Acute pancreatitis: etiology, clinical presentation, diagnosis, and therapy

Defining a therapeutic program for recurrent acute pancreatitis patients with unknown etiology

AIM

To define a therapeutic program for mild-moderate acute pancreatitis (AP), often recurrent, which at the end of the diagnostic process remains of undefined etiology.

MATERIAL AND METHODS

In the period 2011-2012, we observed 64 cases of AP: 52 mild-moderate, 12 severe; biliary 39, biliary in alcoholic chronic pancreatitis 5, unexplained recurrent 20. The clinical and instrumental evaluation of the 20 cases of unexplained AP showed 6 patients with biliary sludge, 4 microlithiasis, 4 sphincter of Oddi dysfunction, and 6 cases that remained undefined.

RESULTS

Among 20 patients with recurrent, unexplained AP at initial etiological assessment, we performed 10 video laparo cholecystectomies (VLCs), 2 open cholecystectomies and 4 endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomies (ERCP/ES) in patients who had undergone previous cholecystectomy; 4 patients refused surgery. Among these 20 patients, 6 had AP that remained unexplained after second-level imaging investigations. For these patients, 4 VLCs and 2 ERCP/ES were performed. Follow-up after six months was negative for further recurrence.

CONCLUSION

The recurrence of unexplained acute pancreatitis could be treated with empirical cholecystectomy and/or ERCP/ES in cases of previous cholecystectomy.

Effect of Da-Huang on intestinal motility failure in rats with severe acute pancreatitis

AIM: To investigate the effect of Da-Huang on intestinal motility failure in rats with severe acute pancreatitis (SAP) and the potential mechanism involved．

METHODS: Fifty-four SD rats were randomly divided into s sham operation (SO) group, a SAP group and a Da-Huang treatment group, with 18 rats in each group. Gastrointestinal motility disturbance in rats with SAP was induced by retrograde injection of sodium taurocholate (0.1 mL/100 g) into the bitiopancreatic duct. Before modeling, the rats in the treatment group received 10% Da-Huang solution (2 mL/100 g), and the rats in other two groups received 0.9% NaCl solution. The rats were sacrificed at 3, 6 and 12 h (6 rats at each time), and blood samples were taken for detecting the levels of amylase, lipase and the contents of 5-hydroxytryptamine (5-HT) by enzyme-linked immunosorbent assay. The jejunum, terminal ileum and sigmoid colon tissues 10 cm apart from the trans-ligament were collected at 6 h for examining the expressions of 5-HT₁ receptor (5-HT₁R) and 5-HT₂ receptor (5-HT₂R).

RESULTS: The levels of serum amylase, lipase and 5-HT at three time points in the SAP group (amylase: 9807 IU/L ± 698 IU/L, 15442 IU/L ± 952 IU/L, 18231 IU/L ± 869 IU/L; lipase: 94 IU/L ± 23 IU/L, 257 IU/L ± 99 IU/L, 306 IU/L ± 107 IU/L; 5-HT: 1192 ng/mL ± 142 ng/mL, 1437 ng/mL ± 114 ng/mL, 1646 ng/mL ± 163 ng/mL) and treatment group (amylase: 2238 IU/L ± 298 IU/L, 2313 IU/L ± 302 IU/L, 2289 IU/L ± 323 IU/L; lipase: 62 IU/L ± 16 IU/L, 71 IU/L ± 17 IU/L, 69 IU/L ± 15 IU/L; 5-HT: 794 ng/mL ± 86 ng/mL, 814 ng/mL ± 83 ng/mL, 798 ng/mL ± 81 ng/mL) were significantly higher than those in the SO group (amylase: 1853 IU/L ± 272 IU/L, 1959 IU/L ± 269 IU/L, 1897 IU/L ± 293 IU/L; lipase: 46 IU/L ± 9 IU/L, 54 IU/L ± 11, 52 IU/L ± 14 IU/L; 5-HT: 699 ng/mL ± 64 ng/mL, 721 ng/mL ± 76 ng/mL, 705 ng/mL ± 72 ng/mL)(all P < 0.01), but they were lower in the treatment group than in the SAP group at each time point (all P < 0.01). The expression of 5-HT1R and 5-HT₂R proteins was significantly decreased in the jejunum, terminal ileum and sigmoid colon in the SAP group compared with the SO group (all P < 0.05). The areas of 5-HT₁R and 5-HT₂R positive cells in the jejunum, terminal ileum and sigmoid colon in the SAP group (5-HT₁R positive cells: 4.58 × 10⁴ μm² ± 0.56 × 10⁴ μm²、4.64 × 10⁴ μm² ± 0.63 × 10⁴ μm²、4.79 × 10⁴ μm² ± 0.56 × 10⁴ μm², 5-HT₂R positive cells: 4.89 × 10⁴ μm² ± 0.61 × 10⁴ μm², 4.76 × 10⁴ μm² ± 0.51 × 10⁴ μm², 5.03 × 10⁴ μm² ± 0.73 × 10⁴ μm²) were significantly decreased compared with the SO group (5-HT₁R positive cells: 5.63 × 10⁴ μm² ± 0.82 × 10⁴ μm², 5.94 × 10⁴ μm² ± 0.91 × 10⁴ μm², 6.37 × 10⁴ μm² ± 0.87 × 10⁴ μm², 5-HT₂R positive cells: 6.02 × 10⁴ μm² ± 0.78 × 10⁴ μm², 5.98 × 10⁴ μm² ± 0.66 ×10⁴ μm², 6.49× 10⁴ μm² ± 0.85 × 10⁴ μm²). The expression of 5-HT₁R protein and the areas of 5-HT₁ positive cells in the jejunum, terminal ileum and sigmoid colon in the treatment group (5.57 × 10⁴ μm² ± 0.83 × 10⁴ μm², 5.82 × 10⁴ μm² ± 0.74 × 10⁴ μm², 6.02 × 10⁴ μm² ± 0.81 × 10⁴ μm²), but not the areas of 5-HT₂ positive cells (4.94 × 10⁴ μm² ± 0.59 × 10⁴ μm², 4.81 × 10⁴ μm² ± 0.63 × 10⁴ μm², 5.16 × 10⁴ μm² ± 0.79 × 10⁴ μm²), were increased in comparison with SAP group (all P < 0.05)．

