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Introduction Dearth in the literature pertaining to natural history of acute pancreatitis (AP) necessitates further studies to evaluate the outcome of local pancreatic complications using the revised Atlanta classification. Objective To evaluate the outcomes of local pancreatic complications after first episode of AP, risk factors for their development and predictors of need for intervention. Methodology A prospective study was carried out on 50 consecutive cases of AP who developed local pancreatic complications from January 2015 to July 2016. After imaging, they were categorised into acute pancreatic fluid collection (APFC) and acute necrotic collection (ANC). The risk factors for their development and the need for intervention were assessed. Results Of 50 patients, 20 developed APFC and 30 ANC. Of ANC cases, 27 progressed into walled-off necrosis (WON), of which 4 were managed conservatively and 18 collections were drained percutaneously, 3 underwent endotherapy (transmural drainage and endoscopic necrosectomy) and 2 died following percutaneous drainage (PCD) and surgery. Ten WON collections persisted at the end of 3rd month. Collections resolved in 6 of 20 APFC patients, 14 formed pseudocysts, of which 10 showed resolution with or without intervention and only 4 of them persisted at the end of study. Size of collection ≥6 cm was independent predictor of intervention irrespective of type of collections while in cases of ANC, extensive necrosis (>30%) and multiple collections were more likely to require intervention. Conclusion Incidence of ANC is more common than APFC when local pancreatic fluid collections develop most of which develop WON and require intervention.

Acute pancreatitis (AP) is a common cause of abdominal pain, and drug-induced pancreatitis (DIP) is uncommon. We report a 61-year-old woman with probable DIP. She had a history of rheumatoid arthritis, osteoporosis and laparoscopic cholecystectomy for acute cholecystitis. She was admitted with 1 day history of epigastric pain radiating to the back. She did not consume alcohol. Serum amylase was normal, and a CT scan revealed interstitial edematous pancreatitis (IEP), with morphologic changes at the head and uncinate process of the pancreas. Fasting lipids, serum calcium and liver function tests were normal. A magnetic resonance cholangiopancreatography (MRCP) scan also confirmed IEP with the absence of a common bile duct …

Acute pancreatitis (AP) accounts for over 230 000 US and 28 000 UK hospital admissions annually. Abdominal pain is the most common presenting symptom in AP but may not reflect severity. The clinical challenge is identifying the 20% of patients in whom AP will be severe. We summarise the common aetiologies, the risk stratification strategies including the simplified Bedside Index for Severity in Acute Pancreatitis, acute management approaches in the initial presentation setting, conditions for using advance imaging and opinions on antibiotic use. Some warning signs of impending complications are also discussed.

Early and accurate assessment of both the aetiology and the severity of acute pancreatitis enables clinicians to follow therapeutic algorithms and can result in better outcomes. Technological advances over the past decade, in particular the development of imaging modalities, have revolutionised the management of patients with acute pancreatitis. This article reviews approaches to determining the diagnosis, aetiology and severity of acute pancreatitis, with particular emphasis on new imaging techniques.

Pancreatic cancer continues to pose an enormous challenge to clinicians and cancer scientists. With a more affluent world the global incidence of pancreatic cancer is rising. For the first time significant advances are now being made into the management of the disease. There is a more sophisticated approach to palliative care and the centralisation of pancreatic cancer services is leading to greater tumour resection rates. Newer adjuvant modalities are also greatly increasing the 5 year survival rates. The molecular basis of pancreatic cancer is now better understood than ever before, leading to the development of new diagnostic approaches and the introduction of mechanistic based treatments. Technical advances in imaging and great improvements in conventional and molecular pathology have led to a deeper understanding of the pathological variables of the disease. This is now an important time for making big inroads into what still remains the most lethal of the common cancers. Pancreatic ductal adenocarcinoma remains one of the most difficult cancers to treat. It is the commonest cancer affecting the exocrine pancreas. In 2000, there were 217 000 new cases of pancreatic cancer and 213 000 deaths world wide and in Europe 60 139 new patients (10.4% of all digestive tract cancers) and 64 801 deaths.1 In 2002 there were 7152 new cases in the UK, with similar numbers in men and women.2 In the USA in 2006 there were 33 730 new cases and 32 300 deaths.3 Without active treatment, metastatic pancreatic cancer has a median survival of 3–5 months and 6–10 months for locally advanced disease, which increases to around 11–15 months with resectional surgery.4 The late presentation and aggressive tumour biology of this disease mean that only a minority (10–15%) of patients can undergo potentially curative surgery. Major advances in the past decade …

