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Diabetes mellitus in patients with autoimmune pancreatitis: an often overlooked complication
Letters to the Editor 5. Hondo FY, Giordano-Nappi JH, Maluf-Filho F, et al. Transgastric access by balloon overtube for intraperitoneal surgery. Surg Endosc 2007;21:1867-9. 6. Pauli EM, Moyer MT, Haluck RS, et al. Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study (with video). Gastrointest Endosc 2008;67:690-7. doi:10.1016/j.gie.2008.02.028
Diabetes mellitus in patients with autoimmune pancreatitis: an often overlooked complication
5. Fukui T, Mitsuyama T, Takaoka M, et al. Pancreatic cancer associated with autoimmune pancreatitis in remission. Intern Med 2008;47:151-5. doi:10.1016/j.gie.2008.01.001
Is there a role for intravenous omeprazole in patients with duodenal diverticular bleeding after successful initial endoscopic hemostasis? To the Editor:
1. Greenberger NJ. Autoimmune pancreatitis: time for a collective effort. Gastrointest Endosc 2007;66:1152-3. 2. Pearson RK, Longnecker DS, Chari ST, et al. Controversies in clinical pancreatology: autoimmune pancreatitis: does it exist? Pancreas 2003;27:1-13. 3. Tanaka S, Kobayashi T, Nakanishi K, et al. Corticosteroid-responsive diabetes mellitus associated with autoimmune pancreatitis: pathological examinations of the endocrine and exocrine pancreas. Ann N Y Acad Sci 2002;958:152-9. 4. Tanaka S, Kobayashi T, Nakanishi K, et al. Corticosteroid-responsive diabetes mellitus associated with autoimmune pancreatitis. Lancet 2000;356:910-1.
We read with interest the articles by Chen et al1 entitled ‘‘Impact of endoscopy in the management of duodenal diverticular bleeding: experience of a single medical center and a review of recent literature’’ and by Onozato et al2 entitled ‘‘Endoscopic management of duodenal diverticular bleeding.’’ In both studies, the authors retrospectively evaluated the efficacy of endoscopic management of duodenal diverticular bleeding (DDB) and concluded that endoscopy is effective (8/11 in the study of Chen at al and 6/7 in the study of Onozato et al).1,2 However, both studies were limited to small case numbers (11 cases in the study of Chen et al and 7 cases in the study of Onozato et al) and both were retrospective.1,2 We fully agree that endoscopic management is effective in achieving initial hemostasis of DDB. We had 2 DDB cases presenting with hypovolemic shock, and both received successful initial endoscopic hemostasis. One patient who received a subsequent intravenous famotidine (20 mg bolus plus 20 mg every 12 hours) infusion rebled and required surgery on the third day after endoscopy; the other patient receiving a 3-day high-dose (80 mg bolus plus 40 mg every 6 hours) of intravenous omeprazole had an uneventful course. There is an important issue concerning the optimal management of acute DDB that deserves discussion. Patients with DDB often have massive bleeding (mean hemoglobin level 7.58 g/dL [normal 12-16 g/dL] and high percentage of shock status 61.29%).1 Because DDB rebleeding needs to be prevented, pharmacologic treatment after endoscopic hemostasis is important. Although DDB is a different entity from peptic ulcer disease, if the duodenum is bleeding, the low intragastric pH (pH!6) is probably risky for rebleeding, as it is in peptic ulcer bleeding.3 Is there a role of intravenous omeprazole in patients with DDB after successful initial endoscopic hemostasis? In our previous study, we found that high-dose intravenous omeprazole (80 mg bolus plus 40 mg every 6 hours) effectively elevated the intragastric pH to 6.4, range 6.2 to 6.5 (mean, 95% CI). 4 Furthermore, Lin et al5 reported that a combination of an endoscopic epinephrine injection with a large dose of omeprazole (80 mg bolus plus 40 mg every 6 hours) is superior to that with cimetidine (400 mg infusion every 12 hours) infusion for preventing recurrent bleeding from peptic ulcer in patients with active bleeding or a nonbleeding visible vessel. Accordingly, the addition of pharmacologic treatment to endoscopic treatment in acute DDB may be an optimal
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 405
To the Editor: I read with interest the editorial on autoimmune pancreatitis.1 One common and significant complication of autoimmune pancreatitis that is often forgotten is diabetes mellitus. Rates of diabetes mellitus in patients with autoimmune pancreatitis as high as 43% to 68% have been reported in certain populations, especially in Japan.2 It is believed that the islets in the pancreas in patients with autoimmune pancreatitis are infiltrated by CD8 T lymphocytes, resulting in b-cell destruction and subsequent type II diabetes mellitus.3 Tanaka et al,4 in a recent study involving 4 patients with diabetes mellitus secondary to autoimmune pancreatitis, reported that the elevated glycosylated hemoglobins in all 4 patients reverted back to normal after the initiation of steroid therapy. Autoimmune pancreatitis may also be associated with other rare complications. For instance, Fukui et al5 recently described a case of pancreatic cancer that was diagnosed in a patient with underlying autoimmune pancreatitis. Early recognition of diabetes in patients with autoimmune pancreatitis is necessary so that early intervention with steroid therapy can be initiated, and thus complications associated with diabetes can be prevented. Physicians treating patients with autoimmune pancreatitis should be aware of this complication so as to decrease the morbidity associated with the disease. Shailendra Kapoor, MD University of Illinois at Chicago Chicago, Illinois, USA REFERENCES
Diabetes mellitus in patients with autoimmune pancreatitis: an often overlooked complication
5. Fukui T, Mitsuyama T, Takaoka M, et al. Pancreatic cancer associated with autoimmune pancreatitis in remission. Intern Med 2008;47:151-5. doi:10.1016/j.gie.2008.01.001
Is there a role for intravenous omeprazole in patients with duodenal diverticular bleeding after successful initial endoscopic hemostasis? To the Editor:
1. Greenberger NJ. Autoimmune pancreatitis: time for a collective effort. Gastrointest Endosc 2007;66:1152-3. 2. Pearson RK, Longnecker DS, Chari ST, et al. Controversies in clinical pancreatology: autoimmune pancreatitis: does it exist? Pancreas 2003;27:1-13. 3. Tanaka S, Kobayashi T, Nakanishi K, et al. Corticosteroid-responsive diabetes mellitus associated with autoimmune pancreatitis: pathological examinations of the endocrine and exocrine pancreas. Ann N Y Acad Sci 2002;958:152-9. 4. Tanaka S, Kobayashi T, Nakanishi K, et al. Corticosteroid-responsive diabetes mellitus associated with autoimmune pancreatitis. Lancet 2000;356:910-1.
