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Evans D, Hajibandeh S, Hajibandeh S, Athwal TS, Satyadas T. Meta-analysis and trial sequential analysis of randomized controlled trials comparing aggressive versus non-aggressive intravenous fluid therapy in acute pancreatitis: an insight into the existence of type 2 error. J Gastroenterol Hepatol 2024. [PMID: 38872377 DOI: 10.1111/jgh.16648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/26/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND AND AIM We aimed to evaluate comparative outcomes of aggressive versus non-aggressive intravenous fluid (IVF) therapy in patients with acute pancreatitis. METHODS A systematic search of electronic data sources and bibliographic reference lists were conducted. All randomized controlled trials (RCTs) reporting outcomes of aggressive versus non-aggressive IVF therapy in acute pancreatitis were included and their risk of bias were assessed. Effect sizes were determined for overall mortality, systemic inflammatory response syndrome (SIRS), sepsis, respiratory failure, pancreatic necrosis, severe pancreatitis, clinical improvement, AKI, and length of stay using random-effects modeling. Trial sequential analysis was conducted to determine risk of types 1 or 2 errors. RESULTS We included 10 RCTs reporting 993 patients with acute pancreatitis who received aggressive (n = 475) or non-aggressive (n = 518) IVF therapy. Aggressive IVF therapy was associated with significantly higher rate of sepsis (OR: 2.68, P = 0.0005) and longer length of stay (MD: 0.94, P < 0.00001) compared with the non-aggressive approach. There was no statistically significant difference in mortality (RD: 0.02, P = 0.31), SIRS (OR: 0.93, P = 0.89), respiratory failure (OR: 2.81, P = 0.07), pancreatic necrosis (OR: 1.98, P = 0.06), severe pancreatitis (OR: 1.31, P = 0.38), clinical improvement (OR: 1.12, P = 0.83) or AKI (OR: 1.06, P = 0.91) between the two groups. Sub-group analysis demonstrated higher morbidity and mortality associated with the aggressive approach in more severe disease. Trial sequential analysis detected risk of type 2 error. CONCLUSIONS Aggressive IVF therapy may be associated with higher morbidity in patients with acute pancreatitis compared with the non-aggressive approach, particularly in patients with more severe disease. It may also prolong length of hospital stay. The available evidence is subject to type 2 error indicating the need for adequately powered RCTs.
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Affiliation(s)
- Daisy Evans
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, Morriston Hospital, Swansea, UK
| | - Tejinderjit S Athwal
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Thomas Satyadas
- Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK
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Olson CG, Karime C, Chirila R. 34-Year-Old Man With Sudden Epigastric Abdominal Pain. Mayo Clin Proc 2024; 99:649-654. [PMID: 38323944 DOI: 10.1016/j.mayocp.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 02/08/2024]
Affiliation(s)
- Caroline G Olson
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Christian Karime
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Razvan Chirila
- Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Jacksonville, FL
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3
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Newton MV. D-dimer as a Marker of Severity and Prognosis in Acute Pancreatitis. Int J Appl Basic Med Res 2024; 14:101-107. [PMID: 38912365 PMCID: PMC11189266 DOI: 10.4103/ijabmr.ijabmr_483_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/27/2024] [Accepted: 03/18/2024] [Indexed: 06/25/2024] Open
Abstract
Background and Objectives Acute pancreatitis (AP) scores need a battery of tests that are not helpful at an early stage. Can a single test predict Complicated Acute Pancreatitis (CAP) which includes moderate and severe AP, local complications, and need for intensive care unit (ICU). Methodology 30 patients of AP. D-dimer, C-reactive protein levels done within 3 days of AP onset. APACHE II, Ranson's score, CT severity index were done. Inhospital disease course for development of organ failure and need for ICU care was followed daily. Results D-dimer in CAP was 2732 ng/L (MAP 567 ng/L), in abnormal computed tomography (CT) was 1916 ng/L (normal CT 363 ng/L), and in organ failure was 4776 ng/L (776.5 ng/L absent organ failure). D-dimer increases as the severity of organ failure increases (P = 0.04). D-dimer in ICU patients was significantly elevated (P = 0.021). D-dimer correlates with APACHE II score well, with an increase in predictive mortality rate (P = 0.01). On receiver operator characteristics, D-dimer >933.5 ng/L predicts CAP, >827.5 ng/L predicts positive CT findings (local complications), and >1060.5 ng/L predicts the development of organ failure. Conclusion Coagulopathy and microthrombi play a significant role in early pathogenesis. D-dimer test acts at the level of this core pathogenesis, even before the complications set in. D-dimer within 72 h of AP correlates well with the CT findings after 72 h. This is the first study that correlates D-dimer levels with CT scores, ICU requirement. D-dimer can guide primary care physicians in selecting AP patients for referral to a higher center in a resource-limited setting.
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Affiliation(s)
- Mario Victor Newton
- Department of General Surgery, St. John's Medical College Hospital, Bengaluru, Karnataka, India
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4
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Milano RV, Morneault-Gill K, Kamal HY, Barkin JA, Chadwick CB. Pancreatitis in cystic fibrosis: Presentation, medical and surgical management, and the impact of modulator therapies. Pediatr Pulmonol 2024. [PMID: 38501345 DOI: 10.1002/ppul.26958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/19/2024] [Accepted: 03/01/2024] [Indexed: 03/20/2024]
Abstract
Patients with Cystic Fibrosis (CF) are at increased risk of acute (AP) and chronic (CP) pancreatitis, and their complications. The extent of remaining healthy pancreatic parenchyma determines the risk of developing future episodes of pancreatitis, as well as pancreatic exocrine or endocrine insufficiency. Pancreatitis may be the presenting symptom of CF, and genetic testing is especially important in pediatrics. AP and recurrent AP are managed with intravenous fluid hydration and pain control, in addition to early refeeding and treatment of complications. With the use of modulator therapy in CF, pancreatic function may be restored to some extent. CP related pain is managed with analgesics and neuromodulators, with surgery if indicated in specific situations including TPIAT as a possible type of surgical intervention. Long-term sequelae of CP in patients with CF include exocrine pancreatic insufficiency treated with pancreatic enzyme replacement therapy, fat-soluble vitamin deficiencies and associated metabolic complications such as bone disease/osteoporosis, pancreatogenic diabetes, and less commonly, pancreatic cancer. We review the presentation and etiologies of pancreatitis in CF patients as well as the management of AP and CP primarily in children.
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Affiliation(s)
- Reza V Milano
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Kayla Morneault-Gill
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Hebat Y Kamal
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Jodie A Barkin
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Christina Baldwin Chadwick
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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Acehan F, Aslan M, Demir MS, Koç Ş, Dügeroğlu B, Kalkan C, Tez M, Comoglu M, Altiparmak E, Ates I. The red cell distribution width-to-albumin ratio: A simple index has high predictive accuracy for clinical outcomes in patients with acute pancreatitis. Pancreatology 2024; 24:232-240. [PMID: 38184456 DOI: 10.1016/j.pan.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 12/06/2023] [Accepted: 12/31/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND/OBJECTIVES Ongoing research is seeking to identify the best prognostic marker for acute pancreatitis (AP). The purpose of this study was to investigate the role of the red blood cell distribution width-to-albumin ratio (RAR) in the prognosis of AP. METHODS This 18-month prospective cohort study was conducted between June 2021 and December 2022 with patients diagnosed with AP. The patients were divided into two groups: severe AP (SAP) and non-severe AP. Factors associated with SAP within the first 48 h of admission were determined. In addition, RAR values at admission and at 48 h (RAR-48th) were calculated, and their ability to predict clinical outcomes was assessed. The primary outcomes were severe disease and in-hospital mortality. RESULTS Fifty (13.7 %) of 365 patients had SAP. Systemic inflammatory response syndrome, blood urea nitrogen, calcium, and RAR at 48 h after admission were independent predictors of SAP. When RAR-48th was >4.35, the risk of SAP increased approximately 18-fold (OR: 18.59; 95 % CI: 8.58-40.27), whereas no patients with a RAR-48th value of <4.6 died. For in-hospital mortality, the area under the curve (AUC) value of RAR-48th was 0.960 (95 % CI: 0.931-0.989), significantly higher than the AUC values of existing scoring systems. The results of RAR-48th were comparable to those of the other scoring systems with regard to the remaining clinical outcomes. CONCLUSIONS RAR-48th successfully predicted clinical outcomes, particularly in-hospital mortality. Being simple and readily calculable, RAR-48th is a promising alternative to burdensome and complex scoring systems for the prediction of clinical outcomes in AP.
