LETTERS TO THE EDITOR
nature publishing group
Response to Tenner et al. Marije Smit, MD1, Jan G. Zijlstra, MD, PhD1 and Matijs van Meurs, MD, PhD1 doi:10.1038/ajg.2013.465
To the Editor: We read with great interest the article “American College of Gastroenterology Guideline: Management of Acute Pancreatitis” (1). We would like to complement the authors. We agree with the recommendation that patients with organ failure should be admitted to an intensive care unit whenever possible. Furthermore, we support the recommendation that caution is required with aggressive hydration for patients with SIRS or sepsis to avoid complications such as the abdominal compartment syndrome (ACS). In addition to this, we would like to suggest that more attention should be focused on this complication in future guidelines. Intra-abdominal hypertension (IAH) is defined by a sustained or repeated pathological elevation in intra-abdominal pressure (IAP)≥12 mm Hg, whereas the ACS is defined as a sustained IAP > 20 mm Hg, which is associated with new organ dysfunction or failure (2). Acute pancreatitis is a risk factor for IAH and ACS (2). Reported incidence of ACS in severe acute pancreatitis is 25–56% (3). In the setting of pancreatitis with organ failure, measurement of IAP and protocolized monitoring and management of IAPs are recommended (Grade 1 C evidence) (2). IAP can be measured easily and reliably in patients through the bladder using simple tools (4). IAH may affect all organ systems, but respiratory, cardiovascular, and kidney function are affected most often (4). Even slightly elevated abdominal pressures may lead to signs of systemic inflammation and acute kidney injury (5). The article describes that death occurs in the early phase of the disease as a result of the development of organ failure that © 2014 by the American College of Gastroenterology
appears to be related to the development of SIRS. Although the exact mechanisms are not completely understood, IAH in severe acute pancreatitis is usually an early phenomenon and may have an important role in the development of early organ failure, often classified as SIRS (3). We suggest that the development of IAH and ACS is underestimated and may, in fact, have a role of paramount importance. However, if IAP is not measured, this diagnosis cannot be made, nor can adequate treatment (for example decompressive laparotomy) be initiated. In conclusion, the recommendation “If you do not measure the temperature, you cannot find a fever” made by Shem (6) should not apply to modernday clinical practice. Therefore, we recommend inclusion of measurement of IAP in all patients with acute pancreatitis and signs of organ failure in future guidelines. CONFLICT OF INTEREST
The authors declare no conflict of interest. REFERENCES 1. Tenner S, Bailly J, DeWitt J et al. American college of gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400–15. 2. Kirkpatrick AW, Roberts DJ, de Waele J, et al., the Pediatric Guidelines Sub-Cmmittee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013;39: 1190–206. 3. De Waele JJ, Leppaniemi AK. Intra-abdominal hypertension in acute pancreatitis. Wold J Surg 2009;33:1128–33. 4. De Waele JJ, De Laet I, Kirkpatrick AW et al. Intra-abdominal hypertension and abdominal compartment syndrome. Am J Kidney Dis 2011;57:159–69. 5. Smit M, Hofker HS, Leuvenink HGD et al. A human model of intra-abdominal hypertension: even slightly elevated pressures lead to increased acute systemic inflammation and signs of acute kidney injury. Crit Care 2013;17:425. 6. Shem S. The House of God. Bantam Doubleday Dell Publishing Group: New York, NY, 1978. 1
Department of Critical Care, University Medical Center Groningen, University of Groningen,
Groningen, The Netherlands. Correspondence: Marije Smit, MD, Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands. E-mail: [email protected]
The Role of Endoscopic Retrograde Cholangiopancreatography in Acute Pancreatitis Frances Tse, MD, MSc1, Yuhong Yuan, MD, PhD1 and Grigorios I. Leontiadis, MD, PhD1 doi:10.1038/ajg.2013.469
