Endoscopic ultrasound-guided pancreatic fluid collection drainage: Where are we?

Pancreatic fluid collections(PFCs)result from injury to the pancreas from acute or chronic pancreatitis,surgery,or trauma.Management of these collections has evolved over the last 2 decades.The choice of interventions includes percu-taneous,endoscopic,minimally invasive surgery,or a combined approach.Endoscopic drainage is the drainage of PFCs by creating an artificial communication between the collection and gastrointestinal lumen that is maintained by placing a stent across the fistulous tract.In this editorial,we endeavored to update the current status of endoscopic ultrasound-guided drainage of PFCs.

Chronic hepatitis B and occult infection in chemotherapy patients-evaluation in oncology and hemato-oncology settings:The CHOICE study

BACKGROUND Reactivation of hepatitis B virus(HBV)infection is a well-known risk that can occur spontaneously or following immunosuppressive therapies,including cancer chemotherapy.HBV reactivation can cause significant morbidity and even mortality,which are preventable if at-risk individuals are identified through screening and started on antiviral prophylaxis.AIM To determine the prevalence of chronic HBV(CHB)and occult HBV infection(OBI)among oncology and hematology-oncology patients undergoing chemo-therapy.METHODS In this observational study,the prevalence of CHB and OBI was assessed among patients receiving chemotherapy.Serological markers of HBV infection[hepatitis B surface antigen(HBsAg)/anti-hepatitis B core antigen(HBc)]were evaluated for all patients.HBV DNA levels were assessed in those who tested negative for HBsAg but positive for total anti-HBc.RESULTS The prevalence of CHB in the study cohort was determined to be 2.3%[95%confidence interval(95%CI):1.0-4.2].Additionally,the prevalence of OBI among the study participants was found to be 0.8%(95%CI:0.2-2.3).CONCLUSION The findings of this study highlight the importance of screening for hepatitis B infection in oncology and hematology-oncology patients undergoing chemotherapy.Identifying individuals with CHB and OBI is crucial for implementing appropriate antiviral prophylaxis to prevent the reactivation of HBV infection,which can lead to increased morbidity and mortality.

Controversies in the management of acute pancreatitis:An update

This review summarized the current controversies in the management of acute pancreatitis(AP).The controversies in management range from issues involving fluid resuscitation,nutrition,the role of antibiotics and antifungals,which analgesic to use,role of anticoagulation and intervention for complications in AP.The interventions vary from percutaneous drainage,endoscopy or surgery.Active research and emerging data are helping to formulate better guidelines.The available evidence favors crystalloids,although the choice and type of fluid resuscitation is an area of dynamic research.The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not.The empirical use of antibiotics and antifungals are gray zones,and more data is needed for conclusive guidelines.The choice of analgesic is being studied,and the recommendations are still evolving.The position of using anticoagulation is still awaiting consensus.The role of intervention is well established,although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery.It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Diabetes mellitus as a consequence of acute severe pancreatitis:Unraveling the mystery

The occurrence of diabetes mellitus(DM)in pancreatitis is being increasingly recognized lately.Diabetes can develop not only with chronic pancreatitis but even after the first episode of acute pancreatitis(AP).The incidence of diabetes after AP varies from 18%to 23%in 3 years and reaches up to 40%over 5 years.The exact pathogenesis of diabetes after AP is poorly understood and various mechanisms proposed include loss of islet cell mass,AP-induced autoimmunity,and alterations in the insulin incretin axis.Risk factors associated with increased risk of diabetes includes male sex,recurrent attacks of pancreatitis,presence of pancreatic exocrine insufficiency and level of pancreatitic necrosis.Diagnosis of post-pancreatitis DM(PPDM)is often excluded.Treatment includes a trial of oral antidiabetic drugs in mild diabetes.Often,insulin is required in uncontrolled diabetes.Given the lack of awareness of this metabolic disorder after AP,this review will evaluate current information on epidemiology,risk factors,diagnosis and management of PPDM and identify the knowledge gaps.

Pancreatic fluid collections: What is the ideal imaging technique?