Objective Percutaneous transhepatic gallbladder drainage (PTGD) was compared with endoscopic treatment (within 72 hours after the onset of symptoms) in patients with severe biliary pancreatitis to evaluate the curative effect of PTGD in preventing bile track complications in these patients. Methods Eligible patients were randomised to receive early treatment with PTGD or endoscopic treatment. If the initial emergency endoscopic or PTGD treatment failed, patients received another drainage treatment within 24 hours. From November 2001 to August 2005, 101 patients were randomly assigned to early PTGD (n = 51) or endoscopic retrograde cholangiopancreatography (ERCP) (n = 50). Overall mortality, mortality due to pancreatitis and complications were compared in these two groups. Results 48 of 52 patients were successfully treated with ERCP and 53 of 55 with PTGD. Seven patients (6.9%; three in the endoscopic treatment group and four in the PTGD group) died within four months after the onset of pancreatitis (p = 0.798); three patients in the endoscopic group and three in the PTGD group died from acute biliary pancreatitis. The overall rate of complications was similar in the two groups and there were no major differences in the incidence of local or systemic complications. Conclusions PTGD treatment is a simple, convenient and effective treatment of severe gallstone associated acute pancreatitis when endoscopic treatment fails.

Trypsin activity is properly suppressed by pancreatic secretory trypsin inhibitor (PSTI), which is also known as serine protease inhibitor Kazal type 1 (SPINK1), thereby preventing damage to pancreatic acinar cells as a first line of defence. However, if trypsin activation exceeds the capacity of PSTI/SPINK1, a subsequent cascade of events leads to the activation of various proteases that damage cells. Five mutations (R122H, N29I, A16V, D22G and K23R) in cationic trypsinogen and two mutations (N34S and M1T) in the PSTI/SPINK1 gene have been found to correlate significantly with the onset of pancreatitis. From analyses of hereditary pancreatitis and the phenotype of PSTI/SPINK1 (Spink3) knockout mice, we showed that the imbalance of trypsin activation and its inhibition by PSTI/SPINK1 would lead to the development of pancreatitis.

The relation between gall stones and chronic pancreatitis is uncertain; there are differing opinions on this issue. Firstly, gall stones are the most common reason for acute pancreatitis, but it cannot cause chronic pancreatitis. Secondly, a connection between gall stones and chronic inflammation of the pancreas might exist. Numerous studies or investigations have shown that changes associated with chronic pancreatitis are common in gallstone patients. Although it seems that gall stones might be a cause of chronic pancreatitis according to these findings, clinical and experimental studies are still needed for confirmation, and further studies are required to determine the mechanisms involved.

Chronic pancreatitis represents a condition that is challenging for clinicians secondary to the difficulty in making an accurate diagnosis and the less than satisfactory means of managing chronic pain. This review emphasises the various manifestations that patients with chronic pancreatitis may have and describes recent advances in medical and surgical therapy. It is probable that many patients with chronic abdominal pain are suffering from chronic pancreatitis that is not appreciated. As the pathophysiology of this disorder is better understood it is probable that the treatment will be more successful.

Tropical chronic pancreatitis (TCP) is a juvenile form of chronic calcific non-alcoholic pancreatitis, seen almost exclusively in the developing countries of the tropical world. The classical triad of TCP consists of abdominal pain, steatorrhoea, and diabetes. When diabetes is present, the condition is called fibrocalculous pancreatic diabetes (FCPD) which is thus a later stage of TCP. Some of the distinctive features of TCP are younger age at onset, presence of large intraductal calculi, more aggressive course of the disease, and a high susceptibility to pancreatic cancer. Pancreatic calculi are the hallmark for the diagnosis of TCP and in non-calcific cases ductal dilation on endoscopic retrograde cholangiopancreatography, computed tomography, or ultrasound helps to identify the disease. Diabetes is usually quite severe and of the insulin requiring type, but ketosis is rare. Microvascular complications of diabetes occur as frequently as in type 2 diabetes but macrovascular complications are uncommon. Pancreatic enzyme supplements are used for relief of abdominal pain and reducing the symptoms related to steatorrhoea. Early diagnosis and better control of the endocrine and exocrine dysfunction could help to ensure better survival and improve the prognosis and quality of life of TCP patients.

