Clinical features, concurrent disorders, and survival time in cats with suppurative cholangitis-cholangiohepatitis syndrome

OBJECTIVE To characterize clinical features, comorbidities, frequency of bacterial isolation, and survival time in cats with suppurative cholangitis-cholangiohepatitis syndrome (S-CCHS). ANIMALS 168 client-owned cats with S-CCHS. PROCEDURES Data were prospectively (1980 to 2019) collected regarding clinical features, comorbidities, bacterial infection, illness duration, and treatments. Variables were evaluated for associations with survival time. RESULTS Median age of cats was 10.0 years, with no breed or sex predilection observed. Common clinical features included hyporexia (82%), hyperbilirubinemia (80%), lethargy (80%), vomiting (80%), jaundice (67%), weight loss (54%), and hypoalbuminemia (50%). Comorbidities included extrahepatic bile duct obstruction (53%), cholelithiasis (42%), cholecystitis (40%), and ductal plate malformation (44%) as well as biopsy-confirmed inflammatory bowel disease (60/68 [88%]) and pancreatitis (41/44 [93%]). Bacterial cultures were commonly positive (69%) despite prebiopsy antimicrobial administration in most cats. Of surgically confirmed choleliths, diagnostic imaging identified only 58%. Among 55 cats with “idiopathic pancreatitis,” 28 (51%) were documented to have transiting choleliths, and 20 had pancreatic biopsies confirming pancreatitis. Cholelithiasis (with or without bile duct obstruction) and cholecystectomy were associated with survival advantages. Survival disadvantages were found for leukocytosis, ≥ 2-fold increased alkaline phosphatase, and hyperbilirubinemia. Cholecystoenterostomy had no survival impact. Cats with ductal plate malformations were significantly younger at diagnosis and death than other cats. Chronic treatments with antimicrobials, S-adenosylmethionine, and ursodeoxycholic acid were common postbiopsy. CLINICAL RELEVANCE S-CCHS in cats was associated with bacterial infection and various comorbidities and may be confused with pancreatitis. Surgically correctable morbidities (ie, cholecystitis, cholecystocholelithiasis) and cholecystectomy provided a significant survival advantage.

P-EUS02 The value of Endoscopic Ultrasound (EUS) in the investigative pathway of Acute Idiopathic Pancreatitis (AIP)

Background The British Society of Gastroenterology (BSG) guidelines on the management of acute idiopathic pancreatitis (AIP) state the incidence of idiopathic cases to be no more than 30%. However, before a firm diagnosis of AIP is made, Endoscopic Ultrasound (EUS) may be used to determine occult causes. This approach may help prevent recurrent attacks which may evolve into chronic pancreatitis. Methods Retrospective analysis over a one-year period of cases of AIP in a tertiary referral center was performed to see the incidence of AIP and the role of EUS. Patients with an identifiable cause for pancreatitis were excluded, leaving only those who had received a diagnosis of AIP and the diagnostic value of EUS was examined. Results Of the 101 patients diagnosed with AIP, 19% (n = 19) underwent an EUS succesfully. 79% (n = 15) had no underlying cause of pancreatitis identified on EUS. In the remaining 21% of cases (n = 4), microlithiasis, ductal stones, and pus requiring drainage were common findings. Of these patents, only 1 was referred for surgery. In the patient group with negative findings on EUS, 4% were unaffected, 2% were refered for surgery, 2% died and 7% had recurrent episodes of pancreatitis. Conclusions The results of this study show that EUS is a valuable modality in patients with suspected AIP, with a positive diagnostic rate of 21%. Therefore, we propose EUS needs to be included in the investigative pathway of all suspected AIP. Although EUS is a relatively scarce resource, further research is required to establish guidelines for the investigation of suspected AIP.

Mini-laparoscopic cholecystectomy: evolution of a new technique

Background Since the first laparoscopic cholecystectomy (LC) in 1985, there has been much advancement in laparoscopic surgery in terms of reduction in number and size of ports. We report a new technique of performing mini laparoscopic cholecystectomy using only three ports, 5 mm each. The indications of this procedure include GB polyps, GB dyskinesia, microlithiasis, and idiopathic pancreatitis. Case presentation In this case report, we present a new technique that has been performed safely in a 49-year-old male patient with pancreatitis caused by microlithiasis. This was performed using a novel three port procedure consisting of only 5 mm ports, and he was discharged as a day case without complications. Informed patient consent was obtained. Conclusions The fundamentals of this mini-LC technique remain the same as that of a standard laparoscopic cholecystectomy throughout the procedure. It is a feasible option in selected cases, and it has the potential to further augment the inherent benefits of minimal access surgery namely less analgesia, improved cosmesis and faster recovery. Further trials will help ascertain its potential advantages.

