. Rising levels of plasma fibrinogen were recorded. The kaolin cephalin clotting time was shorter than its control in twenty-one patients. Eighteen patients had elevated fibrinogen degradation products and fourteen had a positive ethanol gelation test. It is suggested that by taking into account the results in series of individual patients a degree of intravascular coagulation may be a common feature of acute pancreatitis. In one patient (presented in detail) strong evidence for disseminated intravascular coagulation was found

Serum amylase has been determined on admission in 63 (52 per cent) of 122 patients with acute mesenteric infarction. Amylase levels were normal in 34 (54 per cent) and reached greater than twice normal in 15 patients (24 per cent). In 5 patients (3 on admission) amylase levels were in the diagnostic range of acute pancreatitis (greater than 1200 units/l) leading to inappropriate non-operative treatment in 4. Hyperamylasaemia was found in association with all aetiologies of infarction. The magnitude of the hyperamylasaemia appeared to be related to the extent of the bowel infarction, the highest levels occurring when infarction involved the small bowel and colon. The mechanism of hyperamylasaemia in acute mesenteric infarction is discussed.

Acute haemorrhagic pancreatitis was induced by intraductal injection of a bile-trypsin blood mixture in 22 dogs, with a 100% mortality in 4 dogs given supportive therapy alone. Control animals survived without ill effect. The remaining 18 dogs were given supplementary intravenous aprotinin (400,000 KI units) at varying times after onset of acute pancreatitis. 10 given this treatment starting 1--6 h after induction of pancreatitis survived without appreciable morbidity. A 9- and 12-hour delay in starting aprotinin therapy was associated with a 25 and 75% mortality rate, respectively. Monitoring of serum (and urinary) amylase, serum calcium and albumin is documented.

A patient with occult pancreatic carcinoma associated with recurrent acute pancreatitis is reported. Endoscopic retrograde cholangiopancreatography after the first attack was normal, the diagnosis being made at repeat examination 10 months later.

The stimulated pancreatic polypeptide (PP) response was compared to standard tests of pancreatic function in patients with proven chronic pancreatitis and control subjects. Although the median values of the PP test in patients were statistically significantly different from those of controls, much variability was seen in both groups. The PP response seems to correlate with pancreatic exocrine function and shows good agreement with the results of other tests of exocrine pancreatic function while avoiding many of the difficulties inherent in performing other tests. Although more studies are needed, the PP response provides a valuable test of pancreatic function.

Since 1971, in Glasgow Royal Infirmary 880 patients with acute pancreatitis (AP) have been prospectively studied. Only two (0.23 per cent) have been found with associated hyperparathyroidism (HPT), one of whom also had gallstones. During the period of study daily serum calcium levels were measured routinely in all patients with AP and, in addition, a consecutive series of 200 patients had daily mineral metabolism screening of blood and urine in an attempt to identify patients with hypercalcaemia as an aetiological factor. A separate group of 90 patients had sequential daily serum calcium and parathyroid hormone assays (PTH) performed for the first five days of their hospital admission and one of the patients described in this paper came from this group. She is the first patient, to our knowledge, documented in this manner. The overall pattern of the PTH and calcium response from all these patients is also recorded according to the severity of the AP. Hyperparathyroidism is uncommonly associated with AP and when it is other aetiological factors must be excluded.

Grey scale ultrasound scanning has been performed within 1 week of admission in 114 patients with acute pancreatitis in order to establish its reliability in detecting gallstones and to document early pancreatic changes. When the gallbladder was identified (69.4 per cent of patients), grey scale ultrasound was 96.1 per cent accurate in predicting the presence of gallstones. Of 85 patients (74.5 per cent), in whom adequate pancreatic imaging was achieved on the initial scan, 35 were reported within normal limits, 28 had generalized pancreatic swelling and 22 a localized pancreatic mass of cystic collection. These ultrasound findings did not correlate significantly with the objective assessment of severity of disease. However, all 9 patients (8.1 per cent) who developed a pseudocyst were in the group shown to have early localized pancreatic swelling. Grey scale ultrasound is a useful method of detecting gallstones in patients with acute pancreatitis, thus permitting early accurate biliary surgery. However, in almost one-third of our patients ultrasound failed to outline the gallbladder on the initial scan. While ultrasound scanning of the pancreas will detect the formation of pseudocysts and accurately chart their subsequent progress, we doubt whether an early scan is required to achieve this purpose. Although generalized pancreatic swelling is frequently reported, this finding was of no major clinical importance and did not relate to the severity of disease.

