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BACKGROUND/OBJECTIVES Within the last two decades, an increased incidence of acute pancreatitis (AP) has been reported in childhood, with some progressing to acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). Training future pancreatologists is critical to improve the care of children with pancreatic diseases. There are no studies to assess whether the pediatric gastroenterology (GI) fellowship curriculum prepares specialists to care for children with pancreatic diseases. METHODS An electronic survey was distributed to all North American Pediatric Gastroenterology Fellows. The survey included 31 questions on pancreatology training including academic resources, research experience, clinical exposure, clinical confidence, and career plans. RESULTS A total of 112 (25.8%) fellows responded from 41 (41/72, 56.9%) training centers in North America. Pancreas-specific didactic lectures were reported by 90.2% (n = 101); 49.5% (50/101) had at least quarterly or monthly lectures. Clinical confidence (Likert 4-5) was highest in managing and treating AP (94.6% and 93.8% respectively), relatively lower for ARP (84.8% and 71.4%) and lowest for CP (63.4% and 42.0%). Confidence in diagnosing both ARP and CP was associated with the variety of pancreatic diseases seen (p

The aim of this study was to evaluate the long-term outcomes of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for pediatric patients with pancreas divisum (PD) presenting with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP).Between May 2008 and August 2017, pediatric patients with PD who received endotherapy at Ruijin Hospital were identified and grouped according to clinical presentation, namely ARP and CP. Primary success was defined as patients' improvement in symptoms after index ERCPs, without further intervention or any analgesic.A total of 74 ERCPs were performed in 38 pediatric patients. The frequency of at least 1 genetic mutation identified in patients with ARP and CP was 44.4% and 68.4%, respectively. Patients with CP required more ERCPs than those with ARP (2.4 ± 1.7 vs. 1.1 ± 0.4, P = 0.005). The incidence of post-ERCP complications was 14.9%, including pancreatitis of 13.5% and hemorrhage of 1.4%. During a median follow-up duration of 41 months (range, 12-123 months), the frequency of pancreatitis episodes decreased significantly from 2.31 to 0.45 (P 0.0001). The 25% recurrence and reintervention rates were estimated at 25 and 48 months, respectively, without significant difference between patients with ARP or CP. There was a nonsignificant trend towards a higher rate of primary success in patients with ARP than those with CP (92.9% vs. 69.6%, P = 0.123). After further endotherapy, 91.3% patients with CP improved clinically.Therapeutic ERCP is an effective and safe intervention for pediatric patients with symptomatic PD. Patients presenting with CP seem to achieve improvement after additional ERCPs.

Background/objectives Acute pancreatitis (AP) is emerging in pediatrics. A subset of children with AP progresses to acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP). The role of extensive gene testing in the progression has not been investigated previously. We have followed children enrolled in the registry and at our center for progression to ARP and CP after the first attack. Methods This study utilizes an extensive gene sequencing panel as a platform to evaluate the role of genetics in first attack AP, and the progression over time, from first attack to ARP and CP in children. Results Genes, with corresponding variants were involved in the 3 groups studied: AP, ARP and CP. We have shown that the presence of gene variants from the eight tested genes is enriched in the CP group compared to the AP and ARP groups. The presence of more than one gene was associated with CP (p = 0.01). SPINK1 mutation(s) was significantly associated with faster progression to ARP, (p = 0.04). Having a variant from CFTR, SPINK1 or PRSS1, was associated with the faster progression from AP to CP over time (p Conclusions This study shows that genetics have a significant role in progression to ARP and CP from the first attack of pancreatitis.

Acute pancreatitis is an entity of notable importance due to its high incidence and its non-negligible morbidity and mortality. Idiopathic acute pancreatitis is that in which the cause of the clinical condition cannot be determined after an initial basic study. Understanding the underlying etiology enables clinicians to propose a targeted treatment to reduce the risk of recurrence. Endoscopic ultrasonography and magnetic resonance cholangiopancreatography are the tests of choice to deepen the aetiological study. The main cause is undiagnosed lithiasic disease in the initial study, whose treatment of choice is cholecystectomy. Moreover, recurrent acute pancreatitis is diagnosed after 2 or more episodes of acute pancreatitis. The objective of this review is to provide an updated approach for these 2 entities, reviewing aspects of their epidemiology, diagnosis and available alternative therapies.