CONCLUSION: The level of 5-HT is significantly increased in SAP, but its receptors (5-HT₁R and 5-HT₂R) are decreased, which may induce intestinal motility failure. Da-Huang may improve enteric dynamic failure by activating 5-HT₁R or increasing the expression of 5-HT₁R, and may be a choice for treatment of SAP with intestinal motility failure．

Effect of mesenchymal stem cells on renal injury in rats with severe acute pancreatitis

The aim of this study was to preliminarily investigate the effect of bone marrow mesenchymal stem cells (MSCs) on structural change of capillary endothelial barrier and expression variation of aquaporin 1 (AQP1) in kidney at the onset of renal injury caused by severe acute pancreatitis (SAP). Ninety male Sprague-Dawley (SD) rats were divided into the control group, the SAP group in which animals received induction of SAP and the MSCs-treated group in which SAP-induced animals were injected with MSCs. They were further subdivided according to the time point that the animals were killed; 6 h, 12 h and 24 h after the closure of the incision, serum, pancreatic and renal samples were collected, respectively. The level of serum amylase (AMY), creatinine (Cr) and blood urea nitrogen (BUN) were analysed, the change of pancreatic histology was assessed, the structural change of the renal interstitial capillaries was evaluated using the transmission electron microscope (TEM) and the location and expression of AQP1 in kidney were analysed using immunohistochemistry, quantitative polymerase chain reaction and Western blot. The outcomes showed that the level of serum AMY, Cr, BUN elevated, the damage of pancreatic tissue and renal capillary endothelial barrier was aggravated and the expression of AQP1 was reduced significantly after induced pancreatitis. But after treatments with MSCs, the elevation of AMY, Cr and BUN was inhibited, the damage of pancreatic tissue and renal interstitial capillary barrier was alleviated and the down-regulation of AQP1 was reversed. In summary, the MSCs therapy could alleviate renal injury in rats with SAP, the mechanism of which might be related to reduction of the damage to renal interstitial capillary endothelial barrier, and up-expression of AQP1 in kidney.

Effect of tetracycline administration on serum amylase activity in calves

Tetracycline and related compounds are used extensively as broad spectrum antibiotics in the treatment of bacterial infections in ruminants. Tetracycline may cause acute pancreatitis which may result in increased serum amylase activity. However, it has been shown that administration of oxytetracycline in human results in decrease serum amylase activity. In this study changes in serum amylase activity were measured in 20 clinically healthy calves following intravenous injection of oxytetracycline hydrochloride at 10 mg/kg of body weight. Blood samples were collected at 30, 60, and 120 minutes after oxytetracycline injection. Serum amylase activity was measured using the amyloclastic assay. The activity of serum amylase was increased significantly (P < 0.05) at 30 (40.5%), 60 (35.1%), and 120 (39.3%) minutes after oxytetracycline hydrochloride administration. To the authors' knowledge this is the first study on the acute effect of tetracycline administration on serum amylase activity in calves.