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Affiliation(s)
- Fatih Acehan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey.
| | - Meryem Aslan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | | | - Şifa Koç
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Büşra Dügeroğlu
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Cagdas Kalkan
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Mesut Tez
- Department of General Surgery, Ankara City Hospital, Ankara, Turkey
| | - Mustafa Comoglu
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Emin Altiparmak
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
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Tomanguillo J, Searls L, Annie FH, Kemper S, Drabish K, Naravadi V. A Nationwide Analysis of Fluid Resuscitation Outcomes in Patients With Acute Pancreatitis. Cureus 2023; 15:e50182. [PMID: 38192944 PMCID: PMC10771961 DOI: 10.7759/cureus.50182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Traditionally, fluid resuscitation has been the foundation of effective acute pancreatitis (AP) treatment. Experts advocate for aggressive intravenous fluid (IVF) resuscitation, especially within the first 24 hours. Research suggests limited efficacy of this approach; in fact, some studies show there may be a risk of increased complications. The aim of this study was to assess outcomes of aggressive IVF resuscitation in patients with AP. METHODS We queried the TriNetX Research Network (Cambridge, Massachusetts, United States) for patients admitted between January 1, 2010, and December 31, 2020, with a diagnosis of AP and who had received IVF on admission for at least 24 hours. We compared two cohorts; cohort 1 consisted of patients receiving aggressive IVF resuscitation (>3 ml/kg/hr), and cohort 2 was comprised of patients receiving non-aggressive (≤1.5 ml/kg/hr) IVF resuscitation. We compared mortality during index hospitalization, hospital length of stay (HLS), mechanical ventilation rates, acute kidney injury (AKI), and severe sepsis between the cohorts with propensity scoring matched (PSM) pairs of patients. A sub-analysis of patients with severe AP was performed. RESULTS After comparing the two well-matched PSM cohorts (3,680/3,680), we found no significant differences in mortality, HLS, mechanical ventilation rates, AKI, or severe sepsis. We found similar results after conducting the sub-analysis of patients with severe pancreatitis. CONCLUSIONS We found no significant differences in mortality and HLS when comparing rates of IVF resuscitation.
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Affiliation(s)
- Julton Tomanguillo
- Internal Medicine, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
| | - Lauren Searls
- Internal Medicine, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
| | - Frank H Annie
- Cardiology, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
| | - Suzanne Kemper
- Outcomes Research, Charleston Area Medical Center (CAMC) Health Education and Research Institute, Charleston, USA
| | - Kerry Drabish
- Research, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
| | - Vishnu Naravadi
- Gastroenterology, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
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8
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Mehta MS. Acute pancreatitis in children: risk factors, management, and outcomes. Curr Opin Pediatr 2023; 35:590-595. [PMID: 37594373 DOI: 10.1097/mop.0000000000001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
PURPOSE OF REVIEW Pediatric acute pancreatitis is an infrequent but potentially serious condition in children. Most have mild cases with spontaneous resolution, but up to one-third of patients can have moderate or severe disease or progress to recurrent or chronic pancreatitis. RECENT FINDINGS Significant advances have been made in the field of pediatric pancreatology with a recognition that pediatric acute pancreatitis can vary significantly from adult disease with different risk factors and outcomes. There is better understanding of appropriate management for pediatric pancreatitis as well as growing literature in complications of pancreatitis. SUMMARY The most common risk factors for pediatric acute pancreatitis include biliary disease, drug/toxin and idiopathic. Management involves adequate fluid resuscitation, early enteral nutrition and appropriate pain control. Systemic and local complications, including SIRS, necrosis and fluid collections, can occur in up to one-third of patients and care is largely supportive with a careful step-up approach to fluid collections and necrosis.
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Affiliation(s)
- Megha S Mehta
- Division of Pediatric Gastroenterology, UT Southwestern Medical Center, Dallas, Texas, USA
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9
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Gianesini G, Drigo M, Zoia A. Immune-Mediated Hemolytic Anemia and Clinically Suspected Acute Pancreatitis in Dogs, a Pilot Study. Top Companion Anim Med 2023; 56-57:100821. [PMID: 37802244 DOI: 10.1016/j.tcam.2023.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/17/2023] [Accepted: 10/01/2023] [Indexed: 10/08/2023]
Abstract
Acute pancreatitis can be a complication of massive hemolysis, above all when intravascular in nature. Therefore, the aim of this study was to investigate the association between canine immune mediated hemolytic anemia (IMHA) and clinically suspected acute pancreatitis (CSAP) and the role of calculated free plasma hemoglobin (Hbfp) in CSAP occurrence/development. In this cohort study the records of 95 dogs with IMHA and 95 sick dogs with pathologies other than IMHA were compared for CSAP occurrence/development. At presentation, 12/95 dogs with IMHA met criteria for CSAP, while only 3/95 sick control dogs met these criteria (χ2 =1.58, P = .008). Within 7 days of hospitalization 9 additional dogs with IMHA had developed CSAP. The Hbfp was calculated and compared for dogs with IMHA that had/developed CSAP and for those without CSAP. In dogs with IMHA, a calculated Hbfp concentration ≥ 0.08 g/dL resulted in an increased relative risk (RR) of having/developing CSAP (RR = 2.54, 95% CI, 1.51-4.29; P = .003). No significant effect on short-term prognosis in dogs with IMHA was found between those having/developing CSAP and those without CSAP. This study showed that dogs with IMHA have an increased risk of having CSAP and Hbfp concentration may be involved in the pathogenesis of acute pancreatitis.
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Affiliation(s)
- Giulia Gianesini
- Division of Internal Medicine, San Marco Veterinary Clinic, Veggiano, Italy
| | - Michele Drigo
- Department of Medicina Animale, Produzione e Salute, Padua University, Legnaro, Italy
| | - Andrea Zoia
- Division of Internal Medicine, San Marco Veterinary Clinic, Veggiano, Italy.
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Guo J, Hong J, He Y, Li Q, Huang T, Lou D, Zhang J. Comparison of early aggressive versus nonaggressive fluid resuscitation in acute pancreatitis: a meta-analysis. Therap Adv Gastroenterol 2023; 16:17562848231192144. [PMID: 37655061 PMCID: PMC10467253 DOI: 10.1177/17562848231192144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/19/2023] [Indexed: 09/02/2023] Open
Abstract
Background Early fluid resuscitation is one of the main therapeutic strategies for acute pancreatitis (AP). This study investigated the effects of early aggressive and nonaggressive hydration on AP. Objectives The aim of this meta-analysis is to investigate the differences between aggressive and nonaggressive intravenous fluid resuscitation in AP. Design This study was based on publicly available data, all of which have been extracted from previous ethically approved studies. Data sources and methods Two authors systematically searched PubMed, Embase (via OVID), Web of Science, and Cochrane Library to find all published research before February 2023. In-hospital mortality were set as primary endpoints. Results This meta-analysis included seven randomized controlled trials (RCTs) and eight cohort studies with 4072 individuals in nonaggressive (n = 2419) and aggressive (n = 1653) hydration groups. The results showed that patients in the nonaggressive group had a lower mortality rate than those in the aggressive hydration group [relative risks (RR), 0.66; p = 0.02]. Subgroup analysis results showed that patients in the nonaggressive hydration group had lower mortality rates in RCTs (RR, 0.39; p = 0.001), studies conducted in Eastern countries (RR, 0.63; p = 0.002), and studies with severe pancreatitis (RR, 0.65; p = 0.02). In addition, the nonaggressive hydration group had lower rates of infection (RR, 0.62; p < 0.001), organ failure (RR, 0.65; p = 0.02), and shock (RR, 0.21; p = 0.02), as well as a shorter hospital stay (weighted mean difference, -1.63; p = 0.001) than the aggressive hydration group. Conclusions Early nonaggressive fluid resuscitation is associated with lower mortality, lower risk of organ failure and infection, and shorter hospital stays than aggressive fluid resuscitation. Registration prospero registration number CRD42023396388.
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Affiliation(s)
- Jian Guo
- Intensive Care Unit, The Affiliated Hospital of Ningbo University, LiHuiLi Hospital, Ningbo, Zhejiang, China
| | - Jiaze Hong
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yujing He
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qingyuan Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Tongmin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Dandi Lou
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jie Zhang
- Emergency Department, Zhuji People’s Hospital, No.9, Jianmin Road, Taozhu Street, Shaoxing, Zhejiang 311899, China
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Yang AL, Vege SS. Fluid resuscitation in acute pancreatitis. Curr Opin Gastroenterol 2023:00001574-990000000-00086. [PMID: 37421393 DOI: 10.1097/mog.0000000000000959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW The purpose of the review is to critically evaluate the evidence from the literature to establish the current perspective on fluid resuscitation (FR) in acute pancreatitis (AP). We will review the rationale, type of fluid, rate of administration, total volume, duration, monitoring, ideal outcomes to be studied in clinical trials and recommendations for future studies. RECENT FINDINGS FR remains the key component of supportive therapy in AP. The paradigm has shifted from administration of aggressive fluid resuscitation towards more moderate FR strategies. Lactated Ringer's remains the preferred fluid for resuscitation. There remain critical gaps in knowledge regarding the end point(s) to indicate adequate resuscitation, and accurate assessments of fluid sequestration and intravascular volume deficit in AP. SUMMARY There is insufficient evidence to state that goal-directed therapy, using any of the parameters to guide fluid administration, reduces the risk of persistent organ failure, infected pancreatic necrosis, or mortality in AP, as well as the most appropriate method for the same.
