[The role of calcitonin in the diagnosis, treatment and prognosis of acute pancreatitis and its complications]

Results of investigation of the calcitonin and calcium level in the blood serum in dynamics in 15 patients with various forms of an acute pancreatitis were analyzed. In oedematous form of an acute pancreatitis the calcitonin content had constituted 4.5 pg/ml at average, promoting the calcium level rising up to 2.97 mmol/l; in necrotic form of an acute pancreatitis the calcitonin concentration had constituted 164.4 pg/ml, calcium--1.74 mmol/l; in purulent--necrotic form--accordingly 288 pg/ml and 1.5 mmol/l.

[Jejunal feeding in necrotizing pancreatitis or after esophagectomy]

Has early jejunal glutamine-rich diet any advantage in the treatment of patients suffering from acute pancreatitis and after oesophagectomy? Eleven patients suffering from necrotizing pancreatitis and 23 patients operated on radically for esophageal cancer were fed intra jejunally with glutamine-rich Stresson Multi Fibre diet. Eight patients with necrotising pancreatitis and 13 oesophagectomy patients were fed with glutamine-poor Nutrition Multi Fibre. Nutritional status, serum proteins, acute phase proteins, immune-globulins, complement components (C3, C4), the ratio of subsets of peripheral lymphocytes were analysed on the 1st, 2nd, 4th and 10th days. Serum protein parameters were measured by laser nephelometry. CD cell surface antigen expression was measured with flow cytofluorometry, activity of phagocytes with whole blood chemiluminescences. Laboratory parameters showed an improvement during the 10-day-treatment in both diet types, but significant improvement could be measured only in patients with necrotizing pancreatitis and fed with Stresson Multi Fibre: IgG (p < 0.05), serum protein (p < 0.02), prealbumin (p < 0.05), retinol binding protein (p < 0.03). The different diets did not cause difference in the laboratory results of the oesophagectomy patients. Early immune-enhancing diet improved serum proteins, acute phase proteins and immunoglobulins significantly in necrotizing pancreatitis. The length of hospital stay also decreased.

[Therapeutic effects of human interleukin 10 gene transfer on severe acute pancreatitis in rats, an experimental study]

OBJECTIVE

To study the therapeutic effects of human interleukin 10 (IL-10) gene transfer on severe acute pancreatitis (SAP) in rats.

METHODS

Twenty healthy SD rats were injected intraperitoneally with SA liposome, SA liposome/pcDNA3 or SA liposome/pcDNA3-IL-10. Another twenty SD rats were randomly divided into five groups: rats in one group underwent laparotomy only (normal control), and SAP was induced in the other 4 groups induced by homogeneous injection of sodium taurocholate beneath the pancreatic capsule. Among the 4 SAP groups, one group did not receive any drugs, and liposomes, pcDNA3 or pcDNA3-IL-10 complexed with cationic liposomes were administered to the other groups. Drugs were administered by a single intraperitoneal injection thirty minutes after SAP had been induced. The levels of IL-10 in pancreas, liver and lungs were determined by ELISA kits. The level of serum amylase, histology, and tissue tumor necrosis factor (TNF) were assessed and mortality rate was observed in different groups for one week.

RESULTS

The levels of IL-10 in the pancreas, liver and lung 24 hours after IL-10 gene transfer, increased significantly (all > 350 pg/g), and then gradually decreased, however, the levels of IL-10 were still significantly higher that those in the control groups (P < 0.05) 96 hours later and decreased to normal in one week. The levels of IL-10 of transfer control group were not significantly different from those of the normal control group. The levels of IL-10 expression in pancreas, liver and lungs were increased significantly in the gene therapy group, compared with the SAP group. The serum amylase level was (4 300 +/- 700) U/L in normal control group, increased to (20 300 +/- 1 100) U/L 24 hour after SAP induction without a difference between the therapy control group and SAP group, and decreased to (6 800 +/- 700) U/L after IL-10 gene therapy (P < 0.05). The histological score of pancreas was 4.1 +/- 0.2 24 hours after the induction of SAP, and was 3.2 +/- 0.3 in the IL-10 therapy group. The level of TNF in pancreas, liver, and lungs 24 hours after the induction of SAP was significantly higher than that in normal control group (P < 0.05) and was not different from that in therapeutic control group. However, it was decreased markedly in IL-10 therapy group (P < 0.05). No rat in any group died within 2 days after onset. There was no difference of mortality between SAP group and therapeutic control group. The one-week mortality was 90% in the whole SAP group. The one-week mortality of IL-10 gene therapy group was 30 %, significantly lower than that in SAP group (P < 0.05). There was no significant difference in the therapeutic control groups and the SAP group. The values of relative risk of SAP group, SA liposome group, and pcDNA3 group were 12, 8, and 11 times higher than that of gene therapy group (P < 0.05).

