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Shi J, Nie S, Shi Z, Liu K, Zhou Q, Wang X, Jiang Y, Zhang S, Peng C, Lv Y, Tang B, Cheng H, Qiu Y, Li H, Yu Y, Kong B, Friess H, Liu S, Wang L, Zou X, Shen S. Clinical characteristics of pancreatic cancer presenting with acute pancreatitis: a propensity-matched cohort study. Surg Endosc 2025; 39:3307-3316. [PMID: 40232404 DOI: 10.1007/s00464-025-11654-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Accepted: 03/02/2025] [Indexed: 04/16/2025]
Abstract
BACKGROUND AND AIM The symptoms of pancreatic cancer (PC) are usually nonspecific or absent, and the early diagnosis remains challenging. 7-14% of PC patients present initially with acute pancreatitis (AP). This study aims to distinguish the PC patients initially presenting with AP from simple AP patients, further evaluating the role of endoscopic ultrasound (EUS) in the early diagnosis. METHODS We retrospectively evaluated 1376 consecutive patients with AP between 2010 and 2023.To overcome selection bias, we used propensity score matching between PC patients initially presenting with AP and non-cancer-related AP patients. Clinical information, especially EUS were collected for comparison. RESULTS After matching, 72 patients (PC group) and 216 patients (AP group) were included. The unknown etiology in the PC group was significantly higher than that in the AP group (54.2% vs. 27.8%). Regarding initial symptoms, non-cancer-related AP patients exhibited significantly more abdominal distension, vomiting and fever compared to the PC group (p < 0.05). In terms of lab results, PC group patients had lower serum amylase (p < 0.001), but higher CA19-9, CA72-4, and CA242 levels when compared to AP group patients (p < 0.001). Additionally, AP group patients had more systematic and local complications, and the severity of AP was much higher than that of PC group patients. Moreover, PC patients exhibited more frequent imaging findings, such as pancreatic duct dilation or atrophy, and enlarged lymph nodes (p < 0.05). Notably, the EUS examination in PC patients missing diagnosis initially and PC patients presenting with relapsed AP showed more sensitive results and more detective rates. CONCLUSION Pancreatic cancer patients presenting initially with acute pancreatitis tend to exhibit mild, recurrent pancreatitis than common AP patients. EUS holds potential diagnostic value in detecting pancreatic cancer in patients with initially negative cross-sectional imaging and recurrent pancreatitis.
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Affiliation(s)
- Jiaqi Shi
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Shuang Nie
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Zhao Shi
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Kun Liu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Quan Zhou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Xuan Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yihang Jiang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Song Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Chunyan Peng
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Ying Lv
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Bei Tang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Hao Cheng
- Department of Pancreatic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yudong Qiu
- Department of Pancreatic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Hongzhen Li
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yuanyuan Yu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Bo Kong
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Song Liu
- Department of Radiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
| | - Xiaoping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
| | - Shanshan Shen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
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Salgado D, Kang J, Costa AF. Mimics of pancreatic neoplasms at cross-sectional imaging: Pearls for characterization and diagnostic work-up. Curr Probl Diagn Radiol 2025; 54:382-391. [PMID: 39701879 DOI: 10.1067/j.cpradiol.2024.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 11/13/2024] [Accepted: 12/09/2024] [Indexed: 12/21/2024]
Abstract
Interpreting imaging examinations of the pancreas can be a challenge. Several different entities can mimic or mask pancreatic neoplasms, including normal anatomic variants, non-pancreatic lesions, and both acute and chronic pancreatitis. It is important to distinguish these entities from pancreatic neoplasms, as the management and prognosis of a pancreatic neoplasm, particularly adenocarcinoma, have considerable impact on patients. Normal pancreatic variants that mimic a focal lesion include focal fatty atrophy, annular pancreas, and ectopic pancreas. Extra-pancreatic lesions that can mimic a primary pancreatic neoplasm include vascular lesions, such as arteriovenous malformations and pseudoaneurysms, duodenal diverticula, and intra-pancreatic accessory spleen. Both acute and chronic pancreatitis can mimic or mask a pancreatic neoplasm and are also associated with pancreatic ductal adenocarcinoma. Awareness of these entities and their imaging features will enable the radiologist to narrow the differential diagnosis, provide recommendations that expedite diagnosis and avoid unnecessary work-up or delays in patient care.
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Affiliation(s)
- David Salgado
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University. Victoria General Building, 3rd floor, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada.
| | - Jessie Kang
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University. Victoria General Building, 3rd floor, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada.
| | - Andreu F Costa
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University. Victoria General Building, 3rd floor, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada.
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Yamao K, Takenaka M, Yoshida A, Yamazaki T, Omoto S, Minaga K, Kamata K, Takada Y, Uetsuki K, Iida T, Mizutani Y, Ishikawa T, Kawashima H, Kudo M. Concealed pancreatic cancer in acute pancreatitis: Early MRCP and EUS surveillance improves prognosis and identifies high-risk patients. Pancreatology 2025:S1424-3903(25)00041-9. [PMID: 40102117 DOI: 10.1016/j.pan.2025.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 02/03/2025] [Accepted: 02/27/2025] [Indexed: 03/20/2025]
Abstract
BACKGROUND/OBJECTIVES Acute pancreatitis (AP) may obscure small pancreatic cancers (PCs) on computed tomography during the acute phase. Surveillance with magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) may enhance early detection and improve patient outcomes. This study evaluated the impact of early MRCP/EUS surveillance on PC outcomes in AP patients and identified high-risk subgroups for early screening. METHODS We retrospectively analyzed 1562 AP patients treated between 2010 and 2021, categorizing them into early surveillance (MRCP/EUS within three months of AP onset; n = 760) and nonearly surveillance groups (n = 802). Key outcomes included time to PC diagnosis, surgical resection rate, tumor stage, and overall survival. Multivariate analysis was performed to identify risk factors for concealed PC in AP patients. RESULTS Among 27 PC cases analyzed, the early surveillance group achieved significantly earlier diagnosis, higher surgical resection rates, increased detection of early-stage PC, and improved overall survival compared with the nonearly surveillance group. Multivariate analysis revealed that subthreshold main pancreatic duct (MPD) dilation (≥2.5 mm) and moderately severe AP were significant predictors of PC. CONCLUSIONS Early MRCP/EUS surveillance in AP patients facilitates timely detection of occult PC and enhances patient prognosis. These findings support prioritizing early surveillance for AP patients with subthreshold MPD dilation and moderately severe disease. Further large-scale studies are warranted to validate these strategies in clinical practice.
