Akutní a chronická pankreatitida v Centre National Hospitalier Universitaire de Cotonou v letech 2011 až 2022: epidemiologické, diagnostické, terapeutické a prognostické aspekty

Overview

Úvod: Akutní pankreatitida (AP) je lékařsko-chirurgická pohotovost, jejíž prevalence celosvětově stoupá. Podobně roste i incidence chronické pankreatitidy (CP). Cílem naší práce bylo určit incidenci, prevalenci a komorbidity akutní a chronické pankreatitidy u hospitalizovaných pacientů v největší nemocnici v Cotonou v Beninu. Metody: Jednalo se o retrospektivní deskriptivní průřezovou studii provedenou v období od 9. září do 31. října 2022 s využitím lékařských záznamů pacientů hospitalizovaných v období od 1. ledna 2011 do 31. října 2022 pro akutní nebo chronickou pankreatitidu na třech odděleních Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM) v Cotonou v Beninu. Výsledky: Během studie bylo hospitalizováno 15 682 pacientů, z toho 14 případů AP, což představuje prevalenci v nemocnici 0,09 % a frekvenci 1,2 případu ročně, a 8 případů CP, což představuje prevalenci v nemocnici 0,05 % a frekvenci 0,7 případu ročně. Ve vážném klinickém stavu dominovaly bolesti břicha (zjištěné u 100 % případů AP a 75 % případů CP). Bohužel bylo mnoho neurčených příčin (35,7 % AP a 62,5 % CP), ale nebylo možné identifikovat žádné specificky tropické příčiny. Léčba byla převážně medikamentózní, s výjimkou chirurgického zákroku v případech, kdy byla nemoc objevena intraoperativně. Mortalita byla 14,3 % u AP a 37,5 % u CP. Závěr: V Cotonou byla nemocniční prevalence nízká jak u akutní, tak u chronické pankreatitidy. K identifikaci příčin těchto patologií v Beninu by bylo vítáno podrobné etiologické šetření. 

Klíčová slova:

akutní pankreatitida – chronická pankreatitida – prevalence – příčina – léčba – Benin

Introduction

The pancreas, an essential amphicrine gland in the human body, plays an important role through its endocrine (nutrient metabolism) and exocrine (digestion) functions. Pancreatitis, cystic fibrosis, diabetes mellitus and pancreatic tumors are just a few of the pathologies that can lead to dysfunction. Pancreatitis is an inflammatory process, with both acute and chronic manifestations.

Acute pancreatitis is a medical-surgical emergency whose prevalence is rising worldwide. According to worldwide estimates, the incidence of acute pancreatitis was 33.74 cases per 100,000 people per year, with no statistically significant difference between men and women; and mortality was 1.60 deaths per 100,000 people per year [1]. Chronic pancreatitis is widespread throughout the world, although there are significant differences in clinical presentation and management in different countries [2].

There is a lack of data on these pathologies in certain countries, especially in the Third World, including Benin. However, work has already been done on acute pancreatitis in pregnancy [3], and acute alcoholic pancreatitis associated with polycythemia [4]. The aim of the present study was to review the statistical, epidemiological, diagnostic, therapeutic, and prognostic data on pancreatitis at the CNHU-HKM in Cotonou.

Study methods

This was a descriptive cross-sectional study, with retrospective data collection over a period of 11 years 9 months from January 1, 2011 to October 31, 2022. It focused on the records of patients with AP and/or PC in the university clinics of Hepato-gastroenterology, Visceral Surgery, and Internal Medicine at CNHU -⁠ -HKM. Diagnoses of acute and chronic pancreatitis were based on clinical, biological, and/or morphological evidence.

Patients with insufficient data to support the diagnosis of AP and/or CP were not included in the study.

Data were collected on survey forms (based on a standardized questionnaire) and analyzed using Epi info software.

From an ethical point of view, administrative authorizations were obtained, and respect for anonymity was taken into account at all stages of the study.