Correlation of fibrinogen-like protein 2 with progression of acute pancreatitis in rats

AIM: To examine fibrinogen-like protein 2 (fgl2) expression during taurocholate-induced acute pancreatitis progression in rats and its correlation with pancreatic injury severity.

METHODS: Forty-eight male Sprague-Dawley rats were randomly divided into the severe acute pancreatitis (SAP) group (n = 24) and the sham operation (SO) group (n = 24). Sodium taurocholate (4% at doses of 1 mL/kg body weight) was retrogradely injected into the biliopancreatic ducts of the rats to induce SAP. Pancreatic tissues were prepared immediately after sacrifice. At the time of sacrifice, blood was obtained for determination of serum amylase activity and isolation of peripheral blood mononuclear cells (PBMCs). Pancreatic tissue specimens were obtained for routine light microscopy including hematoxylin and eosin staining, and the severity of pancreatic injury was evaluated 1, 4 and 8 h after induction. Expression of fgl2 mRNA was measured in the pancreas and PBMCs using reverse transcription polymerase chain reaction. Expression of fgl2 protein was evaluated in pancreatic tissues using Western blotting and immunohistochemical staining. Masson staining was also performed to observe microthrombosis.

RESULTS: At each time point, levels of fgl2 mRNAs in pancreatic tissues and PBMCs were higher (P < 0.05) in the SAP group than in the SO group. For pancreatic tissue in SAP vs SO, the levels were: after 1 h, 3.911 ± 1.277 vs 1.000 ± 0.673; after 4 h, 9.850 ± 3.095 vs 1.136 ± 0.609; and after 8 h, 12.870 ± 3.046 vs 1.177 ± 0.458. For PBMCs in SAP vs SO, the levels were: after 1 h, 2.678 ± 1.509 vs 1.000 ± 0.965; after 4 h, 6.922 ± 1.984 vs 1.051 ± 0.781; and after 8 h, 13.533 ± 6.575 vs 1.306 ± 1.179. Levels of fgl2 protein expression as determined by Western blotting and immunohistochemical staining were markedly up-regulated (P < 0.001) in the SAP group compared with those in the SO group. For Western blotting in SAP vs SO, the results were: after 1 h, 2.183 ± 0.115 vs 1.110 ± 0.158; after 4 h, 2.697 ± 0.090 vs 0.947 ± 0.361; and after 8 h, 3.258 ± 0.094 vs 1.208 ± 0.082. For immunohistochemical staining in SAP vs SO, the results were: after 1 h, 1.793 ± 0.463 vs 0.808 ± 0.252; after 4 h, 4.535 ± 0.550 vs 0.871 ± 0.318; and after 8 h, 6.071 ± 0.941 vs 1.020 ± 0.406. Moreover, we observed a positive correlation in the pancreas (r = 0.852, P < 0.001) and PBMCs (r = 0.735, P < 0.001) between fgl2 expression and the severity of pancreatic injury. Masson staining showed that microthrombosis (%) in rats with SAP was increased (P < 0.001) compared with that in the SO group and it was closely correlated with fgl2 expression in the pancreas (r = 0.842, P < 0.001). For Masson staining in SAP vs SO, the results were: after 1 h, 26.880 ± 9.031 vs 8.630 ± 3.739; after 4 h, 53.750 ± 19.039 vs 8.500 ± 4.472; and after 8 h, 80.250 ± 12.915 vs 10.630 ± 7.003.

CONCLUSION: Microthrombosis due to fgl2 overexpression contributes to pancreatic impairment in rats with SAP, and fgl2 level may serve as a biomarker during early stages of disease.

Pancreatitis and myocarditis followed by pulmonary hemorrhage, a rare presentation of leptospirosis- a case report and literature survey

Background

Leptospirosis is a potentially fatal disease which can cause multi-organ dysfunction. It can rarely present as acute pancreatitis. This is the first ever report of leptospirosis presenting with acute pancreatitis and myocarditis followed by diffuse pulmonary hemorrhages to the best of our knowledge.