Introduction Abdominal pain is common and is associated with high disease burden and health care costs in pediatric acute recurrent and chronic pancreatitis (ARP/CP). Despite the strong central component of pain in ARP/CP and the efficacy of psychological therapies for other centralized pain syndromes, no studies have evaluated psychological pain interventions in children with ARP/CP. The current trial seeks to 1) evaluate the efficacy of a psychological pain intervention for pediatric ARP/CP, and 2) examine baseline patient-specific genetic, clinical, and psychosocial characteristics that may predict or moderate treatment response. Methods This single-blinded randomized placebo-controlled multicenter trial aims to enroll 260 youth (ages 10–18) with ARP/CP and their parents from twenty-one INSPPIRE ( IN ternational S tudy Group of P ediatric P ancreatitis: I n search for a cu RE) centers. Participants will be randomly assigned to either a web-based cognitive behavioral pain management intervention (Web-based Management of Adolescent Pain Chronic Pancreatitis; WebMAP; N = 130) or to a web-based pain education program (WebED; N = 130). Assessments will be completed at baseline (T1), immediately after completion of the intervention (T2) and at 6 months post-intervention (T3). The primary study outcome is abdominal pain severity. Secondary outcomes include pain-related disability, pain interference, health-related quality of life, emotional distress, impact of pain, opioid use, and healthcare utilization. Conclusions This is the first clinical trial to evaluate the efficacy of a psychological pain intervention for children with CP for reduction of abdominal pain and improvement of health-related quality of life. Findings will inform delivery of web-based pain management and potentially identify patient-specific biological and psychosocial factors associated with favorable response to therapy. Clinical Trial Registration #: NCT03707431.

There are two main indicators of endoscopic ultrasound (EUS) in acute pancreatitis: (1) suspicion of a biliary cause and intermediate probability of a common bile duct stone and (2) idiopathic acute (recurrent) pancreatitis. In cases of suspected biliary pancreatitis, EUS reliably selects patients for therapeutic endoscopic retrograde cholangiography. In approximately two-third of cases with idiopathic acute pancreatitis, EUS reveals the etiology of acute pancreatitis (biliary microlithiasis and sludge, common bile duct stones, pancreas divisum and other abnormalities of the pancreatobiliary ducts, chronic pancreatitis, intraductal papillary mucinous neoplasms, and solid pancreatic tumors). This article is part of an expert video encyclopedia.

Duodenal duplication cysts are rare congenital anomalies that can cause acute pancreatitis. Pancreas divisum is also a congenital anomaly, often discovered incidentally, but is considered a possible cause of acute pancreatitis. We report the case of the combination of both anomalies causing recurrent episodes of acute pancreatitis in a young man. Endoscopic treatment by partial excision of the cyst with a polypectomy snare and sphincterotomy of the minor papilla was successful.

Endoscopic pancreatic sphincterotomy (EPS) has fallen into disuse for some time because of the risk of severe complications. More recently, EPS has been advocated as an effective treatment modality for several pancreatic disorders, including severe chronic pancreatitis, pancreatic pseudocyst, ampulloma, pancreas divisum, and pancreatic sphincter dysfunction. Favorable outcomes in patients undergoing EPS to facilitate further interventions, in whom long-term follow-up was available, was 70%; complications occurred in 14% and reintervention was required in 23%. The results were as good as those of surgery after long-term follow-up. Patients who underwent some form of pancreatic drainage after sphincterotomy had fewer complications (p = 0.03). Approximately 75% of patients with pancreas divisum who presented with idiopathic acute recurrent pancreatitis improved after endoscopic therapy, but only 25% of patients experienced pain reduction of at least 50%. The National Institutes of Health Consensus recommends EPS in patients with type I sphincter of Oddi dysfunction (SOD). In patients with type II SOD, prior manometry should be performed. In our series of 17 patients, we obtained results similar to those of other studies, although the number of patients was small. EPS appears to be a safe and effective technique, but further, well-designed, multicenter, prospective and long-term studies are required to evaluate these results and settle current controversies.