CONCLUSION

Cationic liposome mediated pcDNA3-IL-10 gene therapy decreases significantly the severity and mortality of SAP.

[Procalcitonin rapid test in surgical patients treated in the intensive care unit]

Procalcitonin test (PCT) has been proposed to check severity of generalized infections or sepsis. The authors measured the PCT values with PCT-Q quick test (BRAHMS DIAGNOSTICA GmbH, Berlin) at 14 surgical patients treated in their intensive care unit (7 sepsis, 4 peritonitis, 2 localized pancreatic abscess, 1 postoperative fever). At 3 septic patients (2 pancreatitis, 1 intestinal necrosis) they measured the PCT levels repeatedly during treatment. In 2 patients with localized pancreatic abscess and in 1 patient with postoperative fever without evidence of infection the PCT levels were low (< 0.5 ng/ml). At 4 patients with peritonitis following gastric or colon perforation the PCT levels were highly elevated (> 10 ng/ml). At 7 patients with severe sepsis the PCT values were high (> 2 ng/ml), except for 1 patient with intestinal necrosis. At this patient the PCT levels were repeatedly low. In 2 septic patients with pancreatitis elevated PCT levels indicated the need for surgery. In most patients PCT was a good indicator of generalized infections. PCT levels measured repeatedly in sepsis were lower than in patients with peritonitis.

[Blood fatty acid transporters in acute pancreatitis]

A relationship between of acute pancreatitis severity and concentrations of blood transporters of nonesterified fatty acids (albumin) and esterified fatty acids (lipoproteins) was studied. In necrotizing pancreatitis, there was a positive correlation between decrease of albumin and lipoprotein concentrations in serum, but no correlation was in edematous pancreatitis. High levels of serum albumin (> 32 g/L) and lipoproteins (cholesterol + triglycerides, CH + TG, > 260 mg/dL) had good prognostic value in terms of favourable development of this disease, whereas lower concentrations indicated unfavourable prognosis. Both albumin and lipoproteins appeared in the peritoneal exsudate where they represented 73 and 53% of the serum concentrations, respectively. Albumin efflux from blood to the exsudate correlated with lipoprotein efflux (r = 0.7) in necrotizing pancreatitis. The latter suggests that proteins penetrated together the tissue barrier blood/peritoneal space. The less albumin and lipoprotein concentrations in serum, the more they are in the exsudate (r = -0.57 and -0.47, respectively); probably, their concentration decrease in blood is due to to their efflux into the exsudate.

Relationship between plasma D(-)-lactate and intestinal damage after severe injuries in rats

AIM: To explore the kinetic changes in plasma D(-)-lactate and lipopolysaccharide (LPS) levels, and investigate whether D(-)-lactate could be used as a marker of intestinal injury in rats following gut ischemia/reperfusion, burn, and acute necrotizing pancreatitis (ANP).

METHODS: Three models were developed in rats: ① gut ischemia/reperfusion obtained by one hour of superior mesenteric artery occlusion followed by reperfusion; ② severe burn injury created by 30% of total body surface area (TBSA) full-thickness scald burn; and ③ ANP induced by continuous inverse infusion of sodium taurocholate and trypsin into main pancreatic duct. Plasma levels of D(-)-lactate in systemic circulation and LPS in portal circulation were measured by enzymatic-spectrophotometric method and limulus amebocyte lysate (LAL) test kit, respectively. Tissue samples of intestine were taken for histological analysis.

