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Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis. © 2021 Elsevier España, S.L.U.

Resumen La pancreatitis cronica se asocia a calidad de vida deteriorada, elevada incidencia de comorbilidades, complicaciones graves y mortalidad. Los costes sanitarios son enormes. Algunas sociedades medicas han elaborado guias clinicas basadas en evidencia cientifica, pero el nivel de evidencia para cada aspecto de la enfermedad suele ser bajo y, consecuentemente, las recomendaciones tienden a ser vagas o debiles. En los presentes documentos de posicionamiento de la Societat Catalana de Digestologia y la Societat Catalana de Pancrees hemos buscado redactar declaraciones bien definidas orientadas al clinico, basadas en revisiones actualizadas de la literatura y acuerdos de expertos. El objetivo es proponer el uso de terminologia comun y circuitos diagnostico/terapeuticos racionales basados en el conocimiento actual. Para este fin se revisaron 51 secciones relacionadas con pancreatitis cronica por 21 expertos de 6 especialidades diferentes para generar finalmente 88 declaraciones que buscan armonizar conceptos y formular recomendaciones precisas. La parte 2 de esta serie de documentos discute temas sobre tratamiento y seguimiento. La aproximacion terapeutica debe incluir la evaluacion de factores etiologicos, manifestaciones clinicas y complicaciones. La complejidad de estos pacientes requiere un estudio detallado individualizado en comites multidisciplinares donde todas las opciones (conservadoras, endoscopicas, de radiologia intervencionista y quirurgicas) sean sopesadas. Deberian constituirse unidades especializadas de pancreatologia. Las indicaciones quirurgicas son dolor refractario, complicaciones locales y sospecha de neoplasia. El tratamiento enzimatico esta indicado si existe evidencia de insuficiencia exocrina o tras cirugia pancreatica. La respuesta debe evaluarse mediante parametros nutricionales y sintomas. Se debe planificar un programa de seguimiento para cada paciente.

Chronic pancreatitis tends to develop a number of complications that may constitute the form of presentation of the disease. Some societies have issued guidelines for diagnosis and treatment of chronic pancreatitis complications, but the level of evidence for any topic is usually low and recommendations tend to be weak. We aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The goal was to propose defined terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 14 sections related to complications and special forms of chronic pancreatitis (early chronic, groove and autoimmune pancreatitis) were reviewed by 21 specialists from 6 different fields to generate 32 statements. Featured statements assert common bile duct stenosis does not require invasive treatment (endoscopic or surgical) unless cholestasis, cholangitis, lithiasis or other symptoms develop. Pancreatic duct strictures and calculi should be approached (after ruling out malignancy) if causing pain, pancreatitis, pseudocysts or other complications. Treatment of symptomatic pseudocysts must be individualized, considering associated main duct stenosis, vascular and pericystic complications. Higher risk conditions for pancreatic cancer are advance age, smoking, genetic background, recent diagnosis of chronic pancreatitis or diabetes, and appearance of new symptoms. Groove pancreatitis can initially be treated with conservative measures. Both prednisolone or rituximab can induce remission and maintenance of autoimmune pancreatitis. Internal fistula, vascular complications, bacterial overgrowth, osteoporosis and renal lithiasis require specific therapeutic approaches.

Chronic pancreatitis is a chronic fibroinflammatory disease of the pancreas with prevalence around 50 cases per 100,000 inhabitants. It appears to originate from diverse and yet mixed etiological factors. It shows highly variable presenting features, complication types and disease progression rates. Treatment options are as wide as the multiple personalized scenarios the disease might exhibit at a given time point. Some medical societies have developed guidelines for diagnosis and treatment based on scientific evidence. Although these efforts are to be acknowledged, the gathered level of evidence for any topic is usually low and, therefore, recommendations tend to be vague or weak. In the present series of position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pancrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on interdisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 1 of this paper series discusses topics on aetiology and diagnosis of chronic pancreatitis. Main clinical features are abdominal pain, exocrine and endocrine insufficiency and symptoms derived from complications. Some patients remain symptom-free. Diagnosis (definitive, probable or uncertain) should be based on objective data obtained from imaging, histology, or functional tests. (C) 2021 Elsevier Espana, S.L.U. All rights reserved.