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Affiliation(s)
- Allison L Yang
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York
| | - Santhi Swaroop Vege
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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12
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Ciuntu BM, Vintilă D, Tanevski A, Chiriac Ș, Stefănescu G, Abdulan IM, Balan GG, Veliceasa B, Bădulescu OV, Ghiga G, Fătu AM, Georgescu A, Vascu MB, Vasilescu AM. Severe Acute Pancreatitis Treated with Negative Pressure Wound Therapy System: Influence of Laboratory Markers. J Clin Med 2023; 12:jcm12113721. [PMID: 37297916 DOI: 10.3390/jcm12113721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/21/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
(1) Background: An open abdomen is a serious medical condition that requires prompt and effective treatment to prevent complications and improve patient outcomes. Negative pressure therapy (NPT) has emerged as a viable therapeutic option for temporary closure of the abdomen, offering several benefits over traditional methods. (2) Methods: We included 15 patients with pancreatitis who were hospitalized in the I-II Surgery Clinic of the Emergency County Hospital "St. Spiridon" from Iasi, Romania, between 2011-2018 and received NPT. (3) Results: Preoperatively, the mean IAP level was 28.62 mmHg, decreasing significantly postoperatively to 21.31 mmHg. The mean level of the highest IAP value recorded in pancreatitis patients treated with VAC did not differ significantly by lethality (30.31 vs. 28.50; p = 0.810). In vacuum-treated pancreatitis patients with a IAP level > 12, the probability of survival dropped below 50% during the first 7 days of stay in the ICU, so that after 20 days the probability of survival was approximately 20%. IAP enters the determinism of surgery with a sensitivity of 92.3% and a specificity of 99%, the cut-off value of IAP being 15 mmHg. (4) Conclusions: The timing of surgical decompression in abdominal compartment syndrome is very important. Consequently, it is vital to identify a parameter, easy to measure, within the reach of any clinician, so that the indication for surgical intervention can be made judiciously and without delay.
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Affiliation(s)
- Bogdan Mihnea Ciuntu
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Dan Vintilă
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Adelina Tanevski
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Ștefan Chiriac
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Gabriela Stefănescu
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Irina Mihaela Abdulan
- Department of Medical Specialties I, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Gheorghe G Balan
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Bogdan Veliceasa
- Department of Traumatology and Orthopaedics, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Oana Viola Bădulescu
- Department of Haematholohy, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Gabriela Ghiga
- Department of Mother and Child Medicine, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Ana Maria Fătu
- Discipline of Ergonomy, Department of Implantology Removable Denture Technology, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Andrei Georgescu
- Department of Odontology, Periodontology and Fixed Prosthesis, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Mihai Bogdan Vascu
- Department of Odontology, Periodontology and Fixed Prosthesis, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Alin Mihai Vasilescu
- Department of General Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
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Yaowmaneerat T, Sirinawasatien A. Update on the strategy for intravenous fluid treatment in acute pancreatitis. World J Gastrointest Pharmacol Ther 2023; 14:22-32. [PMID: 37179816 PMCID: PMC10167805 DOI: 10.4292/wjgpt.v14.i3.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/21/2023] [Accepted: 04/18/2023] [Indexed: 04/27/2023] Open
Abstract
Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process. For many years, without clear evidence, early and aggressive fluid resuscitation with crystalloid solutions (normal saline solution or Ringer lactate solution) was recommended. Recently, many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates, and this has triggered a paradigm shift in fluid management strategies. Meanwhile, there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context. The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis, including the type, optimal amount, rate of infusion, and monitoring guides. Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors' recommendations based on the available evidence.
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Affiliation(s)
- Thanapon Yaowmaneerat
- Nanthana-Kriangkrai Chotiwattanaphan Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai , Songkhla 90110, Thailand
| | - Apichet Sirinawasatien
- Department of Medicine, Division of Gastroenterology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
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14
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Ding X, Chen B. Effect of Aggressive Intravenous Fluid Resuscitation Versus Nonaggressive Fluid Resuscitation in the Treatment of Acute Pancreatitis: A Systematic Review and Meta-Analysis. Pancreas 2023; 52:e89-e100. [PMID: 37523599 DOI: 10.1097/mpa.0000000000002230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
OBJECTIVES Despite the need for active fluid therapy, fluid management of most acute pancreatitis (AP) cases is still supportive. The aim of this review is to compare the effect of aggressive versus nonaggressive intravenous (IV) fluid resuscitation in the treatment of acute pancreatitis. METHODS A systematic search of medical databases, such as Medline, Google Scholar, Science Direct, Cochrane Central, was conducted for publication until April 2022. We included randomized controlled trials or cohort (prospective and retrospective) studies reporting the outcomes of AP in patients that were managed with aggressive and nonaggressive IV fluid resuscitation. The primary outcome of interest was in-hospital mortality. RESULTS Fourteen trials involving 3423 acute pancreatitis patients were included in the review. We did not observe any differences in the risk of mortality, persistent organ failure, and systemic inflammatory response syndrome in both study groups. However, there was an increased risk of development of pancreatic necrosis, renal failure, and respiratory failure in the aggressive fluid therapy group compared with nonaggressive therapy. The funnel plot showed no publication bias. CONCLUSIONS Aggressive fluid therapy did not improve mortality rates in acute AP patients and was associated with an increased risk of acute renal failure, and respiratory failure.
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Affiliation(s)
| | - Bo Chen
- Department of Gastroenterology, QiLu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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15
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Bangolo AI, Akhter M, Auda A, Akram R, Nagesh VK, Athem D, Thomas R, Tibalan L, Trivedi M, Mushtaq S, Singh N, Bagale P, Arana GV, Khan T, Sharma S, Mynedi S, Patel DD, Saini M, Chinthakuntla MR, Ahmed K, Gad M, Gondhi SDDR, Arana G, Gurumoorthy RB, Weissman S. A Case Report of Acute Severe Necrotizing Pancreatitis following the Johnson & Johnson Vaccine against the Novel SARS-CoV-2. Case Rep Infect Dis 2023; 2023:9965435. [PMID: 37008512 PMCID: PMC10060063 DOI: 10.1155/2023/9965435] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/26/2023] [Accepted: 03/16/2023] [Indexed: 04/04/2023] Open
Abstract
Acute pancreatitis is an inflammatory condition, which is a leading gastrointestinal cause of hospitalization in the United States. Several conditions are associated with acute pancreatitis. More recently, there have been a few cases reported of acute pancreatitis following the Pfizer-BioNTech COVID-19 mRNA vaccine. To our knowledge, no cases of acute pancreatitis have been yet reported following the Johnson & Johnson's Janssen COVID-19 vaccine (J& J vaccine). Herein we report a 34-year-old male with no significant past medical history admitted with acute necrotizing pancreatitis, the day following the receipt of the J&J vaccine. Based on the Naranjo and the modified Naranjo scale, the patient met the requirements for probable drug induced pancreatitis. This case report has the objective to raise awareness of a potentially severe side effect of the J&J vaccine. We hope to use this case to support screening all patients for previous history of acute pancreatitis before administration of the J& J vaccine.
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Affiliation(s)
- Ayrton I. Bangolo
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Mahabuba Akhter
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Auda Auda
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Rahina Akram
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Vignesh K. Nagesh
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Donnee Athem
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Reenu Thomas
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Ligaya Tibalan
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Mansi Trivedi
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Saima Mushtaq
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Neha Singh
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Pracheta Bagale
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Georgemar V. Arana
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Tayyaba Khan
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Shelja Sharma
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Swetha Mynedi
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Dhara D. Patel
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | - Mandeep Saini
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | | | - Kareem Ahmed
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Mary Gad
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | | | - Georgemar Arana
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
| | | | - Simcha Weissman
- Department of Internal Medicine, Palisades Medical Center, North Bergen, NJ, USA
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16
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Crosignani A, Spina S, Marrazzo F, Cimbanassi S, Malbrain MLNG, Van Regenemortel N, Fumagalli R, Langer T. Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review. Ann Intensive Care 2022; 12:98. [PMID: 36251136 PMCID: PMC9576837 DOI: 10.1186/s13613-022-01072-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/11/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.
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Affiliation(s)
- Andrea Crosignani
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Spina
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Marrazzo
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Manu L N G Malbrain
- First Department of Anaesthesia and Intensive Therapy, Medical University of Lublin, Lublin, Poland.,International Fluid Academy, Lovenjoel, Belgium
| | - Niels Van Regenemortel
- Department of Intensive Care Medicine, Antwerp University Hospital, Antwerp, Belgium.,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Antwerp, Belgium
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Thomas Langer
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. .,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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Gardner TB. Fluid Resuscitation in Acute Pancreatitis - Going over the WATERFALL. N Engl J Med 2022; 387:1038-1039. [PMID: 36103418 DOI: 10.1056/nejme2209132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Timothy B Gardner
- From the Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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18
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Wu F, She D, Ao Q, Zhang S, Li J. Aggressive intravenous hydration protocol of Lactated Ringer's solution benefits patients with mild acute pancreatitis: A meta-analysis of 5 randomized controlled trials. Front Med (Lausanne) 2022; 9:966824. [PMID: 36160176 PMCID: PMC9492986 DOI: 10.3389/fmed.2022.966824] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/22/2022] [Indexed: 01/30/2023] Open
Abstract
Objective The aim of this meta-analysis was to determine the role of an aggressive intravenous hydration protocol of Lactated Ringer's solution in patients with mild acute pancreatitis (MAP). Methods A systematic search was conducted in PubMed, EMBASE, Cochrane Library, and China National Knowledge Infrastructure (CNKI) to identify randomized controlled trials (RCTs) published before August 19, 2022. The clinical outcomes were evaluated using the standard mean difference (SMD), mean difference (MD), risk ratio (RR), and 95% confidence interval (CI). The primary outcome was clinical improvement, while the secondary outcomes were the development of systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), relief of epigastric abdominal pain, and length of hospital stay (LoH). Statistical analysis was performed with RevMan 5.4. Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group system was used to determine the quality of evidences. Results There were five RCTs with 370 MAP patients included, and the overall methodological quality was moderate. Aggressive hydration protocol was comparable to standard hydration protocol in terms of clinical improvement (RR = 1.33, 95%CI = 0.95-1.87, P = 0.10; very low evidence). Fewer events of SIRS (RR = 0.48, 95%CI = 0.31-0.72, P < 0.001; low evidence) and MODS (RR = 0.34, 95%CI = 0.13-0.91, P = 0.03; moderate evidence) were reported in patients receiving aggressive hydration protocol. Meanwhile, aggressive hydration protocol also significantly relieved epigastric abdominal pain (SMD = -0.53, 95%CI = -0.81 to -0.25, P < 0.001; low evidence) and shorten the LoH (MD = -2.36, 95%CI = -3.17 to -1.55, P < 0.001; low evidence) compared with standard hydration protocol. Conclusion For patients with MAP, aggressive hydration protocol may be more effective than standard hydration protocol at lowering SIRS and MODS rates, relieving epigastric abdominal pain, and shortening the LoH. Due to the small number of studies that are eligible and poor methodological quality of eligible studies, further studies are required to validate our findings.