RESULTS: One hour gut ischemia followed by reperfusion injuries resulted in a significant elevation in plasma D(-)-lactate and LPS levels, and there was a significant correlation between the plasma D(-)-lactate and LPS (r = 0.719, P < 0.05). The plasma concentrations of D(-)-lactate and LPS increased significantly at 6 h postburn, and there was also a remarkable correlation between them (r = 0.877, P < 0.01). D(-)-lactate and LPS levels elevated significantly at 2 h after ANP, with a similar significant correlation between the two levels (r = 0.798, P < 0.01). The desquamation of intestine villi and infiltration of inflammatory cells in the lamina propria were observed in all groups.

CONCLUSION: The changes of plasma D(-)-lactate levels in systemic blood paralleled with LPS levels in the portal vein blood. The measurement of plasma D(-)-lactate level may be a useful marker to assess the intestinal injury and to monitor an increase of intestinal permeability and endotoxemia following severe injuries in early stage.

Clinical relevance of caspase-1 activated cytokines in acute pancreatitis: high correlation of serum interleukin-18 with pancreatic necrosis and systemic complications

OBJECTIVES

There is recent experimental evidence that caspase-1 activation plays an instrumental role in the pathomechanism of severe acute pancreatitis. Besides interleukin-1beta, interleukin-18, a recently described proinflammatory cytokine, is cleaved into its biologically active form by caspase-1 as well. Interleukin-18 is known to have potent properties concerning the activation of the Th1-lymphocyte subset via costimulation of interferon-gamma production. In contrast to interleukin-1beta, little is known about the clinical impact of interleukin-18 in the course of acute pancreatitis.

DESIGN

Cohort study comparing patients with mild and severe acute pancreatitis associated with local and systemic complications during the course of the disease.

SETTING

Surgical and anesthesiological intensive care unit as well as wards of the department of general surgery.

PATIENTS

We included 68 patients with acute pancreatitis in the present study. In terms of local complications, pancreatic necrosis was present in 37 patients, of whom 21 developed pancreatic infections. Systemic complications included pulmonary, renal, or cardiocirculatory insufficiency and were observed in 40, 18, and 25 patients, respectively. Severe multiple-organ dysfunction syndrome involving all three organ systems occurred in 18 patients, all suffering from pancreatic necrosis.

INTERVENTIONS

Serum samples were collected over 14 consecutive days after study inclusion. Ascites or peripancreatic exudate was obtained by ultrasound-guided fine needle aspiration in 14 cases. Sera and local aspirates were stored at -70 degrees C until analysis.

MEASUREMENTS AND RESULTS

Interleukin-18 and interferon-gamma were measured by commercially available enzyme-linked immunosorbent assays. Interleukin-18 concentrations were significantly increased after the fourth day of disease onset until the end of the observation period in patients who developed pancreatic necrosis and systemic complications such as pulmonary, renal, and cardiocirculatory failure as well as severe multiple-organ dysfunction syndrome. However, no correlation was found between the development of pancreatic infections and interleukin-18 concentrations. In contrast with interleukin-18, interferon-gamma concentrations did not show any significant difference with respect to the presence or absence of either systemic or local complications. Local interleukin-18 concentrations in ascites or peripancreatic exudate were up to 20-fold higher than systemic concentrations, whereas interferon-gamma concentrations did not differ.

CONCLUSIONS

Serum interleukin-18 concentrations are significantly elevated in patients with acute pancreatitis complicated by pancreatic necrosis and remote organ failure. The present data suggest an important role of caspase-1 dependent cytokine activation in the pathomechanism of severe acute pancreatitis beyond the experimental setting. In this context, interleukin-18 may serve as a potential target for new therapeutic approaches.

Histoprotective effect of antihypoxant olifen during experimental acute pancreatitis

We evaluated the efficiency of perfusion with olifen in preventing oxidative stress at the early stage of acute pancreatitis. Transaortic perfusion with olifen prevented clinical and biochemical symptoms of acute pancreatitis, attenuated oxidative stress, reduced peritoneal exudation, and restricts the area of pancreatic necrosis to 6% tissue.

[The influence of clexane on the fibronectin content in the blood plasma in patients with destructive pancreatitis]

The fibronectin content dynamics in the blood serum was estimated in patients with various clinical forms of an acute pancreatitis. The fibronectin level lowering may be a predictor of occurrence and diagnostical criterion for infective complications in patients with destructive pancreatitis. Application of clexane had promoted the fibronectin level raising in the blood serum in patients with sterile and infected pancreatic necrosis.