Commentary A cause for acute pancreatitis is not identified in 10% to 30% of patients after careful history, physical examination, laboratory testing, and radiologic evaluation. These patients are conventionally classified as having idiopathic acute pancreatitis (IAP). Patients with recurrent episodes of IAP are diagnosed with idiopathic acute recurrent pancreatitis (IARP). IAP and IARP are challenging clinical problems for the physician and often frustrating for the patient. Dr. Stuart Sherman has reviewed the role of ERCP and ancillary endoscopic techniques in the evaluation and therapy of these patients. Grace Elta, MD Editor

Cystic fibrosis is a multiorgan autosomal recessive disease resulting from mutations in a gene located on the long arm of chromosome 7. The disease is usually diagnosed in the first few years of life when it typically presents with severe pulmonary manifestations and pancreatic insufficiency; however, a small percentage of patients with less dramatic symptoms is not diagnosed until adolescence or even adulthood. The genotype of each patient seems to influence the various forms of clinical presentation. Although uncommon, acute recurrent pancreatitis can be one of the forms of delayed presentation of cystic fibrosis. We report the case of an 17-year-old man who was diagnosed with cystic fibrosis after presenting 2 episodes of acute pancreatitis without associated pancreatic insufficiency. Subsequent study also revealed nasal polyps.

Enalapril, an angiotensin-converting enzyme inhibitor, has several adverse effects, but acute pancreatitis is uncommon. The case of a patient with enalapril-induced pancreatitis is described. Development of severe, necrotizing pancreatitis after inadvertent rechallenge confirmed the causal relationship between enalapril and acute pancreatitis.

Pancreas divisum is the most common congenital pancreatic anomality and is seen in more than 5% of the general population. In many cases, this variant is a coincidental finding at endoscopy or imaging studies, but it is also implicated as a cause of acute recurrent pancreatitis in some patients. Here the author shows an endoscopic retrograde cholangiopancreatography of a patient with complete pancreas divisum with an ansa pancreatica, and demonstrate the typical findings and techniques for cannulation of the ventral and dorsal pancreatic ducts. Moreover, several variants of pancreas divisum are illustrated. This article is part of an expert video encyclopedia.

Background and study aims: Sphincter of Oddi dysfunction (SOD) is one important cause of idiopathic acute-recurrent pancreatitis (ARP). Several trials have documented complete remission from ARP after endoscopic sphincterotomy during a 2-3-year follow-up. Data with longer follow-up, however, are not available. Patients and methods: Between 1995 and 1998, endoscopic sphincterotomy was performed in 37 patients with manometrically documented SOD and ARP. Afterwards, all patients were prospectively re-evaluated over a period of at least 2 years. In 2008, all patients and their primary physicians were contacted and the patients were interviewed using a structured questionnaire. If a case or situation was unclear, the patients were clinically re-evaluated at our hospital. Results: During the initial prospective 2-year follow-up, relapsing pancreatitis was documented in 5/37 patients (14%). At this point, dual endoscopic sphincterotomy was performed in four patients, and one patient underwent surgical pancreatico-jejunostomy. On retrospective re-evaluation (total follow-up, 11.5 ± 1.6 years) at least one episode of recurrent pancreatitis was found among 19/37 patients (51 %). The mean number of relapses that occurred during long-term follow-up (0.7±0.7; range, 0-2) was lower than that recorded at the time of patient enrollment (2.5±0.5; range, 2-4). The recurrence rate did not differ with respect to the patient's first clinical presentation, their demographic data or initial manometric findings. However, relapsing pancreatitis was documented more often in patients who, in the past, had undergone either biliary or pancreatic endoscopic sphincterotomy (12/13 patients) than among those who had undergone dual endoscopic sphincterotomy first (7/24 patients ; P < 0.05). The median interval for relapsing pancreatitis was 3.5 years (range, 3―84 months). Conclusions: Follow-up after endoscopic therapy for SOD in patients with ARP should be considered for at least 5 years. For endoscopic treatment, dual endoscopic sphincterotomy may be preferred, although this will not completely prevent recurrence of pancreatitis. Endoscopic therapy nonetheless helped to decrease the frequency of relapse.

