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Natural history,clinical characteristics,outcomes,and long-term follow-up of pain-free chronic pancreatitis

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Gastroenterology Report 2023年第1期11卷 309-315页

作者： Awais Ahmed Ishani Shah Rachel Bocchino Steven D.Freedman darshan j.kothari Sunil G.Sheth Department of Medicine Division of GastroenterologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMAUSA Department of Medicine Division of Internal MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMAUSA Department of Medicine Division of GastroenterologyDuke UniversityDurhamNCUSA

Background:Chronic pancreatitis(CP)is characterized by chronic abdominal pain and functional ***,a small subset of patients with prior acute pancreatitis(AP)and/or underlying risk factors for developing CP may be pain-free at diagnosis and may have a different clinical *** aimed to compare the clinical characteristics,outcomes,and healthcare utilization between CP patients with and without ***:Reviewed patients with established CP were followed in our Pancreas Center between january 2016 and April *** without risk factors for developing CP and/or without AP prior to their diagnosis and only with incidental radiologic features of CP were excluded,so as tominimize confounding factors of pancreatopathy unrelated to *** were divided into painful and pain-free groups to analyze differences in demographics,outcomes,and healthcare ***:Of 368 CP patients,49(13.3%)were pain-free at diagnosis and had remained so for>9 *** were no significant differences in body mass index,race,sex,or co-morbidities between the two ***-free patients were older at diagnosis(53.9 vs 45.7,P=0.004)and had less recurrent AP(RAP)(43.8%vs 72.5%,P<0.001)and less exocrine pancreatic insufficiency(EPI)(34.7%vs 65.7%,P<0.001).Pain-free patients had less disability(2.2%vs 22.0%,P=0.003),mental illness(20.4%vs 61.0%,P<0.001),surgery(0.0%vs 15.0%,P=0.059),and therapeutic interventions(0.0%vs 16.4%,P=0.005)for ***:We described a unique subset of patients with underlying risk factors for CP and/or prior AP who were painfree at *** were older at diagnosis,had less EPI and RAP,and overall favorable outcomes with minimal resource utilization.

关键词： chronic pancreatitis pain-free pancreatic insufficiency diabetes

Innovative pathways allow safe discharge of mild acute pancreatitis from the emergency room

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World journal of Gastroenterology 2024年第11期30卷 1475-1479页

作者： darshan j.kothari Sunil G Sheth Division of Gastroenterology Duke University Medical CenterDurhamNC 27710United States Division of Gastroenterology&Hepatology Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA 02215United States

Acute pancreatitis(AP)is a leading cause of gastrointestinal-related hospitalizations in the United States,resulting in 300000 admissions per year with an estimated cost of over$2.6 billion *** severity of AP is determined by the presence of pancreatic complications and end-organ *** moderate/severe pancreatitis can be associated with significant morbidity and mortality,the majority of patients have a mild presentation with an uncomplicated course and mortality rate of less than 2%.Despite favorable outcomes,the majority of mild AP patients are admitted,contributing to healthcare cost and *** this Editorial we review the performance of an emergency department(ED)pathway for patients with mild AP at a tertiary care center with the goal of reducing hospitalizations,resource utilization,and costs after several years of implementation of the *** discuss the clinical course and outcomes of mild AP patients enrolled in the pathway who were successfully discharged from the ED compared to those who were admitted to the hospital,and identify predictors of successful ED discharge to select patients who can potentially be triaged to the *** conclude that by implementing innovative clinical pathways which are established and reproducible,selected AP patients can be safely discharged from the ED,reducing hospitalizations and healthcare costs,without compromising clinical *** also identify a subset of patients most likely to succeed in this pathway.