Experimental acute necrotising pancreatitis: evaluation and characterisation of a model of intraparenchymal injection of sodium taurocholate in rats

OBJECTIVES

To evaluate a simple model that produces progressive dose dependent pancreatitis, by intraparenchymal injection of sodium taurocholate.

DESIGN

Open laboratory study.

SETTING

Teaching hospital, Israel.

MATERIALS

Forty eight Wistar rats.

INTERVENTIONS

Sodium taurocholate was injected, 0.3 ml/100 g body weight, in concentrations of 5% and 10% into the pancreatic parenchyma of 32 Wistar rats, resulting in two distinct groups of severity. In 16 sham controls, saline was injected into the pancreas in similar fashion. Blood samples were withdrawn before, and 6, 24, 48, and 72 hours after induction of pancreatitis.

RESULTS

Six hours after taurocholate injection, there was a sharp increase in the plasma activities of amylase, lipase, and lactate dehydrogenase (LDH). After 24 hours plasma activities of amylase and lipase decreased to near normal values while LDH remained slightly increased for 48 hours and decreased only after 72 hours. At 6 hours after the injection, interleukin-6 (IL-6) concentrations had increased slightly in the 5% group and decreased to the baseline values at 24 hours. In the 10% group, the increase in IL-6 values was significantly greater than in the 5% group (p = 0.04), and correlated well with severity of pancreatitis as defined by histology (p = 0.01) and mortality (p = 0.037). Twenty four hours after injection of taurocholate, morphological changes comprising diffuse necrosis of the pancreas, fat necrosis, and intestinal dilatation secondary to paralytic ileus were severe. Histopathological examination of the pancreas showed good correlation with the clinical findings and with mortality. No morphological changes were detected when saline was injected into the pancreas (sham control), and only mild rises of IL-6, lipase, amylase, and LDH activities were seen at 6 hours after injection. The mortality, after 10 days, was 80% in the 10% taurocholate group, 30% in the 5% taurocholate group, and 0 in the sham control group (p < 0.05).

CONCLUSION

The intraparenchymal injection of taurocholate is easy to perform and highly reproducible. The histopathological injury is dose-dependent, as is the mortality. We conclude that this model is valuable for the study of new treatments for pancreatitis.

[Diagnostic and prognostic significance of the blood neutrophils functional activity in patients with an acute destructive pancreatitis]

The neutrophils functional state was studied in 101 patients with an acute destructive pancreatitis (DP), complicated by parapancreatitis, in 20 patients with edematic pancreatitis and in 25 healthy persons using cytochemical reactions with determination of the enzymes activity of alkaline phosphatase, myeloperoxidase, and also of lysosomic-cation proteins, phospholipids and glycogen. The enzymatic contents of neutrophils changes in acute period of destructive pancreatitis (DP) are causing their function inhibition, promoting the infection complications occurrence. The neutrophils functional activity indexes may be used in early diagnosis and prognostication of the DP course.

Changes in plasma levels of acute phase proteins in pancreatitis

The objective of our study was to determine whether the changes in the plasma levels of C-reactive protein, haptoglobin, transferrin, and alpha 1-acid glycoprotein (orosomucoid) in acute pancreatitis patients examined on days 1, 3, 5, 7, 9, and 14 after their admission to hospital can be used to assess the course and determine the severity of the disease, and to discriminate edematous from necrotizing pancreatitis. The study included 18 patients with mild pancreatitis and 20 patients with severe pancreatitis. Pancreatitis was classified as mild or severe according to Ranson and the Acute Physiology and Chronic Health Evaluation (APACHE) II scores. Acute phase proteins were determined using the immunoturbidometric assay. The C-reactive protein in the mild pancreatitis patients was six-fold higher at admission, then gradually increased for 5 days and started to drop. In the severe clinical forms of pancreatitis the C-reactive protein had significantly high values throughout the whole time of study retaining this high level to day 14; these elevated levels correlated with the persistent severe general state of the patients and the extent of necrosis in the pancreas. The changes in the haptoglobin and transferrin levels were not significant. Orosomucoid level in mild pancreatitis cases remained constant whereas it was elevated and continuously above the reference values in severe pancreatitis.