Mixed malignant ampullary tumours displaying adenomatous and neuroendocrine features are infrequent, with only nine reported cases, and almost all of them are composed of intestinal-type adenocarcinoma and well-differentiated neuroendocrine/carcinoid tumour.1 An 81-year-old man, with personal history of arterial hypertension, hypercholesterolaemia, type 2 diabetes mellitus and a previous appendectomy, presented with abdominal pain, fever and obstructive jaundice of 4-day duration. Physical examination was unremarkable but blood analysis showed an elevated alkaline phosphatase of 189 U/l (normal 40–130 U/l), and an elevated γ-glutamyltransferase of 255 U/l (normal 11–49 U/l). Aminotransferases were slightly elevated. Abdominal ultrasonography revealed dilated gallbladder and extrahepatic bile ducts. A cholangioresonance showed an exophytic mass in the ampulla of Vater, while an abdominal CT indicated a nodular lesion of 2 cm in the papillary region, suggesting ampullary adenocarcinoma. An endoscopic retrograde cholangiopancreatography and sphincterotomy were performed, and cytology and endoscopic biopsy were taken, revealing malignant cells, consistent with adenocarcinoma. Whipple resection was eventually performed. Grossly, the pancreaticoduodenectomy specimen showed an exophytic lesion of 2.7×1.6 cm obstructing the ampulla of Vater. A piece of this exophytic tumour was snap frozen in liquid nitrogen before fixation. H&E-stained sections of the entire lesion revealed an intestinal-type papillary tumour resembling a colonic villous adenoma, with cigar-shaped nuclei and some goblet cells, but with clear malignant features such as high nuclear atypia, high number of mitotic and apoptotic figures, and invasion in the lamina propria of the ampulla, with desmoplastic reaction. Some rests of peripheral adenoma could be seen. In some small areas this infiltrative intestinal-type …

Abdominal pain is the most frequent symptom in patients with chronic pancreatitis. Between 70 and 90% of patients experience pain at some point in the course of their disease. In patients with alcoholic pancreatitis, pain is usually experienced at disease onset. Two distinct forms of idiopathic chronic pancreatitis can be distinguished: in early-onset (juvenile) idiopathic chronic pancreatitis, pain occurs initially, while in late-onset (senile) idiopathic chronic pancreatitis, pain is delayed or may even be absent. According to several authors, between 27 and 67% of patients require surgery due to lack of response to medical treatment. Pain may reoccur in more than 30% of patients who have undergone surgery and consequently, reintervention is not uncommon. Several treatment options are currently available: medical, endoscopic and surgical. The most appropriate treatment for each patient should be chosen on an individualized basis.

Highlights • Tuberculosis is a health public problem, which has increased over the last 20 years. • The diagnosis of extrapulmonary tuberculosis can be challenging, and in particular clinical manifestations of gastrointestinal tuberculosis are unspecific and can mimic other pathologies. • Medical therapy is the treatment of choice and surgery is not required if it is diagnosed at an early stage, anyway diagnosis of abdominal tuberculosis still remains a challenge for both internists and surgeons. • Before starting a therapy with adalimumab, every patient should be tested for latent tuberculosis infection., Introduction Tuberculosis in Europe is a health public problem, which has increased constantly over the last few decades. The most common clinical manifestation of tuberculosis is pulmonary. The diagnosis of extrapulmonary tuberculosis can be challenging and clinical manifestations of gastrointestinal tuberculosis are unspecific and can mimic other pathologies. Presentation of case A young Chinese man, who had recently been diagnosed with Crohn’s disease, was admitted to the emergency room of our hospital with a one-month history of diffuse abdominal pain and weight loss. The patient initially presented with epigastric pain, which had been constantly increasing over the last 48 h. Other symptoms included diarrhea, nausea, and fever. The patient was then admitted with the diagnosis of Crohn’s disease exacerbation, and a treatment with corticosteroids, azathioprine, mesalazine, adalimumab, and antibiotic therapy was started. The symptoms were due to an initially misdiagnosed case of abdominal tuberculosis. Discussion Intestinal tuberculosis is mainly localized at the ileocecal level in 85% of patients. Medical therapy is the treatment of choice and surgery is not required if it is diagnosed at an early stage. Conclusion The diagnosis of abdominal tuberculosis still remains a challenge for both internists and surgeons. Before starting a therapy with adalimumab, every patient should be tested for latent tuberculosis infection.

Background & Aims: In patients with severe, necrotizing pancreatitis, it is common to administer early, broad-spectrum antibiotics, often a carbapenem, in the hope of reducing the incidence of pancreatic and peripancreatic infections, although the benefits of doing so have not been proved. Methods: A multicenter, prospective, double-blind, placebo-controlled randomized study set in 32 centers within North America and Europe. Participants: One hundred patients with clinically severe, confirmed necrotizing pancreatitis: 50 received meropenem and 50 received placebo. Interventions: Meropenem (1 g intravenously every 8 hours) or placebo within 5 days of the onset of symptoms for 7 to 21 days. Main Outcome Measures: Primary endpoint: development of pancreatic or peripancreatic infection within 42 days following randomization. Other endpoints: time between onset of pancreatitis and the development of pancreatic or peripancreatic infection; all-cause mortality; requirement for surgical intervention; development of nonpancreatic infections within 42 days following randomization. Results: Pancreatic or peripancreatic infections developed in 18% (9 of 50) of patients in the meropenem group compared with 12% (6 of 50) in the placebo group (P = 0.401). Overall mortality rate was 20% (10 of 50) in the meropenem group and 18% (9 of 50) in the placebo group (P = 0.799). Surgical intervention was required in 26% (13 of 50) and 20% (10 of 50) of the meropenem and placebo groups, respectively (P = 0.476). Conclusions: This study demonstrated no statistically significant difference between the treatment groups for pancreatic or peripancreatic infection, mortality, or requirement for surgical intervention, and did not support early prophylactic antimicrobial use in patients with severe acute necrotizing pancreatitis