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Background The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. The present systematic review and meta-analysis aims to compare the efficacy of several analgesic modalities trialled in AP. Methods A systematic search of PubMed, MEDLINE and EMBASE was conducted up until June 2021, according to PRISMA Guidelines to identify all randomised control trials (RCTs) comparing analgesic modalities in AP. The primary outcome measure was improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. Results Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), placebo, local anaesthetic, epidural, paracetamol and metamizole. A weighted single-arm effects estimate showed global improvement in VAS across all modalities from baseline to day 2. On visual inspection, epidural analgesia appears to provide the greatest improvement in pain scores within the first 24hrs, however at 48hrs it was comparable to opiates. Within the first 24hrs, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant heterogeneity in pain-relief reporting with relatively small datasets per study. Conclusions Given the incidence of AP there is remarkable paucity of level 1 evidence to guide pain management. Epidural administration is most effective analgesic modality within the first 24hrs of AP. NSAIDs are an effective opiate sparing alternative during the first 24hrs.

Background There is paucity of data on the incidence, risk factors and role of anticoagulation for splanchnic vein thrombosis (SVT) in acute pancreatitis (AP). Methods A retrospective review of AP admissions between 2018-2021 across North East England was undertaken. Data on demographics, etiology, severity of AP and SVT was collected. In addition, a selective anticoagulation policy for portal vein thrombosis (PVT) and progressive splenic vein thrombosis was explored. Results 401 patients were included with a mean age of 57.0 and M:F ratio of 1.6:1. 152 patients developed intestinal oedematous pancreatitis and 249 developed necrotising pancreatitis based on Revised Atlanta criteria (RAC). 109 patients (27.2%) developed SVT of which 27 developed a PVT and splenic vein thrombus, 36 PVT only and 46 splenic vein thrombus only. On univariate analysis, alcoholic aetiology, severe pancreatitis, necrotising pancreatitis with >50% necrosis and elevated CRP at 2 weeks were risk factors for developing SVT. On multivariable analysis, alcohol aetiology (OR 2.6, p = 0.002), and >50% pancreatic necrosis (OR 14.6,p = 0.048) increased the risk of developing SVT . 58 patients received anticoagulation for SVT, with a median duration of 90 days of anticoagulation. Recanalization rates were higher for PVT when compared to splenic vein thrombosis. 6 patients developing bleeding complications whilst on anticoagulation therapy. Conclusions A third of patients with AP develop SVT, particularly those with severe AP secondary to alcohol and with extensive pancreatic necrosis. A selective anticoagulation policy was associated with improved recanalization rates and fewer bleeding complications.

Background IgG4-related disease (IgG4-RD) is a multisystem immune mediated fibro-inflammatory condition characterised by the three histopathologic features of IgG4-RD lymphoplasmacytic infiltration, storiform fibrosis and obliterative phlebitis. The condition can be indolent with few symptoms or present with organ or life-threatening disease. First-line treatment with high dose corticosteroids is often effective, however when tapering steroids, the disease can relapse, and second line agents such as methotrexate (MTX), azathioprine (AZA) or mycophenolate (MMF) are not always effective or tolerated. In 2016, following evidence from observational studies, NHS England approved the use of rituximab (RTX) in refractory IgG4-RD according to strict criteria. In our unit we have used rituximab, with or without cyclophosphamide induction, in eight patients with IgG4-RD. Our aim was to assess effectiveness of rituximab treatment and adherence to NHS England guidelines. Methods Using our connective tissue disease database, patients with IgG4-RD were identified and their electronic notes were reviewed. Outcome after rituximab treatment was assessed by the evaluation of clinical and radiological responses. Results Between August 2017 and September 2019, 15 patients with IgG4-RD were seen in the rheumatology service. 8 patients went on to receive rituximab therapy, 4 with IV cyclophosphamide (CYP). 5/8 patients had head and neck disease and 3/8 had abdominal disease (pancreas, retroperitoneal, renal). By comparison, those patients that did not receive rituximab had a preponderance of abdominal disease (4/7 had abdominal disease, 2/7 head and neck, 1/7 breast). 8/8 patients receiving rituximab were discussed in a designated MDT and met NHS diagnostic guidelines. MDT treatment decisions were made based on ‘refractory’ or ‘organ critical’ disease criteria. In all patients, with available post treatment imaging, radiological response was demonstrated. In one case, imaging showed improvement in some areas and progression in other areas and response was described as ‘partial’. Conclusion In the patients treated to date in our unit, rituximab has been shown to be an effective treatment for IgG4-RD. Cyclophosphamide induction has been used in a subset of patients. Patients with head and neck disease were more likely to require escalation to rituximab therapy, compared with those with abdominal disease. Disclosures F. Rayner None. B. Griffiths None. M. Nayar None. K. Oppong None. J. Vila None.

Ulcerative colitis and Crohn’s disease result from an interaction between genetic and environmental factors. Only one gene, NOD2/CARD15, has been clearly identified; a minority of people with alteration of this gene develop Crohn’s disease. The NOD2/CARD15 protein is thought to be involved in defence against intracellular bacteria. This supports the idea that Crohn’s disease and ulcerative colitis result from altered immunological responses to the normal intestinal flora. Life expectancy is normal in ulcerative colitis and nearly so in Crohn’s disease, but both conditions cause considerable morbidity. Approximately 80% of patients with Crohn’s disease eventually require surgery, and about 25% of patients with ulcerative colitis require colectomy. Treatment of ulcerative colitis is generally by corticosteroids for acute disease and mesalazine for maintenance, but the range of therapies for Crohn’s disease is expanding. Alternative therapies include immunosuppressives, enteral nutrition, antibiotics, anti-TNF antibody (infliximab), corticosteroids, and surgery. High dosages of corticosteroids may provide symptomatic relief in Crohn’s disease but do not affect the long term natural history of the disease, and management strategies should avoid using steroids whenever possible.