Under normal conditions, trypsin activity is properly suppressed in the pancreatic acinar cells. Small amount of trypsin can be inactivated by pancreatic secretory trypsin inhibitor (PSTI) thereby preventing damage to pancreatic acinar cells as a first line of defense. However, if trypsin activation exceeds the capacity of PSTI, a subsequent cascade of events leads to the activation of various proteases that damage cells. This can be interpreted as the main causative agent of pancreatitis onset.
Ischemia, autodigestion, and systemic inflammatory response syndrome (SIRS)/sepsis are the major aggravation mechanisms of acute pancreatitis. The role of trypsin, trypsin receptor (protease-activated receptor-2: PAR-2), pro-inflammatory cytokines, and endothelins are described as the key molecules for the aggravation of acute pancreatitis.

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We sought to clarify features of acute pancreatitis in the elderly by retrospectively examining records of 94 patients with this diagnosis admitted to our hospital between April 1997 and December 2004. Thirty patients were over 70 years old (elderly group), while 64 were under 70 (younger group). In the elderly group women predominated (60%), and pancreatitis was caused mainly by biliary tract stones. Severity of symptoms, the causes of pancreatitis did not differ between groups. Blood test results on admission varied with. Laboratory signs of inflammation were less prominent in the elderly than the younger group. The period before intake in the elderly group (10.8±4.4 days) was longer than that in the younger group (7.1±3.1). Hospitalizations were longer in the elderly group (72.2±8.9 days) than in the younger group (41.3±10.1). Intravenous infusion volumes differed considerably between the age-defined groups, reflecting individual patients' diagnosis and specific management.

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Three cases with Adenosquamous carcinoma (ASC) of the pancreas who underwent surgical resection were retrospectively reviewed. 1 case had pStage III disease while 2 cases had Stage IVa diseases, though 2 cases survived more than 1 year after surgery. The growth pattern was expansive in 2 cases. There were no foci of the adenocarcinomatous component in 2 cases. Results of both US and CT were consistent with an expansive growth nature of the tumor in 2 cases. EUS revealed an increased level of internal echo in all of the tumors compared with ductal adenocarcinoma. ERCP showed marked compression of the main pancreatic duct by the tumor. Expansive growth, increased internal echo level, and compression on the main pancreatic duct would be useful findings for the preoperative diagnosis of ASC.

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A 83-year-old man was admitted to our hospital with the complaint of upper abdominal fullness in September 2004. Diffuse swelling of the pancreas and diffuse irregular narrowing of the main pancreatic duct were observed. Although these findings suggested that he was suffering from autoimmune pancreatitis, neither anti-nuclear antigen nor an increased level of IgG/IgG4 was detected. In October, he complained of severe constipation. Examination revealed the appearance of ascites and thickened rectal wall. Because lymphoma cells were detected both in the ascites and the rectum, and a high level of soluble IL-2 receptor (3,183U/ml) was found serologically, the patient was diagnosed as malignant lymphoma. Chemotherapy improved the pancreas swelling and narrowing of the main pancreatic duct, but the patient died in January 2005 from respiratory distress. We review malignant lymphoma of the pancreas in Japan.

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A 57-year-old female was admitted to our hospital because of elevated serum CA19-9 and a suspicious pancreatic tumor which was detected by abdominal ultrasonograpy (US). Abdominal US revealed a 1.5×1.5 cm hypoechoic solid tumor with a relatively homogeneous inner part located at the pancreatic head. The tumor circumference was enhanced by abdominal enhancing CT. MRI revealed a high signal area, but the tumor had a low intensity area with a T1 WI, and was non-uniform with a T2 WI. The whole tumor showed a light intensity in MRCP. Angiography of the celiac artery also showed dense accumulation of the contrast medium in the tumor. A pancreatic endocrine tumor was diagnosed and pylorus-preserving pancreaticduodenectomy was preformed after receiving informed consent. Gross inspection of the cut surface of the surgical specimen revealed an encapsulated solid tumor measured 1.5×1.5 cm. Histopathologically, the solid part in the center involved colonies of microscopically small cysts composed of cuboidal cells revealing that it was pancreatic serous cystadenoma.

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Pancreatic carcinoma in situ has reportedly increased, but is still rare and mostly diagnosed incidentally. We report herein a case of pancreatic carcinoma in situ which was resected based on intraoperative cytodiagnosis. A 76-year-old man was followed for hyperlipidemia. His serum CA19-9 level was found to be elevated. Endoscopic retrograde pancreatography showed no ductal lesions, but the aspirated pancreatic juice contained adenocarcinoma cells cytologically. The tumor location in the pancreas was unclear in preoperative examinations. On February 12. 1999, a laparotomy was performed. Pancreas was separated at the left edge of superior mesenteric vein. Adenocarcinoma cells were found cytologically in the pancreatic juice from the cranial duct, and then pylorus preserved pancreatoduodenectomy was performed. No tumors were identified macroscopically. Histological findings revealed two lesions of CIS with papillary proliferative mucosa and multiple hypertrophy. A glucagonoma 2 mm in diameter was also found at the uncus. The patient is alive without recurrence 6 years and 9 months after the operation.

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Endoscopic treatment of pancreatic pseudocysts yielded good results with low rates of complication. But the complication rate is uncertain. A 47-year-old man was refered to our hospital with a diagosis of pancreatic stones and pseudocyst. Several imaging tests demonstrated a cyst of approximately 70 mm in diameter and pancreatic stones in the main pancreatic duct at the pancreatic head. Because of communication of the cyst with the main pancreatic duct, we performed EPS (endoscopic transpapillary stenting of the pancreatic duct). EPS resulted in the infection of pseudocyst. Therefore, percutaneous drainage of the cyst was performed to improve the general condition. After ESWL and EPS treatment, the pancreatic stones and cyst had disappeared. His clinical course was uneventful without recurrence of the pancreatic stones and pseudocyst at twenty months after treatment.

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