关键词： Emergency department Mild pancreatitis Pathways Hospitalization Predictors

Two-stage corrective operation for the treatment of pes cavovarus in patients with spina bifida

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World journal of Orthopedics 2024年第7期15卷 618-626页

作者： Anthony Mack Padgett Ezan kothari Michael j Conklin Department of Orthopedics Indiana UniversityIndianapolisIN 46202United States Department of Orthopaedic Surgery University of Alabama at BirminghamBirminghamAL 35233United States Department of Orthopedic Surgery Children’s of AlabamaBirminghamAL 35233United States

BACKGROUND Pes cavovarus has an estimated incidence of 8%-17%in patients with spina bifida(SB).The majority of the current literature on surgical treatment of cavovarus feet in children and adolescents includes a variety of *** are currently no case series describing a treatment algorithm for deformity correction in this specific patient *** authors of this study present the results of a retrospective case series performed to assess the radiographic outcomes of two-stage corrective surgery in patients with *** Retrospective chart review was performed on patients with SB with a diagnosis of pes cavovarus at a freestanding children’s hospital who underwent surgical correction of the *** were excluded for lack of two-stage corrective operation,nonambulatory status,lack of at least six months follow-up,and age>18 years at the time of *** resulted in a cohort of 19 *** analysis was performed on 11 feet that had a complete series of preoperative and postoperative weightbearing *** and postoperative radiographic outcome measurements were compared using a two-sample *** Significant changes between the preoperative and postoperative measurements were seen in Meary’s angle,the anteroposterior talo-first metatarsal(AP TMT1)angle,and the talonavicular *** values of Meary’s angle were 17.9±13.1 preoperatively and 4.7±10.3 postoperatively(P=0.016).Mean AP TMT1 angle was 20.6±15.1 preoperatively and 9.3±5.5 postoperatively(P=0.011).Mean talonavicular coverage values were-10.3±9.6 preoperatively and-3.8±10.1 postoperatively(P=0.025).CONCLUSION The two-stage corrective procedure demonstrated efficacy in correcting cavovarus deformity in patients with *** should strongly consider employing the staged surgical algorithm presented in this manuscript for management of these patients.

关键词： Cavovarus Spina bifida Osteotomy Plantar release Radiographs Pediatrics

Pain management in chronic pancreatitis incorporating safe opioid practices: Challenge accepted

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World journal of Gastroenterology 2021年第23期27卷 3142-3147页

作者： Ishani Shah Sunil G Sheth darshan j.kothari Department of Gastroenterology Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA 02215United States Department of Gastroenterology Duke University Medical CenterDurhamNC 27710United States

Patients with chronic pancreatitis often experience severe,unrelenting abdominal pain,which can significantly impact their quality of *** control,therefore,remains central to the overall management of chronic *** of the strategies aimed at treating the pain of chronic pancreatitis are based on expert opinion and vary from one institution to another,as there are no uniform guidelines to direct a stepwise approach towards achieving this *** this editorial,we comment on best practice strategies targeted towards pain control in chronic pancreatitis,specifically highlighting the use of opioid medications in this patient *** discuss various safe and efficacious prescription monitoring practices in this article.

关键词： Chronic pancreatitis Chronic pain Pain management Opioid use disorder Prescription opioid misuse Prescription opioid abuse

Bone disease in chronic pancreatitis

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World journal of Clinical Cases 2020年第9期8卷 1574-1579页

作者： Awais Ahmed Aman Deep Sunil G Sheth darshan j.kothari Division of Gastroenterology Beth Israel Deaconess Medical CenterBostonMA 02215United States Division of Gastroenterology Duke University Medical CenterDurhamNC 27710United States

Bone disease(osteopenia or osteoporosis)is a highly prevalent condition in society and presents a tremendous,preventable public health *** procedures,such as,dual-energy X-ray absorptiometry scans,have allowed early identification and intervention to improve bone health,and reduce the risk of osteoporotic fractures,which carry significant morbidity and *** association of bone disease has been recognized in several diseases of the gastrointestinal tract,resulting in established guidelines for screening in patients with malabsorptive disorders such as inflammatory bowel disease and celiac ***,the risk of bone disease has been recognized in patients with chronic pancreatitis(CP),who share similar risk factors as patients with other high gastrointestinal *** a result,there have been a number of studies examining the prevalence and risks of bone disease and fractures in patients with *** review aims to summarize the recent literature and current recommendations related to bone disease in CP.