To the Editor: We read with interest the recent guideline on the management of acute pancreatitis (1). The guideline concluded that routine endoscopic retrograde cholangiopancreatography (ERCP) is not appropriate unless there is a high suspicion of a persistent common bile duct stone. Also, it was suggested that the only indication for ERCP within 24 h of admission should be concurrent cholangitis. While this conclusion seems logical, it was not adequately supported by the evidence cited in the guideline. Our recent Cochrane review (2), which was overlooked by this guideline, would have provided stronger support for this recommendation. Yet, the guideline cited a 10-year-old meta-analysis (3) with serious limitations that we discussed previously (2). In fact, contrary to the recommendations made by the guideline, this meta-analysis showed that early ERCP is beneficial in severe pancreatitis (3). Our Cochrane review (2) assessed the effectiveness and safety of early routine ERCP strategy compared to early conservative management strategy in acute biliary pancreatitis (ABP). Having avoided the limitations of previous reviews, we found that in unselected patients with ABP, there is no evidence that early routine ERCP significantly affects mortality, local and systemic complications (as defined by the Atlanta Classification) regardless of predicted severity (2). Subgroup analyses, however, support The American Journal of GASTROENTEROLOGY
443
444
Letters to the Editor
the recommendation that early ERCP should be considered in patients with coexisting cholangitis or biliary obstruction (2). Finally, this guideline concluded that “guidewire cannulation compared with conventional contrast cannulation appears to decrease the risk of severe post-ERCP acute pancreatitis (PEP)”(1). However, this conclusion was reached after considering only a few positive studies without a systematic evaluation of all available evidence. We believe the evidence for the use of guidewire cannulation is much stronger than that reported by the guideline, and we have concerns about its benefits pertaining only to severe PEP. Based on another Cochrane review of ours with inclusion of 12 randomized studies (4), we found that guidewire cannulation significantly reduced PEP compared with contrast cannulation. However, in subgroup analyses, guidewire cannulation only reduced the risk of mild PEP, while the results for moderate or severe PEP were consistent with either no effect or inadequate power to rule out clinically important difference (4). In addition, guidewire cannulation increased primary cannulation success and reduced the need for precut sphincterotomies (4). The results of our meta-analysis (4) therefore strongly support the use of the guidewire technique as first-line cannulation technique, but no conclusion could be drawn for the prevention of severe PEP. CONFLICT OF INTEREST
The authors declare no conflict of interest. REFERENCES 1. Tenner S, Baillie J, DeWitt J et al. American college of gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400–15. 2. Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012;(5):CD009779. 3. Ayub K, Imada R, Slavin J. Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev 2004, CD003630. 4. Tse F, Yuan Y, Moayyedi P et al. Guidewireassisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2012;(12):CD009662.
1
Hamilton Health Sciences Centre, Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario,
The American Journal of GASTROENTEROLOGY
Canada. Correspondence: Frances Tse, MD, MSc, Hamilton Health Sciences Centre, Division of Gastroenterology, Department of Medicine, McMaster University, 2F 53, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5. E-mail: [email protected]
Reply to Letters, Guidelines: Acute Pancreatitis Scott Tenner, MD, MPH, FACG1, John Baillie, MB, ChB, FRCP, FACG2, John M. DeWitt, MD, FACG3 and Santhi Swaroop Vege, MD, FACG4 doi:10.1038/ajg.2013.474
acute pancreatitis. We also agree “that early ERCP should be considered in patients with coexisting cholangitis or biliary obstruction”. Although we did not quote the review cited by the authors, these conclusions reflect our recommendations in the Guidelines (3). We also agree with the authors regarding the importance of using guidewire cannulation in preventing acute pancreatitis. Although there is some controversy regarding the strength of the data in preventing severe disease, as stated in the Guidelines, we agree that clinicians should use the guidewire technique to prevent post-ERCP acute pancreatitis. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES
