- Email: [email protected]
Pancreas divisum and pancreatitis
July 1986
CORRESPONDENCE
observed by the Cleveland Clinic group that would be helpful to others in recognizing DALM appearances. If, in fact, their DALM appearances were identical to what we have previously described, then they should have ackowledged this. Rosenstock et al. (l), however, chose to refer the reader to a 1980 Cleveland Clinic study (3) in which only vague, verbal descriptions are provided rather than any endoscopic photographs. Interestingly, in the 1980 study, in which 4 of 11 cancers had a “recognizable appearance” at colonoscopy, but biopsy specimens showed only dysplasia, it was the dysplasia itself, rather than the fact that dysplasia was present in a macroscopic form, that the authors found significant. It is heartening to learn that the heightened significance of the DALM appearance in predicting cancer contrasted with “flat” dysplasia is now recognized at the Cleveland Clinic. Hopefully, the present Cleveland Clinic study will inspire those colonoscopists who may not as yet have found their first patient with a DALM appearance to keep looking. MICHAEL 0. BLACKSTONE,
previous data, which shows that this congenital anomaly can be considered a risk factor for pancreatic diseases (2-l). Owing to these contradictions it seemed to be reasonable to investigate the incidence of acute pancreatitis in pancreas divisum in a larger group of patients. Of 10,823 endoscopic retrograde cholangiopancreatographies (ERCPs), 209 (2%) patients were found to have pancreas divisum. We compared the incidence of acute pancreatitis in the previous history of two groups of patients: those with pancreas divisum and those with fused pancreas as assessed by ERCP. Statistical analysis was performed by calculating relative risk and by using the ,$ test. The frequency of acute pancreatitis in the history of the two groups of patients was as follows:
Acute pancreatitis in previous history
M.D.
The University of Chicago Department of Medicine Gastroenterology Section 5841 South Maryland Avenue Box 400 Chicago, Illinois 60637 Rosenstock E, Farmer RG, Petras R, et al. Surveillance for colonic carcinoma in ulcerative colitis. Gastroenterology 1985;89:1342-6. Blackstone MO, Riddell RI-I, Rogers BHG, et al. Dysplasiaassociated lesion or mass (DALM) detected by colonoscopy in long-standing ulcerative colitis: an indication for colectomy. Gastroenterology 1981;80:366-74. Fuson JA, Farmer RG, Hawk WA, et al. Endoscopic surveillance for cancer in chronic ulcerative colitis. Am J Gastroenter01 1980;73:120-6. Reply.
The University of Chicago authors have correctly pointed out that the dysplasia associated lesion or mass (DALM) does appear to be clinically significant. Our paper does indeed acknowledge this, and we did not “ignore” their contribution. However, it has been recognized for several years (and it is also obvious) that a visually recognizable lesion should be of interest, if not concern, to the endoscopist. We have typically referred to these visually abnormal-appearing areas as “suspicious” without particularly using the term DALM. The comment that DALM “first saw the light of day” in 1981 makes it seem that it is an entirely new concept, which it is not. Further, there has been a continued evolution of both knowledge and understanding of dysplasia and its significance since 1981. Therefore, I believe we acknowledged tbe contribution of the University of Chicago authors appropriately and hope that publications and exchanges such as this will add to the heightened awareness of this important subject. RICHARDG. FARMER, M.D. Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44106
Pancreas Divisum and Pancreatitis Dear Sir: In the November 1985 issue of GASTROENTEROLOGY, Delhaye et al. (1) interpreted their results as having shown that pancreas divisum should not be regarded as an etiologic factor for pancreatitis. This opinion is in disagreement with most of the
267
Pancreas divisum Fused pancreas
Yes
No
Total
97 2,523
112 8,091
209 10,614
Relative risk, 1.96; p < 0.001. Of the possible predisposing factors for acute pancreatitis, alcoholism and gallstone disease were studied. In randomly selected groups the alcohol consumption and the incidence of gallstone disease were compared in the two patient groups, i.e., those with pancreas divisum and those having a fused pancreas. The two groups did not differ significantly by these criteria. Our results have shown that, similarly to most of the earlier investigations, the incidence of acute pancreatitis is significantly increased among the patients with pancreas divisum compared to those with fused pancreas. We believe, therefore, that pancreas divisum is not merely a congenital anatomic variant but, rather, a congenital anomaly. ZSOLT TULASSAY,
M.D.
JANOS PAP, M.D.
Medical Clinic Semmelweis University H-1083 Budapest Koranyi u. 2la Hungary IVAN E. FARKAS
Kerepestarcsa Hungary
Hospital
Delhaye M, Engelholm L, Cremer M. Pancreas divisum: congenital anatomic variant or anomaly? Contribution of endoscopic retrograde dorsal pancreatography. Gastroenterology 1985;89:951-8. Cotton PB. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut 1980;21:105-14. Tulassay Z, Papp J. New clinical aspects of pancreas divisum. Gastrointest Endosc 1980;26:143-6. Warshaw AL, Richter JM, Schapiro RI-I. The cause and treatment of pancreatitis associated with pancreas divisum. Ann Surg 1983;198:443-52. Reply. In reply to the previous letter, we must admit that the controversies concerning previous data about the clinical significance of pancreas divisum (PD), have persisted for 10 yr, and that the authors with the largest published series do not observe a significant relationship between PD and pancreatic diseases (1,2).