In a retrospective review of 294 patients with spontaneous pneumothorax (398 episodes), 45 patients came to surgical treatment. The period of the study was 7 1/2 years, with a mean follow-up of 3 years in which there was no recurrence of pneumothorax after surgery. Operation consisted of simple excision of bullous lesions, usually located at the apex of the upper lobe, without pleurectomy. This simplified surgical approach has met with excellent result, indicating that pleurectomy is unnecessary in the treatment of this disease.

We performed a multicenter, randomized, controlled clinical trial of therapeutic peritoneal lavage (2 liters per hour for three days) in 91 patients with severe acute pancreatitis. Patients were entered into the study if severe pancreatitis was indicated by multiple laboratory criteria or diagnostic peritoneal lavage. All patients received full supportive treatment. The median time between the onset of symptoms and randomization was 38 hours. Forty-six patients were assigned to the control group and 45 to the lavage group. There were 13 deaths (28 per cent) and 16 patients with major complications (35 per cent) in the control group, as compared with 12 deaths (27 per cent) and 17 patients with major complications (38 per cent) in the lavage group. Lavage did not appear to modify the length of survival, the incidence of pancreatic collections (pseudocysts or abscesses), or the plasma amylase concentration. Considering the statistical power of the design, we conclude that the outcome of severe pancreatitis was not greatly, if at all, influenced by the regimen of peritoneal lavage used in this study.

The clinical course of 47 patients with gallstone-associated acute pancreatitis who had surgery during the same admission has been reviewed. In 37 patients, when the signs and symptoms of pancreatitis settled on conservative management, biliary tract surgery was safely performed during that admission without mortality. The 10 patients whose clinical condition failed to settle prior to surgery had a complicated hospital stay and a 50 per cent mortality. A revised prognostic factor grading system has been outlined in which the age factor is removed and serum transaminase levels are considered of prognostic significance only if greater than 200 u/l within 48 h of admission. This revised system gives a more accurate assessment of the severity of individual attacks of gallstone-associated acute pancreatitis.

In a series of patients with acute pancreatitis we have studied complement factors, antiproteases (alpha 2-macroglobulin and alpha 1-antiprotease) and C-reactive protein to determine the value of their sequential measurement in the prediction of outcome relative to clinical assessment and current multiple factor scoring systems. Complement factors were unhelpful in predicting the severity of an attack. alpha 2-Macroglobulin levels were significantly lower in complicated attacks during days 3-8 and alpha 1-antiprotease levels were significantly higher during days 4-8. C-reactive protein concentrations showed the best discrimination between mild and complicated attacks, levels rising higher and persisting for longer in complicated attacks; these differences were highly significant from day 2 (the morning after admission) to day 8. The concentrations providing the best discrimination were found to be greater than or equal to 210 mg/l for the peak C-reactive protein (on the second, third or fourth day) and greater than or equal to 120 mg/l for the C-reactive protein at the end of the first week. Analysis demonstrated both the peak or seventh-day C-reactive protein concentration to be of similar accuracy to either the Ranson or Glasgow multiple factor scoring systems and slightly better for attacks associated with gallstones. The C-reactive protein assay is simple, quick to perform, provides useful clinical information and is more likely to be of value and to be adopted into routine clinical practice than multiple factor scoring systems.

The incidence and significance of ecchymosis in 770 patients with acute pancreatitis is reported. The over-all incidence of 3 per cent is greater than generally appreciated. The development of this sign predicts the development of severe complications during the course of the disease and, in particular, there is an association with pseudocyst formation. However, the mortality of this group of patients is only 37 per cent which is in contrast to the views of many who believe that the development of Grey-Turner's sign or Cullen's sign, or both, predicts impending death.

Prognostic factor scoring systems provide one method of predicting severity of acute pancreatitis. This paper reports the prospective assessment of a system using nine factors available within 48 hours of admission. This assessment does not include patient data used to compile the system. Of 405 episodes of acute pancreatitis occurring in a seven year period, 72% had severity correctly predicted by the system; 31% of 131 episodes with three or more factors present were severe and 8% of 274 episodes with less than three factors were severe. Assessment of individual factors revealed only one which did not predict severity. A scoring system based on the other eight factors correctly predicted severity in 79% of episodes. Prognostic factor scoring systems (i) alert the clinician to potentially severe disease, (ii) allow comparison of severity within and between patient series and (iii) will allow rational selection of patients for trials of new treatment.