Primary prevention of pancreatic cancer and public health measures to reduce its incidence are dependent on data from epidemiological studies. Currently, the only definite risk factor is smoking, although a diet rich in fruit and vegetables may be protective. The K-ras mutation may have a role in diagnosis and screening. Keywords: pancreatic cancer; epidemiology; risk factors; smoking; diet; alcohol

SummaryThree-dimensional magnetic resonance cholangiopancreatography is currently the most exciting new imaging technique for chronic pancreatitis. Endoscopy-assisted duodenal intubation during the secretin-cholecystokinin test reduces intubation time in difficult cases. The NBT-para-amino benzoic acid test has been refined to enhance its discriminant power. The cholesteryl-[C13]octanoate breath test and the faecal elastase test are newer highly sensitive and specific tubeless tests. Pain in chronic pancreatitis continues to be a vexing therapeutic issue. Enzyme treatment continues despite criticism. Neurotensin is the new suspected mediator of the feedback mechanism, which is downregulated by enzyme therapy. Steroid ganglion block is an exciting therapeutic tool for pain relief. Endoscopic pancreatic sphincterotomy, Dormia basketing and pancreatic stenting in conjunction with extracorporeal shock wave lithotripsy should be performed early in chronic pancreatitis to prevent parenchymal atrophy with ensuing exocrine and endocrine pancreatic dysfunction. The modified Puestow’s procedure preserves endocrine and exocrine pancreatic functions besides relieving pain. Closed loop insulin infusion allows superior management of pancreatic diabetes following near total pancreatectomy. The standardised incidence rate of pancreatic cancer is 16.5 in patients with alcoholic chronic pancreatitis and 100 for tropical chronic pancreatitis. Aggressive treatment protocols combining neo-adjuvant chemoradiation and intra-operative radiation with surgery are being used to improve the prognosis in this dismal complication of chronic pancreatitis.

Acute pancreatitis has a mortality of about 10%: this figure has not changed over the last 20 years. A retrospective audit of fatal acute pancreatitis was performed in a teaching hospital with a catchment population of about 750,000 patients to examine patient characteristics. Using Hospital Activity Analysis code 577.0, all fatal cases of acute pancreatitis were studied in a six-year period 1987-93. Additionally, all post mortem diagnoses of acute pancreatitis were traced. The overall post mortem rate in Nottingham at the time of the study was about 35%. All available records, X-ray and biochemical data were studied and appropriate information recorded and analysed for 65 fatal cases. Only 15% were post mortem diagnoses, lower than in previous series; 72% had respiratory and 67% had renal complications. Only 34% had been admitted to the intensive care unit. A third of patients had had surgery; 67% of these was some form of external drainage. Of the 14 patients with proven gallstone pancreatitis only three had endoscopic retrograde cholangiopancreatography; 42% of patients had idiopathic disease. Not all the patients diagnosed ante mortem had the full biochemical predicted severity criteria analysed: pO2 and calcium analysis was performed in about 80%. Pre-mortem diagnoses of pancreatitis was achieved more frequently than in other comparable series.

The life expectancy for patients with cystic fibrosis has improved remarkably over the last 20 years. Progressive deterioration of pulmonary function continues despite the aggressive use of antimicrobials. The absence of fever, neutrophilia, and systemic symptoms suggest that during pulmonary exacerbations other non-bacterial factors may have played a part. Some have suggested respiratory viruses as main suspects. So far, few data have illustrated the relationship of respiratory viruses and cystic fibrosis. By gaining further knowledge of this relationship, one may change future clinical practice and boost the survival of these patients.