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Affiliation(s)
- Kentaro Yamao
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan; Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan.
| | - Akihiro Yoshida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Tomohiro Yamazaki
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Yoshihisa Takada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kota Uetsuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
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Jeon CY, Arain MA, Korc M, Kozarek RA, Phillips AE. Bidirectional relationship between acute pancreatitis and pancreatic cancer. Curr Opin Gastroenterol 2024; 40:431-438. [PMID: 38935270 PMCID: PMC11305936 DOI: 10.1097/mog.0000000000001051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
PURPOSE OF REVIEW The burdens of pancreatic ductal adenocarcinoma (PDAC) and acute pancreatitis are increasing globally. We reviewed current literature on whether acute pancreatitis is a causal factor for PDAC and examined clinical manifestations of PDAC-associated acute pancreatitis. RECENT FINDINGS Recent findings detail the timing of acute pancreatitis before and after PDAC occurrence, further solidifying the evidence for PDAC-associated acute pancreatitis and for acute pancreatitis as a causal risk factor for PDAC. The risk of PDAC remains elevated above the general population in patients with distant history of acute pancreatitis. PDAC risk also increases with recurrent acute pancreatitis episodes, independent of smoking and alcohol. Mechanisms linking acute pancreatitis to PDAC include inflammation and neutrophil infiltration, which can be attenuated by suppressing inflammation and/or epigenetic modulation, thus slowing the progression of acinar-to-ductal metaplasia. Clinical presentation and management of acute pancreatitis in the context of PDAC are discussed, including challenges acute pancreatitis poses in the diagnosis and treatment of PDAC, and novel interventions for PDAC-associated acute pancreatitis. SUMMARY PDAC risk may be reduced with improved acute pancreatitis prevention and treatment, such as antiinflammatories or epigenetic modulators. Increased acute pancreatitis and PDAC burden warrant more research on better diagnosis and management of PDAC-associated acute pancreatitis.
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Affiliation(s)
- Christie Y. Jeon
- Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | - Mustafa A. Arain
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL 32803
| | - Murray Korc
- Department of Developmental and Cell Biology, University of California, Irvine, Irvine, CA 92697
| | | | - Anna E. Phillips
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
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Does Preoperative Acute Pancreatitis Inevitably Delay Pancreatoduodenectomy in Patients with Periampullary Tumors? Cancers (Basel) 2021; 13:cancers13246289. [PMID: 34944909 PMCID: PMC8699028 DOI: 10.3390/cancers13246289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/05/2021] [Accepted: 12/13/2021] [Indexed: 01/08/2023] Open
Abstract
Simple Summary Acute pancreatitis can occur preoperatively in patients with periampullary tumors and cause technical difficulties in performing pancreatoduodenectomy. The aim of this retrospective study was to investigate how preoperative acute pancreatitis would affect postoperative outcomes and to identify the optimal timing of surgery. There were more patients with operation failure (only exploration or unintended total pancreatectomy) in patients with pancreatitis, but no difference was found in rates of other complications. Moreover, when stratified by the timing of surgery, the surgical outcomes did not differ between the patients with and without pancreatitis. The results imply that in terms of surgical complications, pancreatoduodenectomy could be safely performed in patients with preoperative pancreatitis. Further research is necessary to identify safe conditions and proper timing of surgery for patients with preoperative pancreatitis. Abstract Preoperative acute pancreatitis (PAP) in patients with periampullary tumor can cause technical difficulties when performing pancreatoduodenectomy (PD) but perioperative risks of PAP remain unclear. The purpose of this study was to investigate the impact of PAP on surgical outcomes and determine the optimal timing of PD. Patients undergoing surgery for periampullary tumors between 2009 and 2018 were included. Simple random sampling (1:4) was performed to compare outcomes between the PAP group and the control group. Operative failure was defined as exploration-only or unwanted total pancreatectomy. The rate of operative failure was higher in the PAP group than in the control group (6.6% vs. 0%, p < 0.001). There was no significant difference in postoperative outcomes including complications or in-hospital mortality between the two groups. Surgical outcomes were compared after dividing PAP groups by intervals (2, 3, or 4 weeks) between the onset of PAP and surgery, and there were no differences between the groups. In conclusion, in spite of the increased risk of operation failure, PD could be performed in PAP patients at comparable rates of postoperative complications. Further study is needed to select patients with PAP in proper conditions for performing PD.
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Vasilescu AM, Andriesi Rusu DF, Bradea C, Vlad N, Lupascu-Ursulescu C, Cianga Spiridon IA, Trofin AM, Tarcoveanu E, Lupascu CD. Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology. Life (Basel) 2021; 11:life11111216. [PMID: 34833092 PMCID: PMC8624365 DOI: 10.3390/life11111216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. Methods: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05. Results: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). Conclusions: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.
