Acute pancreatitis (AP) is an important cause of morbidity and mortality worldwide and the annual incidence appears to be increasing. It presents as a mild self-limiting illness in 80% of patients. However, one-fifth of these develop a severe complicated life-threatening disease requiring intensive and prolonged therapeutic intervention. Alcohol and gallstone disease remain the commonest causes of AP but metabolic abnormalities, obesity and genetic susceptibility are thought be increasingly important aetiological factors. The prompt diagnosis of AP and stratification of disease severity is essential in directing rapid delivery of appropriate therapeutic measures. In this review, the range of diagnostic and prognostic assays, severity scoring systems and radiological investigations used in current clinical practice are described, highlighting their strengths and weaknesses. Increased understanding of the complex pathophysiology of AP has generated an array of new potential diagnostic assays and these are discussed. The multidisciplinary approach to management of severe pancreatitis is outlined, including areas of controversy and novel treatments.
Between 1982 and 1991, 20 patients of median age 44 (range 22-76) years were treated for non-functioning neuroendocrine tumours of the pancreas. Presenting features were obstructive jaundice (seven patients), abdominal pain (seven), weight loss (six), abdominal mass (eight) and severe haemorrhage (four). Gut hormone profiles were normal except for one patient who had a raised pancreatic polypeptide level. Contrast-enhanced computed tomography localized the tumour in 17 patients and visceral angiography in 14 of 15; all but three tumours were highly vascular. Ten patients underwent curative resection, and the remainder were managed palliatively by resection (four), bypass procedures (three) or biopsy alone (three). There were two postoperative deaths and seven early complications. Seven of the remaining 18 patients have died from disease a median of 16 (range 4-30) months after presentation. The 11 survivors, eight of whom had curative resections, have been followed for a median of 42 (range 7-72) months. Ten patients are asymptomatic but only five are free from disease. These tumours are seldom curable by radical surgery, but patients may remain free from symptoms for many years.
Using radiological interventional techniques the gall bladder can be cleared of stones with a high success rate. As with any treatment option that leaves the gall bladder in situ there is an accompanying risk of stone recurrence, which is currently unknown for the radiological method. One hundred patients were studied prospectively to determine the recurrence rate of stones and clinical outcome after successful percutaneous cholecystolithotomy. Follow up included both clinical assessment and ultrasound examination at 3, 6, and 12 months and then annual intervals thereafter. The overall stone recurrence rate was 31% at a mean follow up of 26 months (range, 3-50
Many new therapies for the management of gallstone disease have been pioneered in the past decade. The object of this review is to equip the surgeon with the answers to all of the questions a patient will ask about gallstone therapy; the review is therefore didactic as well as comprehensive.
Summary Granular cell tumors are a rare cause of benign biliary stricture. A case is reported which is unusual in that the diagnosis was made before the onset of jaundice. We emphasize the importance of accurate histology of biliary strictures, to eliminate confusion between those of benign and malignant nature and to ensure that the appropriate management is undertaken. Immunohistochemical evidence for the neural origin of this rare tumour is presented.
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