The successful identification of the gene that is altered in cystic fibrosis (CF) represents the first example in which a disease gene was cloned on the basis of genetic linkage data.'-' The success of this approach was facilitated by the availability of three-generation families with multiple affected individuals and the availability of objective criteria for diagnosing CF. In the 4 years since the cloning ofthe CF gene, our understanding of the molecular pathology of CF has emerged with remarkable speed. These advances are reviewed below.

The more frequent deployment of cross-sectional imaging for various abdominal conditions has resulted in an increased detection of cystic pancreatic lesions, particularly cystic pancreatic neoplasms. Cystic pancreatic lesions may be neoplastic or non-neoplastic. They may appear radiologically similar and often present a diagnostic dilemma; they need to be diagnosed and differentiated with accuracy in order to offer optimum treatment. Some of the cystic neoplasms are potentially malignant and have a wide spectrum of histological variation from the frankly benign ‘adenomas’ to invasive adenocarcinomas .When identified, these cystic lesions need a systematic work up and a diagnostic algorithm should be followed to its logical conclusion. This article reviews these cystic lesions of the pancreas, neoplastic and pseudocysts, and aims to update readers with the current trends in their diagnosis and management.

Bronchiectasis is permanently dilated airways caused by chronic bronchial inflammation secondary to inappropriate clearance of various micro-organisms and recurrent infections in the airways. At diagnosis, one should search for the underlying disease process, most of the time excluding cystic fibrosis (CF). However, in a substantial number of patients no cause is found. Next, patients need individualised therapy and follow-up by monitoring of their symptoms. Useful tools are the Leicester Cough Questionnaire and the Sputum Colour Chart. Screening patients for bacterial colonisation on a regular basis seems to be equally important, as many patients become colonised by pathogenic micro-organisms. Treatment for non-cystic fibrosis bronchiectasis differs in certain aspects from cystic fibrosis bronchiectasis and often lacks evidence. Overall, bronchiectasis is an underestimated disease, not only in prevalence and incidence, but also in its ability to cause morbidity and mortality. Further research into the underlying pathophysiological mechanisms and trials evaluating new treatments are an absolute necessity.

Summary A 15 year old girl with a family history of type 1 multiple endocrine adenomatosis presented with reversible neurological disturbances, hypoglycaemia and hyperinsulinaemia. Initial radiology was normal, but portal venous sampling suggested an insulinoma in the tail of the pancreas which was removed with conservation of the spleen. Hypoglycaemia persisted despite high doses of diazoxide and intravenous dextrose. A second laparotomy revealed a pancreatic endocrine tumour and sub-total pancreatectomy was performed. Histology revealed islet cell microadenomatosis. Hypoglycaemia persisted despite treatment with somatostatin analogues and 40% intravenous dextrose was required to maintain normoglycaemia. A possible lesion near the splenic hilum on computed tomographic scan was reported as a splenunculus although further peripheral, hepatic and portal venous sampling suggested hepatic or systemic lesions. A positron emission scan and selective visceral angiography suggested a lesion in the left upper quadrant. Acute lactic acidosis, rhabdomyolysis and renal failure supervened. Post mortem revealed the putative 'splenunculus' to be a residual insulinoma, whilst the splenic vein was thrombosed, accounting in part for discrepant venous sampling data. Hyperinsulinaemia in type 1 multiple endocrine adenomatosis may require more aggressive surgical and hormonal intervention than when dealing with solitary insulinomas. Insulinomas may mimic developmental abnormalities on computed tomographic scanning.

Introduction Early warning scores (EWS) is a physiological scoring system measured hourly. This study determined how progression of EWS affected outcome in acute pancreatitis. Methods The single worst EWS score for each 24 h period following admission was recorded for 110 patients with acute pancreatitis. Scores falling below 3 were defined as improving; scores which remained at 3 or rising were considered deteriorating. Results Deteriorating EWS values were associated with a greatly increased risk of mortality (p Conclusion Deteriorating EWS values within the 48 h from admission are associated with adverse outcome or death in acute pancreatitis. Measuring progression of EWS over 72 h from admission can further improve accuracy of this monitoring system for acute pancreatitis.