IN CONCLUSION

C-reactive protein level changes significantly in patients with acute pancreatitis; it is in the range of 100-120 mg/l in the mild forms of the disease and between 120 and 360 mg/l in the severe pancreatitis. This renders it a valuable indicator for the discrimination of edematous from necrotizing acute pancreatitis.

Fluconazole penetration into the pancreas

Because of antibiotic prophylaxis for necrotizing pancreatitis, the frequency of fungal superinfection in patients with pancreatic necrosis is increasing. In this study we analyzed the penetration of fluconazole into the human pancreas and in experimental acute pancreatitis. In human pancreatic tissues, the mean fluconazole concentration was 8.19 +/- 3.38 microg/g (96% of the corresponding concentration in serum). In experimental edematous and necrotizing pancreatitis, 88 and 91% of the serum fluconazole concentration was found in the pancreas. These data show that fluconazole penetration into the pancreas is sufficient to prevent and/or treat fungal contamination in patients with pancreatic necrosis.

Diagnostic relevance of procalcitonin, IL-6, and sICAM-1 in the prediction of infected necrosis in acute pancreatitis

BACKGROUND

Infected pancreatic necrosis (IPN) is an absolute indication for surgical intervention, therefore an early and accurate laboratory diagnosis is necessary to confirm the infection. The aim of the study was to analyze the clinical value of procalcitonin (PCT) for the prediction of infected necrosis, in comparison with interleukin-6 (IL-6) and sICAM 1.

PATIENTS AND METHODS

A total of 30 patients were investigated; 10 patients with sterile pancreatic necrosis (SPN), 10 with IPN, and 10 with sepsis of different origin. The concentrations of PCT in the patients' sera were measured by immunoluminometric assay (BRAHMS Diagnostica, Berlin, Germany, PCT Lumitest), the IL-6 concentrations by bioassay, applying the B-9 cell line, and the sICAM-1 levels by enzyme-linked immunosorbent assay (ELISA) (R&D). PCT was determined in cell lysates by ECL Western blot.

RESULTS

PCT was found in relatively high concentrations (8.5 +/- 4.8 ng/mL) only in patients with infected pancreatic necrosis, and in patients with sepsis of different origin ( 15 +/- 5.4 ng/mL). Positive values (> 1 ng/mL) preceded positive bacterial results from either blood or surgical samples. None of the serum samples of patients with SPN exhibited PCT concentrations higher than 1.2 ng/mL. In contrast, IL-6 and sICAM-1 were overproduced in both types (infected and sterile) of pancreatic necrosis, and their levels remained elevated for several days even after surgical elimination of the infected focus (widespread necrosectomy and continuous lavage). Sensitivity, specificity, and positive predictive values for discriminating IPN from SPN was 90, 100, and 100% for PCT (p < 0.0001); 100, 20, and 55% for IL-6 (p 0.474 n.s.) and 90, 10, and 50% for sICAM-1 (p 1.000 n.s.). Immunoblotting revealed no PCT in patients' leukocytes, or in human endothelial cell lines.

CONCLUSION

Elevated serum IL-6 and sICAM-1 levels are characteristic in systemic inflammatory response syndrome (SIRS) of either infectious or noninfectious origin. In contrast, the PCT level is an accurate, readily available parameter that allows the discrimination of IPN, and is a helpful marker facilitating a decision concerning surgical intervention.

Pancreatic injury following acute methanol poisoning

BACKGROUND

Methanol ingestion is a cause of potentially life-threatening poisoning with numerous systemic manifestations. Clinicians may overlook the possibility of acute pancreatitis in this setting. The objective of this paper is to document the incidence of this complication in a series of 22 patients and to discuss the respective role of methanol and ethanol in its pathogenesis.

CASE REPORT

A 54-year-old woman developed acute necrotizing pancreatitis following acute methanol poisoning. She was treated by hemodialysis, ethanol infusion, and folinic acid, but, despite maximal supportive therapy, she died from multiple organ failure 54 hours after the ingestion.