We read with interest the articles by Chen et al1 entitled ‘‘Impact of endoscopy in the management of duodenal diverticular bleeding: experience of a single medical center and a review of recent literature’’ and by Onozato et al2 entitled ‘‘Endoscopic management of duodenal diverticular bleeding.’’ In both studies, the authors retrospectively evaluated the efficacy of endoscopic management of duodenal diverticular bleeding (DDB) and concluded that endoscopy is effective (8/11 in the study of Chen at al and 6/7 in the study of Onozato et al).1,2 However, both studies were limited to small case numbers (11 cases in the study of Chen et al and 7 cases in the study of Onozato et al) and both were retrospective.1,2 We fully agree that endoscopic management is effective in achieving initial hemostasis of DDB. We had 2 DDB cases presenting with hypovolemic shock, and both received successful initial endoscopic hemostasis. One patient who received a subsequent intravenous famotidine (20 mg bolus plus 20 mg every 12 hours) infusion rebled and required surgery on the third day after endoscopy; the other patient receiving a 3-day high-dose (80 mg bolus plus 40 mg every 6 hours) of intravenous omeprazole had an uneventful course. There is an important issue concerning the optimal management of acute DDB that deserves discussion. Patients with DDB often have massive bleeding (mean hemoglobin level 7.58 g/dL [normal 12-16 g/dL] and high percentage of shock status 61.29%).1 Because DDB rebleeding needs to be prevented, pharmacologic treatment after endoscopic hemostasis is important. Although DDB is a different entity from peptic ulcer disease, if the duodenum is bleeding, the low intragastric pH (pH!6) is probably risky for rebleeding, as it is in peptic ulcer bleeding.3 Is there a role of intravenous omeprazole in patients with DDB after successful initial endoscopic hemostasis? In our previous study, we found that high-dose intravenous omeprazole (80 mg bolus plus 40 mg every 6 hours) effectively elevated the intragastric pH to 6.4, range 6.2 to 6.5 (mean, 95% CI). 4 Furthermore, Lin et al5 reported that a combination of an endoscopic epinephrine injection with a large dose of omeprazole (80 mg bolus plus 40 mg every 6 hours) is superior to that with cimetidine (400 mg infusion every 12 hours) infusion for preventing recurrent bleeding from peptic ulcer in patients with active bleeding or a nonbleeding visible vessel. Accordingly, the addition of pharmacologic treatment to endoscopic treatment in acute DDB may be an optimal
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 405
To the Editor: I read with interest the editorial on autoimmune pancreatitis.1 One common and significant complication of autoimmune pancreatitis that is often forgotten is diabetes mellitus. Rates of diabetes mellitus in patients with autoimmune pancreatitis as high as 43% to 68% have been reported in certain populations, especially in Japan.2 It is believed that the islets in the pancreas in patients with autoimmune pancreatitis are infiltrated by CD8 T lymphocytes, resulting in b-cell destruction and subsequent type II diabetes mellitus.3 Tanaka et al,4 in a recent study involving 4 patients with diabetes mellitus secondary to autoimmune pancreatitis, reported that the elevated glycosylated hemoglobins in all 4 patients reverted back to normal after the initiation of steroid therapy. Autoimmune pancreatitis may also be associated with other rare complications. For instance, Fukui et al5 recently described a case of pancreatic cancer that was diagnosed in a patient with underlying autoimmune pancreatitis. Early recognition of diabetes in patients with autoimmune pancreatitis is necessary so that early intervention with steroid therapy can be initiated, and thus complications associated with diabetes can be prevented. Physicians treating patients with autoimmune pancreatitis should be aware of this complication so as to decrease the morbidity associated with the disease. Shailendra Kapoor, MD University of Illinois at Chicago Chicago, Illinois, USA REFERENCES