To the Editor: Although we appreciate the comments in the letters submitted to the journal, we do not agree with their recommendations. Although intra-abdominal hypertension (IAH) may complicate the course of patients with acute pancreatitis, it remains unknown whether the measurement of intra-abdominal pressure (IAP) will alter the outcome of patients with severe acute pancreatitis. Although the measurement of IAP may be helpful in monitoring patients with intra-abdominal compartment syndrome, further study is needed in patients with acute pancreatitis (1). We do not agree that IAP can be “measured easily”, as clinicians are typically not trained to perform such a measurement, but, more important, how to respond to the measurements when resuscitating a patient with acute pancreatitis when some level of IAH may be part of the normal process of the disease. We should also point out that urinary sepsis, likely from catheters placed into the bladder, has been shown to be a major cause of morbidity and mortality in patients with acute pancreatitis (2). Until further study demonstrates that the monitoring of IAP can help manage patients with acute pancreatitis, we cannot recommend that the routine monitoring of IAP in all patients with acute pancreatitis is justified. Regarding the role of ERCP in patients with acute pancreatitis, we agree with the authors that “there is no evidence that early ERCP significantly affects mortality, local and systemic complications” in patients with
1. Kirkpatrick AW, Roberts DJ, De Waele J. Intraabdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013;39:1190–206. 2. Saino V, Kemppainem E, Puolakkainen P et al. Early antibiotic treatment in acute necrotizing pancreatitis. Lancet 1995;346:663–7. 3. Tenner S, Baillie J, DeWitt J et al. American College of Gastroenterology Guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400–15. 1
Downstate Medical Center, Division of Gastroenterology, Brooklyn, New York, USA; 2Carteret Medical Group, Morehead City, North Carolina, USA; 3 Indiana University, Medicine, Indianapolis, Indiana, USA; 4Mayo Clinic, Department of Gastroenterology, Rochester, Minnesota, USA. Correspondence: Scott Tenner, Downstate Medical Center, Department of Gastroenterology, 2211 Emmons Avenue, Brooklyn, New York 11235, USA. E-mail: [email protected]
The Relationship Between Symptom Improvement and Gastric Emptying in the Treatment of Gastroparesis: Remember the Pharmacology G.J. Sanger, DSc1 doi:10.1038/ajg.2013.432
VOLUME 109 | MARCH 2014 www.amjgastro.com
nature publishing group
Response to Tenner et al. Marije Smit, MD1, Jan G. Zijlstra, MD, PhD1 and Matijs van Meurs, MD, PhD1 doi:10.1038/ajg.2013.465
To the Editor: We read with great interest the article “American College of Gastroenterology Guideline: Management of Acute Pancreatitis” (1). We would like to complement the authors. We agree with the recommendation that patients with organ failure should be admitted to an intensive care unit whenever possible. Furthermore, we support the recommendation that caution is required with aggressive hydration for patients with SIRS or sepsis to avoid complications such as the abdominal compartment syndrome (ACS). In addition to this, we would like to suggest that more attention should be focused on this complication in future guidelines. Intra-abdominal hypertension (IAH) is defined by a sustained or repeated pathological elevation in intra-abdominal pressure (IAP)≥12 mm Hg, whereas the ACS is defined as a sustained IAP > 20 mm Hg, which is associated with new organ dysfunction or failure (2). Acute pancreatitis is a risk factor for IAH and ACS (2). Reported incidence of ACS in severe acute pancreatitis is 25–56% (3). In the setting of pancreatitis with organ failure, measurement of IAP and protocolized monitoring and management of IAPs are recommended (Grade 1 C evidence) (2). IAP can be measured easily and reliably in patients through the bladder using simple tools (4). IAH may affect all organ systems, but respiratory, cardiovascular, and kidney function are affected most often (4). Even slightly elevated abdominal pressures may lead to signs of systemic inflammation and acute kidney injury (5). The article describes that death occurs in the early phase of the disease as a result of the development of organ failure that © 2014 by the American College of Gastroenterology
appears to be related to the development of SIRS. Although the exact mechanisms are not completely understood, IAH in severe acute pancreatitis is usually an early phenomenon and may have an important role in the development of early organ failure, often classified as SIRS (3). We suggest that the development of IAH and ACS is underestimated and may, in fact, have a role of paramount importance. However, if IAP is not measured, this diagnosis cannot be made, nor can adequate treatment (for example decompressive laparotomy) be initiated. In conclusion, the recommendation “If you do not measure the temperature, you cannot find a fever” made by Shem (6) should not apply to modernday clinical practice. Therefore, we recommend inclusion of measurement of IAP in all patients with acute pancreatitis and signs of organ failure in future guidelines. CONFLICT OF INTEREST