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Affiliation(s)
- Alin Mihai Vasilescu
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Delia Florina Andriesi Rusu
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
- Correspondence:
| | - Costel Bradea
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Nutu Vlad
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Corina Lupascu-Ursulescu
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Irene Alexandra Cianga Spiridon
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Ana Maria Trofin
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Eugen Tarcoveanu
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Cristian Dumitru Lupascu
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
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Gong XH, Xu JR, Qian LJ. Atypical and uncommon CT and MR imaging presentations of pancreatic ductal adenocarcinoma. Abdom Radiol (NY) 2021; 46:4226-4237. [PMID: 33914139 DOI: 10.1007/s00261-021-03089-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
Pancreatic ductal adenocarcinomas (PDACs) occasionally have atypical and uncommon imaging presentations that can present a diagnostic dilemma and result in false interpretation. This article aimed to illustrate these CT and MR imaging findings, including isoattenuating PDAC, coexisting acute pancreatitis, PDAC with a cystic feature, groove PDAC, diffuse PDAC, hypointensity on diffusion-weighted imaging (DWI), multifocal PDAC, intratumoral calcification, and extrapancreatic invasion with a barely discernable mass. A subset of PDACs with atypical features are occasionally encountered during routine clinical practice. Knowledge of and attention to these atypical and uncommon variable imaging features may allow radiologists to avoid misinterpretation and a delayed diagnosis.
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Khalaf N, El-Serag HB, Abrams HR, Thrift AP. Burden of Pancreatic Cancer: From Epidemiology to Practice. Clin Gastroenterol Hepatol 2021; 19:876-884. [PMID: 32147593 PMCID: PMC8559554 DOI: 10.1016/j.cgh.2020.02.054] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 02/05/2020] [Accepted: 02/28/2020] [Indexed: 12/24/2022]
Abstract
Pancreatic cancer is the seventh leading cause of cancer-related deaths worldwide with 432,242 related deaths in 2018. Unlike other cancers, the incidence of pancreatic cancer continues to increase, with little improvement in survival rates. We review the epidemiologic features of pancreatic cancer, covering surveillance and early detection in high-risk persons. We summarize data on worldwide incidence and mortality and analyze the 1975-2016 data from 9 registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results study, on the overall burden of pancreatic cancer as well as age-, sex-, and race-specific incidence, survival rates and trends. It is important to increase our knowledge of the worldwide and regional epidemiologic features of and risk factors for pancreatic cancer, to identify new approaches for prevention, surveillance, and treatment.
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Affiliation(s)
- Natalia Khalaf
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Hannah R Abrams
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
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9
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Factors associated with missed and misinterpreted cases of pancreatic ductal adenocarcinoma. Eur Radiol 2020; 31:2422-2432. [PMID: 32997176 DOI: 10.1007/s00330-020-07307-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/03/2020] [Accepted: 09/16/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To retrospectively examine US, CT, and MR imaging examinations of missed or misinterpreted pancreatic ductal adenocarcinoma (PDAC), and identify factors which may have confounded detection or interpretation. METHODS We reviewed 107 examinations in 66/257 patients (26%, mean age 73.7 years) diagnosed with PDAC in 2014 and 2015, with missed or misinterpreted imaging findings as determined by a prior study. For each patient, images and reports were independently reviewed by two radiologists, and in consensus, the following factors which may have confounded assessment were recorded: inherent tumor factors, concurrent pancreatic pathology, technical limitations, and cognitive biases. Secondary signs of PDAC associated with each examination were recorded and compared with the original report to determine which findings were missed. RESULTS There were 66/107 (62%) and 49/107 (46%) cases with missed and misinterpreted imaging findings, respectively. A significant number of missed tumors were < 2 cm (45/107, 42%), isoattenuating on CT (32/72, 44%) or non-contour deforming (44/107, 41%). Most (29/49, 59%) misinterpreted examinations were reported as uncomplicated pancreatitis. Almost all examinations (94/107, 88%) demonstrated secondary signs; pancreatic duct dilation was the most common (65/107, 61%) and vascular invasion was the most commonly missed 35/39 (90%). Of the CT and MRIs, 28 of 88 (32%) had suboptimal contrast dosing. Inattentional blindness was the most common cognitive bias, identified in 55/107 (51%) of the exams. CONCLUSION Recognizing pitfalls of PDAC detection and interpretation, including intrinsic tumor features, secondary signs, technical factors, and cognitive biases, can assist radiologists in making an early and accurate diagnosis. KEY POINTS • There were 66/107 (62%) and 49/107 (46%) cases with missed and misinterpreted imaging findings, respectively, with tumoral, technical, and cognitive factors leading to the misdiagnosis of pancreatic ductal adenocarcinoma. • The majority (29/49, 59%) of misinterpreted cases of pancreatic ductal adenocarcinoma were mistaken for pancreatitis, where an underlying mass or secondary signs were not appreciated due to inflammatory changes. • The most common missed secondary sign of pancreatic ductal adenocarcinoma was vascular encasement, missed in 35/39 (90%) of cases, indicating the importance of evaluating the peri-pancreatic vasculature.