CASE SERIES

In a series of 22 consecutive patients admitted with a diagnosis of acute methanol poisoning, we found evidence of pancreatic damage in 11 patients. The abnormalities were present from admission and before ethanol therapy in 7 cases and developed after ethanol therapy in 4 cases. Seven patients had a history of chronic ethanol abuse, but no patient had previously suffered from acute or chronic pancreatitis. Three patients presented moderate-to-severe acute pancreatitis according to clinical and radiological criteria and required aggressive supportive therapy including peritoneal dialysis. One patient died from the direct consequences of acute necrotizing pancreatitis and 2 fully recovered from this event. Three patients evolved to brain death; autopsy revealed hemorrhagic lesions in the pancreas in only 1 case.

CONCLUSIONS

Clinical, biological, and radiographic signs of acute pancreatic injury may be more common than previously realized. Acute methanol poisoning appears to produce pancreatic injury, although antidotal treatment with ethanol or prior chronic ethanol abuse may be contributing factors. Because ethanol treatment may complicate the pancreatic injury, fomepizole (4-methylpyrazole) may be the preferable antidote in acute methanol poisoning.

Protein C activation during the initial phase of experimental acute pancreatitis in the rabbit

BACKGROUND

Disturbances of coagulation and fibrinolysis are well-known systemic effects of acute necrotising pancreatitis (ANP). The purpose of this experimental study was to evaluate the initial events in the haemostatic activation during ANP in an animal model with relevance to the human situation.

METHODS

ANP was introduced in 7 rabbits by infusion of chenodeoxycholic acid in the pancreatic duct. Seven rabbits served as sham-operated controls. Serial measurements of coagulation variables (prothrombin time, activated partial thromboplastin time, FVII activity, fibrinogen, tissue factor activity), anticoagulant proteins (protein C, antithrombin) and fibrinolytic factors (tissue plasminogen activator, plasminogen activator inhibitor-1) were performed for 5 h.

RESULTS

ANP was confirmed by elevated serum amylase, development of ascites, and histological changes of the pancreas. A moderate activation of the coagulation system was found in both study groups. A significant decrease in protein C concentration from 1 h after the induction of ANP was found, whereas the response of antithrombin and the inhibition of the fibrinolytic system were similar in the 2 study groups. Microthrombosis of the lungs or kidneys was found in 2 rabbits with ANP.

CONCLUSION

An immediate activation of protein C is a specific characteristic of the haemostatic activation in ANP in rabbits. This activation has not been described previously and the possible therapeutic implications ought to be studied.

[The role of the intestines in the pathogenesis of acute pancreatitis: oxygen extraction and bacteria translocation in rats]

In experiment on 40 male rats of the Wistar line there was investigated the oxygen extraction (O2) and the bacteria translocation in 30 min, 2, 6, 12 and 24 hours after the stimulating operation (control group) and simulation of the ductal-hypertensive form of an acute experimental pancreatitis (AEP)--the main group. The data obtained witness the general extraction of O2 raising by 222% (P < 0.001) at average and lowering of its intestinal extraction in 30 min and 2 hours (by 33 and 31% at average, P < 0.05) and its raising in 24 hours by 138% (P < 0.001) at average also. These disorders had correlated with velocity of the intestinal E. coli reproduction and with the bacteria translocation on the way intestine-->mesenterial lymph nodes in 6 hours after the disease occurrence with preservation of the lymph nodes and the liver barrier function in the AEP duration over 24 hours. The data obtained had permitted to substantiate the necessity of the remedial measures complex application, directed on the frequency of purulent complications lowering.

Endotoxin and antiendotoxin antibodies in patients with acute pancreatitis

OBJECTIVE

To elucidate the time course of endotoxaemia and antiendotoxin antibodies in patients with acute pancreatitis.

DESIGN

Prospective clinical study.

SETTING

University hospital, Germany.

SUBJECTS

25 patients with oedematous (n = 9) or necrotising (n = 16) pancreatitis, and 20 healthy controls.

MAIN OUTCOME MEASURES

Concentrations of endotoxin and immunoglobulins (classes G, M, and A) directed at two lipid A molecules, four lipopolysaccharides, and alpha-haemolysin of Staphylococcus aureus measurements in plasma during a 12 day period.