Role of Alanine Aminotransferase in Determining the Biliary Etiology in Acute Pancreatitis

Introduction: Acute pancreatitis a disorder that has numerous causes and an obscure pathogenesis. It can be a serious abdominal emergency associated with significant morbidity and mortality. Cholelithiasis is most common cause of acute pancreatitis and excessive alcohol consumption is second most frequent cause which together account for approximately 80% of underlying etiology. The detection of biliary etiology is crucial to delivery of definitive therapy to prevent repeated attacks of acute pancreatitis. During an attack of acute pancreatitis, elevation of alanine aminotransferase to >150 IU/L is a predictive factor for biliary cause of acute pancreatitis. Aims: To investigate the predictive value of raised alanine aminotransferase in determining biliary etiology in patients presenting with acute pancreatitis. Methods: A prospective study was done among 70 patients who were admitted in surgery department over a period of one year with diagnosis of acute pancreatitis. Peak alanine aminotransferase within 48 hours of presentation was recorded. The diagnosis was based on typical clinical presentation of acute pancreatitis combined with an increase in serum amylase levels ≥ 3 times the upper limit of the laboratory reference value. All biliary cases were confirmed by abdominal ultrasonography. Results: The mean age of the patients was 47.9 ±15.7 years (19-88 years). Acute pancreatitis was common in 31-40 years of age group. Among them, 40(57.1%) were male and 30(42.9%) were female. Forty two (60%) patients had biliary pancreatitis, 20(28.5%) had alcoholic pancreatitis, 2(2.8%) patients had drug induced pancreatitis and 6(8.5%) patients had idiopathic pancreatitis. Mean alanine aminotransferase for biliary pancreatitis was 205.9U/L, while cases with other etiologies (alcoholic 58.4U/L; drug induced 62.6 U/L; and idiopathic 48.3 U/L) showed significantly lower values (p=0.001). Conclusion: An elevated alanine aminotransferase strongly supports a diagnosis of gallstones in acute pancreatitis.

Clinical Characteristics and Prognosis of Idiopathic Acute Pancreatitis

Objective: Acute pancreatitis is a serious diagnosis with an increasing incidence in the Western world. In this study we sought to investigate the incidence of idiopathic AP and to compare clinical and prognostic characteristics of idiopathic cases with cases of AP with known etiology. Methods: In this retrospective study of adult hospitalized patients diagnosed with acute pancreatitis between 2012 and 2015, a comparison was made between admissions of patients with known etiology and those for whom no cause was found. Primary outcome was defined as composite outcome of 30-day mortality and complications. Results:Among 560 admissions of 437 patients with a primary diagnosis of acute pancreatitis, the main factors identified were gallstones (51.2%) and idiopathic pancreatitis (35.9%), with alcohol ranked third at only 4.8%. Mortality rate within 30 days of hospitalization was 2.9% and within one year was 7.1%. Use of lipid-lowering, anti-hypertensive, and anti-diabetic medications was more frequent among patients with “idiopathic” disease (70%, 68%, and 33% versus 59%, 56%, and 27%, respectively). Patients admitted with idiopathic AP, in comparison to patients with known AP etiology, had milder disease with shorter hospital stay (3 days versus 4, respectively), and less re-admission in 30 days (7.5% versus 21.2%). Idiopathic AP patients had better prognosis in terms of 30-day death and complication (HR 0.33, 95% CI 0.08–0.40, P<0.001). Conclusion: Idiopathic disease is common among acute pancreatitis patients; the two study groups differed in severity of disease and prognosis. Common use of medications with doubtful value suggests possible under-diagnosis of drug-induced acute idiopathic pancreatitis.

Black pleural effusion: an unusual complication of pseudocyst pancreas

Pleural effusion following rupture of pancreatic pseudocyst into the pleural cavity resulting into pancreaticopleural fistula is an extremely uncommon complication of acute pancreatitis. Pancreaticopleural fistula also results from disruption of a major pancreatic duct usually due to an underlying pancreatic disease (chronic pancreatitis), trauma, or iatrogenic injury. Pleural effusion is predominantly left sided; however, right-sided and bilateral effusion occurs in 19% and 14% of patients respectively. The pleural effusate can be either serous, serosanguinous or black in colour. Analysis of pleural fluid for raised amylase will confirm the diagnosis and investigations like computed tomography (CT), endoscopic retrograde cholangiopancreatography (ECRP) or magnetic resonance cholangiopancreatography (MRCP) may establish the fistulous communication between the pancreas, pseudocyst and pleural cavity. The optimal treatment strategy has traditionally been medical management with thoracocentesis and/or tube thoracostomy and exocrine suppression with octreotide and ERCP stenting of the fistulous pancreatic duct. Surgery, in the current era, is considered in the event patient fails to respond to conservative management or the patient’s condition deteriorates. We report the case of a 24-years-old gentleman who was diagnosed with chronic idiopathic pancreatitis with pseudocyst who developed right sided black pleural effusion.