Immediate recognition of ERCP-related perforations leads to more favorable patient outcomes; with lower incidence of SIRS, less need for ICU level care, and shorter hospital stay.
One of the most challenging issues arising in patients with chronic pancreatitis is the management of abdominal pain. Many competing theories exist to explain pancreatic pain including ductal hypertension from strictures and stones, increased interstitial pressure from glandular fibrosis, pancreatic neuritis, and ischemia. This clinical problem is superimposed on a background of reduced enzyme secretion and altered feedback mechanisms. Throughout history, investigators have used these theories to devise methods to combat chronic pancreatic pain including: Lifestyle measures, antioxidants, analgesics, administration of exogenous pancreatic enzymes, endoscopic drainage procedures, and surgical drainage and resection procedures. While the value of each modality has been debated over the years, pancreatic enzyme therapy remains a viable option. Enzyme therapy restores active enzymes to the small bowel and targets the altered feedback mechanism that lead to increased pancreatic ductal and tissue pressures, ischemia, and pain. Here, we review the mechanisms and treatments for chronic pancreatic pain with a specific focus on pancreatic enzyme replacement therapy. We also discuss different approaches to overcoming a lack of clinical response update ideas for studies needed to improve the clinical use of pancreatic enzymes to ameliorate pancreatic pain.
Background: Choice of bariatric procedure may be impacted by esophageal motor disorders and reflux disease, which are not routinely evaluated in obese subjects. Methods: Clinical characteristics on validated questionnaires and esophageal physiologic test findings were collected in 110 consecutive obese subjects (median age 48.5 years, 82% F, median BMI 46.9 kg/m2) evaluated for bariatric surgery. High resolution manometry (HRM) metrics included intragastric pressure (IGP), basal lower esophageal sphincter pressures (LESP), end-expiratory LESP, EGJ contractile integral (EGJ-CI), integrated relaxation pressure (IRP), distal contractile integral (DCI), and Chicago classification (CC) v4.0 diagnoses; acid exposure time (AET, normal if <4%) was obtained from ambulatory reflux monitoring. Comparative analyses determined differences between obese subjects and 15 institutional normal controls (median age 24.7 years, 53% F, median BMI 24.7 kg/m2) and if symptoms predicted abnormal tests. Results: Basal LESP and EGJ-CI were higher in obese subjects ( P = .03) compared to controls, while end-expiratory LESP was similar ( P = .97). IGP was also higher in obese subjects ( P < .0001), which modestly correlated with BMI. The most common CC 4.0 diagnosis was ineffective esophageal motility (IEM, 11.8%). EGJ outflow obstruction was seen in 9.1% and achalasia in 0.9%. Hiatus hernia (type 2 or 3 EGJ morphology) was found in 28%. Of 34 patients completing ambulatory reflux monitoring, 15 (44%) had elevated AET, without symptom or motor predictors. Conclusions: Achalasia, esophageal outflow obstruction, and reflux were encountered in higher than expected proportions without specific symptoms in pre-bariatric surgery patients. Thus, esophageal physiologic testing may be of value prior to bariatric surgery.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.