关键词： Bone disease Osteopenia Osteoporosis Fracture risk Chronic pancreatitis Malabsorption

Liver-gut axis in the regulation of iron homeostasis

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World journal of Gastroenterology 2007年第35期13卷 4737-4745页

作者： Deepak darshan Gregory j Anderson Iron Metabolism Laboratory The Queensland Institute of Medical ResearchBrisbaneAustralia

The human body requires about 1-2 mg of iron per day for its normal functioning, and dietary iron is the only source for this essential metal. Since humans do not possess a mechanism for the active excretion of iron, the amount of iron in the body is determined by the amount absorbed across the proximal small intestine and, consequently, intestinal iron absorption is a highly regulated process. In recent years, the liver has emerged as a central regulator of both iron absorption and iron release from other tissues. It achieves this by secreting a peptide hormone called hepcidin that acts on the small intestinal epithelium and other cells to limit iron delivery to the plasma. Hepcidin itself is regulated in response to various systemic stimuli including variations in body iron stores, the rate of erythropoiesis, inflammation and hypoxia, the same stimuli that have been known for many years to modulate iron absorption. This review will summarize recent findings on the role played by the liver and hepcidin in the regulation of body iron absorption.

关键词： Iron Homeostasis Intestinal iron absorption Liver Hepcidin

Evaluating the accuracy of American Society for Gastrointestinal Endoscopy guidelines in patients with acute gallstone pancreatitis with choledocholithiasis

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World journal of Gastroenterology 2022年第16期28卷 1692-1704页

作者： Supisara Tintara Ishani Shah William Yakah Awais Ahmed Cristina S Sorrento Cinthana Kandasamy Steven D Freedman darshan j.kothari Sunil G Sheth Department of Internal Medicine Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA 02215United States Division of Gastroenterology&Hepatology Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA 02215United States Division of Gastroenterology Duke University Medical CenterDurhamNC 27710United States Division of Gastroenterology Durham VA Medical CenterDurhamNC 27705United States

BACKGROUND Acute gallstone pancreatitis(AGP) is the most common cause of acute pancreatitis(AP) in the United States. Patients with AGP may also present with choledocholithiasis. In 2010, the American Society for Gastrointestinal Endoscopy(ASGE) suggested a management algorithm based on probability for choledocholithiasis, recommending additional imaging for patients at intermediate risk and endoscopic retrograde cholangiopancreatography(ERCP) for patients at high risk of choledocholithiasis. In 2019, the ASGE guidelines were updated using more specific criteria to categorize individuals at high risk for choledocholithiasis. Neither ASGE guideline has been studied in AGP to determine the probability of having *** To determine compliance with ASGE guidelines, assess outcomes, and compare 2019 vs 2010 ASGE criteria for suspected choledocholithiasis in *** We conducted a retrospective cohort study of 882 patients admitted with AP to a single tertiary care center from 2008-2018. AP was diagnosed using revised Atlanta criteria and AGP was defined as the presence of gallstones on imaging or with cholestatic pattern of liver injury in the absence of another cause. Patients with chronic pancreatitis and pancreatic malignancy were excluded as were those who went directly to cholecystectomy prior to assessment for choledocholithiasis. Patients were assigned low, intermediate or high risk based on ASGE guidelines. Our primary outcomes of interest were the proportion of patients in the intermediate risk group undergoing magnetic resonance cholangiopancreatography(MRCP) first and the proportion of patients in the high risk group undergoing ERCP directly without preceding imaging. Secondary outcomes of interest included outcome differences based on if guidelines were not adhered to. We then evaluated the diagnostic accuracy of 2019 in comparison to the 2010 ASGE criteria for patients with suspected choledocholithiasis. We performed the t test or Wilcox

关键词： American Society for Gastrointestinal Endoscopy guidelines Choledocholithiasis Acute gallstone pancreatitis Endoscopic retrograde cholangiopancreatography Magnetic resonance cholangiopancreatography

Extra-pancreatic complications,especially hemodialysis predict mortality and length of stay,in ICU patients admitted with acute pancreatitis