Pancreaticoduodenectomy is widely and reasonably regarded as the treatment of choice for ampullary carcinoma. Reported cases of local excision are few and mainly involve elderly, poor risk patients. Eight patients with ampullary carcinoma treated by local excision are presented. None of these patients who had local excision were considered unfit for pancreaticoduodenectomy. There were two post-operative deaths (25%). Median survival was 57 months with 44% five year actuarial survival. Three of the patients who survived the local excision subsequently developed recurrent disease. If local excision is performed some form of biliary bypass may be advisable.

Review of acute pancreatitis deaths between 1974 and 1984 revealed 126 patients, 53 (42%) of whom were first diagnosed at autopsy. Pancreatitis was undiagnosed in life in 13 (33%) of the patients with a gallstone aetiology, 8 (40%) of those with an alcohol aetiology, 21 (42%) of those of unknown aetiology and 17 (74%) of those with pancreatitis due to other identified aetiological factors. These patients more commonly died within the first week of their illness, more often had significant underlying medical disease and tended to have less severe degrees of pancreatic parenchymal destruction. Only 7 (13%) of the 53 patients undiagnosed in life had presented with abdominal pain. The majority (68%) presented atypically with known or suspected medical conditions, often to internists, or post-operatively (19%). Failure to diagnose these patients in life was most often due to a lack of consideration of the diagnosis, usually because of the atypical presentation, and consequent omission of an amylase determination--made in only 5 (9%) of the patients.

Transduodenal sphincteroplasty (TDS) was performed upon five patients with chronic pancreatitis shown on endoscopic retrograde cholangiopancreatography to have stones in the pancreatic ductal system. Stone removal was achieved after TDS using either a Fogarty balloon catheter, a Dormia basket or surgical forceps. All had suffered from a two to three year history of severe pain and weight loss which was relieved in each after stone removal. One patient suffered recurrent pain in the follow-up period of 21 to 45 months (a median of 35 months) and a recurrent stone in the pancreatic duct was removed endoscopically using a Dormia basket. Contrary to widely held views, TDS and simple stone extraction have a place in the management of some patients with chronic pancreatitis.

Of the 123 patients with acute mesenteric infarction treated over the past 12 years, 16 (13%) had mesenteric venous thrombosis. Eight of the patients with mesenteric venous thrombosis survived the initial episode; two have since died. The remaining six patients were studied for evidence of haemostatic deficiencies or abnormalities. Antithrombin III deficiency, which is known to be associated with recurrent venous thrombosis, was found in three patients. It is recommended that all patients with mesenteric venous thrombosis should be screened for antithrombin III deficiency as treatment with coumarin anticoagulants may be indicated, providing effective prophylaxis against further thrombotic episodes.

All 78 patients with acute pancreatitis admitted to one hospital in a 2-year period were included in a prospective survey of conservative management. The overall mortality rate was 11.5 per cent, being 46 per cent for 11 patients subjected to early laparotomy and only 6 per cent for patients managed without operation. Twenty-six patients were considered to have severe acute pancreatitis and all 9 deaths occurred in this group. Biliary disease was present in 51 per cent of patients, and the majority of those with biliary disease were over 60 years old. Alcohol-related acute pancreatitis occurred in 26 per cent of the total patients, and none of this group was over 60 years old. Acute pancreatitis was considered idiopathic in origin in only 13 per cent of the patients. Elective biliary surgery in 30 patients resulted in freedom from recurrent attacks of acute pancreatitis for the follow-up period (12-30 months). The results compare favourably with those in which glucagon and high dosage aprotinin (Trasylol) have been utilized in the management of acute pancreatitis.