Case presentation

A 15-year-old South Asian boy presented with high grade fever, epigastric discomfort and was anicteric on admission. He developed tachycardia, transient hypotension, changes of electro-cardiogram and positive troponin I suggestive of myocarditis. Acute pancreatitis was diagnosed with 12 fold high serum amylase and with the evidence of computerized tomography. Then he developed diffuse pulmonary hemorrhages and later acute renal failure. Leptospirosis was confirmed by positive leptospira IgM, negative IgG and strongly positive Microscopic Agglutination Test. Other possible infective and autoimmune causes were excluded. Patient recovered completely with antibiotics and the supportive care.

Conclusion

This case illustrates diagnostic difficulties especially in resource poor settings where leptospirosis is common. Additionally it highlights the fact that leptospirosis should be considered in patients presenting with pancreatitis which can be complicated with myocarditis and diffuse pulmonary hemorrhages. We hypothesize that Toll like receptors may play a role in such systemic involvement.

Resultados do tratamento da pancreatite aguda grave

OBJETIVO: Avaliar os resultados do Protocolo de Atendimento de pacientes com diagnóstico de pancreatite aguda grave. MÉTODOS: Foram analisados, consecutivamente, a partir de janeiro de 2002, idade, sexo, etiologia, tempo de internação, tipo de tratamento e mortalidade de 37 pacientes portadores de pancreatite aguda grave. RESULTADOS: A idade dos pacientes variou de 20 a 88 anos (média de 50 anos); 27% foram do sexo feminino e 73% do masculino. O tempo médio global de internação foi 47 dias. Treze pacientes foram tratados cirurgicamente; a média de operações realizadas foi duas por paciente. Ocorreram seis óbitos dentre os pacientes submetidos ao tratamento cirúrgico (46%) e dois óbitos no grupo submetido somente ao tratamento clínico (8,3%). A mortalidade global foi 21% CONCLUSÃO: Após a modificação na forma de abordagem dos pacientes com pancreatite aguda grave, houve diminuição da mortalidade e uma tendência para a conduta expectante.

Diastolic dysfunction, prolonged QTc interval and pericardial effusion as predictors of mortality in acute pancreatitis

BACKGROUND AND AIM

The cardiac changes in acute pancreatitis have been earlier studied but the data on their prognostic significance is limited. This study was done to determine electrocardiographic (ECG) and echocardiographic changes in acute pancreatitis and determine their prognostic significance.

METHODS

Fifty-two consecutive patients (mean age 36.5 ± 11 years (44 males)) with acute pancreatitis and without prior cardiovascular comorbidites were prospectively enrolled and subjected to clinical, laboratory and radiological investigation. ECG and echocardiography was done at admission and during follow up.

RESULTS

Seventeen patients (32.7%) had mild pancreatitis and 35 (67.3%) patients had severe pancreatitis. Sinus tachycardia was the most common ECG abnormality. QTc prolongation was seen in 30/52 (57.7%) patients. On echocardiography, no patient had systolic dysfunction but 31/52 (59.6%) patients had diastolic dysfunction. All 22 patients with QTc interval < 440 ms survived compared with 8/30 patients with QTc interval ≥ 440 ms who died (P = 0.01). All eight patients who died had evidence of diastolic dysfunction (100%). None of the patients without diastolic dysfunction succumbed to illness (P = 0.02). Pericardial effusion was present in 6/52 (11.5%) patients. Of the eight patients who died, pericardial effusion was present in three (37.5%) patients and this frequency was significantly higher than that in patients who recovered (3/44 [6.8%]; P = 0.04).

CONCLUSION

Electrocardiographic and echocardiographic changes are seen in more than 50% of patients with acute pancreatitis. Prolonged QTc interval, pericardial effusion and diastolic dysfunction are associated with higher mortality.

Role of bone marrow-derived mesenchymal stem cells in a rat model of severe acute pancreatitis

AIM: To investigate the role and potential mechanisms of bone marrow mesenchymal stem cells (MSCs) in severe acute peritonitis (SAP).

METHODS: Pancreatic acinar cells from Sprague Dawley rats were randomly divided into three groups: non-sodium deoxycholate (SDOC) group (non-SODC group), SDOC group, and a MSCs intervention group (i.e., a co-culture system of MSCs and pancreatic acinar cells + SDOC). The cell survival rate, the concentration of malonaldehyde (MDA), the density of superoxide dismutase (SOD), serum amylase (AMS) secretion rate and lactate dehydrogenase (LDH) leakage rate were detected at various time points. In a separate study, Sprague Dawley rats were randomly divided into either an SAP group or an SAP + MSCs group. Serum AMS, MDA and SOD, interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α levels, intestinal mucosa injury scores and proliferating cells of small intestinal mucosa were measured at various time points after injecting either MSCs or saline into rats. In both studies, the protective effect of MSCs was evaluated.