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Affiliation(s)
| | - Dong She
- Department of Emergency, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
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19
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Lactated Ringers Does Not Reduce SIRS in Acute Pancreatitis Compared to Normal Saline: An Updated Meta-Analysis. Dig Dis Sci 2022; 67:3265-3274. [PMID: 34328591 DOI: 10.1007/s10620-021-07153-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND We aimed to compare outcomes according to a Lactated Ringers (LR) versus Normal Saline (NS)-based strategy for acute pancreatitis. METHODS A database search through November 2020 was done to identify studies comparing LR to NS for fluid rehydration in AP. The primary endpoint was systemic inflammatory response syndrome (SIRS) at 24 h. Mantel-Haenszel pooled odds ratios (OR) and 95% confidence intervals were constructed using a random effects model. Heterogeneity was assessed using the I2 statistic. Publication bias was assessed using funnel plots. RESULTS Six studies were included totaling 549 patients. No difference in the odds of developing SIRS was noted at 24 h (pooled OR 0.59, 95% CI 0.22-1.62, P = 0.31) between LR and NS. I2 indices showed low heterogeneity between the groups, and a funnel plot showed no obvious publication bias. There was no difference between LR and NS found for SIRS at 48 and 72 h, mortality, and other secondary outcomes. LR was associated with a decreased need for ICU admission. CONCLUSIONS This updated meta-analysis does not support the previously published finding that the use of LR (rather than NS) leads to a statistically significant decreased odds of SIRS in acute pancreatitis.
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20
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Liao J, Zhan Y, Wu H, Yao Z, Peng X, Lai J. Effect of aggressive versus conservative hydration for early phase of acute pancreatitis in adult patients: A meta-analysis of 3,127 cases. Pancreatology 2022; 22:226-234. [PMID: 35031209 DOI: 10.1016/j.pan.2022.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/30/2021] [Accepted: 01/02/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The advantages of aggressive hydration compared to conservative hydration within 24 h for acute pancreatitis (AP) remain controversial in adult patients. A meta-analysis was undertaken to investigate whether aggressive strategies are more beneficial. METHODS We searched (on February 1, 2021) PubMed, Embase, and the Cochrane Library for eligible trials that assessed the two therapies and performed a meta-analysis. The primary endpoint was in-hospital mortality. Secondary outcomes were adverse events (e.g., renal failure and pancreatic necrosis) within 24 h of treatment. RESULTS Five randomized controlled trials and 8 observational trials involving 3127 patients were identified. Patients with severe pancreatitis showed significant difference of in-hospital mortality (OR 1.75; 95% CI 1.32-2.33) in aggressive hydration group, which were less susceptible to study type and age. Patients with severe pancreatitis were likely to develop respiratory failure (OR 5.08; 95% CI 2.31-11.15), persistent SIRS (OR 2.83; 95% CI 1.58-5.04), renal failure (OR 2.58; 95% CI 1.90-3.50) with significant difference. A longer hospital stay was observed in patients with severe pancreatitis (WMD 7.61; 95% CI 5.51-9.71; P < 0.05) in the aggressive hydration group. Higher incidence of pancreatic necrosis (OR 2.34; 95% CI 1.60-3.42; P < 0.05) was major susceptible to observational studies, old patients and mild pancreatitis. CONCLUSIONS Compared to conservative hydration, aggressive hydration increases in-hospital mortality and the incidence of renal failure, pancreatic necrosis with relatively strong evidence. Further investigation should be designed with a definitive follow-up period and therapeutic goals to address reverse causation bias.
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Affiliation(s)
- Jiyang Liao
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Yang Zhan
- The Acupuncture Rehabilitation Clinical College of Guangzhou University of Chinese Medicine, No. 12 Airport Road, Baiyun District, Guangzhou, 510000, Guangdong Province, China
| | - Huachu Wu
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Zhijun Yao
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Xian Peng
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Jianbo Lai
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China.
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HEPOKUR MN, ÖZKÖK M, ÖNDER A, ÇAĞLAR M, ÖZEMİR İA. A Rare Cause of Hypercalcemia : Two Cases of Parathyroid Adenoma. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.842622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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22
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Hudson-Phillips S, Mayo K, Cox K, Sharif Z, Burns J. Anorexia nervosa and pancreatitis. Br J Hosp Med (Lond) 2021; 82:1-7. [PMID: 34983221 DOI: 10.12968/hmed.2021.0429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute pancreatitis is a condition whereby erroneous activation of trypsin and zymogen results in pancreatic autodigestion. There are many aetiologies, with alcohol intake and gallstones being the most common. Anorexia nervosa is an eating disorder in which patients' reduced food intake and psychological aversion of weight gain can result in low body weight and malnourishment. The link between pancreatitis and anorexia nervosa is not well understood; this article explores the theorised pathophysiology connecting the two conditions, as well as the optimal management of patients when the conditions co-exist based on current literature. A literature search was performed using MEDLINE, EMBASE and CINAHL databases for all journal articles on the topic of presentations of acute or chronic pancreatitis in adults with anorexia nervosa. The literature proposes various links between anorexia nervosa and pancreatitis. It is theorised that pancreatitis may arise as a result of malnourishment itself or secondary to the refeeding process. Some explanations focus on the histopathological changes to the pancreas that malnourishment induces, while others focus on the enzymatic changes and oxidative damage that arise in the malnourished state. More mechanical mechanisms such as gastric dilatation, gastrointestinal ileus and compartmental fluid shift during refeeding have also been proposed as explanations for the link between the conditions. Some medications used in the management of anorexia nervosa have also been linked to pancreatitis.
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Affiliation(s)
| | - Kate Mayo
- Department of General Surgery, St George's Hospital, London, UK
| | - Kofi Cox
- St George's University, London, UK
| | | | - Joshua Burns
- Department of General Surgery, St George's Hospital, London, UK
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23
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Cohen RZ, Freeman AJ. Pancreatitis in Children. Pediatr Clin North Am 2021; 68:1273-1291. [PMID: 34736589 DOI: 10.1016/j.pcl.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric pancreatitis describes a spectrum covering acute pancreatitis, acute recurrent pancreatitis, and chronic pancreatitis, each with varying clinical manifestations and risk factors requiring a tailored diagnostic approach. We emphasize management strategies based on age, risk factors, recurrence, and complications. A discussion of the role of therapeutic endoscopy is reviewed and highlights the growing role of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in children with pancreatitis. Particular diagnostic challenges in autoimmune pancreatitis are reviewed with an emphasis on differentiating this entity from alternate pancreaticobiliary pathologies. Finally, we explore a multidisciplinary approach to acute recurrent and chronic pancreatitis.
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Affiliation(s)
- Reuven Zev Cohen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road Northeast, Atlanta, GA 30329, USA.
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road Northeast, Atlanta, GA 30329, USA
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24
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Aziz M, Ahmed Z, Weissman S, Ghazaleh S, Beran A, Kamal F, Lee-Smith W, Assaly R, Nawras A, Pandol SJ, McDonough S, Adler DG. Lactated Ringer's vs normal saline for acute pancreatitis: An updated systematic review and meta-analysis. Pancreatology 2021; 21:1217-1223. [PMID: 34172360 DOI: 10.1016/j.pan.2021.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/18/2021] [Accepted: 06/09/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Recent studies have evaluated and compared the efficacy of normal saline (NS) and lactated Ringer's (LR) in reducing the severity of acute pancreatitis (AP) and improving outcomes such as length of stay, the occurrence of the systemic inflammatory response syndrome (SIRS), ICU admission and mortality. We performed an updated systematic review and meta-analysis of the available studies to assess the impact of these fluids on outcomes secondary to AP. METHODS We systematically searched the following databases: PubMed/Medline, Embase, Cochrane, and Web of Science through February 8th, 2021 to include randomized controlled trials (RCTs) and cohort studies. Random effects model using DerSimonian-Laird approach was employed and risk ratios (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated for binary and continuous outcomes, respectively. RESULTS 6 studies (4 RCTs and 2 cohort studies) with 549 (230 in LR and 319 in NS) were included. The overall mortality (RR: 0.73, CI: 0.31-1.69) and SIRS at 24 h (RR: 0.69, CI: 0.32-1.51) was not significantly different. The overall ICU admission was lower in LR group compared to NS group (RR: 0.43, CI: 0.22-0.84). Subgroup analysis of RCTs demonstrated lower length of hospital stay for LR group compared to NS group (MD: 0.77 days, CI: 1.44 -0.09 days). CONCLUSION Our study demonstrated that LR improved outcomes (ICU admission and length of stay) in patients with AP compared to NS. There was no difference in rate of SIRS development and mortality between LR and NS treatments.