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Umans DS, Timmerhuis HC, Hallensleben ND, Bouwense SA, Anten MPG, Bhalla A, Bijlsma RA, Boermeester MA, Brink MA, Hol L, Bruno MJ, Curvers WL, van Dullemen HM, van Eijck BC, Erkelens GW, Fockens P, van Geenen EJM, Hazen WL, Hoge CV, Inderson A, Kager LM, Kuiken SD, Perk LE, Poley JW, Quispel R, Römkens TE, van Santvoort HC, Tan AC, Thijssen AY, Venneman NG, Vleggaar FP, Voorburg AM, van Wanrooij RL, Witteman BJ, Verdonk RC, Besselink MG, van Hooft JE. Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study. BMJ Open 2020; 10:e035504. [PMID: 32819938 PMCID: PMC7440829 DOI: 10.1136/bmjopen-2019-035504] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 06/10/2020] [Accepted: 07/15/2020] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Idiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional diagnostic modalities such as endoscopic ultrasonography (EUS) are warranted after a first episode of IAP in order to uncover this aetiology. Failure to timely determine treatable aetiologies delays appropriate treatment and might subsequently cause recurrence of acute pancreatitis. Therefore, the aim of the Pancreatitis of Idiopathic origin: Clinical added value of endoscopic UltraSonography (PICUS) Study is to determine the value of routine EUS in determining the aetiology of pancreatitis in patients with a first episode of IAP. METHODS AND ANALYSIS PICUS is designed as a multicentre prospective cohort study of 106 patients with a first episode of IAP after complete standard diagnostic work-up, in whom a diagnostic EUS will be performed. Standard diagnostic work-up will include a complete personal and family history, laboratory tests including serum alanine aminotransferase, calcium and triglyceride levels and imaging by transabdominal ultrasound, magnetic resonance imaging or magnetic resonance cholangiopancreaticography after clinical recovery from the acute pancreatitis episode. The primary outcome measure is detection of aetiology by EUS. Secondary outcome measures include pancreatitis recurrence rate, severity of recurrent pancreatitis, readmission, additional interventions, complications, length of hospital stay, quality of life, mortality and costs, during a follow-up period of 12 months. ETHICS AND DISSEMINATION PICUS is conducted according to the Declaration of Helsinki and Guideline for Good Clinical Practice. Five medical ethics review committees assessed PICUS (Medical Ethics Review Committee of Academic Medical Center, University Medical Center Utrecht, Radboud University Medical Center, Erasmus Medical Center and Maastricht University Medical Center). The results will be submitted for publication in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER Netherlands Trial Registry (NL7066). Prospectively registered.
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Affiliation(s)
- Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Hester C Timmerhuis
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Nora D Hallensleben
- Research and Development, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Marie-Paule Gf Anten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HagaZiekenhuis, Den Haag, Zuid-Holland, The Netherlands
| | - Rina A Bijlsma
- Department of Gastroenterology and Hepatology, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Menno A Brink
- Department of Gastroenterology and Hepatology, Meander MC, Amersfoort, Utrecht, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, North Brabant, The Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, UMCG, Groningen, Groningen, The Netherlands
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - G Willemien Erkelens
- Department of Gastroenterology and Hepatology, Gelre Ziekenhuizen, Apeldoorn, Gelderland, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud university medical center, Nijmegen, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
| | - Chantal V Hoge
- Department of Gastroenterology and Hepatology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, LUMC, Leiden, Zuid-Holland, The Netherlands
| | - Liesbeth M Kager
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, Noord-Holland, The Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Lars E Perk
- Department of Gastroenterology and Hepatology, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, Zuid-Holland, The Netherlands
| | - Tessa Eh Römkens
- Department of Gastroenteroloy and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, Noord-Brabant, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Adriaan Citl Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, Gelderland, The Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, Zuid-Holland, The Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Overijssel, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Annet McJ Voorburg
- Department of Gastroenterology and Hepatology, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, Utrecht, The Netherlands
| | - Roy Lj van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Ben J Witteman
- Department of Gastroenterology and Hepatology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, Saint Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
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Konur S, Ozkahraman A, Surmeli N, Gunduz I, Iliklerden UH, Dertli R, Kayar Y. The Severity of Acute Pancreatitis According to Modified Balthazar Classification in Patients With Pancreatic Cancer. TUMORI JOURNAL 2020; 106:356-361. [PMID: 32811352 DOI: 10.1177/0300891620948961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Although acute pancreatitis (AP) is a self-limited disease under supportive and medical treatment, it can have life-threatening potential in some patients. Results of studies reporting outcomes of AP-associated pancreatic malignancy are controversial. The aim of this study was to evaluate the severity and prognosis of pancreatic cancer (PC)-related AP by modified Balthazar score. METHODS A total of 354 patients hospitalized and followed up in our clinic between 2013 and 2019 were included in the study. Demographic data of all patients were recorded. The etiology of all cases was determined. According to the etiology, the cases were divided into 2 groups: AP related to pancreatic malignancy and AP due to nonmalignant causes. The patients underwent computed tomography of the abdomen within the first 12 hours of admission and after 3 to 7 days. Patients were evaluated and classified by modified Balthazar classification. RESULTS Malignancy-related AP was detected in 18 (5.1%) patients. A total of 336 cases (94.9%) were related to nonmalignant causes. There was no statistically significant difference in the severity of AP in both groups at admission and after 3 days (p > 0.05). The changes (regression, progression, or no change) in the disease severity at the first and the subsequent imaging were examined. There was no significant relationship between the 2 groups (p > 0.05). CONCLUSION AP may be the clinical manifestation of PC or PC may induce AP in various ways. It was shown that the underlying malignancy did not adversely affect the severity and course of AP.