RESULTS: In vitro, The cell survival rate of pancreatic acinar cells and the density of SOD were significantly reduced, and the concentration of MDA, AMS secretion rate and LDH leakage rate were significantly increased in the SDOC group compared with the MSCs intervention group and the Non-SDOC group at each time point. In vivo, Serum AMS, IL-6, TNF-α and MAD level in the SAP + MSCs group were lower than the SAP group; however serum IL-10 level was higher than the SAP group. Serum SOD level was higher than the SAP group at each time point, whereas a significant between-group difference in SOD level was only noted after 24 h. Intestinal mucosa injury scores was significantly reduced and the proliferating cells of small intestinal mucosa became obvious after injecting MSCs.

CONCLUSION: MSCs can effectively relieve injury to pancreatic acinar cells and small intestinal epithelium, promote the proliferation of enteric epithelium and repair of the mucosa, attenuate systemic inflammation in rats with SAP.

Role of parathyroid hormone-related protein in the pro-inflammatory and pro-fibrogenic response associated with acute pancreatitis

Pancreatitis is a common and potentially lethal necro-inflammatory disease with both acute and chronic manifestations. Current evidence suggests that the accumulated damage incurred during repeated bouts of acute pancreatitis (AP) can lead to chronic disease, which is associated with an increased risk of pancreatic cancer. While parathyroid hormone-related protein (PTHrP) exerts multiple effects in normal physiology and disease states, its function in pancreatitis has not been previously addressed. Here we show that PTHrP levels are transiently elevated in a mouse model of cerulein-induced AP. Treatment with alcohol, a risk factor for both AP and chronic pancreatitis (CP), also increases PTHrP levels. These effects of cerulein and ethanol are evident in isolated primary acinar and stellate cells, as well as in the immortalized acinar and stellate cell lines AR42J and irPSCc3, respectively. Ethanol sensitizes acinar and stellate cells to the PTHrP-modulating effects of cerulein. Treatment of acinar cells with PTHrP (1-36) increases expression of the inflammatory mediators interleukin-6 (IL-6) and intracellular adhesion protein (ICAM-1), suggesting a potential autocrine loop. PTHrP also increases apoptosis in AR42J cells. Stellate cells mediate the fibrogenic response associated with pancreatitis; PTHrP (1-36) increases procollagen I and fibronectin mRNA levels in both primary and immortalized stellate cells. The effects of cerulein and ethanol on levels of IL-6 and procollagen I are suppressed by the PTH1R antagonist, PTHrP (7-34). Together these studies identify PTHrP as a potential mediator of the inflammatory and fibrogenic responses associated with alcoholic pancreatitis.

Serum lipid and fatty acid profiles are highly changed in patients with alcohol induced acute pancreatitis

BACKGROUND/AIMS

Hyperlipidemia is one known etiology of acute pancreatitis. Alcohol use is known to induce changes in lipid metabolism and might alter the serum lipid and fatty acid profile. We hypothesized that these changes may explain individual susceptibility of developing acute pancreatitis. We compared lipid and fatty acid profiles of patients with acute alcoholic pancreatitis and alcoholic controls.

METHODS

19 patients with their first alcoholic pancreatitis and 20 controls were included. Late follow-up samples were obtained from 16 patients. Serum lipids were analyzed enzymatically and the fatty acid profile using gas chromatography.

RESULTS

The concentrations of serum total cholesterol, LDL-cholesterol and HDL-cholesterol were markedly lower in patients than in controls during the acute disease but normalized after follow-up. Patients had statistically significantly lower fatty acid proportions of saturated C14:0, polyunsaturated C18:2, C18:3 and C20:3 of the n-6-series and C18:3 of the n-3-series than controls. In contrast, patients had higher percentages of saturated C16:0 and monounsaturated C18:1n9 fatty acids than controls. Mead acid, C20:3n9, marker of essential fatty acid deficiency, was lower in patients than in controls. C14:0, C20:3n6, C18:3n3 and C20:3n9 remained altered after follow-up.

CONCLUSION

Serum lipid and fatty acid levels were significantly altered during the acute disease and returned toward normal after 18-24 months, suggesting that the changes are secondary to acute pancreatitis. They are unlikely to be the much sought 'trigger factor' of pancreatic necro-inflammation. However, further studies are warranted to fully establish this point.

The role of intraductal US in the management of idiopathic recurrent pancreatitis without a definite cause on ERCP

BACKGROUND

The cause of pancreatitis is unknown in as many as 30% of cases of recurrent acute pancreatitis, even after ERCP.