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Affiliation(s)
- Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA.
| | - Zohaib Ahmed
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Simcha Weissman
- Department of Medicine, Hackensack University - Palisades Medical Center, North Bergen, NJ, USA
| | - Sami Ghazaleh
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Faisal Kamal
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, OH, USA
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Stephen J Pandol
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Douglas G Adler
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA.
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Clinical Outcomes of Acute Pancreatitis in Patients with Cirrhosis According to Liver Disease Severity Scores. Dig Dis Sci 2021; 66:2795-2804. [PMID: 32892261 DOI: 10.1007/s10620-020-06575-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 08/21/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Literature on acute pancreatitis (AP) outcomes in patients with cirrhosis is limited. We aim to investigate the mortality and morbidity of AP in patients with cirrhosis. METHODS We conducted a retrospective cohort study, and propensity score matching was done to match cirrhotic with non-cirrhotic patients on a 1:2 basis. Outcomes included inpatient mortality, organs failure, systemic inflammatory response syndrome, and length of hospital stay. We performed subgroup analysis of cirrhotics according to Child-Pugh and MELD scores. Multivariable logistic regression models were tested. RESULTS From 819 AP patients, cirrhosis prevalence was 4.9% (40). There was no significant difference between cirrhotics and non-cirrhotics for inpatient mortality (7.5% vs. 1.3%, p = 0.1), severe AP (17.5% vs. 7.5%), shock (7.9% vs. 3%), respiratory failure (10% vs. 3.8%), need for intensive care unit (15% vs. 6.3%), systemic inflammatory response syndrome (SIRS) on admission (22.5% vs. 32.5%), and SIRS on day 2 (25% vs. 15%). Cirrhotics had similar rates of pancreatic necrosis, ileus, BISAP score, Marshall score, admission hematocrit, BUN, and hospital length of stay. Finally, cirrhotics who had severe AP, required ICU, and/or die in-hospital appeared to have more severe liver diseases (Child-C, higher MELD score > 17) and had lower AP severity scores (BISAP < 3, Marshall scores < 2). CONCLUSION In our study, cirrhotics hospitalized with AP had similar morbidity and mortality when compared to non-cirrhotics.
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The impact of fluid resuscitation via colon on patients with severe acute pancreatitis. Sci Rep 2021; 11:12488. [PMID: 34127776 PMCID: PMC8203607 DOI: 10.1038/s41598-021-92065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/04/2021] [Indexed: 11/09/2022] Open
Abstract
Severe acute pancreatitis (SAP) is a life-threatening disease. Fluid Resuscitation Via Colon (FRVC) may be a complementary therapy for early controlled fluid resuscitation. But its clinical application has not been reported. This study aims to explore the impact of FRVC on SAP. All SAP patients with the first onset within 72 h admitted to the hospital were included from January 2014 to December 2018 through electronic databases of Ruijin hospital and were divided into FRVC group (n = 103) and non-FRVC group (n = 78). The clinical differences before and after the therapy between the two groups were analyzed. Of the 181 patients included in the analysis, the FRVC group received more fluid volume and reached the endpoint of blood volume expansion ahead of the non-FRVC group. After the early fluid resuscitation, the inflammation indicators in the FRVC group were lower. The rate of mechanical ventilation and the incidence of hypernatremia also decreased significantly. Using pure water for FRVC was more helpful to reduce hypernatremia. However, Kaplan–Meier 90-day survival between the two groups showed no difference. These results suggest that the combination of FRVC might benefit SAP patients in the early stage of fluid resuscitation, but there is no difference between the prognosis of SAP patients and that of conventional fluid resuscitation. Further prospective study is needed to evaluate the effect of FRVC on SAP patients.
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Letter to the Editor on "Early Rapid Fluid Therapy Is Associated with Increased Rate of Noninvasive Positive-Pressure Ventilation in Hemoconcentrated Patients with Severe Acute Pancreatitis". Dig Dis Sci 2021; 66:1757-1758. [PMID: 33433809 DOI: 10.1007/s10620-020-06736-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 11/18/2020] [Indexed: 12/09/2022]
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Abstract
PURPOSE OF REVIEW With a potentially life-threatening course, acute pancreatitis (AP) is one of the most common gastrointestinal diseases requiring hospitalization and often necessitating intensive care. Based on recent insights and recommendations, this review provides an overview on clinical management of AP patients with a focus on intensive care unit care. RECENT FINDINGS Possible benefits of percutaneous paracentesis and/or drainage on outcome or inflammation have been further explored. Combined opioid and epidural analgesia for pain management might be a valuable alternative for pain management. Very recent international guidelines now agree on a step-up approach for the management of acute necrotizing pancreatitis favoring a minimally invasive approach with either endoscopic or percutaneous drainage first. Studies for the best timing of these interventions are ongoing. In spite of a better understanding of pathophysiological mechanisms mediating AP, specific treatments are still awaited. SUMMARY New evidence and recent international consensus direct the current management of AP toward a tailored, multidisciplinary and less invasive therapy with complementary roles for hepatologists, intensivists, radiologists, and surgeons.
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Abstract
Acute pancreatitis is one of the most common gastrointestinal diseases requiring acute hospitalization and its incidence is increasing. A particular challenge is the prediction and treatment of severe cases, which only affect a minority of patients, but are associated with mortality rates of up to 30 percent. In this review, we consider the diagnostic evaluation of the disease and provide an overview of current conservative and interventional treatment strategies.
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Forman MA, Steiner JM, Armstrong PJ, Camus MS, Gaschen L, Hill SL, Mansfield CS, Steiger K. ACVIM consensus statement on pancreatitis in cats. J Vet Intern Med 2021; 35:703-723. [PMID: 33587762 PMCID: PMC7995362 DOI: 10.1111/jvim.16053] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 12/16/2022] Open
Abstract
Background Pancreatitis in cats, although commonly diagnosed, still presents many diagnostic and management challenges. Objective To summarize the current literature as it relates to etiology, pathogenesis, diagnosis, and management of pancreatitis in cats and to arrive at clinically relevant suggestions for veterinary clinicians that are based on evidence, and where such evidence is lacking, based on consensus of experts in the field. Animals None. Methods A panel of 8 experts in the field (5 internists, 1 radiologist, 1 clinical pathologist, and 1 anatomic pathologist), with support from a librarian, was formed to assess and summarize evidence in the peer reviewed literature and complement it with consensus clinical recommendations. Results There was little literature on the etiology and pathogenesis of spontaneous pancreatitis in cats, but there was much in the literature about the disease in humans, along with some experimental evidence in cats and nonfeline species. Most evidence was in the area of diagnosis of pancreatitis in cats, which was summarized carefully. In contrast, there was little evidence on the management of pancreatitis in cats. Conclusions and Clinical Importance Pancreatitis is amenable to antemortem diagnosis by integrating all clinical and diagnostic information available, and recognizing that acute pancreatitis is far easier to diagnose than chronic pancreatitis. Although both forms of pancreatitis can be managed successfully in many cats, management measures are far less clearly defined for chronic pancreatitis.
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Affiliation(s)
- Marnin A Forman
- Cornell University Veterinary Specialists, Stamford, Connecticut, USA
| | - Joerg M Steiner
- Gastrointestinal Laboratory, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - P Jane Armstrong
- College of Veterinary Medicine, University of Minnesota, St Paul, Minnesota, USA
| | - Melinda S Camus
- Department of Pathology, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Lorrie Gaschen
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Louisiana, USA
| | - Steve L Hill
- Flagstaff Veterinary Internal Medicine Consulting, Flagstaff, Arizona, USA
| | | | - Katja Steiger
- Institute of Pathology, School of Medicine, Technical University of Munich, Munich, Germany
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Di Mauro D, Smith R, Wijesurendere C, Hubble S, Manzelli A. Does the Implementation of a Clinical Care Pathway Have an Impact on Early Intravenous Fluid Therapy of Acute Pancreatitis?: A Pilot Quality Improvement Study. Pancreas 2021; 50:189-195. [PMID: 33565794 DOI: 10.1097/mpa.0000000000001736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Early intravenous fluid (IVF) resuscitation is crucial in the management of acute pancreatitis; variation in IVF prescription practice had been demonstrated. This pilot study aims to assess whether the implementation of an Acute Pancreatitis Care Pathway (APCP) produces a change toward a more adequate IVF regimen in the first 24 hours. METHODS Patients with confirmed diagnosis of acute pancreatitis, from July 2015 to February 2016 (group 1) and from September 2017 to March 2018 (group 2), were considered. The APCP was developed between March 2016 and August 2017. Median IVF rate, volume, and type infused in the first 24 hours, were compared between groups. Nonparametric data were analyzed with the Mann-Whitney U test, differences in frequencies with the McNemar test; significance was set at P < 0.05. RESULTS Seventy-two patients were included, 36 in each group. In the first 24 hours, the median IVF rate was 177 mL/h vs 225 mL/h (P = 0.004); Ringer lactate infusion was 30% vs 77.8% (P = 0.0003). The median total IVF volume did not differ between groups. CONCLUSIONS The implementation of the APCP has the potential to lead to a successful change in early IVF resuscitation practice.
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Affiliation(s)
- Davide Di Mauro
- From the Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter
| | - Radford Smith
- Department of Surgery, Norwich & Norfolk University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | | | - Sheena Hubble
- From the Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter
| | - Antonio Manzelli
- From the Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter
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Abstract
Acute pancreatitis is one of the most common reasons for gastroenterology-related hospitalization in the United States. With significant morbidity and subsequent mortality related to both the acute presentation and subsequent sequelae, prompt diagnosis and appropriate management are critical, especially in the first 24 hours of illness. It is also important to accurately recognize complications, such as pancreatic fluid collections and vascular events, and identify a definitive cause so that a strategy to prevent future attacks can be implemented.