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Affiliation(s)
- Sevki Konur
- Department of Internal Medicine, Van Education and Research Hospital, Van, Turkey
| | - Adnan Ozkahraman
- Department of Internal Medicine, Van Education and Research Hospital, Van, Turkey
| | - Neslihan Surmeli
- Nutrition and Diets Unit, Health High School, Van Yüzüncü Yıl University, Van, Turkey
| | - Ihsan Gunduz
- Department of Surgery of Gastroenterology, Van Education and Research Hospital, Van, Turkey
| | | | - Ramazan Dertli
- Department of Gastroenterology, Van Education and Research Hospital, Van, Turkey
| | - Yusuf Kayar
- Department of Gastroenterology, Van Education and Research Hospital, Van, Turkey
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12
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Predictors of underlying pancreatic cancer in patients with acute pancreatitis: a Danish nationwide cohort study. HPB (Oxford) 2020; 22:553-562. [PMID: 31521499 DOI: 10.1016/j.hpb.2019.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/06/2019] [Accepted: 08/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND To identify demographic characteristics, comorbidities, medical procedures, and prescription drug use that may act as predictors of underlying pancreatic cancer in acute pancreatitis. METHODS A cohort study of all patients admitted to Danish hospitals with incident acute pancreatitis during 1999-2015. The ability of age, sex, selected comorbidities, medical procedures, and prescription drug use to predict underlying pancreatic cancer in acute pancreatitis (i.e., pancreatic cancer diagnosed up to one year after acute pancreatitis) was examined. The absolute risk and odds ratio (OR) with 95% confidence interval (CI) of cancer was computed for each variable. RESULTS 28,231 patients with incident acute pancreatitis, of which 283 (1.0%) had underlying pancreatic cancer, were included. Age >50 years was a predictor of pancreatic cancer with highest risk in patients aged 56-70 years. New-onset chronic pancreatitis (multivariable OR: 2.36 [95% CI: 1.35-4.14]) and new-onset diabetes (multivariable OR: 1.94 [95% CI: 1.30-2.92]) were also predictors of pancreatic cancer. Diagnoses of biliary or alcohol-related diseases were predictors of no underlying pancreatic cancer. Most variables examined had no or limited predictive ability. CONCLUSION Age, new-onset chronic pancreatitis, new-onset diabetes, and absence of biliary or alcohol-related diseases were predictors of underlying pancreatic cancer in acute pancreatitis patients.
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13
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Easler JJ. Detecting Pancreatic Carcinoma in the Setting of Idiopathic Pancreatitis and Negative Cross-Sectional Imaging: Why EUS Is Useful. Dig Dis Sci 2019; 64:3372-3374. [PMID: 31643034 DOI: 10.1007/s10620-019-05880-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, USA.
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14
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Extracellular acidosis differentiates pancreatitis and pancreatic cancer in mouse models using acidoCEST MRI. Neoplasia 2019; 21:1085-1090. [PMID: 31734629 PMCID: PMC6888716 DOI: 10.1016/j.neo.2019.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 01/07/2023] Open
Abstract
Differentiating pancreatitis from pancreatic cancer would improve diagnostic specificity, and prognosticating pancreatitis that progresses to pancreatic cancer would also improve diagnoses of pancreas pathology. The high glycolytic metabolism of pancreatic cancer can cause tumor acidosis, and different levels of pancreatitis may also have different levels of acidosis, so that extracellular acidosis may be a diagnostic biomarker for these pathologies. AcidoCEST MRI can noninvasively measure extracellular pH (pHe) in the pancreas and pancreatic tissue. We used acidoCEST MRI to measure pHe in a KC model treated with caerulein, which causes pancreatitis followed by development of pancreatic cancer. We also evaluated the KC model treated with PBS, and wild-type mice treated with caerulein or PBS as controls. The caerulein-treated KC cohort had lower pHe of 6.85–6.92 before and during the first 48 h after initiating treatment, relative to a pHe of 6.92 to 7.05 pHe units for the other cohorts. The pHe of the caerulein-treated KC cohort decreased to 6.79 units at 5 weeks when pancreatic tumors were detected with anatomical MRI, and sustained a pHe of 6.75 units at the 8-week time point. Histopathology was used to evaluate and validate the presence of tumors and inflammation in each cohort. These results showed that acidoCEST MRI can differentiate pancreatic cancer from pancreatitis in this mouse model, but does not appear to differentiate pancreatitis that progresses to pancreatic cancer vs. pancreatitis that does not progress to cancer.
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15
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Feng Q, Li C, Zhang S, Tan CL, Mai G, Liu XB, Chen YH. Recurrence and survival after surgery for pancreatic cancer with or without acute pancreatitis. World J Gastroenterol 2019; 25:6006-6015. [PMID: 31660036 PMCID: PMC6815799 DOI: 10.3748/wjg.v25.i39.6006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/12/2019] [Accepted: 09/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In pancreatic cancer, acute pancreatitis (AP) is a serious morbidity, but its negative effect on long-term outcomes remains to be elucidated. AIM To investigate the effects of AP on the tumor recurrence pattern of pancreatic ductal adenocarcinoma (PDAC) and tumor-specific survival. METHODS The medical records of 219 patients with curative pancreatectomy for pancreatic cancer at the Pancreatic Surgery Center of West China Hospital from July 2012 to December 2016 were analyzed retrospectively. The severity of acute pancreatitis was classified according to the Atlanta classification of AP. The patient demographics and tumor characteristics were assessed. Early recurrence was defined as a relapse within 12 mo after surgery. Overall and disease-free survival and recurrence patterns were analyzed. Mild acute pancreatitis was excluded because its negative effects can be negligible. RESULTS Early recurrence in AP group was significantly higher than in non-AP group (71.4% vs 41.2%; P = 0.009). Multivariate analysis of postoperative early recurrence showed that moderate or severe AP was an independent risk factor for an early recurrence [odds ratio (OR): 4.13; 95% confidence interval (CI): 1.41-12.10; P = 0.01]. The median time to recurrence was shorter in patients with AP than in those without (8.4 vs 12.8 mo; P = 0.003). Multivariate analysis identified AP as an independent prognostic factor for overall survival [relative risk (RR): 2.35; 95%CI: 1.45-3.83] and disease-free survival (RR: 2.24; 95%CI: 1.31-3.85) in patients with PDAC. CONCLUSION Patients with moderate or severe acute pancreatitis developed recurrences earlier than those without. Moderate or severe AP is associated with shorter overall and disease-free survival of patients with PDAC.