OBJECTIVE

To investigate the role of intraductal US (IDUS) for managing idiopathic recurrent pancreatitis (IRP).

DESIGN

Prospective study.

SETTING

Tertiary referral hospital.

PATIENTS

Thirty-one patients with suspicious IRP with negative findings on ERCP.

INTERVENTIONS

IDUS during ERCP.

MAIN OUTCOME MEASUREMENTS

IDUS findings showing any possible cause of pancreatitis.

RESULTS

IDUS revealed small bile duct stones (≤3 mm) in 5 patients (16.1%) and sludge in 3 patients (9.7%). The detection rate for a bile duct stone and sludge was significantly higher in patients with a dilated CBD than a nondilated CBD on ERCP (71.4 vs 12.5%; P < .05). Recurrent pancreatitis did not develop in 7 of 8 patients with biliary stones or sludge after an endoscopic sphincterotomy (EST). Two patients (6.5%) demonstrated a small polypoid lesion on the distal end of the pancreatic duct. One patient underwent surgery for intra-ampullary cancer, and another one underwent EST without another attack of pancreatitis. Three patients (9.7%) showed evidence of chronic pancreatitis with small pancreatic stones and/or calcifications on IDUS.

LIMITATIONS

Small number of patients. IDUS results were not compared with those of conventional EUS. There was no reference standard for chronic pancreatitis as diagnosed by IDUS.

CONCLUSIONS

IDUS identified a possible cause of idiopathic recurrent pancreatitis in 42% of patients with negative findings on ERCP. The IDUS-guided approach combined with ERCP and EST may be useful for decreasing recurring attacks of pancreatitis.

Hyperglycemia and diabetes mellitus in children with pancreatitis

OBJECTIVE

To assess the risk factors for developing hyperglycemia and diabetes mellitus (DM) in children with pancreatitis.

STUDY DESIGN

Patients (from infants to age 21 years) hospitalized with acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis were studied retrospectively. Subjects with known DM or cystic fibrosis before presentation with pancreatitis were excluded.

RESULTS

A total of 176 patients met the study criteria. Of these, 140 had AP, 29 had ARP, and 7 had chronic pancreatitis. Severe pancreatitis was associated with hyperglycemia; 41% of the patients with hyperglycemia required insulin, and 8 patients (4.5%) developed DM requiring insulin by the time of discharge. These 8 patients with postpancreatitis DM were more likely to be overweight. Five of the 8 patients had a seizure disorder, and 4 had another comorbidity, such as mental retardation or cerebral palsy. Seven of the 8 patients who developed DM had a single episode of AP, and one patient had ARP.

CONCLUSIONS

Our findings indicate that hyperglycemia and DM can occur with pancreatitis. In some cases, postpancreatitis DM was associated with mental retardation, seizure disorder, and use of antiseizure medication. As opposed to adults who develop DM after chronic pancreatitis, children can develop DM due to a single episode of AP.

Acute superior mesenteric artery syndrome and pancreatitis in anorexia nervosa

OBJECTIVE

The aim of this paper is to describe the presentation and clinical management of a patient with anorexia nervosa complicated by superior mesenteric artery syndrome and pancreatitis, and discuss the association between these conditions.

METHOD

We present a case report and briefly review the relevant literature.

RESULTS

A 17-year-old girl with undiagnosed anorexia nervosa presented acutely with abdominal symptoms and vomiting. After numerous investigations, she was diagnosed with the rare condition of superior mesenteric artery syndrome and pancreatitis, leading to a prolonged hospital admission and management on both an acute medical/surgical ward and an eating disorders unit.

CONCLUSIONS

Anorexia nervosa has been associated with superior mesenteric artery syndrome and pancreatitis. Clinical awareness of these conditions can result in prompt diagnosis and optimal management of these patients.