The authors declare no conflict of interest. REFERENCES 1. Tenner S, Bailly J, DeWitt J et al. American college of gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400–15. 2. Kirkpatrick AW, Roberts DJ, de Waele J, et al., the Pediatric Guidelines Sub-Cmmittee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013;39: 1190–206. 3. De Waele JJ, Leppaniemi AK. Intra-abdominal hypertension in acute pancreatitis. Wold J Surg 2009;33:1128–33. 4. De Waele JJ, De Laet I, Kirkpatrick AW et al. Intra-abdominal hypertension and abdominal compartment syndrome. Am J Kidney Dis 2011;57:159–69. 5. Smit M, Hofker HS, Leuvenink HGD et al. A human model of intra-abdominal hypertension: even slightly elevated pressures lead to increased acute systemic inflammation and signs of acute kidney injury. Crit Care 2013;17:425. 6. Shem S. The House of God. Bantam Doubleday Dell Publishing Group: New York, NY, 1978. 1
Department of Critical Care, University Medical Center Groningen, University of Groningen,
Groningen, The Netherlands. Correspondence: Marije Smit, MD, Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands. E-mail: [email protected]
The Role of Endoscopic Retrograde Cholangiopancreatography in Acute Pancreatitis Frances Tse, MD, MSc1, Yuhong Yuan, MD, PhD1 and Grigorios I. Leontiadis, MD, PhD1 doi:10.1038/ajg.2013.469
To the Editor: We read with interest the recent guideline on the management of acute pancreatitis (1). The guideline concluded that routine endoscopic retrograde cholangiopancreatography (ERCP) is not appropriate unless there is a high suspicion of a persistent common bile duct stone. Also, it was suggested that the only indication for ERCP within 24 h of admission should be concurrent cholangitis. While this conclusion seems logical, it was not adequately supported by the evidence cited in the guideline. Our recent Cochrane review (2), which was overlooked by this guideline, would have provided stronger support for this recommendation. Yet, the guideline cited a 10-year-old meta-analysis (3) with serious limitations that we discussed previously (2). In fact, contrary to the recommendations made by the guideline, this meta-analysis showed that early ERCP is beneficial in severe pancreatitis (3). Our Cochrane review (2) assessed the effectiveness and safety of early routine ERCP strategy compared to early conservative management strategy in acute biliary pancreatitis (ABP). Having avoided the limitations of previous reviews, we found that in unselected patients with ABP, there is no evidence that early routine ERCP significantly affects mortality, local and systemic complications (as defined by the Atlanta Classification) regardless of predicted severity (2). Subgroup analyses, however, support The American Journal of GASTROENTEROLOGY
443
444
Letters to the Editor
the recommendation that early ERCP should be considered in patients with coexisting cholangitis or biliary obstruction (2). Finally, this guideline concluded that “guidewire cannulation compared with conventional contrast cannulation appears to decrease the risk of severe post-ERCP acute pancreatitis (PEP)”(1). However, this conclusion was reached after considering only a few positive studies without a systematic evaluation of all available evidence. We believe the evidence for the use of guidewire cannulation is much stronger than that reported by the guideline, and we have concerns about its benefits pertaining only to severe PEP. Based on another Cochrane review of ours with inclusion of 12 randomized studies (4), we found that guidewire cannulation significantly reduced PEP compared with contrast cannulation. However, in subgroup analyses, guidewire cannulation only reduced the risk of mild PEP, while the results for moderate or severe PEP were consistent with either no effect or inadequate power to rule out clinically important difference (4). In addition, guidewire cannulation increased primary cannulation success and reduced the need for precut sphincterotomies (4). The results of our meta-analysis (4) therefore strongly support the use of the guidewire technique as first-line cannulation technique, but no conclusion could be drawn for the prevention of severe PEP. CONFLICT OF INTEREST
The authors declare no conflict of interest. REFERENCES 1. Tenner S, Baillie J, DeWitt J et al. American college of gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400–15. 2. Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012;(5):CD009779. 3. Ayub K, Imada R, Slavin J. Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev 2004, CD003630. 4. Tse F, Yuan Y, Moayyedi P et al. Guidewireassisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Cochrane Database Syst Rev 2012;(12):CD009662.