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Affiliation(s)
- Qian Feng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Cheng Li
- Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Sheng Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang 453100, Henan Province, China
| | - Chun-Lu Tan
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Gang Mai
- Department of Hepatobiliary Surgery, Deyang People's Hospital, Deyang 618000, Sichuan Province, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yong-Hua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Pancreatic Cancer Presenting as a Pancreatic Duct Disruption. Case Rep Surg 2019; 2019:6381249. [PMID: 31263623 PMCID: PMC6556244 DOI: 10.1155/2019/6381249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/14/2019] [Indexed: 11/18/2022] Open
Abstract
The high mortality rate associated with pancreatic cancer necessitates accurate and early detection methods. Computed tomography currently is the primary diagnostic modality used; however, subtle imaging features in concert with novel clinical presentations may obscure the initial diagnosis. Here, we describe a unique initial presentation of pancreatic cancer as a pancreatic leak, with subtle initial CT evidence of malignancy. An 83-year-old female with prior surgical history of open splenectomy and ventral hernia repair presented with two weeks of vague abdominal pain and leukocytosis. Initial CT revealed abdominal peripancreatic fluid collections. Interventional radiology-guided drain placement was performed, which revealed amylase-rich pancreatic fluid within the collections. Repeat CT scan revealed subtle pancreatic duct dilation with slow resolution of the fluid collections. Ultimately, endoscopic ultrasound identified an ill-defined pancreatic mass, revealed to be pancreatic adenocarcinoma. The patient subsequently underwent an open distal pancreatectomy. Diagnosis of pancreatic cancer relies heavily on cross-sectional imaging, with no screening tests currently available. However, subtle radiographic features and unique clinical presentations may delay accurate diagnosis and staging. EUS may be a useful tool for initial evaluation of high-risk individuals.
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17
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Sánchez Rodríguez E, García García de Paredes A, Albillos A. Current management of acute idiopathic pancreatitis and acute recurrent pancreatitis. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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18
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Sánchez Rodríguez E, García García de Paredes A, Albillos A. Manejo actual de la pancreatitis aguda idiopática y la pancreatitis aguda recurrente. Rev Clin Esp 2019; 219:266-274. [DOI: 10.1016/j.rce.2018.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 02/07/2023]
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19
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Teng D, Wu K, Sun Y, Zhang M, Wang D, Wu J, Yin T, Gong W, Ding Y, Xiao W, Lu G, Li W. Significant increased CA199 levels in acute pancreatitis patients predicts the presence of pancreatic cancer. Oncotarget 2018; 9:12745-12753. [PMID: 29560106 PMCID: PMC5849170 DOI: 10.18632/oncotarget.23993] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/13/2017] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Carbohydrate antigen 19-9 (CA199) has been identified as a tumor marker for pancreatic cancer but also increases in benign lesions of the digestive system. However, literature associated with the relationship between CA199 and acute pancreatitis (AP) is limited. This study aimed to focus on serum CA199 level measurements in AP patients and the associated clinical significance. Materials and methods From January 2006 to December 2015, 1,609 consecutive patients with AP were admitted to our department and included in the study. The relationships among the etiology of AP, the disease severity, the incidence of pancreatic cancer during hospitalization and CA199 levels were analyzed. Results Serum CA199 levels were measured for 693 of 1,609 AP patients. Of those patients, 186 (26.8%) had elevated CA199 levels (> 37 U/ml). Patients with high CA199 levels were older and had predominantly biliary causes in comparison with patients with normal CA199 levels. There were no definite specific correlations between CA199 levels and disease severity in AP. In addition, serum levels of CA199 positively correlated with serum alanine aminotransferase, aspartate transaminase, glutamyl transpeptidase, alkaline phosphatase and creatinine levels. After stratification, the incidence of pancreatic cancer increased proportionally to CA199 levels in AP patients. Conclusions Serum CA199 levels was elevated in patients with AP, especially in patients with biliary pancreatitis. AP patients with significantly increased CA199 levels may have a higher risk for the presence of pancreatic cancer. We recommended routinely monitoring CA199 levels during hospitalization for AP patients.
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Affiliation(s)
- Dongling Teng
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Keyan Wu
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Yunyun Sun
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Min Zhang
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Dan Wang
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Jian Wu
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Tao Yin
- Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Weijuan Gong
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Yanbing Ding
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Weiming Xiao
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Guotao Lu
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China.,Laboratory of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225000, Jiangsu, China
| | - Weiqin Li
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu, China
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Minato Y, Kamisawa T, Tabata T, Hara S, Kuruma S, Chiba K, Kuwata G, Fujiwara T, Egashira H, Koizumi K, Saito I, Endo Y, Koizumi S, Fujiwara J, Arakawa T, Momma K, Kurata M, Honda G. Pancreatic cancer causing acute pancreatitis: a comparative study with cancer patients without pancreatitis and pancreatitis patients without cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 20:628-33. [PMID: 23494612 DOI: 10.1007/s00534-013-0598-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND/PURPOSE Although pancreatic cancer produces upstream obstructive pancreatitis, acute pancreatitis is a less common manifestation of pancreatic cancer. This study aimed to clarify the subgroup of pancreatic cancer patients who present with an episode of acute pancreatitis (Group I) in comparison with a matched group of pancreatic cancer patients without pancreatitis (Group II) and another group of acute pancreatitis patients without pancreatic cancer (Group III). METHODS This was a retrospective comparative study of 18 patients in Group I, 300 patients in Group II and 141 patients in Group III. RESULTS The mean age of Group I was 63.7 years and the male to female ration was 1:0.3. Serum CA 19-9 levels were elevated in 80 %. The main pancreatic duct was incompletely obstructed in 7 patients. There were no significant differences in location of tumor, clinical stage, resection rate and survival months between Group I and II. Acute pancreatitis secondary to pancreatic cancer was more likely to be mild (94 vs. 72 %,p < 0.05) and relapsed (39 vs. 16 %,p < 0.05) compared with Group III. CONCLUSIONS Anatomic evaluation of the pancreas should be performed in patients with acute pancreatitis with no obvious etiology, even if the pancreatitis is mild, to search for underlying malignancy.