Clinical studies of liraglutide, a novel, once-daily human glucagon-like peptide-1 analog for improved management of type 2 diabetes mellitus

Liraglutide, a new glucagon-like peptide-1 (GLP-1)-receptor agonist with 97% homology to human GLP-1, can be administered once/day independent of meals in patients with type 2 diabetes mellitus. Clinical trials have demonstrated its efficacy in controlling hyperglycemia, helping patients achieve hemoglobin A(1c) level goals; in facilitating weight loss, and in improving indexes of beta-cell function when used alone or in combination with metformin, glimepiride, or rosiglitazone. These studies also suggest that liraglutide may be associated with modest improvements in systolic blood pressure. Data from a comparative trial of liraglutide and insulin glargine have suggested that liraglutide provides greater glycemic control with less weight gain, and another study demonstrated that liraglutide provides greater improvements in glycemic control with less hypoglycemia than exenatide and with comparable weight loss. Although liraglutide is well tolerated and is associated with low rates of hypoglycemia, transient and mild nausea can occur when therapy is initiated. However, rates of hypoglycemia appear to be lower and nausea appears to be less persistent with liraglutide than with exenatide. Even though data on the long-term use of liraglutide are still needed, this drug may provide a useful treatment option in patients poorly controlled with dietary modification and exercise and in those whose diabetes is inadequately controlled by oral antidiabetic agents.

Altered phospholipid transfer protein gene expression and serum lipid profile by topotecan

Camptothecin (CPT) and its structural analogues including topotecan and irinotecan, are inhibitors of topoisomerase I. These drugs are clinically active against a broad spectrum of cancers. To understand the genesis of chemotherapeutic resistance to the CPT family of anticancer drugs, we examined by gene expression profiling the pharmacological response to topotecan in the human hepatoma HepG2 cells and found a striking induction of the phospholipid transfer protein (PLTP) gene expression by topotecan. We showed that activation of PLTP gene expression is specific to CPT and its analogues including specific enantiomers that inhibit topoisomerase I. PLTP-mediated lipid transfer to high-density lipoprotein (HDL) is thought to be important for shuttling and redistribution of lipids between lipoproteins, which are normally returned to the liver for metabolism via the reverse cholesterol transport pathway. Hence, we asked whether elevated PLTP levels might increase the transfer of drugs into HDL. We observed that CPT was not accumulated in HDL and other lipoproteins. In addition, topotecan treatment in mice caused a marked reduction in serum HDL that was accompanied by an increase in triglyceride and cholesterol levels. These results showed that PLTP does not mediate the transfer of topoisomerase I inhibitors to serum lipoproteins. However, elevated serum PLTP levels following treatment with topoisomerase I inhibitors in cancer patients may serve as a biomarker for monitoring the development of hypertriglyceridemia and acute pancreatitis.

Pancreatitis: understanding the disease and implications for care

Pancreatitis, or inflammation of the pancreas, has a variety of etiologies. Severity of the disease can range from its mildest form, which resolves quickly with few complications, to its most severe form, necrotizing pancreatitis, which is associated with an increased risk for developing multiple system organ failure and mortality. Treatment of pancreatitis aims to eliminate the etiologic factors for the disease while managing its complications and preventing further disease progression. Patients with mild forms of pancreatitis may improve with symptom management, whereas those with more severe disease will need significant supportive interventions. Most patients are managed medically. Surgery may be indicated for severe pancreatitis. It is important to understand the disease process and its impact on other organ systems when caring for these patients. Accurate assessment of changes in the patient's condition can lead to interventions that can limit complications and reduce the risk of mortality. This article reviews the pathophysiology of pancreatitis, its diagnosis and treatment, associated complications and their management, and essential nursing assessment and interventions.

Antithrombin III prevents cerulein-induced acute pancreatitis in rats

OBJECTIVES

Systemic inflammatory mediators, including the protein high-mobility group box 1 (HMGB1), play an important role in the development of acute pancreatitis. Anticoagulants, such as antithrombin III (AT III), inhibit inflammation resulting from various causes, but their mechanism of action is not well understood. Because acute pancreatitis is a severe inflammatory disease, we hypothesized that AT III would inhibit inflammation and prevent cerulein-induced acute pancreatitis.

METHODS

Experimental animals received or were saline injected with a bolus of 250 IU/kg of AT III followed by intraperitoneal injections of 50 mg/kg of cerulein. Levels of cytokines (interleukin 6 and tumor necrosis factor alpha), nitric oxide (NO), and HMGB1 were measured in serum and pancreatic tissue at regular intervals for 12 hours after the cerulein injection.

RESULTS

Pancreas histopathology and wet-dry ratio significantly improved in the AT III-injected (250 IU/kg) animals compared with the saline-injected rats. Serum and pancreas HMGB1 levels decreased over time in AT III-treated animals. Antithrombin III also decreased cytokine, NO, and HMGB1 levels during cerulein-induced inflammation. As a result, AT III ameliorated the pathologic pancreas in the rat model of cerulein-induced acute pancreatitis.

CONCLUSIONS

Antithrombin III treatment inhibited the secretion of cytokines, NO, and HMGB1 and prevented cerulein-induced acute pancreatitis in the rat model.