RESULTS

There were no differences in the degree of endotoxaemia between patients with oedematous and necrotising pancreatitis on admission. However, from the day after admission and throughout the observation period patients with necrotising pancreatitis had significantly higher concentrations of endotoxin than those with oedematous pancreatitis. Concentrations of IgM specific for endotoxin peaked at day 4, and then decreased in patients with oedematous pancreatitis while remaining high for those with necrotising pancreatitis. There was only a slight increase in IgA specific for endotoxin, and IgG and immunoglobulins to gamma-haemolysin remained steady throughout the observation period. There was strong cross-reactivity (r > 0.7) between IgM specific for endotoxin (70%), but this was less with IgA (52%), and IgG (20%).

CONCLUSIONS

Necrotising pancreatitis is accompanied by persistent endotoxaemia with an extended rise in antiendotoxin antibodies. Patients with oedematous pancreatitis have a transient endotoxaemia with a temporary increase of Ig specific for endotoxin. Endotoxin stimulates the synthesis of specific antibodies (IgM) despite general immunosuppression.

[The dynamics of blood serum middle-molecule peptides in the prognosis of the course of acute pancreatitis]

The work is devoted to studying the dynamics of endogenous toxemia by the level of middle mass peptides of blood serum in patients with acute pancreatitis. The level of middle mass peptides was investigated in 116 patients spectrophotometrically after Gabriélian with the wave length 254 nm (1st fraction, MMP-1) and with the wave length 282 nm (2nd fraction, MMP-2). It was found that the ratio of these fractions could be used as a prognostic index of the complicated course of acute pancreatitis. When the initial ration MMp-2/MMP-1 is less that 1 the risk of the development of complications of the second phase of acute pancreatitis is real. The decrease of the level of MMP-1 and MMP-2 during treatment by the 3rd-4th days is considered to be an indicator of the favorable outcome of the disease. The elevation of the level of MMP-1 and MMP-2 by the 3rd-4th days despite the treatment predicts an unfavorable outcome of the disease.

[Lipid peroxidation, the antioxidant system and the trace element level in acute pancreatitis]

Overall, thirty-two patients with acute pancreatitis (edematous, destructive, purulent forms) were studied for the state of lipid peroxidation (LPO), antioxidant defence (AOD), and trace element status. The development of destructive and purulent forms of acute pancreatitis was found out to be accompanied by activation of LPO processes, AOD breakdown, with profound disturbances having been disclosed in the metabolism of zinc, selenium, cuprum, manganum, that play an important part in LPO, AOD processes, and in those of immune defence. The secured results suggest that there is a need for us to include into a complex therapy of acute pancreatitis antioxidants and some trace elements (zinc, celenium) and that it is expedient to use indices for the LPO, AOD systems, and for trace element status in the differential diagnosis of clinical forms of acute pancreatitis, prognostication of development of purulent complications.

Role of procalcitonin and granulocyte colony stimulating factor in the early prediction of infected necrosis in severe acute pancreatitis

BACKGROUND

Infected pancreatic necrosis (IPN) is the main cause of death in patients with severe acute pancreatitis. Therefore an early prediction of IPN is of utmost importance.

AIM

Analysis of new blood variables as potential early predictors to differentiate between IPN and sterile pancreatic necrosis (SPN).

PATIENTS

64 consecutive patients with acute pancreatitis were enrolled in this prospective study; 29 were suffering from acute oedematous pancreatitis (AIP), and 35 from necrotising disease (NP) as diagnosed by contrast enhanced computed tomography.

METHODS

Procalcitonin (PCT) and granulocyte colony stimulating factor (G-CSF) in the serum were examined and compared with C reactive protein (CRP). CRP was measured with a turbidimetric immunoassay (Autokit CRP; Wako, Osaka, Japan), and PCT and G-CSF by ELISA (Lumitest PCT; Brahms Diagnostica, Berlin, Germany; G-CSF-Elisa; R&D Systems, Abingdon, Oxon, UK). Monitoring was performed daily and related to the onset of symptoms.

RESULTS

Within the first week, all three variables (CRP, PCT, and G-CSF) were significantly higher in patients with NP than in those with AIP (CRP, p<0.001; G-CSF, p<0. 001; PCT, p<0.001). During the course of the study, 12 of the 35 patients with NP developed late IPN after a median of 20.5 (range 3-49) days. Neither the peak nor the lowest concentrations during the monitoring period were of any value for predicting IPN (median peak values in SPN v IPN: PCT, 0.93 v 1.93 ng/ml; G-CSF, 347 v 421 pg/ml; CRP, 270 v 325 mg/l).