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Scurt FG, Bose K, Canbay A, Mertens PR, Chatzikyrkou C. [Acute kidney injury following acute pancreatitis (AP-AKI): Definition, Pathophysiology, Diagnosis and Therapy]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:1241-1266. [PMID: 33291178 DOI: 10.1055/a-1255-3413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis (AP) is the most frequent gastrointestinal cause for hospitalization and one of the leading causes of in-hospital deaths. Severe acute pancreatitis is often associated with multiorgan failure and especially with acute kidney injury (AKI). AKI can develop early or late in the course of the disease and is a strong determinator of outcome. The mortality in the case of dialysis-dependent AKI and acute pancreatitis raises exponentially in the affected patients. AP-induced AKI (AP-AKI) shows many similarities but also distinct differences to other causes of AKI occurring in the intensive care unit setting. The knowledge of the exact pathophysiology can help to adjust, control and improve therapeutic approaches to the disease. Unfortunately, there are only a few studies dealing with AP and AKI.In this review, we discuss recent data about pathogenesis, causes and management of AP-AKI in patients with severe acute pancreatitis and exploit in this regard the diagnostic and prognostic potential of respective newer serum and urine markers.
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Affiliation(s)
- Florian Gunnar Scurt
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University, Magdeburg, Germany
| | - Katrin Bose
- Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University, Magdeburg, Germany.,Universitätsklinik für Gastroenterologie, Hepatologie und Infektiologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Otto-von-Guericke-Universität, Magdeburg, Deutschland
| | - Ali Canbay
- Ruhr-Universität Bochum, Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Deutschland
| | - Peter R Mertens
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto-von-Guericke-University, Magdeburg, Germany
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Effects of Fluid Resuscitation on the Occurrence of Organ Failure and Mortality in Patients With Acute Pancreatitis. Pancreas 2020; 49:1315-1320. [PMID: 33122519 DOI: 10.1097/mpa.0000000000001681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Acute pancreatitis (AP) is a serious gastroenterological condition requiring urgent fluid resuscitation and emergent intensive care. However, the benefit of fluid resuscitation is inconsistent. Therefore, this study aimed to examine the effects of fluid resuscitation on the occurrence of organ failure and mortality in patients with AP. METHODS The data were retrospectively extracted from the Medical Information Mart for Intensive Care III 2002-2012 database. The fluid resuscitation and fluid balance were calculated at 12, 24, 36, and 48 hours after intensive care unit admission. Multivariate analysis models were used. RESULTS A total of 317 patients with AP were included. Odds of organ failure increased significantly with increased fluid input at 0 to 12 hours [adjusted odds ratio (aOR), 1.124; 95% confidence interval (CI), 1.015-1.244] and with increased fluid balance at 36 to 48 hours (aOR, 1.184; 95% CI, 1.009-1.389). Odds of in-hospital mortality increased significantly with increased fluid balance at 24 to 36 hours (aOR, 1.201; 95% CI, 1.052-1.371). Odds of 30-day mortality increased significantly with increased fluid balance at 24 to 36 hours (aOR, 1.189; 95% CI, 1.039-1.361). CONCLUSIONS Increased fluid balance was associated with increased risk of organ failure and mortality. Increased fluid output may decrease mortality.
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Mazrouei SSA, Saeed GA, Al Helali AA. COVID-19-associated acute pancreatitis: a rare cause of acute abdomen. Radiol Case Rep 2020; 15:1601-1603. [PMID: 32685078 PMCID: PMC7287434 DOI: 10.1016/j.radcr.2020.06.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/06/2020] [Accepted: 06/07/2020] [Indexed: 01/08/2023] Open
Abstract
Covid-19 is a viral disease that has spread throughout the world causing unprecedented impact on millions of people. It's a pandemic disease called officially by the World Health Organization in March 11, 2020. The disease mainly involves the upper respiratory tract system. Extrapulmonary manifestations are still not well understood. In this report, we describe a case of acute pancreatitis in a patient with Covid-19 infection who presented to our hospital.
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Affiliation(s)
| | - Ghufran Aref Saeed
- General radiology, Sheikh Department of Radiology, Khalifa Medical City, Abu Dhabi, UAE
| | - Abeer Ahmed Al Helali
- Department of General radiology, Sheikh Department of Radiology, Khalifa Medical City, Abu Dhabi, UAE
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Simons-Linares CR, Romero-Marrero C, Jang S, Bhatt A, Lopez R, Vargo J, Stevens T, Carey W, Chahal P. Clinical outcomes of acute pancreatitis in patients with cirrhosis. Pancreatology 2020; 20:44-50. [PMID: 31734110 DOI: 10.1016/j.pan.2019.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 11/02/2019] [Accepted: 11/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AP outcomes in cirrhotic patients have not yet been studied. We aim to investigate the outcomes of cirrhotics patients with acute pancreatitis. METHODS The National Inpatient Sample (NIS) database (2003-2013) was queried for patients with a discharge diagnosis of AP and liver cirrhosis. Cirrhosis was further classified as compensated and decompensated using the validated Baveno IV criteria. Primary outcome was inpatient mortality. The analysis was adjusted for age, gender, race, Charlson comorbidity index (CCI), median income quartile, and hospital characteristics. RESULTS Over 2.8 million patients with acute pancreatitis were analyzed. Cirrhosis prevalence was 2.8% (80,093). Both compensated and decompensated cirrhosis subjects had significantly higher mortality. Highest odds ratios (OR) were: inpatient mortality (OR 3.4, P < 0.001), Shock (OR 1.5, P = 0.02), Ileus (OR: 1.3, p = 0.02, ARDS (OR 1.2, p = 0.03), upper endoscopy performed (OR 2.0, p < 0.001), blood transfusions (OR 3.1, p < 0.001), gastrointestinal bleed (OR 5.5, p < 0.001), sepsis (OR 1.3, p = 0.005), portal vein thrombosis (PVT) (OR 7.2, p < 0.001), acute cholecystitis (OR 1.3, p < 0.001). Interestingly, cirrhosis patients had lower hospital length of stay, (OR 0.16, p < 0.001), AKI (OR 0.93, p = 0.06), myocardial infarction (OR 0.31, p < 0.001), SIRS (OR 0.62, p < 0.001), parenteral nutrition requirement (OR 0.84, p = 0.002). Decompensated cirrhosis had higher inflation-adjusted hospital charges (+$3896.60; p < 0.001). CONCLUSION AP patients with cirrhosis have higher inpatient mortality, but it is unlikely to be due to AP severity as patients had lower incidence of SIRS and AKI. Higher mortality is possibly related to complications of cirrhosis and portal hypertension itself such as GI bleed, shock, PVT, AC and sepsis.
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Affiliation(s)
- C Roberto Simons-Linares
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Carlos Romero-Marrero
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sunguk Jang
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Amit Bhatt
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rocio Lopez
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John Vargo
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tyler Stevens
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - William Carey
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Prabhleen Chahal
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Shemesh E, Zafrir B. Hypertriglyceridemia-Related Pancreatitis In Patients With Type 2 Diabetes: Links And Risks. Diabetes Metab Syndr Obes 2019; 12:2041-2052. [PMID: 31632114 PMCID: PMC6789969 DOI: 10.2147/dmso.s188856] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/15/2019] [Indexed: 12/11/2022] Open
Abstract
Disturbances in glucose and lipid homeostasis are cardinal features of the metabolic syndrome that affect millions of people worldwide. These conditions have multi-organ impact, and while cardiovascular effects are usually the core for studies and preventive measures, other systems may also be affected, including the pancreas. Acute pancreatitis related to severe hypertriglyceridemia is an under-recognized condition that could lead to significant morbidity and mortality. Therefore, when suspected, prompt diagnosis and treatment should be initiated to cover the various aspects of this disorder. Though commonly known to be associated with excess of alcohol use, hypertriglyceridemia-related pancreatitis is particularly observed in diabetics, especially when uncontrolled. Here, we portray the possible mechanisms and clinical features that link type 2 diabetes, hypertriglyceridemia and pancreatitis, and discuss their health-related outcomes and the current and novel treatment options for this unique disease.
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Affiliation(s)
- Elad Shemesh
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Barak Zafrir
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
- Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel
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38
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Goodchild G, Chouhan M, Johnson GJ. Practical guide to the management of acute pancreatitis. Frontline Gastroenterol 2019; 10:292-299. [PMID: 31288253 PMCID: PMC6583768 DOI: 10.1136/flgastro-2018-101102] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/09/2018] [Indexed: 02/04/2023] Open
Abstract
Acute pancreatitis (AP) is characterised by inflammation of the exocrine pancreas and is associated with acinar cell injury and both a local and systemic inflammatory response. AP may range in severity from self-limiting, characterised by mild pancreatic oedema, to severe systemic inflammation with pancreatic necrosis, organ failure and death. Several international guidelines have been developed including those from the joint International Association of Pancreatology and American Pancreatic Association, American College of Gastroenterology and British Society of Gastroenterology. Here we discuss current diagnostic and management challenges and address the common dilemmas in AP.
