Chronic pancreatitis: issues remain unresolved

Key points. Article is devoted to one of the major syndromes of chronic pancreatitis — exocrine pancreatic insufficiency. Clinical symptoms of exocrine insufficiency: diarrhea with steatorrhea and flatulence are nonspecific and inconsistent. Laboratory diagnostics nowadays in our country is based on a single method — pancreatic elastase stool test which has low sensitivity and specificity, moreover it is characterized by low reproducibility. Thus, in practical situation it is reasonable to control both severity of disorders of pancreatic secretion, and efficacy of enzyme replacement therapy according to scores of trophological status of the patient both clinical (BMI), and laboratory (serum levels of prealbumin, retinol-binding protein, cholesterol, magnesium). Treatment should include high dose microgranulated enzymes in the form of capsules (the starting dose should be no less than 40 U of lipolytic activity per meal) as well as proton pump inhibitors. Replacement treatment should be life-long

Pain at chronic pancreatitis: origin and treatment options

The aim of review. To present basic mechanisms of pain at pancreatitis and determine main management approaches in pain-predominant cases.Summary. Direct toxic action of damaging factors (first of all — alcohol), pancreatic enzyme deviation phenomenon, parenchymal damage by overflow of free radicals, elevation of intraductal pressure, damage of nerves (neuropathic pain) and compression of adjacent organs play primary role in development of pain. Enzyme supplements at chronic pancreatitis can be indicated not only as replacement treatment, but also as addition to complex treatment of patients with severe abdominal pain. Proton pump inhibitors, spasmolytics or prokinetics are recommended as additional therapy. At absence of desirable results application of nonsteroid anti-inflammatory drugs and analgetics, in resistant pain — non-narcotic opiates or pregabalin are indicated. Efficacy of analgetics can be increased by coadministration of psychotropic agents, most often — tricyclic antidepressants. In severe cases intractable pain at a chronic pancreatitis itself can become indication to surgical intervention.Conclusion. Treatment efficacy in each given case depends on duly establishment and adequate treatment of complications, motivation for abstain of alcohol intake and smoking; strict diet restriction for relapse period, and functional rest for the pancreas

Diagnostics and evaluation of biliary deposit at ultrasound investigation

National college of gastroenterologists, hepatologist

Efficacy of Hymecromone in Post-Cholecystectomy Patients

Background. The cholecystectomy is the major cause of sphincter of Oddi dysfunction (SOD), that may be classified as post-cholecystectomy syndrome (PCES). Treatment of PCES requires in most of the cases application of selective antispasmodic drugs.Aim. To evaluate efficacy and safety of hymecromone in patients with post-cholecystectomy SOD, to compare standard and reduced doses of hymecromone.Methods. Overall, 26 patients were enrolled in non-interventional comparative study: 2 males, 24 females, aged from 25 to 74 years. All patients underwent cholecystectomy for symptomatic gallstone disease within 1 to 10 years prior to beginning of the study. All patients were diagnosed to have SOD according to Rome IV Diagnostic Criteria for functional biliary sphincter of Oddi disorder (E1b). All patients underwent hymecromone monotherapy for 3 weeks. Patients were randomized to group A and B to receive full-dose or half-dose of the drug respectively.Results. Abdominal pain completely subsided in 85 % of patients, significant improvement was found for bloating and diarrhea. Mild increase in fasting common bile duct (CBD) diameter after treatment (7.23 ± 0.99 vs 6.78 ± 1.01; p = 0.029) was attributed to choleretic action of hymecromone. Hymecromone resulted in significant improvement of CBD response to fatty meal stimulation (ΔCBD): –1.08 ± 0.46 mm vs –0.10 ± 0.33 mm pretreatment (p = 0.016). Degree of improvement was more pronounced in the group A (full-dose) as compared to group B (half-dose) for abdominal pain (Z = 2.74, p = 0.031), bloating (Z = 2.63, p = 0.035) and constipation (Z = 2.61, p = 0.038)Conclusion. Hymecromone demonstrated itself to be an effective and safe drug, that may be applied both in standard and half dose. However, the efficacy of full-dose is higher both for the treatment of biliary pain and dyspeptic symptoms. Transabdominal ultrasound may be applied as a reliable test for both prediction of treatment efficacy and to monitor patients state during treatment course

Severe Diverticulitis Associated to <i>Clostridioides difficile</i> Infection in a 91 Year Old Patient (Clinical Case)

Aim. To present a clinical case of a 91-year-old patient with a severe course of diverticulitis combined with the development of Clostridioides difficile-associated disease.Key points. On admission the patient complained of pain in the left iliac region, increased body temperature, constipation and bloating. The medical history showed that constipation increased on the background of prolonged bed rest and discontinuation of psyllium. According to the laboratory and instrumental examinations, the patient had signs of acute diverticulitis, antibacterial therapy was corrected twice, positive dynamics of the condition was noted. However, a few days later, the patient developed a clinic of C. difficile-associated disease, which required the prescription of anticlostridial therapy (vancomycin), until the laboratory confirmation of the accession of this infection was obtained. Combined therapy of exacerbation of diverticular disease and C. difficile-associated disease made it possible to achieve a steady improvement of the condition.Conclusion. The exclusion of possible development of C. difficile-associated disease on the background or prior antibiotic therapy is an important condition for correct and adequate management of a patient with exacerbation of diverticular disease. If the patient develops a clinical picture of C. difficile-associated disease, treatment may be initiated before laboratory confirmation

New Coronavirus Infection (COVID-19) and Digestive System

Aim. The study reviews current evidence on digestive system lesions provoked by the new COVID-19 coronavirus infection.Key points. Alongside the destructive impact on respiratory system, COVID-19 manifests itself in gastrointestinal symptoms (nausea, vomiting, diarrhoea) that may precede respiratory signs and prevail in the clinical picture of infection. Patients with chronic inflammatory bowel diseases receiving immunosuppressive therapy are at elevated risk of severe COVID-19 progression. The new coronavirus infection may induce liver damage with increased transaminase activity.Conclusion. Association of digestive system lesions with COVID-19 remains understudied and requires further research

European guideline on IgG4-related digestive disease – UEG and SGF evidence-based recommendations

The overall objective of these guidelines is to provide evidence-based recommendations for the diagnosis and management of immunoglobulin G4 (IgG4)-related digestive disease in adults and children. IgG4-related digestive disease can be diagnosed only with a comprehensive work-up that includes histology, organ morphology at imaging, serology, search for other organ involvement, and response to glucocorticoid treatment. Indications for treatment are symptomatic patients with obstructive jaundice, abdominal pain, posterior pancreatic pain, and involvement of extra-pancreatic digestive organs, including IgG4-related cholangitis. Treatment with glucocorticoids should be weight-based and initiated at a dose of 0.6–0.8 mg/kg body weight/day orally (typical starting dose 30-40 mg/day prednisone equivalent) for 1 month to induce remission and then be tapered within two additional months. Response to initial treatment should be assessed at week 2–4 with clinical, biochemical and morphological markers. Maintenance treatment with glucocorticoids should be considered in multi-organ disease or history of relapse. If there is no change in disease activity and burden within 3 months, the diagnosis should be reconsidered. If the disease relapsed during the 3 months of treatment, immunosuppressive drugs should be added

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

\ua9 2024 The Author(s). United European Gastroenterology Journal published by Wiley Periodicals LLC on behalf of United European Gastroenterology.Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed