Stone in the middle gallbladder.
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Adult↗
Biomedical subjects
C W Imrie
Publications and source records attributed to C W Imrie.
Acute pancreatitis and octreotide.
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Acute Disease↗
Current concepts in the management of pancreatitis.
Acute pancreatitis is often a mild, self-limiting illness that responds to simple supportive therapy in the form of intravenous fluids and analgesics. More severe attacks may result in organ failure or pancreatic necrosis. Such patients should be identified early in the course of an attack and actively monitored within an intensive care unit or high dependency area. Supportive therapy remains the basis of management. Attention to the adequacy of the fluid balance and oxygenation are of prime importance and supportive therapy may include inotropic support, assisted ventilation and renal dialysis. Pancreatic necrosis should be sought by contrast-enhanced computed tomography (CT) scanning, and surgical intervention may be required if the patient's clinical condition continues to deteriorate. Surgery should ideally be delayed until the second or subsequent week when necrosectomy (debridement of necrotic pancreatic tissue) may be possible rather than formal pancreatic resection. The role of various drugs to suppress pancreatic secretion and inhibit pancreatic enzymes, although shown to be consistently effective in experimental pancreatitis, has not been established by controlled clinical trials in humans. Recent controlled studies examining peritoneal lavage in humans have failed to confirm the beneficial results suggested in earlier studies. Early endoscopic sphincterotomy for patients with severe gallstone pancreatitis and ductal calculi has been reported to reduce mortality and morbidity in one controlled clinical trial and may prove to be an important advance.
Acute Disease↗
Epidemiology of sharps accidents in general surgery.
A prospective study was carried out of all general surgical operations in one theatre of a teaching hospital over a 6-week period to identify the predisposing factors involved in the occurrence of sharps accidents and their relative importance. Although various predisposing factors have been intimated, the relative importance has never been ascertained. Glove puncture was used as an objective measure of a sharps accident and this was compared with subjective reporting of needlestick injury. The overall rate of sharps accidents per surgeon per operation was 23%. The position at the operating table and medical rank of operator affected the rate of accidents more than duration of operation. The group at most risk of sharps accidents was junior surgeons acting as the principal operator. It is important to recommend inoculation against hepatitis B in this group before starting surgical training. Another method of minimizing the risk to junior surgeons would be compulsory training on surgical rigs. Operations on patients with AIDS or hepatitis B should be carried out by the most senior surgeon available to reduce the risk of sharps injury and disease transmission.
Accidents, Occupational↗
Needlestick injury in surgeons: what is the incidence?
A prospective study by questionnaire was carried out to investigate the incidence of needlestick injury in the operating theatre staff of a teaching hospital and to calculate the individual risk of acquiring blood-borne virus infection in the UK from this source. The individual rate of needlestick injury in operating theatre staff was 1.55% per surgeon per operation (confidence interval (Cl) 0.6-2.5%). The calculated rate of clinical hepatitis B in surgeons compared with the observed rate suggests that needlestick in theatre is the main mode of transmission.
Accidents, Occupational↗
Trypsinogen activation peptides assay in the early prediction of severity of acute pancreatitis.
Trypsinogen activation can be quantified by measurement of released activation peptides (TAP assay). TAP assay in urine was performed on admission for 55 patients with acute pancreatitis. TAP concentration correlated with subsequent disease severity in 87%, whereas C-reactive protein concentration, and multifactorial scoring at 48 h, were correct in 55% and 84%. Sensitivity and specificity for TAP assay were 80% and 90%, for C-reactive protein 53% and 55%, and for multifactorial scoring at 48 h, 60% and 93%. Urine TAP assay distinguishes acute pancreatitis without trypsinogen activation from acute pancreatitis with trypsinogen activation, and helps to identify patients who will progress to the severe acute disease. Use of the assay should allow early intensive treatment of those who need it.
Acute Disease↗
Changing patterns of incidence and mortality from acute pancreatitis in Scotland, 1961-1985.
Data on all discharges from hospitals in Scotland have been recorded since 1961 as the Scottish Hospital In-Patient Statistics and examination of these data has permitted analysis of the incidence and mortality trends from acute pancreatitis. The number of discharges recorded has increased 11-fold in males from 69 patients/year in 1961 to 750 patients/year in 1985, and fourfold in females from 112 patients/year to 484 patients/year respectively. This increase has occurred particularly amongst young and middle-aged males (20-59 years) and in elderly females (over 60 years), the most marked increases occurring in the health boards of the 'central belt' area of Scotland. Mortality rate did not show a corresponding change, increasing only two-fold in males from 15 patients/year to 30 patients/year and in females from 29 patients/year to 37 patients/year. As a consequence the case mortality rate has fallen from 17.8 per cent over the period 1961-65 to 5.6 per cent over the period 1981-85. An apparent increase in the incidence of acute pancreatitis may be inferred from these data, much of which is thought to be due to improved accuracy in diagnosis.
Acute Disease↗
Effective intraperitoneal antiprotease therapy for taurocholate-induced pancreatitis in rats.