Acute pancreatitis at the beginning of the 21st century: the state of the art

Acute pancreatitis is an acute inflammatory disease of the pancreas which can lead to a systemic inflammatory response syndrome with significant morbidity and mortality in 20% of patients. Gallstones and alcohol consumption are the most frequent causes of pancreatitis in adults. The treatment of mild acute pancreatitis is conservative and supportive; however severe episodes characterized by necrosis of the pancreatic tissue may require surgical intervention. Advanced understanding of the pathology, and increased interest in assessment of disease severity are the cornerstones of future management strategies of this complex and heterogeneous disease in the 21st century.

Acute pancreatitis at the beginning of the 21st century: The state of the art

Acute pancreatitis is an acute inflammatory disease of the pancreas which can lead to a systemic inflammatory response syndrome with significant morbidity and mortality in 20% of patients. Gallstones and alcohol consumption are the most frequent causes of pancreatitis in adults. The treatment of mild acute pancreatitis is conservative and supportive; however severe episodes characterized by necrosis of the pancreatic tissue may require surgical intervention. Advanced understanding of the pathology, and increased interest in assessment of disease severity are the cornerstones of future management strategies of this complex and heterogeneous disease in the 21st century.

Expression of 5-lipoxygenase in rat pancreatic tissue during acute necrotizing pancreatitis

AIM: To investigate the expression of 5-lipoxygenase in rat pancreatic tissue during acute necrotizing pancreatitis.

METHODS: Fifty four SD rats were randomized into 3 groups: sham operation group, acute necrotizing pancreatitis group (ANP group) and zileuton treatment group. The model of ANP was induced by retrograde injection of 5% sodium taurocholate into biliopancreatic duct. At 6, 12, 24 h, the animals were sacrificed. Immunohistochemistry and Western blot were used to detect the expression of 5-lipoxygenase of pancreas. The mRNA expression of 5-lipoxygennase in the pancreas was determined using RT-PCR. The serum level of LTB4 was analyzed by enzyme-linked immunosorbent assay (ELISA). The serum level of amylase was detected.

RESULTS: The levels of 5-LOX and 5-LOX mRNA were significantly lower at each time point in zileuton group than in ANP group (1.333% ± 0.516% vs 2.667% ± 0.516%, 3.000% ± 0.632% vs 4.500% ± 0.548%, 3.833% ± 0.753% vs 5.833% ± 0.408%; 0.285% ± 0.005% vs 0.366% ± 0.004%, 0.608% ± 0.005% vs 0.949% ± 0.013%, 0.297% ± 0.002% vs 0.400% ± 0.006%, all P < 0.05). Compared with sham operation group, ANP group and zileuton group had significantly elevated serum levels of amylase and LTB4. However, serum levels of amylase and LTB4 were significantly lower in zileuton group than in ANP group (amylase: 1967.50 ± 41.21 IU/L vs 2123.50 ± 49.11 IU/L, 3242.33 ± 87.76 IU/L vs 3531.17 ± 74.14 IU/L, 2286.83 ± 93.91 IU/L vs 2903.33 ± 90.90 IU/L, all P < 0.05).

CONCLUSION: The expression of 5-LOX is significantly higher during acute necrotizing pancreatitis.

Study on protecting effects of Baicalin and Octreotide on hepatic injury in rats with severe acute pancreatitis

AIM: To investigate the protective effects and mechanisms of Baicalin and Octreotide on hepatic injury in rats with severe acute pancreatitis (SAP).

METHODS: The SAP rat models were prepared and randomly assigned to the model control group, Baicalin treated group, and Octreotide treated group while other healthy rats were assigned to the sham-operated group. Rat mortality, levels of ALT, AST, liver and pancreas pathological changes in all groups were observed at 3, 6 and 12 h after operation. Tissue microarray (TMA) sections of hepatic tissue were prepared to observe expression levels of Bax, Bcl-2 protein and Caspase-3, and changes of apoptotic indexes.

RESULTS: Rat survival at 12 h, expression levels of Bax, Caspase-3 protein and apoptotic indexes of liver were all significantly higher in treated groups than in model control group. While the liver and pancreas pathological scores, contents of ALT, AST, and expression levels of Bcl-2 protein were all lower in treated groups than in the model control group.

CONCLUSION: Both Baicalin and Octreotide can protect rats with SAP by decreasing the contents of ALT, AST and expression levels of Bcl-2 protein, and improving the expression levels of Bax protein, Caspase-3 protein, and inducing apoptosis.