Thirty nine patients undergoing surgery for chronic pancreatitis were investigated for evidence of hepatobiliary disease. In addition to pre-operative assessment by liver function tests, ultrasound, ERCP (in 33) and percutaneous transhepatic cholangiography (in five), all had peroperative liver biopsy. Common bile duct stenosis was diagnosed in 16 (62%) of the 26 patients with successful cholangiography. Features of extrahepatic biliary obstruction were found on biopsy in 11 patients, three of whom showed features of secondary sclerosing cholangitis. No patients had secondary biliary cirrhosis. Three had parenchymal liver disease (cirrhosis, resolving hepatitis and alcoholic hepatitis respectively) and two others had features suggestive of previous alcohol-induced injury. Five (83%) of the patients with clinical jaundice had biopsy features of extrahepatic biliary obstruction, as did eight (67%) with alkaline phosphatase above twice normal and seven (44%) with radiological common bile duct stenosis. Neither alkaline phosphatase rise, nor common bile duct stenosis alone or in combination, were a reliable indication of the need for biliary enteric bypass surgery. Pre-operative liver biopsy may be a valuable adjunct in the assessment of such patients.

Hypoalbuminaemia has been consistently observed in a prospective study of 130 patients with acute pancreatitis. A study was initiated, therefore, to find out if the hypocalcaemia of acute pancreatitis could be explained by the associated hypoalbuminaemia. 64.4% of all serum calcium results were in the apparently hypocalcaemic range. A comparable incidence of hypoalbuminaemia was observed. The 'uncorrected' total serum calcium and serum albumin showed a similar pattern in their daily changes and also a significant correlation overall. When correction of serum calcium was made for albumin levels, only 10.9% of all results represented varying degrees of 'true' hypocalcaemia. Mortality and severity of acute pancreatitis related as closely to hypoalbuminaemia as to uncorrected hypocalcaemia. It is concluded that a low serum albumin should be regarded as the most common cause of a low serum calcium in acute pancreatitis. Routine albumin administration is proposed, a procedure which has been shown to be associated with improved mortality rate and morbidity in this disease.

Acute pancreatitis is an unusual feature of non-pancreatic neoplasia. The presentation and clinical course of 7 patients with carcinoma metastatic to the pancreas is reported. In 5 the initial presentation was acute pancreatitis, and in the remaining 2 the diagnosis was made at autopsy. The primary sites of cancer were in the stomach (5 patients), bronchus (1 patient) and tonsil (1 patient).

The accuracy and possible clinical value of grey scale ultrasonography in the detection of gallstones has been prospectively studied in 100 unselected patients presenting with recurrent biliary colic, acute cholecystitis or acute pancreatitis. Adequate visualization of the gallbladder was obtained in 79 cases, with 3 false positive and no false negative reports. Oral cholecystography remains the initial investigation of choice in patients presenting with recurrent biliary colic, but grey scale ultrasound has been shown in this study to be a reliable means of detecting gallstones in the 'acute' situation, when conventional contrast radiology is of limited value.

Of 311 patients with primary acute pancreatitis, seven revealed major and seven minor lipid abnormalities on hospital admission. One pregnant woman suffered acute pancreatitis associated with Fredrickson type I hyperlipoproteinaemia. Twelve of the 13 men with types IV and V hyperlipoproteinaemia suffered alcohol abuse pancreatitis and represented 13.2 per cent of this aetiological group. However, only one of the 157 patients (0.6 per cent) with biliary disease had lipid abnormalities. Two of the 13 men died--the oldest, who had gallstones, and one with alcohol related disease. The remaining 11 were subject to follow-up (5-10 years). Six, who had improvement of their lipid abnormalities, had abstained from alcohol. The other five had a persistent lipid disorder, and all admitted continuing heavy alcohol ingestion. The clinical diagnosis of acute pancreatitis was supported by serum amylase elevation in only nine of the fourteen patients. Urinary amylase levels were consistent with the diagnosis in 11 of the 12 patients. Estimation of both serum and urinary amylase gave 100 per cent support to the clinical diagnosis of acute pancreatitis. Hyperlipidaemia associated with acute pancreatitis may be secondary to alcohol abuse but the possible role of HLP cannot be discounted. Urinary amylase is useful in diagnosing acute pancreatitis in the presence of hyperlipidaemia.