 

Results

Characteristics of the study population

We identified 22 cases of pancreatitis out of the 15,682 admissions recorded in the target departments during the study period, including 14 cases of PA, i.e. a prevalence of 0.09%; 8 cases of PC, i.e. a prevalence of 0.05%.

Mean age of patients in the study was 35.6 ± 15.3 years, with extremes of 20 and 83 years. The patients were predominantly male (15 men, 68.2%), with a sex ratio of 2.1. The predominant profession was that of craftsman, shopkeeper, and company director (41%; N = 9).

AP was equally represented in men and women, with a relatively young mean age (42.8 ± 12.6 years); whereas CP was present only in men (100%), with a mean age of 40.5 ± 9.7 years.

Alcohol consumption was reported in 57.1% of AP patients (N = 8) and 37.5% of CP patients (N = 3). Consumption of cannabis, manioc (tuber and leaves) and its derivatives was not reported in the files studied.

 

Diagnostic data

The most consistent reason for consultation in patients with AP was abdominal pain (epigastric in nature), present in 100% of cases, followed by nausea and/or vomiting and cessation of gas in 78.6% and 35.7% respectively. Upon admission, physical examination revealed abdominal tenderness in over half of AP patients (64.3%), followed by abdominal guarding in 21.4% (Tab. 1). Hyperlipasemia, the key biological test for the diagnosis of AP, was performed in 71.4% of cases, with a value greater than or equal to three times the mean in 80%. Abdominal ultrasonography was performed in 50% of AP patients, demonstrating pancreatic edema, heterogeneous pancreas, and pancreatic necrosis. Only 42.9% of AP patients were able to undergo abdominal CT scans, which enabled the diagnosis to be made (evidence of pancreatic edema in 6 patients and necrotic flow in 2) and the Balthazar score to be established. Alcohol was the main cause of AP (50%), as shown in Graph 1.

With regard to chronic pancreatitis, abdominal pain (epigastric in nature) was also the most frequent reason for consultation, occurring in 6 patients (75%), followed by fatty diarrhea in 25% of cases. General condition was altered (weight loss and anorexia) in 62.5% of cases (N = 5), and physical examination was essentially poor (Tab. 2). Biologically, macrocytosis and cholestasis syndrome associated with a cytolysis syndrome were noted in 25% each. Fecal elastase was not measured in any of the study patients, and fasting blood glucose levels were normal in all cases. Abdominal CT scans were carried out in 25% of CP cases, revealing calcification and pseudocysts. In 62.5% of cases, the etiology of CP was not determined (Graph 2).

Treatment data

Most patients in the present study were treated according to international Guidelines: symptomatically, mainly with analgesics for pain management (100% of AP cases and 87.5% of CP cases), fluid and electrolyte rehydration, resting of the digestive tract (100% of AP cases), and antibiotic therapy (8 AP cases, 57.1%). In this study, 21.4% (N = 4) of AP patients had undergone peritoneal lavage-drainage following exploratory laparotomy.

 

Progression and prognosis

SRIS criteria were present upon admission in 42.8% of AP cases. The outcome was favorable in 11 patients (85.7%), with 1 patient suffering multivisceral failure. Mortality occurred in 2 patients (14.3%).

The outcome was unfavorable in 62.5% of CP cases, with death occurring in 3 patients (37.5%).

 

Discussion

Pancreatitis is a major public health problem worldwide with geographical variation. The highest prevalences of pancreatitis per 100,000 people per year have been reported in Central and Eastern Europe and tropical Latin America. In contrast, the lowest rates were observed in sub-Saharan Africa [5].

In our study, we noted a prevalence of 0.09% for AP and 0.05% for CP. This shows how rare these pathologies are in sub-Saharan Africa, particularly in Benin. However, it should be noted, that these results relate only to the number of patients hospitalized during the study period, and not to the overall number of patients suffering from these pathologies in our countries, where many patients do not come to hospitals on time or at all, due to a lack of financial means or ignorance. This could slightly bias the statistics of these pathologies in the global population. Broadly speaking, and considering the results of other studies in the sub-region [5], it could be seen that the trend remains the same and that the incidence and prevalence in our countries remain lower than those in developed countries.