CONCLUSIONS

Serum PCT, G-CSF, and CRP concentrations are of similar value for early differentiation between mild and severe acute pancreatitis. However, these variables are not suitable for the early prediction of IPN.

Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis

BACKGROUND

The risk factors predisposing to organ failure in patients with necrotizing pancreatitis remain unclear. The relationship between the extent of pancreatic necrosis, the presence of infection and the incidence of organ failure was analysed.

METHODS

In a retrospective review, the occurrence of pulmonary insufficiency, renal insufficiency, shock, sepsis/sepsis-like syndrome (SLS) and coagulopathy was evaluated in 273 patients with necrotizing pancreatitis, and a comparison was made between patients with sterile or infected necrosis. Additionally, the relation between the incidence of organ failure and extent of pancreatic parenchymal necrosis was investigated by classifying the patients into three groups according to the amount of necrotic tissue found by contrast-enhanced computed tomography (group 1, extent less than 30 per cent; group 2, 30-50 per cent; group 3, more than 50 per cent).

RESULTS

Organ failure was more frequent in patients with infected necrosis than in those with sterile necrosis. Differences were found in the incidence of pulmonary insufficiency, sepsis/SLS and coagulopathy. Organ failure occurred more frequently in group 3 than in group 2 or 1 (95 versus 79 and 66 per cent; P = 0.0004). The extent of infected necrosis was not related to the incidence of organ failure (group 1, 88 per cent; group 2, 86 per cent; group 3, 96 per cent). However, there was a relation between the incidence of organ failure and the extent of sterile necrosis (group 1, 59 per cent; group 2, 74 per cent; group 3, 94 per cent; P = 0.0001). Multivariate analysis confirmed the presence of infection and the extent of necrosis as independent determinants of organ failure.

CONCLUSION

The incidence of organ failure is determined by both bacterial infection and extent of necrosis. The incidence of organ failure is determined by the extent of necrotic parenchyma in patients with sterile necrosis. Infected necrosis is associated with a high incidence of organ failure irrespective of the extent of necrosis.

Time course of plasma soluble intercellular adhesion molecule-1 (sICAM-1) is related to severity of acute pancreatitis

BACKGROUND/AIMS

In severe acute pancreatitis the release of cytokines indicates a key step from local to systemic inflammation. Increased plasma concentrations of circulating soluble intercellular adhesion molecule-1 (sICAM-1), a marker of leukocyte activation, were detected in necrotizing pancreatitis at the time of diagnosis, however, the exact role of sICAM-1 in the development of complications such as shock or organ dysfunction is unclear. Therefore, we investigated in what manner the time course of plasma sICAM-1 is associated with the development of severe pancreatitis and whether these results are of any predictive value for the further course of the disease.

METHODOLOGY

In a medical intensive care unit we studied 29 consecutive patients admitted for acute pancreatitis. Plasma levels of sICAM-1 were measured serially over a period of 6 days and the time courses were assigned either to a group of patients with uncomplicated, mild disease or to patients who developed complications including multiple organ failure.

RESULTS

In mild pancreatitis, decreasing and peak sICAM-1 concentrations were found in 88% of the patients with a mean maximal level of 574 +/- 59 ng/ml (SE) (upper limit of normal: 400 ng/ml) on day 1. Partial pancreatic necrosis was present in 24% and no deaths were observed. In severe pancreatitis an increase of sICAM-1 levels or an initial fall followed by an increase (relapsing response) was the predominant pattern (92%). Maximal values of 1453 +/- 136 ng/ml occurred on day 6, significantly different when compared to mild disease (p < 0.0001). Necrotizing pancreatitis was diagnosed in 75% and the mortality rate was 58%. The sensitivity in predicting severe pancreatitis using sICAM-1 plasma levels with an increasing or relapsing pattern was much higher (92%) when compared with serial C-reactive protein measurements (42%).

CONCLUSIONS

In acute pancreatitis, increasing or relapsing plasma levels of sICAM-1 over 6 days after admission to hospital are associated with a high rate of pancreatic necrosis and a high mortality. Daily measurements of sICAM-1 would allow early recognition of patients prone to develop complications and follow a severe course.