Respiratory Function has been measured in 14 patients with acute pancreatitis, none of whom has a previous history of cardiac or respiratory disease. Their mean age was 40 years, mean PaO2 on admission, 11 kPa, and all had normal chest radiographs at that time. Arterial hypoxia was a common development and the mean PaO2 at the time of most severe hypoxia was 8.6 kPa with the lowest individual recording 4.9 kPa. In addition to daily arterial blood gas monitoring, dynamic ventilatory tests and measurements of lung volume, transfer factor, closing volume, right to left shunts and studies of gas exchange were performed. Gas exchange and shunt measurements indicated that the major abnormality responsible for arterial hypoxia was right to left shunting. Seven patients developed radiological abnormalities, five of whom has pleural effusions. Five patients showed a mild restriction in lung volume but there were no major consistent abnormalities of dynamic ventilatory tests, transfer factor, or closing volumes. Thus small airway closure, in dependent parts of the lung and less certainly loss of surfactant are unlikely to be major factors in the aetiology of arterial hypoxia in patients with acute pancreatitis. All measurements were repeated at least three months after the acute illness. The respiratory insufficiency which occurs in this disease is possibly another variant of the adult respiratory distress syndrome.

Three variants of closed duodenal loop models of experimental acute pancreatitis in the rat have been analysed histologically and bacteriologically. Histological studies showed that the resulting pancreatitis was usually mild to moderate, being severe only in association with sepsis. Furthermore the duodenal wall became necrotic in most animals. Bacteriological studies revealed gross infection as a major complication. Peritoneal fluid and blood cultures taken at the time of animal sacrifice consistently demonstrated large numbers of bacteria. It is concluded that although these models undoubtedly cause acute pancreatitis, other more severe pathological events occur. Deductions regarding acute pancreatitis drawn from this type of model are therefore not relevant to the human disease.

Three patients are presented in whom internal pancreatic fistulae were accurately demonstrated by ERCP. It is recommended that this procedure be considered in the investigation of patients with continuing acute pancreatitis who are not settling on standard conservative treatment and in whom internal fistula formation is suspected. The procedure should also be considered in patients who present with unusual respiratory symptoms or with amylase-rich effusions.

Thirty-eight patients have been examined by ultrasound when symptoms or sign suggested the development of a pseudocyst following an attack of proven acute pancreatitis. Pseudocyst was diagnosed in 23 of the 38 cases. Five patients had multilocular cysts, four of which were shown to be communicating. Laparotomy was carried out on 14 of the 23 patients and surgical drainage was performed in 12 cases. The remaining nine cases were monitored and showed steady regression. Small cysts arising in the head of pancreas may give rise to recurrent or persistent pancreatitis and may be demonstrated pre-operatively by ultrasound but not readily by other means. A further 12 patients showed an area of irregular absorption of ultrasound interpreted as an inflammatory mass. Monitoring of these cases showed progressive resolution without cyst formation. Three of these cases subsequently required laparotomy-one developed an abscess and one necrosis of the body and tail of pancreas while a third developed severe pancreatic fibrosis of the area identified by ultrasound. The ability to distinguish between pseudocysts and inflammatory masses and to demonstrate communication between multiple cysts is of considerable value in pre-operative diagnosis.

Severe arterial hypoxia while breathing ambient air (Pao2 less than 60 mm Hg) was recorded in 38 (45 per cent) of a group of 84 patients with acute pancreatitis when arterial blood gas monitoring was performed during the first week of illness. This contrasted with an incidence of 19 per cent severe hypoxia in a heterogeneous group of 68 patients with acute abdominal pain admitted as surgical emergencies. Clinical evidence of respiratory embarrassment was rarely present in either the patients with acute pancreatitis or the other patients. Arterial hypoxia was related to the prognosis in both groups. It is recommended that all patients with acute pancreatitis have routine arterial blood gas monitoring performed during the first 5 days of illness. Furthermore, all older patients (over 60 years) and younger patients with moderate hypoxia (Pao2 less than 70 mm Hg) should be given supplementary humidified oxygen. An awareness of occult respiratory insufficiency in surgical emergency admissions, and especially in acute pancreatitis, is of importance.

Forty-one patients presented to our hospital between 1959 and 1983 with periampullary carcinoma. Twenty-six (63 per cent) underwent radical surgery, eight (20 per cent) local excision of the tumour, six (15 per cent) had bypass procedures and one was treated by endoscopic sphincterotomy (2 per cent). Potentially curative resection was performed in 83 per cent of the 41 patients. The operative mortalities for radical, local and bypass surgery were 7.7 per cent, 25 per cent and 16.6 per cent respectively. The degree of tumour differentiation significantly affected survival while local spread did not significantly affect survival in patients treated radically. The 5 year survival rates (calculated actuarially) for radical, local and bypass surgery were 34, 44 and 0 per cent respectively.