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Affiliation(s)
- George Goodchild
- Department of Gastroenterology, University College Hospital, London, UK
| | - Manil Chouhan
- Department of Radiology, University College Hospital, London, UK
| | - Gavin J Johnson
- Department of Gastroenterology, University College Hospital, London, UK
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Hong W, Lillemoe KD, Pan S, Zimmer V, Kontopantelis E, Stock S, Zippi M, Wang C, Zhou M. Development and validation of a risk prediction score for severe acute pancreatitis. J Transl Med 2019; 17:146. [PMID: 31068202 PMCID: PMC6505180 DOI: 10.1186/s12967-019-1903-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/02/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The available prognostic scoring systems for severe acute pancreatitis (SAP) have limitations that restrict their clinical value. The aim of this study was to develop a simple model (score) that could rapidly identify those at risk for SAP. METHODS We derived a risk model using a retrospective cohort of 700 patients by logistic regression and bootstrapping methods. The discriminative power of the risk model was assessed by calculating the area under the receiver operating characteristic curves (AUC). The classification and regression tree (CART) analysis was used to create risk categories. The model was internally validated by a tenfold cross-validation and externally validated in a separate prospective cohort of 194 patients. RESULTS The incidence of SAP was 9.7% in the derivation cohort and 9.3% in the validation cohort. A prognostic score (We denoted it as the SABP score), ranging from 0 to 10, consisting of systemic inflammatory response syndrome, serum albumin, blood urea nitrogen and pleural effusion, was developed by logistic regression and bootstrapping analysis. Patients could be divided into three risk categories according to total SABP score based on CART analysis. The mean probability of developing SAP was 1.9%, 12.8% and 41.6% in patients with low (0-3), moderate (4-6) and high (7-10) SABP score, respectively. The AUCs of prognostic score in tenfold cross-validation was 0.873 and 0.872 in the external validation. CONCLUSION Our risk prediction score may assist physicians in predicting the development of SAP.
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Affiliation(s)
- Wandong Hong
- grid.414906.e0000 0004 1808 0918Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000 Zhejiang People’s Republic of China
| | - Keith D. Lillemoe
- grid.32224.350000 0004 0386 9924Department of Surgery, Massachusetts General Hospital Harvard Medical School, Boston, MA 02114 United States
| | - Shuang Pan
- grid.414906.e0000 0004 1808 0918Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang People’s Republic of China
| | - Vincent Zimmer
- grid.11749.3a0000 0001 2167 7588Department of Medicine II, Saarland University Medical Center, Saarland University, 66424 Homburg, Germany
- Department of Medicine, Marienhausklinik St. Josef Kohlhof, 66539 Neunkirchen, Germany
| | - Evangelos Kontopantelis
- grid.5379.80000000121662407Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9GB UK
- grid.5379.80000000121662407NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Simon Stock
- Department of Surgery, World Mate Emergency Hospital, Battambang, Cambodia
| | - Maddalena Zippi
- grid.415113.30000 0004 1760 541XUnit of Gastroenterology and Digestive Endoscopy, Sandro Pertini Hospital, Rome, Italy
| | - Chao Wang
- grid.429222.d0000 0004 1798 0228Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Jiangsu, People’s Republic of China
| | - Mengtao Zhou
- grid.414906.e0000 0004 1808 0918Department of Surgery, Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang People’s Republic of China
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Temporal Trends in Incidence and Outcomes of Acute Pancreatitis in Hospitalized Patients in the United States From 2002 to 2013. Pancreas 2019; 48:169-175. [PMID: 30629021 DOI: 10.1097/mpa.0000000000001228] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES We sought to examine temporal trends in incidence and outcomes of acute pancreatitis (AP) in hospitalized adult patients in the United States. METHODS Subjects were obtained from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for the years 2002-2013. Incidence of AP, all-cause mortality, cost, and duration of hospitalization were assessed. RESULTS We identified 4,791,802 cases of AP. A significant increase in the incidence of AP was observed from 9.48 cases per 1000 hospitalizations in 2002 to 12.19 per 1000 hospitalizations in 2013 (P < 0.001). In-hospital mortality decreased from 2.99 cases per 100 cases in 2002 to 2.04 cases per 100 cases in 2013 (P < 0.001). Mean length of stay decreased from 6.99 (standard deviation [SD], 9.37) days in 2002 to 5.74 (SD, 7.94) days in 2013 (P < 0.001). Cost of hospitalization increased from $27,827 (SD, $54,556) in 2002 to $49,772 (SD, $106,205) in 2013 (P < 0.001). CONCLUSIONS Hospital admissions for AP in adults increased significantly in the United States from 2002 to 2013. In-hospital all-cause mortality and mean length of stay significantly decreased. In contrast, total cost of hospitalization rose.
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Early Hemoconcentration Is Associated With Increased Opioid Use in Hospitalized Patients With Acute Pancreatitis. Pancreas 2019; 48:193-198. [PMID: 30629025 DOI: 10.1097/mpa.0000000000001240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Opioids are commonly required for abdominal pain in hospitalized patients with acute pancreatitis (AP). The factors associated with increased opioid requirements are unknown. METHODS The medical records of adult inpatients with AP from 2006 to 2016 were reviewed. Patients with chronic pancreatitis, psychiatric comorbidities, intubation, chronic opioid, and illicit drug use were excluded. The total quantity of opioids required during the first 7 days of hospitalization was converted to oral morphine equivalents (OME), divided by the number of days opioids were required to obtain the mean OME per day(s) of treatment (MOME). Multiple regression analysis was performed to identify factors associated with MOME. RESULTS A total of 267 patients were included. The mean (standard deviation) age was 46.9 (13.9) years and 56% were males. The most common etiology was alcohol (55.4%). The mean (standard deviation) MOME was 59.1 (54.5) mg. Although age (P = 0.008), black race (P = 0.004), and first episode of AP (P = 0.049) were associated with a lower MOME, early hemoconcentration (hematocrit ≥44%) (P < 0.001) was associated with an increased MOME. CONCLUSIONS Early hemoconcentration is associated with an increased opioid requirement in hospitalized patients with AP. The impact of fluid therapy in these patients merits prospective study.
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Grover AS, Freeman AJ, Abu-El-Haija M, Eisses JF, Gardner TB, Liu QY, Lowe ME, Nathan JD, Palermo TM, Singh VK, Trout AT, Uc A, Husain SZ, Morinville VD. Updates in Pediatric Pancreatology: Proceedings of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Frontiers in Pediatric Pancreatology Symposium. J Pediatr Gastroenterol Nutr 2019; 68:e27-e33. [PMID: 30888340 PMCID: PMC6444930 DOI: 10.1097/mpg.0000000000002186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Pancreas Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition aims to promote awareness of pediatric pancreatic diseases, support clinical and basic science research in the field, educate pediatric gastroenterologists, and advocate on behalf of pediatric patients with pancreatic disorders. At the 2017 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the Pancreas Committee held a full day symposium on pediatric pancreatic diseases, entitled, "Frontiers in Pediatric Pancreatology." The symposium served as a timely and novel academic meeting that brought together individuals with a vested interest in the care of children with pancreatic disorders. The objective of this day-long course was to update practicing gastroenterologists on the latest advances in research, management algorithms, endoscopic therapies, radiographic resources, surgical approaches, and novel drug therapies targeted to pediatric pancreatitis. Presentations were divided into 4 modules: diagnosis, risk factors, and natural history of pancreatitis; pancreatic imaging and exocrine function; management of pancreatitis; and new frontiers in pediatric pancreatitis research. The course fostered a unique ecosystem for interdisciplinary collaboration, in addition to promoting discussion and stimulating new research hypotheses regarding pediatric pancreatic disorders. Oral presentations by experts in various fields of pancreatology led to thought-provoking discussion; in addition, a meet-the-professor luncheon stimulated critical evaluation of current research in pediatric pancreatic diseases, highlighting knowledge gaps and future research endeavors. The current report summarizes the major learning points from this novel symposium focusing on the growing demographic of pediatric pancreatic diseases.
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Affiliation(s)
- Amit S Grover
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Alvin J Freeman
- Childrens' Healthcare of Atlanta, Division of Gastroenterology, Hepatology and Nutrition, Emory University, Atlanta, GA
| | - Maisam Abu-El-Haija
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - John F Eisses
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Timothy B Gardner
- Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Quin Y Liu
- Cedars-Sinai Medical Center, Digestive Diseases Center, Los Angeles, CA
| | - Mark E Lowe
- Department of Pediatrics, Children's Hospital of St. Louis, Washington University School of Medicine, St. Louis, MO
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Johns Hopkins Medical School, Baltimore, MD
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Aliye Uc
- Stead Family Children's Hospital, University of Iowa, Iowa City, IA
| | - Sohail Z Husain
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Veronique D Morinville
- Division of Pediatric Gastroenterology and Nutrition, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Yamashita T, Horibe M, Sanui M, Sasaki M, Sawano H, Goto T, Ikeura T, Hamada T, Oda T, Yasuda H, Ogura Y, Miyazaki D, Hirose K, Kitamura K, Chiba N, Ozaki T, Koinuma T, Oshima T, Yamamoto T, Hirota M, Masuda Y, Tokuhira N, Kobayashi M, Saito S, Izai J, Lefor AK, Iwasaki E, Kanai T, Mayumi T. Large Volume Fluid Resuscitation for Severe Acute Pancreatitis is Associated With Reduced Mortality: A Multicenter Retrospective Study. J Clin Gastroenterol 2019; 53:385-391. [PMID: 29688917 DOI: 10.1097/mcg.0000000000001046] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although fluid resuscitation is critical in acute pancreatitis, the optimal fluid volume is unknown. The aim of this study is to evaluate the association between the volume of fluid administered and clinical outcomes in patients with severe acute pancreatitis (SAP). METHODS We conducted a multicenter retrospective study at 44 institutions in Japan. Inclusion criteria were age 18 years or older, and diagnosed with SAP from 2009 to 2013. Patients were stratified into 2 groups: administered fluid volume <6000 and ≥6000 mL in the first 24 hours. We evaluated the association between the 2 groups and clinical outcomes using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes included the incidence of pancreatic infection and the need for surgical intervention. RESULTS We analyzed 1097 patients, and the mean fluid volume administered was 5618±3018 mL (mean±SD), with 708 and 389 patients stratified into the fluid <6000 mL and fluid ≥6000 mL groups, respectively. Overall in-hospital mortality was 12.3%. The fluid ≥6000 mL group had significantly higher mortality than the fluid <6000 mL group (univariable analysis, 15.9% vs. 10.3%; P<0.05). In multivariable logistic regression analysis, administration of ≥6000 mL of fluid within the first 24 hours was significantly associated with reduced mortality (odds ratio, 0.58; P<0.05). No significant association was found between the administered fluid volume and pancreatic infection, or between the volume administered and the need for surgical intervention. CONCLUSIONS In patients with SAP, administration of a large fluid volume within the first 24 hours is associated with decreased mortality.