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Affiliation(s)
- Yohei Minato
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
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Abstract
OBJECTIVES As a strategy to diagnose early-stage pancreatic ductal adenocarcinoma (PDAC) is urgently needed, we aimed to clarify characteristics of early-stage PDAC. METHODS We retrospectively reviewed medical records of 299 consecutive patients who underwent R0 or R1 surgical resection for PDAC between 1994 and 2013 and compared clinical characteristics between patients with early-stage (stages 0-I by Japanese General Rules for Pancreatic Cancer) and advanced-stage (stages II-IV) disease. Diagnostic processes were also analyzed. RESULTS Twenty-four patients (8%) had early-stage PDAC (stage 0: 11; stage I: 13). Univariate and multivariate analyses showed that presence or history of intraductal papillary mucinous neoplasm (P < 0.01), history of pancreatitis (P < 0.01), and presence or history of extrapancreatic malignancies (P = 0.01) independently predicted detection of early-stage PDAC. Cytological examination during endoscopic retrograde pancreatography cytology was ∼65% sensitive in preoperative diagnosis of early-stage PDAC, whereas other imaging modalities were only 29% to 38% sensitive; 9 of 24 early-stage PDACs were diagnosed by endoscopic retrograde pancreatography cytology alone. CONCLUSIONS Endoscopic retrograde pancreatography cytology for patients with intraductal papillary mucinous neoplasm or pancreatitis may help diagnose early-stage PDAC. Surveillance of extrapancreatic malignancies might also provide opportunities to detect early-stage PDAC as a second malignancy.
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Zaheer A, Wadhwa V, Oh J, Fishman EK. Pearls and pitfalls of imaging metastatic disease from pancreatic adenocarcinoma: a systematic review. Clin Imaging 2015; 39:750-8. [PMID: 25981735 DOI: 10.1016/j.clinimag.2015.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/21/2015] [Accepted: 04/29/2015] [Indexed: 12/12/2022]
Abstract
Pancreatic adenocarcinoma is a systemic disease due to the presence of metastatic disease at the time of diagnosis and local recurrence as well as distant metastatic disease after treatment in a majority of patients. Recognition of these metastatic sites may help in accurate staging and assessment of therapeutic response. The authors discuss and illustrate imaging findings of metastatic disease from pancreatic adenocarcinoma in different organ systems with emphasis on entities that can mimic metastatic pancreatic cancer.
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Affiliation(s)
- Atif Zaheer
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21231; Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD 21231.
| | - Vibhor Wadhwa
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21231
| | - Joseph Oh
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21231
| | - Elliot K Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21231
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Chen YH, Xie SM, Zhang H, Tan CL, Ke NW, Mai G, Liu XB. Clinical impact of preoperative acute pancreatitis in patients who undergo pancreaticoduodenectomy for periampullary tumors. World J Gastroenterol 2015; 21:6937-6943. [PMID: 26078571 PMCID: PMC4462735 DOI: 10.3748/wjg.v21.i22.6937] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/11/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the impact of preoperative acute pancreatitis (PAP) on the surgical management of periampullary tumors. METHODS Fifty-eight patients with periampullary tumors and PAP were retrospectively analyzed. Thirty-four patients who underwent pancreaticoduodenectomy (PD) and 4 patients who underwent total pancreatectomy were compared with a control group of 145 patients without PAP during the same period. RESULTS The preoperative waiting time was significantly shorter for the concomitant PAP patients who underwent a resection (22.4 d vs 54.6 d, P < 0.001) compared to those who did not. The presence of PAP significantly increased the rate of severe complications (Clavien grade 3 or higher) (17.6% vs 4.8%, P = 0.019) and lengthened the hospital stay (19.5 d vs 14.5 d, P = 0.006). A multivariate logistic regression analysis revealed that PAP was an independent risk factor for postoperative pancreatic fistula (OR = 2.91; 95%CI: 1.10-7.68; P = 0.032) and severe complications (OR = 4.70; 95%CI: 1.48-14.96; P = 0.009) after PD. There was no perioperative mortality. CONCLUSION PAP significantly increases the incidence of severe complications and lengthens the hospital stay following PD. PD could be safely performed in highly selective patients with PAP.
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Bolado F, Tarifa A, Zazpe C, Urman JM, Herrera J, Vila JJ. Acute recurrent pancreatitis secondary to hepatocellular carcinoma invading the biliary tree. Pancreatology 2015; 15:191-3. [PMID: 25683638 DOI: 10.1016/j.pan.2015.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/17/2015] [Accepted: 01/21/2015] [Indexed: 12/11/2022]
Abstract
Hepatocellular carcinoma rarely invades the biliary tree. Clots or tumor embolus passing though the bile duct can cause pancreatitis by a mechanism similar to gallstone pancreatitis. We present the case of a patient with recurrent acute pancreatitis, initially suspicious of biliary origin. Despite cholecystectomy he had new episodes of acute pancreatitis. Hepatocellular carcinoma was diagnosed after the third episode. ERCP findings suggested the presence of a fistula connecting the tumor and the biliary tree. The patient was operated and the hepatocellular carcinoma was resected. Its pathological analysis confirmed the communication between the tumor and the biliary duct.