1
Hamilton Health Sciences Centre, Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario,
The American Journal of GASTROENTEROLOGY
Canada. Correspondence: Frances Tse, MD, MSc, Hamilton Health Sciences Centre, Division of Gastroenterology, Department of Medicine, McMaster University, 2F 53, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5. E-mail: [email protected]
Reply to Letters, Guidelines: Acute Pancreatitis Scott Tenner, MD, MPH, FACG1, John Baillie, MB, ChB, FRCP, FACG2, John M. DeWitt, MD, FACG3 and Santhi Swaroop Vege, MD, FACG4 doi:10.1038/ajg.2013.474
acute pancreatitis. We also agree “that early ERCP should be considered in patients with coexisting cholangitis or biliary obstruction”. Although we did not quote the review cited by the authors, these conclusions reflect our recommendations in the Guidelines (3). We also agree with the authors regarding the importance of using guidewire cannulation in preventing acute pancreatitis. Although there is some controversy regarding the strength of the data in preventing severe disease, as stated in the Guidelines, we agree that clinicians should use the guidewire technique to prevent post-ERCP acute pancreatitis. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES
To the Editor: Although we appreciate the comments in the letters submitted to the journal, we do not agree with their recommendations. Although intra-abdominal hypertension (IAH) may complicate the course of patients with acute pancreatitis, it remains unknown whether the measurement of intra-abdominal pressure (IAP) will alter the outcome of patients with severe acute pancreatitis. Although the measurement of IAP may be helpful in monitoring patients with intra-abdominal compartment syndrome, further study is needed in patients with acute pancreatitis (1). We do not agree that IAP can be “measured easily”, as clinicians are typically not trained to perform such a measurement, but, more important, how to respond to the measurements when resuscitating a patient with acute pancreatitis when some level of IAH may be part of the normal process of the disease. We should also point out that urinary sepsis, likely from catheters placed into the bladder, has been shown to be a major cause of morbidity and mortality in patients with acute pancreatitis (2). Until further study demonstrates that the monitoring of IAP can help manage patients with acute pancreatitis, we cannot recommend that the routine monitoring of IAP in all patients with acute pancreatitis is justified. Regarding the role of ERCP in patients with acute pancreatitis, we agree with the authors that “there is no evidence that early ERCP significantly affects mortality, local and systemic complications” in patients with
1. Kirkpatrick AW, Roberts DJ, De Waele J. Intraabdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013;39:1190–206. 2. Saino V, Kemppainem E, Puolakkainen P et al. Early antibiotic treatment in acute necrotizing pancreatitis. Lancet 1995;346:663–7. 3. Tenner S, Baillie J, DeWitt J et al. American College of Gastroenterology Guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400–15. 1
Downstate Medical Center, Division of Gastroenterology, Brooklyn, New York, USA; 2Carteret Medical Group, Morehead City, North Carolina, USA; 3 Indiana University, Medicine, Indianapolis, Indiana, USA; 4Mayo Clinic, Department of Gastroenterology, Rochester, Minnesota, USA. Correspondence: Scott Tenner, Downstate Medical Center, Department of Gastroenterology, 2211 Emmons Avenue, Brooklyn, New York 11235, USA. E-mail: [email protected]
The Relationship Between Symptom Improvement and Gastric Emptying in the Treatment of Gastroparesis: Remember the Pharmacology G.J. Sanger, DSc1 doi:10.1038/ajg.2013.432
VOLUME 109 | MARCH 2014 www.amjgastro.com