Summary We present a case of pancreatic malignancy which presented as chronic pancreatitis. The diagnostic difficulties are discussed. We recommend that when there is any doubt about a diagnosis of chronic pancreatitis with a pancreatic mass, then early resection is appropriate.

Summary A case is described where accidental acid ingestion resulted in the development of oesophageal stricture and complete gastric outlet obstruction. Following a smoothly conducted pre-surgery endoscopic examination the patient developed acute pancreatitis, which, on initial clinical examination, was diagnosed as a viscus perforation. The severity of pancreatitis was such as to lead to disseminated intravascular coagulopathy and ultimately death. The interest lies in the fact that pancreatitis was precipitated in a previously traumatised stomach by such an innocuous procedure as fibre-optic endoscopy.

Few data exist about the incidence of drug induced acute pancreatitis in the general population. Drugs are related to the aetiology of pancreatitis in about 1.4%–2% of cases. Although angiotensin converting enzymes are generally well tolerated, acute pancreatitis has been reported in a few subjects treated with captopril, enalapril, and lisinopril. A 85 year old man with a long standing history of hypertension, who was treated with ramipril 5 mg once daily, presented with acute pancreatitis. Other causes of the disease were ruled out. After cessation of ramipril his condition improved and amylase level decreased. This was his third episode of acute pancreatitis since ramipril was started in 2000. To the authors’ knowledge ramipril induced pancreatitis has not previously been reported.

Objectives To audit the specificity and value of the pancreolauryl test (PLT) for the diagnosis of pancreatic insufficiency. Design A retrospective case note review of 47 patients who had a PLT during three consecutive years. Setting A 650 bedded district general hospital. Main outcome measures Patient demographics, symptoms, baseline blood, endoscopic and radiological investigations, and alcohol consumption were related to the results of the PLT to determine if the test could be better targeted. Response to therapy and final diagnoses were noted to determine the specificity of the test. Results Forty seven patients had a PLT during the three years studied. All successfully performed the test as outpatients. Seven inconclusive tests were repeated. Thirty eight patients (81%) had diarrhoea, of whom 10 (21%) described steatorrhoea; 23 (49%) had an abnormal PLT. All with an abnormal test had diarrhoea, more frequently describing watery stools than steatorrhoea. Those treated with pancreatic enzyme supplements had an excellent response, although two of these had a final diagnosis of coeliac disease. Nineteen patients with an abnormal PLT were thought to be suffering from pancreatic insufficiency. All patients with a normal PLT were clinically thought not to have pancreatic insufficiency. Age, sex, and alcohol intake correlated poorly with final diagnosis. Conclusions The PLT can be used in a district general hospital setting as an outpatient test for pancreatic insufficiency and has a specificity of 83%–91%. Its use should be restricted to thse presenting with diarrhoea, not necessarily steatorrhoea, and not restricted to those with a history of high alcohol consumption.

Eosinophilic gastroenteritis is a condition characterised by eosinophilic infiltration of the gastrointestinal tract. Biliary obstruction is an unusual presentation. A case where the initial investigations were consistent with carcinoma of the head of pancreas but the resection specimen showed no malignancy is presented. The diagnosis was suspected from a review of the patient’s past history and confirmed by re-examination of the histology.

Summary Common bile duct perforation causing biliary peritonitis is an unusual entity and a pancreatic calculus causing this perforation is all the more rare, and to our knowledge has not been reported previously. Such an unusual presentation of chronic calcific pancreatitis is herein reported.

Summary We present the case of a patient that progressively developed xerophthalmia, xerostomia, cutaneous xerosis and exocrine pancreatic insufficiency 3 months after metamizole-induced toxic epidermal necrolysis. Though the association of Sjögren's syndrome and exocrine pancreatic impairment is well established, the Sjögren-like syndrome after drug-induced toxic epidermal necrolysis in association with such a wide exocrine glandular insufficiency has not been previously described, to our knowledge.