CORRESPONDENCE
observed by the Cleveland Clinic group that would be helpful to others in recognizing DALM appearances. If, in fact, their DALM appearances were identical to what we have previously described, then they should have ackowledged this. Rosenstock et al. (l), however, chose to refer the reader to a 1980 Cleveland Clinic study (3) in which only vague, verbal descriptions are provided rather than any endoscopic photographs. Interestingly, in the 1980 study, in which 4 of 11 cancers had a “recognizable appearance” at colonoscopy, but biopsy specimens showed only dysplasia, it was the dysplasia itself, rather than the fact that dysplasia was present in a macroscopic form, that the authors found significant. It is heartening to learn that the heightened significance of the DALM appearance in predicting cancer contrasted with “flat” dysplasia is now recognized at the Cleveland Clinic. Hopefully, the present Cleveland Clinic study will inspire those colonoscopists who may not as yet have found their first patient with a DALM appearance to keep looking. MICHAEL 0. BLACKSTONE,
previous data, which shows that this congenital anomaly can be considered a risk factor for pancreatic diseases (2-l). Owing to these contradictions it seemed to be reasonable to investigate the incidence of acute pancreatitis in pancreas divisum in a larger group of patients. Of 10,823 endoscopic retrograde cholangiopancreatographies (ERCPs), 209 (2%) patients were found to have pancreas divisum. We compared the incidence of acute pancreatitis in the previous history of two groups of patients: those with pancreas divisum and those with fused pancreas as assessed by ERCP. Statistical analysis was performed by calculating relative risk and by using the ,$ test. The frequency of acute pancreatitis in the history of the two groups of patients was as follows:
Acute pancreatitis in previous history
M.D.
The University of Chicago Department of Medicine Gastroenterology Section 5841 South Maryland Avenue Box 400 Chicago, Illinois 60637 Rosenstock E, Farmer RG, Petras R, et al. Surveillance for colonic carcinoma in ulcerative colitis. Gastroenterology 1985;89:1342-6. Blackstone MO, Riddell RI-I, Rogers BHG, et al. Dysplasiaassociated lesion or mass (DALM) detected by colonoscopy in long-standing ulcerative colitis: an indication for colectomy. Gastroenterology 1981;80:366-74. Fuson JA, Farmer RG, Hawk WA, et al. Endoscopic surveillance for cancer in chronic ulcerative colitis. Am J Gastroenter01 1980;73:120-6. Reply.
The University of Chicago authors have correctly pointed out that the dysplasia associated lesion or mass (DALM) does appear to be clinically significant. Our paper does indeed acknowledge this, and we did not “ignore” their contribution. However, it has been recognized for several years (and it is also obvious) that a visually recognizable lesion should be of interest, if not concern, to the endoscopist. We have typically referred to these visually abnormal-appearing areas as “suspicious” without particularly using the term DALM. The comment that DALM “first saw the light of day” in 1981 makes it seem that it is an entirely new concept, which it is not. Further, there has been a continued evolution of both knowledge and understanding of dysplasia and its significance since 1981. Therefore, I believe we acknowledged tbe contribution of the University of Chicago authors appropriately and hope that publications and exchanges such as this will add to the heightened awareness of this important subject. RICHARDG. FARMER, M.D. Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44106
Pancreas Divisum and Pancreatitis Dear Sir: In the November 1985 issue of GASTROENTEROLOGY, Delhaye et al. (1) interpreted their results as having shown that pancreas divisum should not be regarded as an etiologic factor for pancreatitis. This opinion is in disagreement with most of the
267
Pancreas divisum Fused pancreas
Yes
No
Total
97 2,523
112 8,091
209 10,614
Relative risk, 1.96; p < 0.001. Of the possible predisposing factors for acute pancreatitis, alcoholism and gallstone disease were studied. In randomly selected groups the alcohol consumption and the incidence of gallstone disease were compared in the two patient groups, i.e., those with pancreas divisum and those having a fused pancreas. The two groups did not differ significantly by these criteria. Our results have shown that, similarly to most of the earlier investigations, the incidence of acute pancreatitis is significantly increased among the patients with pancreas divisum compared to those with fused pancreas. We believe, therefore, that pancreas divisum is not merely a congenital anatomic variant but, rather, a congenital anomaly. ZSOLT TULASSAY,
M.D.
JANOS PAP, M.D.
Medical Clinic Semmelweis University H-1083 Budapest Koranyi u. 2la Hungary IVAN E. FARKAS
Kerepestarcsa Hungary
Hospital
Delhaye M, Engelholm L, Cremer M. Pancreas divisum: congenital anatomic variant or anomaly? Contribution of endoscopic retrograde dorsal pancreatography. Gastroenterology 1985;89:951-8. Cotton PB. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut 1980;21:105-14. Tulassay Z, Papp J. New clinical aspects of pancreas divisum. Gastrointest Endosc 1980;26:143-6. Warshaw AL, Richter JM, Schapiro RI-I. The cause and treatment of pancreatitis associated with pancreas divisum. Ann Surg 1983;198:443-52. Reply. In reply to the previous letter, we must admit that the controversies concerning previous data about the clinical significance of pancreas divisum (PD), have persisted for 10 yr, and that the authors with the largest published series do not observe a significant relationship between PD and pancreatic diseases (1,2).