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Affiliation(s)
- Federico Bolado
- Departments of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain.
| | - Antonio Tarifa
- Hepato-biliary-pancreatic Surgery, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Cruz Zazpe
- Hepato-biliary-pancreatic Surgery, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Jose Maria Urman
- Departments of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Javier Herrera
- Hepato-biliary-pancreatic Surgery, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Juan Jose Vila
- Departments of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain
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Boadas J, Balsells J, Busquets J, Codina-B A, Darnell A, Garcia-Borobia F, Ginés À, Gornals J, Gruartmoner G, Ilzarbe L, Merino X, Oms L, Puig I, Puig-Diví V, Vaquero E, Vida F, Molero X. Valoración y tratamiento de la pancreatitis aguda. Documento de posicionamiento de la Societat Catalana de Digestologia, Societat Catalana de Cirurgia y Societat Catalana de Pàncrees. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:82-96. [DOI: 10.1016/j.gastrohep.2014.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/07/2014] [Accepted: 09/10/2014] [Indexed: 12/12/2022]
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Abstract
OBJECTIVES Pancreatitis is considered a possible risk factor for and a presentation of pancreatic adenocarcinoma (PA). We aimed to evaluate a large PA patient registry to determine whether prior history of pancreatitis influenced survival. METHODS We retrospectively analyzed the Mayo Clinic Biospecimen Resource for Pancreas Research database from January 1992 to September 2011. Data collected included demographic characteristics, history of tobacco or alcohol use, diabetes mellitus (DM), cholelithiasis, pseudocyst, and details regarding PA. Clinical characteristics and outcomes of PA patients with pancreatitis were compared with PA patients without pancreatitis history. RESULTS We analyzed 2573 patients with PA diagnosis. Among these patients, 195 (8%) were identified who had pancreatitis diagnosis ≥ 10 days before PA diagnosis. The cohort with pancreatitis history included more patients with DM (30% vs. 18%; P<0.001) and more smokers (68% vs. 58%; P=0.02). Compared with patients without pancreatitis history, these patients received diagnoses of PA at a younger age (63 vs. 65 y; P=0.005) and earlier stage (stages I and II; 52% vs. 37%; P<0.001). A greater percentage had history of surgery with curative intent (50% vs. 43%; P=0.001) and significantly better survival [median (range), 387 d (314 to 460 d) vs. 325 d (306 to 344 d); P=0.003]. CONCLUSIONS Patients with PA and pancreatitis had more weight loss and DM, but had PA diagnosis at an earlier stage, were more likely to have pancreatic surgery, and therefore better survival than PA patients without pancreatitis, likely due to the earlier diagnosis. Further studies are needed to evaluate whether screening for PA in patients with pancreatitis history would provide survival benefit.
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Liu Z, Long J, Guo KJ, Xu YH. Diagnosis and treatment of pancreatic neoplasms with acute pancreatitis as first symptom: An analysis of 12 cases. Shijie Huaren Xiaohua Zazhi 2014; 22:4168-4171. [DOI: 10.11569/wcjd.v22.i27.4168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the clinical manifestations, early diagnosis and treatment of pancreatic neoplasms with acute pancreatitis as first symptom.
METHODS: Twelve pancreatic neoplasm patients with acute pancreatitis as the first symptom treated at our hospital from July 2006 to February 2014 were analyzed to explore the etiology, clinical manifestations, diagnosis and treatment of this condition.
RESULTS: After blood amylase and lipase detection, physical examination and CT scans, all the 12 cases were initially diagnosed as acute pancreatitis, with or without the increase of CA19-9. Two cases had gallbladder stones and cholecystitis, and two cases had a history of alcohol drinking. All patients underwent surgery or biopsy cytology, with 5 cases finally diagnosed as pancreatic head carcinoma, 2 as pancreatic body carcinoma, 5 as IPMN, and 2 as severe acute pancreatitis. Only 7 cases received radical surgery.
CONCLUSION: Pancreatic neoplasms with pancreatitis as the first symptom has a lower morbidity. Early diagnosis is difficult, and the initial diagnosis of acute pancreatitis often results in delayed surgery. A comprehensive analysis of clinical manifestations, CT findings and CA19-9 level should be conducted to make a correct diagnosis.
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Munigala S, Kanwal F, Xian H, Scherrer JF, Agarwal B. Increased risk of pancreatic adenocarcinoma after acute pancreatitis. Clin Gastroenterol Hepatol 2014; 12:1143-1150.e1. [PMID: 24440214 DOI: 10.1016/j.cgh.2013.12.033] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 12/23/2013] [Accepted: 12/25/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acute pancreatitis (AP) is often the initial presentation of pancreatic cancer (pancreatic adenocarcinoma [PaCa]). We evaluated the risk of PaCa after AP. METHODS We performed a retrospective study of patients with AP who sought care in the Veterans Health Administration from 1998 through 2007. We excluded patients with pre-existing PaCa or recurrent AP and those who had the first episode of acute pancreatitis, from 1998 through 2000. RESULTS Of 495,504 patients with Veterans Health Administration inpatient and outpatient records, 5720 were diagnosed with AP (1.15%) and 710 were diagnosed with PaCa (0.14%), from 2000 through 2007. Seventy-six patients had AP within 2 years before being diagnosed with PaCa (10.7% of all patients with cancer diagnosed during that period). The risk for PaCa was greatest in the first year after AP (14.5 per 1000 patient-years) and then decreased rapidly. Risk for PaCa was negligible in patients <40 years old. The incidence of PaCa within the first year after AP was 7.69 per 1000 patient-years in fifth decade of life and reached 28.67 after the seventh decade. Time to diagnosis of PaCa after AP was ≤2 months for 34 patients, 3-12 months for 35 patients, 13-24 months for 7 patients, and >24 months for 10 patients. CONCLUSIONS A significant number of patients with PaCa initially present with AP; the diagnosis of cancer is often delayed by up to 2 years. We suggest that PaCa be routinely considered as a potential etiology of AP in patients ≥40 years old.
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Affiliation(s)
- Satish Munigala
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St Louis, Missouri
| | - Fasiha Kanwal
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St Louis, Missouri
| | - Hong Xian
- Veterans Affairs, St Louis Health Care System, St Louis, Missouri; Department of Biostatistics, Saint Louis University School of Public Health, St Louis, Missouri
| | - Jeffrey F Scherrer
- Veterans Affairs, St Louis Health Care System, St Louis, Missouri; Department of Family and Community Medicine, Saint Louis University School of Medicine, St Louis, Missouri
| | - Banke Agarwal
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St Louis, Missouri.
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