Pancreatic fluid collections(PFCs) are seen in up to 50% of cases of acute pancreatitis. The Revised Atlanta classification categorized these collections on the basis of duration of disease and contents, whether liquid alone or a mixture of fluid and necrotic debris. Management of these different types of collections differs because of the variable quantity of debris; while patients with pseudocysts can be drained by straight-forward stent placement, walledoff necrosis requires multi-disciplinary approach. Differentiating these collections on the basis of clinical severity alone is not reliable, so imaging is primarily performed. Contrast-enhanced computed tomography is the commonly used modality for the diagnosis and assessment of proportion of solid contents in PFCs; however with certain limitations such as use of iodinated contrast material especially in renal failure patients and radiation exposure. Magnetic resonance imaging(MRI) performs better than computed tomography(CT) in characterization of pancreatic/peripancreatic fluid collections especially for quantification of solid debris and fat necrosis(seen as fat density globules), and is an alternative in those situations where CT is contraindicated. Also magnetic resonance cholangiopancreatography is highly sensitive for detecting pancreatic duct disruption and choledocholithiasis. Endoscopic ultrasound is an evolving technique with higher reproducibility for fluid-to-debris component estimation with the added advantage of being a single stage procedure for both diagnosis(solid debris delineation) and management(drainage of collection) in the same sitting. Recently role of diffusion weighted MRI and positron emission tomography/CT with ^(18)F-FDG labeled autologous leukocytes is also emerging for detection of infection noninvasively. Comparative studies between these imaging modalities are still limited. However we look forward to a time when this gap in literature will be fulfilled.

Fluid resuscitation in acute pancreatitis

Acute pancreatitis remains a clinical challenge,despite an exponential increase in our knowledge of its complex pathophysiological changes.Early fluid therapy is the cornerstone of treatment and is universally recommended;however,there is a lack of consensus regarding the type,rate,amount and end points of fluid replacement.Further confusion is added with the newer studies reporting better results with controlled fluid therapy.This review focuses on the pathophysiology of fluid depletion in acute pancreatitis,as well as the rationale for fluid replacement,the type,optimal amount,rate of infusion and monitoring of such patients.The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers.For this review,various studies and reviews were critically evaluated,along with authors’recommendations,for predicted severe or severe pancreatitis based on the available evidence.

Current and emerging therapeutic strategies in pancreatic cancer: Challenges and opportunities

Pancreatic carcinoma(PC)is one of the leading causes of cancer-related deaths worldwide.Despite early detection and advances in therapeutics,the prognosis remains dismal.The outcome and therapeutic approach are dependent on the stage of PC at the time of diagnosis.The standard of care is surgery,followed by adjuvant chemotherapy.The advent of newer drugs has changed the landscape of adjuvant therapy.Moreover,recent trials have highlighted the role of neoadjuvant therapy and chemoradiotherapy for resectable and borderline resectable PC.As we progress towards a better understanding of tumor biology,genetics,and microenvironment,novel therapeutic strategies and targeted agents are now on the horizon.We have described the current and emerging therapeutic strategies in PC.

Anemia in cirrhosis:An underestimated entity

Anemia in a patient with cirrhosis is a clinically pertinent but often overlooked clinical entity.Relevant guidelines highlight the algorithmic approach of managing a patient of cirrhosis presenting with acute variceal hemorrhage but day-to-day management in hospital and out-patient raises multiple dilemmas:Whether anemia is a disease complication or a part of the disease spectrum?Should iron,folic acid,and vitamin B complex supplementation and nutritional advice,suffice in those who can perform tasks of daily living but have persistently low hemoglobin.How does one investigate and manage anemia due to multifactorial etiologies in the same patient:Acute or chronic blood loss because of portal hypertension and bone marrow aplasia secondary to hepatitis B or C viremia?To add to the clinician’s woes the prevalence of anemia increases with increasing disease severity.We thus aim to critically analyze the various pathophysiological mechanisms complicating anemia in a patient with cirrhosis with an emphasis on the diagnostic flowchart in such patients and proposed management protocols thereafter.

Endoscopic ultrasound in the diagnosis and management ofcarcinoma pancreas

Endoscopic ultrasound(EUS) has become an important component in the diagnosis and treatment of carcinoma pancreas. With the advent of advanced imaging techniques and tissue acquisition methods the role of EUS is becoming increasingly important. Small pancreatic tumors can be reliably diagnosed with EUS. EUS guided fine needle aspiration establishes diagnosis in some cases. EUS plays an important role in staging of carcinoma pancreas and in some important therapeutic methods that include celiac plexus neurolysis, EUS guided biliary drainage and drug delivery. In this review we attempt to review the role of EUS in diagnosis and management of carcinoma pancreas.