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Affiliation(s)
- Takahiro Yamashita
- Emergency Medical Center, Fukuyama City Hospital, Zao-cho, Fukuyama City
- Acute Care Medical Center, Hyogo Prefectural Kakogawa Medical Center, Kanno-cho, Kakogawa City, Hyogo
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Shinjuku-ku
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Musashidai, Fuchu City
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Amanumacho, Omiya-ku, Saitama
| | - Mitsuhito Sasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tsukiji, Chuo-ku
| | - Hirotaka Sawano
- Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, Tsukumodai, Suita
| | - Takashi Goto
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, Motomachi, Naka-ku, Hiroshima City, Hiroshima
| | - Tsukasa Ikeura
- The Third Department of Internal Medicine, Kansai Medical University, Shinmachi, Hirakata
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Hongo, Bunkyo-ku
| | - Takuya Oda
- Department of General Internal Medicine, Iizuka Hospital, Yoshiomachi, Iizuka-shi
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Musashino Hospital, Kyounancho, Musashino City
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Musashidai, Fuchu City
| | - Dai Miyazaki
- Advanced Emergency Medical and Critical Care Center, Japanese Red Cross Maebashi Hospital, Asahi-cho, Maebashi City, Gunma
| | - Kaoru Hirose
- Department of Emergency Medicine, Shonan Kamakura General Hospital, Okamoto, Kamakura City, Kanagawa
| | - Katsuya Kitamura
- Division of Gastroentelology, Department of Medicine, Showa University School of Medicine, Hatanodai, Shinagawa-ku
| | - Nobutaka Chiba
- Department of Emergency and Critical Care Medicine, Nihon University Hospital, Kanda-Surugadai, Chiyoda-ku
| | - Tetsu Ozaki
- Department of Acute care and General Medicine, Saiseikai Kumamoto Hospital, Chikami, minami-ku, Kumamoto city, Kumamoto
| | - Toshitaka Koinuma
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Inohana, Chuo-ku, Chiba City, Chiba
| | - Tomonori Yamamoto
- Department of Traumatology and Critical Care Medicine, Osaka City University, Asahimachi, Abenoku, Osaka City, Osaka
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku University Hospital, Seiryo-cho, Aoba-ku
| | - Yukiko Masuda
- Emergency and Critical Care Center, National Hospital Organization Nagasaki Medical Center, Kubara, Omura, Nagasaki
| | - Natsuko Tokuhira
- Division of Intensive Care Medicine, University Hospital, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Mioko Kobayashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Kotobashi, Sumida-ku
| | - Shinjiro Saito
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Nishi-Shinbashi, Minato-ku, Tokyo
| | - Junko Izai
- Department of Surgery, Saka General Hospital, Nishiki-cho, Shiogama City, Miyagi
| | - Alan K Lefor
- Department of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Shinjuku-ku
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Shinjuku-ku
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Iseigaoka, Yahata Nishi, KitaKyushu, Fukuoka
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Abstract
Acute pancreatitis (AP) is a common clinical emergency disorder, and its morbidity is increasing gradually. Severe AP (SAP) often occurs with a sudden onset and high mortality. Microcirculation disturbance and hemodynamic abnormality is one of the main pathophysiologic mechanisms of SAP. Early fluid resuscitation is the cornerstone of therapy. However, at present, the fluid type, the amount of fluid resuscitation, and the rehydration rate are still in dispute. Early goal-directed fluid therapy as an important individualized liquid resuscitation strategy has great significance to improve the prognosis of SAP. This article reviews the pathophysiological mechanisms of microcirculation disturbance, the related dispute of liquid resuscitation therapy, and the application of early goal-directed treatment strategy.
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Affiliation(s)
- Ai-Ru Liu
- Department of Gastroenterology, the Second Hospital of Suzhou University, Suzhou 215004, Jiangsu Province, China
| | - Duan-Min Hu
- Department of Gastroenterology, the Second Hospital of Suzhou University, Suzhou 215004, Jiangsu Province, China
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45
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D'Haese J, Werner J. Translational Research for Acute Pancreatitis - Which Results Have Really Influenced Our Therapy? Visc Med 2018; 34:436-438. [PMID: 30675489 DOI: 10.1159/000493890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Acute pancreatitis is a common disease characterized by acinar cell destruction and acute inflammatory changes of the pancreas that lead to a systemic inflammatory response. A major research effort has been undertaken to unravel the underlying pathophysiology and to identify possible therapeutic targets. Still, only very few findings have influenced our clinical practice in the treatment of acute pancreatitis. Pancreatic microcirculation and capillary blood flow have long been suspected to play a major role in the course of the disease. It therefore seemed tempting to speculate that manipulation of the vasoconstrictor endothelin or its antagonist nitrogen monoxide could positively influence the outcome. We had to acknowledge, however, that these mechanisms take place very early in the disease course and that only prophylactic applications show an effect; this is useful in the setting of pancreas transplantation and endoscopic retrograde cholangiopancreatography but not applicable for clinical use in the therapy of acute pancreatitis. Research then focused on later pathophysiological stages of the disease, mainly on the process of adhesion and extravasation of leukocytes into the pancreatic tissue. Here, integrins and adhesion molecules like the intercellular adhesion molecule-1 (ICAM-1) were investigated in detail. A monoclonal antibody to ICAM-1 showed promising results in experimental models but was never further evaluated in the clinical setting. Hemodilution and fluid resuscitation was recognized to be an important therapeutic tool in acute pancreatitis. Here, initial experimental studies favored colloid solutions, and especially dextrans for isovolemic fluid resuscitation. It was recognized only later that colloid solutions are not effective and may even increase mortality in critically ill patients. Therefore, goal-directed infusion of Ringer's lactate solution at a moderate infusion rate to optimize volume status and hemoconcentration in acute pancreatitis is now advocated. In summary, out of the numerous experimental and translational studies, only very few have really influenced our daily clinical practice. Further research is therefore needed to find more specific and effective therapeutic agents for the treatment of acute pancreatitis.
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Affiliation(s)
- Jan D'Haese
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University of Munich, LMU, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University of Munich, LMU, Munich, Germany
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46
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Williams L, Rhodes KS, Karmally W, Welstead LA, Alexander L, Sutton L. Familial chylomicronemia syndrome: Bringing to life dietary recommendations throughout the life span. J Clin Lipidol 2018; 12:908-919. [DOI: 10.1016/j.jacl.2018.04.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/03/2018] [Accepted: 04/22/2018] [Indexed: 12/12/2022]
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47
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Mandalia A, Wamsteker EJ, DiMagno MJ. Recent advances in understanding and managing acute pancreatitis. F1000Res 2018; 7. [PMID: 30026919 DOI: 10.12688/f1000research.14244.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 12/16/2022] Open
Abstract
This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.
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Affiliation(s)
- Amar Mandalia
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
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48
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Abstract
This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.
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Affiliation(s)
- Amar Mandalia
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
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49
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Abstract
Acute pancreatitis represents a disorder characterized by acute necroinflammatory changes of the pancreas and is histologically characterized by acinar cell destruction. Diagnosed clinically with the Revised Atlanta Criteria, and with alcohol and cholelithiasis/choledocholithiasis as the two most prominent antecedents, acute pancreatitis ranks first amongst gastrointestinal diagnoses requiring admission and 21st amongst all diagnoses requiring hospitalization with estimated costs approximating 2.6 billion dollars annually. Complications arising from acute pancreatitis follow a progression from pancreatic/peripancreatic fluid collections to pseudocysts and from pancreatic/peripancreatic necrosis to walled-off necrosis that typically occur over the course of a 4-week interval. Treatment relies heavily on fluid resuscitation and nutrition with advanced endoscopic techniques and cholecystectomy utilized in the setting of gallstone pancreatitis. When necessity dictates a drainage procedure (persistent abdominal pain, gastric or duodenal outlet obstruction, biliary obstruction, and infection), an endoscopic ultrasound with advanced endoscopic techniques and technology rather than surgical intervention is increasingly being utilized to manage symptomatic pseudocysts and walled-off pancreatic necrosis by performing a cystogastrostomy.
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50
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Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology 2018; 154:1103-1139. [PMID: 29421596 DOI: 10.1053/j.gastro.2018.01.031] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Chris E Forsmark
- Division of Gastroenterology, University of Florida, Gainesville, Florida
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
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