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Gastroenterology Report 2018年第3期6卷 202-209,I0001页

作者： darshan kothari Maarten R.Struyvenberg Michael C.Perillo Ghideon Ezaz Steven D.Freedman Sunil G.Sheth Department of Medicine Beth Israel Deaconess Medical CenterHarvard Medical School330 Brookline AveBostonMA 02215USA

Background and aims:Patients in the intensive care unit(ICU)with acute pancreatitis(AP)are at risk for extra-pancreatic complications given their severe illness and prolonged length of *** sought to determine the rate of extra-pancreatic complications and its effect on length of stay(LOS)and mortality in ICU patients with ***:We performed a retrospective cohort study of ICU patients admitted to a tertiary-care center with a diagnosis of AP.A total of 287 ICU patients had a discharge diagnosis of AP,of which 163 met inclusion *** calculated incidence rates of extra-pancreatic complications and performed a univariate and multi-variable analysis to determine predictors of LOS and ***:There were a total of 158 extra-pancreatic complications(0.97 extra-pancreatic complications per patient).Ninetyfive patients had at least one extra-pancreatic complication,whereas 68 patients had no extra-pancreatic *** with extra-pancreatic complications had a significantly longer LOS(14.7 vs 8.8 days,p<0.01)when controlling for local pancreatic *** with non-infectious extra-pancreatic complications had a higher rate of mortality(24.0%vs 16.2%,p=0.04).Patients requiring dialysis was an independent predictor for LOS and mortality(incidence risk ratio[IRR]1.73,95%confidence interval[CI]:1.263–2.378 and IRR 1.50,95%CI 1.623–6.843,p<0.01)on multi-variable *** events were also a predictor for mortality(p=0.05).Other extra-pancreatic complications were not ***:Extra-pancreatic complications occur frequently in ICU patients with AP and impact *** with noninfectious extra-pancreatic complications have a higher mortality *** controlling for local pancreatic complications,patients requiring dialysis remained an independent predictor for LOS and mortality.

关键词： Severe acute pancreatitis extra-pancreatic complications intensive care unit length of stay in-hospital mortality infections

An open-access endoscopy screen correctly and safely identifies patients for conscious sedation

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Gastroenterology Report 2016年第4期4卷 281-286,I0001页

作者： darshan kothari joseph D.Feuerstein Laureen Moss julie D’Souza Kerri Montanaro Daniel A.Leffler Sunil G.Sheth Department of Medicine and Division of Gastroenterology Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMAUSA Department of Nursing Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMAUSA

Background and aims:Open-access scheduling is highly utilized for facilitating generally low-risk *** screening addresses sedation requirements;however,procedural safety may be compromised if screening is *** sought to determine the reliability of our open-access scheduling system for appropriate use of conscious ***:We prospectively and consecutively enrolled outpatient procedures booked at an academic center by open-access using screening after in-office gastroenterology(GI)*** collected the cases inappropriately booked for conscious sedation and compared the characteristics for significant ***:A total of 8063 outpatients were scheduled for procedures with conscious sedation,and 5959 were booked with *** 78 patients(0.97%,78/8063)were identified as subsequently needing anesthesiologist-assisted sedation;44(56.4%,44/78)were booked through open-access,of which chronic opioid(47.7%,21/44)or benzodiazepine use(34.1%,15/44)were the most common reasons for needing anesthesiologist-assisted *** on chronic benzodiazepines required more midazolam than those not on chronic benzodiazepines(P=0.03)of those patients who underwent conscious ***,patients with chronic opioid use required more fentanyl than those without chronic opioid use(P=0.04).Advanced liver disease and alcohol use were common reasons for patients being booked after in-office consultation and were significantly higher than those booked with open-access(both Pjority of patients can be triaged for conscious sedation using a multi-tiered screening ***,few patients(<1.0%)were inappropriately booked for conscious *** most common reasons for considering anesthesiologist-assisted sedation were chronic opioid,benzodiazepine and/or alcohol use and advanced liver *** suggests that these entities could be included in screening proces

关键词： open-access endoscopy sedation screen