We describe a woman with the syndrome characterised by hyperandrogenism, insulin resistance and acanthosis nigricans (the HAIR-AN syndrome), and an associated insulinoma (islet B-cell tumour), whose signs and symptoms cleared after partial pancreatectomy. Keywords: acanthosis nigricans; insulinoma; HAIR-AN syndrome; hyperinsulinaemia

A 37-year-old white woman was infected with the human immunodeficiency virus (HIV) through a blood transfusion which she received during a complicated labour in the Ivory Coast. Three years later, due to a decline in the CD4+ cell counts to 200/ml, zidovudine (AZT) and trimethoprim-cotrimoxazole were administered. A few months later, zalcitabine (ddC) was added, due to the appearance of fever, abdominal pain and weight loss, and a further decline in the CD4+ cell counts down to 15/ml. Despite these measures the patient continued to complain of abdominal pain, which was often exacerbated by food intake. Laboratory studies then showed normal serum amylase and liver enzyme levels. Abdominal ultrasonography (US) and gastroscopy were normal. Due to a suspected role of the antiretroviral drug therapy in inducing the abdominal pain, AZT and ddC were discontinued. Three months later, the patient was admitted because of severe abdominal pain, vomiting and a fever of 38.5°C. On examination, marked epigastric tenderness was noted. Investigation results were as follows: amylase 1120 IU/l, hypocalcaemia (1.52 mmol/l), alkaline phosphate 219 IU/l, and gamma-glutamyl transpeptidase 478 IU/l. US and computed tomography (CT) revealed gall bladder wall thickening, with a dilated common bile duct and no evidence of stones. The pancreas was mildly enlarged and oedematous. A diagnosis of pancreatitis was made, a nasogastric tube …

Summary Pancreatic pseudocyst is a significant complication of both acute and chronic pancreatitis. Several methods of cyst drainage have been described. Endoscopic cystogastrostomy is a relatively new technique which is illustrated by the following case report, the first in the UK literature.

A 32-year-old Indian man presented with a 4-week history of intermittent pyrexia with rigours, associated with malaise and weight loss. Physical examination was normal except for pyrexia without evidence of lymphadenopathy. The white cell count was 13.2 x 10 9 /l (3.5-11.0) with increased lymphocytes. Erythrocyte sedimentation rate and C-reactive protein were elevated. Liver function tests showed mildly raised liver enzymes. Blood and sputum cultures were negative for acid-fast bacilli. A computed tomography (CT) scan of the abdomen revealed a multiloculated mass in the head of the pancreas with peripancreatic and mesenteric lymphadenopathy (figure).

Summary The differential diagnosis between pancreatic cancer and chronic pancreatitis is very important as the management and prognosis of these two diseases is different. In most patients with pancreatic disease, the diagnosis can be established but there is a subgroup of patients in whom it is difficult to differentiate between these conditions because the clinical presentation is often similar and currently available diagnostic tests may be unable to distinguish between an inflammatory or neoplastic pancreatic mass. This paper reviews the aetiology, pathology and clinical features of these diseases and discusses the limitations of conventional diagnostic methods and how newer techniques may be of value in the differential diagnosis.

SummaryAdenocarcinoma of the pancreas is a common and dreadful disease with an extremely poor prognosis. In practice, only a few patients are cured but surgical resection, although feasible in less than 20% of patients, offers maximum prolongation of life and provides good palliation of symptoms. This can now be performed safely, even in elderly patients, in specialist units. Better radiological imaging and laparoscopy allow selection of resectable tumours effectively. All patient with pancreatic cancer should now be assessed for surgical resection and potentially suitable patients should be referred to a specialist team at an early stage.

Summary Cystic lymphangioma of the pancreas is a rare condition. A 14-year-old girl presented with a cystic abdominal mass and abdominal pain. She was initially treated by biopsy and cyst drainage, and subsequently with partial excision of the cystic mass. The mass, which was a cystic lymphangioma involving the pancreas, recurred after each operation. Persisting symptoms led to a pylorus-preserving pancreatectomy and hepaticojejunostomy. Total excision is the only effective method of treating this benign tumour. The patient remains symptom free 2 1/2 years after pancreatectomy.