In canine pancreatitis, irreversible hypotension and death follow saturation of the antiprotease molecules in peritoneal exudate by activated proteolytic enzymes which are released from the pancreas. This study has examined, in rats with taurocholate-induced pancreatitis, the efficacy of removal of the peritoneal exudate by aspiration and a single lavage, followed by instillation of an exogenous antiprotease solution. Instillation of human fresh frozen plasma, containing alpha 2-macroglobulin and alpha 1-antiprotease, was associated with the longest median survival. Aprotinin, although possessing a much greater trypsin inhibitory capacity, just failed to significantly improve the median survival time compared with the control group. Intraperitoneal antiprotease therapy is simple to perform, has a beneficial effect on survival time in this model and merits investigation in man.
Acute Disease↗
Prediction of outcome in acute pancreatitis: a comparative study of APACHE II, clinical assessment and multiple factor scoring systems.
The APACHE II severity of disease classification system has been examined prospectively in 160 patients with acute pancreatitis. Using clinical and simple laboratory data APACHE II was able to provide useful discrimination between uncomplicated, complicated and fatal attacks within a few hours of admission. Peak APACHE II scores (recorded during the first 3 days) had a prognostic accuracy similar to the multiple factor scoring systems, but then incurred a similar delay. Patients could be graded according to their risk of death or of developing a major complication; no deaths occurred in patients with a peak APACHE II score less than 10. APACHE II can be repeated daily, uncomplicated attacks demonstrating falling scores in association with clinical improvement, in contrast to the rising scores associated with clinical deterioration in those dying early. APACHE II appears to reflect any continuing disease activity and may prove a useful means of monitoring the course of the illness and response to therapy.
Acute Disease↗
Acute pancreatitis and renal cortical necrosis.
A 21-year-old man presented with acute pancreatitis and acute renal failure. Diffuse bilateral renal cortical necrosis was diagnosed by renal biopsy and selective renal arteriography. The patient recovered from the attack of pancreatitis but remained anuric. Possible mechanisms for the association between acute pancreatitis and renal cortical necrosis are discussed.
Acute Disease↗
C-reactive protein, antiproteases and complement factors as objective markers of severity in acute pancreatitis.
In a series of patients with acute pancreatitis we have studied complement factors, antiproteases (alpha 2-macroglobulin and alpha 1-antiprotease) and C-reactive protein to determine the value of their sequential measurement in the prediction of outcome relative to clinical assessment and current multiple factor scoring systems. Complement factors were unhelpful in predicting the severity of an attack. alpha 2-Macroglobulin levels were significantly lower in complicated attacks during days 3-8 and alpha 1-antiprotease levels were significantly higher during days 4-8. C-reactive protein concentrations showed the best discrimination between mild and complicated attacks, levels rising higher and persisting for longer in complicated attacks; these differences were highly significant from day 2 (the morning after admission) to day 8. The concentrations providing the best discrimination were found to be greater than or equal to 210 mg/l for the peak C-reactive protein (on the second, third or fourth day) and greater than or equal to 120 mg/l for the C-reactive protein at the end of the first week. Analysis demonstrated both the peak or seventh-day C-reactive protein concentration to be of similar accuracy to either the Ranson or Glasgow multiple factor scoring systems and slightly better for attacks associated with gallstones. The C-reactive protein assay is simple, quick to perform, provides useful clinical information and is more likely to be of value and to be adopted into routine clinical practice than multiple factor scoring systems.
Acute Disease↗
Acute pancreatitis and pancreatic fistula formation.
The cause, management and outcome of 23 patients with a pancreatic fistula following acute pancreatitis are reviewed. Nineteen patients developed an external fistula following necrosectomy or drainage of a pancreatic abscess or pseudocyst; four of these patients died. In the 15 survivors spontaneous closure occurred in 11 cases with low output fistulae; operative intervention was needed in the four cases with high output fistulae. Four patients with internal fistulae had not undergone previous surgery; two of them had a pancreaticopleural fistula with associated pancreaticogastric fistulae, while two had pancreatic ascites. All four of these patients required surgical intervention and one died.
Abscess↗
Management of gallstone pancreatitis.
The clinical course of 143 patients with gallstone pancreatitis is reviewed. Thirty-one patients (22%) had three or more positive prognostic factors on admission and 24 (77%) of these had a complicated course. Thirteen patients died, giving an overall mortality rate of 9%. Patients were divided into three groups on the basis of performance and timing of surgery. In group 1 (n = 56), surgery was undertaken during the first admission with acute pancreatitis; eight of these patients had a complicated course and three died. In group 2 (n = 40), biliary surgery was deferred to a subsequent admission; none of these patients died but 10 experienced further attacks of pancreatitis while awaiting reoperation. Group 3 patients (n = 47) did not undergo surgery; nine patients were diagnosed as having gallstone pancreatitis for the first time at autopsy, five refused operation, seven were lost to follow-up, six were dealt with by endoscopic sphincterotomy, and in 20 cases surgery was not considered appropriate because of general debility or advanced age. Despite the zero mortality rate in group 2, it is advocated that biliary surgery be carried out during the index hospital admission. Endoscopic sphincterotomy can now be considered as an alternative to cholecystectomy and duct clearance in the elderly and unfit, and may be used as a preliminary manoeuvre when severe acute pancreatitis fails to settle promptly on conservative management.