The mean age of our study on AP was 42.8 years, a relatively young age as found in the African literature: 42.7 years by Ouangré et al. [6] and 49 years by Slimane et al. [7]. The prevalence of both AP and CP in young subjects could be explained by the youth of the African population, which is more exposed to pancreatitis risk factors. In addition, several studies have shown that acute and chronic pancreatitis are more frequent in adults and the elderly [8,9].

Pancreatitis, particularly CP, had traditionally been considered a disease of men [10,11]. This assertion was also confirmed by the results of our study, with a unisex (male) distribution of CP cases. This male predominance could be explained by a greater presence of chronic pancreatitis risk factors such as alcohol in men. Higher alcohol consumption would also explain the male predominance of AP cases in our study, in contrast to the female predisposition in Maghreb countries, where biliary lithiasis is the most common cause (more frequent in women) due to alcohol prohibition, as shown in the studies by Slimane et al. [7] and Aissaoui [12].

Abdominal pain, the main functional sign of AP, was present in 100% of our patients, as in the Burkinabe and Gabonese series [6,13]. Physical signs were mainly represented by abdominal tenderness and abdominal guarding. These signs could easily simulate a surgical abdomen, leading to diagnostic errors in the absence of good diagnostic investigation. Good diagnostic investigation was not possible in our study, given the low proportion of hyperlipasemia (71.4%) compared with Ouangré‘s et al. study (100%) [6], and abdominal CT (42.9%) versus 100% in Abdoul‘s study [14]. The low proportions of paraclinical examinations performed and the absence of other diagnostic methods such as endosonographic ultrasound in our study could be attributed to their low prescription due to the financial conditions in these countries like Benin. The etiology of AP in our study, as in other series from sub-Saharan Africa [6,13,15], was dominated by alcohol (50%). This would confirm data in the literature showing that the etiology of acute pancreatitis is lithiasis followed by alcohol in West [16,17] and North Africa [7], whereas it is alcohol followed by lithiasis in sub-Saharan Africa.

Alteration in general condition, mainly due to weight loss, was found in 62.5% of CP cases, a high rate which could be linked to the reduction in food intake during painful episodes. Fecal elastase could not be measured in any of the patients in the study. This did not allow us to confirm the presence of exocrine pancreatic insufficiency. In 62.5% of CP cases, the etiology had not been determined. This could be explained by the high cost of digestive explorations, without which a proper etiological investigation could not be carried out. Tropical causes could not be identified either. Although the age of onset was young, other criteria such as maternal malnutrition during pregnancy or N34S mutation were not documented in the medical records.

Medical treatment of acute pancreatitis was recommended for all patients in our study, but to varying degrees depending on the severity of the disease. The main lines of treatment were rapid fluid rehydration, adequate analgesia, and appropriate nutrition, as described in the literature [16]. No surgical treatment of CP was actually performed, apart from cases of exploratory laparotomy following misdiagnosis due to simulation of the surgical abdomen by clinical signs of CP and inadequate performance of paraclinical examinations.

Treatment of CP was based on pain management with analgesics. The new trends of early endoscopic management of the complications of pancreatitis [18,19] could also influence morbidity and mortality linked to this disease, but are unfortunately currently unavailable in our country.

More than half the cases of AP and/or CP had a favorable outcome and mortality was low, which was significantly lower in Kenya (2.9% mortality in AP in Mutebi [15]). This favorable outcome in our study could be explained by the virtual absence of complications in our series.

 

Conclusion

Acute and chronic pancreatitis are infrequent, predominantly male conditions whose diagnosis, based on clinical arguments, is often limited by the absence of biological and morphological investigations. Etiologies are dominated by alcohol in our study, although undetermined causes still play an important role. It would be interesting to extend the study over a longer period with prospective collection and financial support in order to specify the causes more precisely.