Metformin is a biguanide commonly used in type 2 diabetes and considered to be a safe drug with minimal side effects. Approximately 2% of cases of acute pancreatitis may be caused by drugs, but it is not a known complication of metformin therapy. To date only one case of pancreatitis has been reported in association with metformin, but that was secondary to metformin poisoning (overdose). This is the first reported case of pancreatitis caused by a therapeutic dose of metformin (although in this case renal failure precipitated the metformin toxicity). Severe lactic acidosis is a rare but life threatening complication of metformin, which occurs particularly in patients with renal failure.

Tuberculosis of the pancreas is extremely rare. We report a case which demonstrates the diagnostic confusion which may arise in this condition. A 55-year-old alcoholic caucasian man presented with loss of weight and obstructive jaundice. Ultrasonography, endoscopic retrograde cholangiopancreatography and computed tomography showed a mass lesion in the head of the pancreas, diagnosed as probably malignant. He underwent a Whipple’s pancreatoduodencetomy and made a good recovery. Histological examination showed typical features of tuberculosis. In the absence of other foci of active disease chemotherapy was not given. He remains well 12 months after operation.

There are a number of important pulmonary complications of acute pancreatitis which make a significant contribution to the morbidity and mortality of the condition. The pathophysiology and management guidelines are given for each and approaches towards better treatment in the future are discussed.

Many problems may arise within the gastrointestinal tract of patients with cystic fibrosis. We report a new cause of subacute intestinal obstruction due to a fibrotic stricture of the ascending colon in a child with cystic fibrosis. Treatment was with a right hemicolectomy. There has been no recurrence after nine months follow-up. Recent similar cases suggest that this new pathology is linked to the use of enteric-coated high-strength pancreatin microspheres.

Although cystic fibrosis (CF) is still the most frequently fatal childhood disease, many adults now survive into their third and fourth decades. Uncommon complications of chronic diseases, such as amyloidosis, while infrequent, may now appear during the course of CF in adulthood. We present a case of a patient with CF who was diagnosed with hypothyroidism due to amyloid deposits in the thyroid.

To date, there is no consensus on the evolution of chronic pancreatitis. Comfort’s initial proposal of acute pancreatitis progressing to chronic pancreatitis was discarded by protagonists of the ‘separate’ theory. Sarles thus stresses the de novo evolution of chronic pancreatitis-acinar protein hypersecretion associated with an imbalance of pancreatic stone promoting and inhibiting factors. However, the ‘necrosis-fibrosis sequence’ hypothesis of Kloppel and Mallet resurrects the probability of acute pancreatitis leading to chronic pancreatitis. Dimagno offers a unifying concept that the degree of acinar injury determines the natural history of pancreatitis. Uninhibited release of toxic free radicals could be a common end point for various aetiologies resulting in acute or chronic pancreatitis. The pathogenesis of chronic calcifying pancreatitis of the tropics is possibly no different from alcoholic chronic pancreatitis. Neurocrine and paracrine mechanisms have been offered to explain pain out of proportion to radiological and histological pancreatic abnormalities in minimal change chronic pancreatitis.

Summary A 34 year old female developed acute pancreatitis after commencing diclofenac for a painful arthropathy. The possible role of prostaglandin inhibition in non-steroidal analgesic drug-induced pancreatitis is discussed and the suggestion is made that serum amylase should be measured in patients who develop abdominal pain, following ingestion of non-steroidal anti-inflammatory

Milk alkali syndrome is rare and although pancreatitis secondary to hypercalcaemia is well recognised, there has only been one other reported case of pancreatitis secondary to the milk alkali syndrome. Such a case, caused by self medication of over the counter medication, is reported. Keywords: milk alkali syndrome; pancreatitis; over the counter medication

Summary A 67-year-old woman with a history of thyroiditis presented with recent intermittent epigastric pain and nausea. Hyperamylasaemia, oedema of the pancreas, and high serum levels of lipase and CA 19-9 were found. Xerostomia and dry eyes developed later, accompanied by an abnormal Schirmer's test. The diagnosis of Sjögren's syndrome was confirmed by increased anti-Ro and anti-La antibodies and the histological findings of parotid gland biopsy. Two additional cases of Sjögren's syndrome with elevated serum CA 19-9 are also described. These observations of elevated serum lipase and serum CA 19-9 in Sjögren's syndrome without evidence of malignancy may reflect pancreatic involvement in this disorder.