Acute Disease↗
Hepatobiliary complications in chronic pancreatitis.
Thirty nine patients undergoing surgery for chronic pancreatitis were investigated for evidence of hepatobiliary disease. In addition to pre-operative assessment by liver function tests, ultrasound, ERCP (in 33) and percutaneous transhepatic cholangiography (in five), all had peroperative liver biopsy. Common bile duct stenosis was diagnosed in 16 (62%) of the 26 patients with successful cholangiography. Features of extrahepatic biliary obstruction were found on biopsy in 11 patients, three of whom showed features of secondary sclerosing cholangitis. No patients had secondary biliary cirrhosis. Three had parenchymal liver disease (cirrhosis, resolving hepatitis and alcoholic hepatitis respectively) and two others had features suggestive of previous alcohol-induced injury. Five (83%) of the patients with clinical jaundice had biopsy features of extrahepatic biliary obstruction, as did eight (67%) with alkaline phosphatase above twice normal and seven (44%) with radiological common bile duct stenosis. Neither alkaline phosphatase rise, nor common bile duct stenosis alone or in combination, were a reliable indication of the need for biliary enteric bypass surgery. Pre-operative liver biopsy may be a valuable adjunct in the assessment of such patients.
Adult↗
The assessment of chronic pancreatitis.
The stimulated pancreatic polypeptide (PP) response was compared to standard tests of pancreatic function in patients with proven chronic pancreatitis and control subjects. Although the median values of the PP test in patients were statistically significantly different from those of controls, much variability was seen in both groups. The PP response seems to correlate with pancreatic exocrine function and shows good agreement with the results of other tests of exocrine pancreatic function while avoiding many of the difficulties inherent in performing other tests. Although more studies are needed, the PP response provides a valuable test of pancreatic function.
Adult↗
Surgical treatment of acute necrotizing pancreatitis.
Between January 1980 and June 1986, 21 patients required surgery for acute necrotizing pancreatitis. Four patients had been transferred from other hospitals; the remaining 17 patients had been treated from the outset at Glasgow Royal Infirmary, representing 3.7 per cent of the 456 patients treated for acute pancreatitis during this time. Necrosectomy was performed on 14 patients and 7 patients were treated by pancreatic resection, with 4 deaths in each group; thus 8 patients (38 per cent) died at a median time of 22 days from onset of their attack. Three of the four patients transferred to our care died, giving a mortality in our own patients of 29 per cent. Of the survivors, all but three had a prolonged and complicated hospital course. Our data confirm that acute necrotizing pancreatitis is still associated with a considerable mortality and morbidity. Early multi-organ failure, advanced age, underlying medical illness and the presence of infected necrosis were associated with a poor outcome. Necrosectomy delayed until the second or subsequent week appeared to be a suitable procedure for the majority of our patients, but shortcomings were apparent with the traditional methods of closed drainage of the pancreatic bed postoperatively. The many demands imposed by this small group of patients suggests that their management is best undertaken in centres in which there is special expertise and this should contribute to a further reduction in the mortality from this condition.
Acute Disease↗
Deaths from acute pancreatitis: why do we miss the diagnosis so frequently?
Review of acute pancreatitis deaths between 1974 and 1984 revealed 126 patients, 53 (42%) of whom were first diagnosed at autopsy. Pancreatitis was undiagnosed in life in 13 (33%) of the patients with a gallstone aetiology, 8 (40%) of those with an alcohol aetiology, 21 (42%) of those of unknown aetiology and 17 (74%) of those with pancreatitis due to other identified aetiological factors. These patients more commonly died within the first week of their illness, more often had significant underlying medical disease and tended to have less severe degrees of pancreatic parenchymal destruction. Only 7 (13%) of the 53 patients undiagnosed in life had presented with abdominal pain. The majority (68%) presented atypically with known or suspected medical conditions, often to internists, or post-operatively (19%). Failure to diagnose these patients in life was most often due to a lack of consideration of the diagnosis, usually because of the atypical presentation, and consequent omission of an amylase determination--made in only 5 (9%) of the patients.
Acute Disease↗
Importance of cause in the outcome of pancreatic pseudocysts.
Among 100 consecutive patients with pancreatic pseudocysts, a biliary cause for the preceding acute pancreatitis was found in 27, for a mortality rate of 22 percent. Patients with alcohol abuse as the cause had a more favorable prognosis, with a 5 percent mortality rate among 59 patients (p less than 0.05, chi-square test). Despite an age difference between the two groups, we consider that this feature of patients with pancreatic pseudocyst warrants attention and we make recommendations herein with respect to therapy. Pseudocysts developed in 86 patients consequent to an episode of acute pancreatitis, and all 12 deaths (14 percent) were in this group. None of the remaining 14 patients whose pseudocysts were a feature of chronic pancreatitis died. Of the 81 patients in whom amylase levels were measured, 76 percent had an increased level.
Acute Disease↗