s / Pancreatology 12 (2012) 502–597 519 pancreatitis patients is necessary for effective treatment. Investigation of concentration of peroxides in plasma can give to assess oxidative status in general, because there is a direct correlation between the presence of free radicals and circulating biological peroxides. Materials and methods: The blood plasma peroxides levels were measure in 53 patients with acute pancreatitis. Results: Concentration of peroxides in plasma in admission significantly increased in patients with severe acute pancreatitis. Average concentrations of peroxides in plasma of patients with acute necrotizing pancreatitis exceeded the levels in patients with acute interstitial pancreatitis in admission at 2.55 times, on the third day at 2.35 times in the seventh in 2.27 times. It was noted that the concentration of peroxides in plasma of patients during hospitalization significantly correlated with the occurrence of organ dysfunction, including respiratory, renal, hepatic, metabolic, and therefore the MODS. Conclusion: Thus, in patients with acute necrotizing pancreatitis in circulating plasma increased the number of peroxides, including hydrogen peroxide, peroxides of lipids, proteins and DNA, which can worsen the disease because of its various negative impacts.

Background and Study Aims: Incomplete pancreas divisum (PD) has been generallyregarded as a mere normal anatomic variant without clinical implication. In thisstudy, we compared the prevalence, symptom occurrence rate, clinical presentationand the response to the endoscopic treatment of incomplete PD with those of completePD. Patients and Methods: The study population consisted of 56 (1.25%)patients (complete PD: 27, incomplete PD: 29) of 4,473 new ERCPs. Twenty-fivesymptomatic patients with pancreas divisum, which was suspected to be a cause ofassociated pancreatic diseases (acute recurrent pancreatitis;ARP, chronic pancreatitis; CP, and pancreatic type pain; PP), underwent endoscopic treatment (minor papillasphincterortomy with stents or nasopancreatic drainage tube insertion). Mean follow- up period was 17 months (range 9 to 49 months). Results: In twelve (44%) of 27patients with complete PD, it was suspected that PD was a cause of associated pancreaticdisease:ARP;6 (6/27, 22%),CP;5 (5/27, 18%), PP 1 (1/27, 4%).Ten of 12 symptomaticcomplete PD patients underwent successful endoscopic treatment and seven(70%) of 10 patients benefited from endoscopic treatment. In fourteen (48%) of 29patients with incomplete PD, it was suspected that pancreas divisum was a cause ofassociated pancreatic disease:ARP; 8 (8/29, 28%), CP: 5 (5/29, 17%), PP: 1 (1/29 3%). Thirteen of 14 symptomatic incomplete patients underwent successful endoscopic treatment and eight (62%) of 13 patients had a clinical improvement. Conclusions: The prevalence, symptom occurrence rate, clinical presentation and response to endoscopic treatment were similar between the patients with complete PD and with incomplete PD.Incomplete PD,therefore,may have same clinical implication as complete PD.

Aims : Long term results of endoscopic pancreatic stenting in pancreas divisum are still debated. The aim of this study was to evaluate the efficacy of dorsal duct stenting and endoscopic papillotomy of the minor papilla in patients presenting with acute recurrent pancreatitis. Patients and methods : Between 1980 and 1998, 34 patients presenting with acute recurrent pancreatitis associated with pancreas divisum were diagnosed. 21 were treated by pancreatic stenting during 11 months (group 1) and 13 were treated by sphincterotomy of the minor papilla (group 2). Results : In group 1, the median of follow-up was 50 ( range 11-105) months. The number of patients presenting with acute pancreatitis before pancreatic stenting, at the end of stenting and at the end of the follow-up was respectively 21/21 (100%), 2/19 (10%) and 2/18 (11%) (p