Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus

Differential impact of recent heavy drinking on first and recurrent acute pancreatitis

BACKGROUND

While alcohol is known to sensitize the pancreas to acute injury, the role of short-term episodic drinking in regular drinkers is unknown.

METHODS

We conducted a case-crossover study to (1) determine the hazardous period of drinking prior to a first episode of acute pancreatitis (FAP) or recurrent acute pancreatitis (RAP) and (2) evaluate the dose-response association between short-term drinking and FAP/RAP. Patients hospitalized for FAP/RAP with an AUDIT-C score of ≥3 were enrolled. Recent and lifetime drinking history were collected through interviews. Drinking prior to the index pancreatitis attack was compared to that of an asymptomatic control period. Conditional logistic regression quantified the association of heavy drinking and FAP/RAP.

RESULTS

Of 141 patients who completed a short-term drinking questionnaire, 77 had RAP, and 64 experienced FAP. We found that both FAP and RAP patients drank at moderate-to-heavy levels regularly, with modest day-to-day variation (intraclass correlation of drinks/day 67%-82%). Alcohol consumption increased 2 days preceding the onset of the index pancreatitis attack as compared to the week prior. Stratifying by prior AP history, heavy drinking in the hazard period was associated with RAP (OR = 3.79, 95% confidence interval [CI] 1.57-9.12). Each drink was associated with 1.22-fold (95%CI 1.10-1.35) increased odds of RAP. Short-term heavy drinking was not associated with a FAP (OR = 1.06, 95%CI 0.43-2.57).

CONCLUSION

In summary, we found that patients with a prior history of AP face a higher risk of RAP due to excess drinking. Drinking intensity did not increase prior to a FAP, which may have been triggered by other cofactors warranting further examination.

Acute pancreatitis in intraductal papillary mucinous neoplasm: Associations with epithelial subtype, degree of dysplasia, and risk of recurrence

BACKGROUND

Acute pancreatitis is an uncommon presentation of intraductal papillary mucinous neoplasm; however, it is considered a worrisome feature in current guidelines and can be an indication for surgery. There is controversy regarding its association with malignancy, and there is little information regarding the recurrence of pancreatitis after surgical resection.

METHODS

We retrospectively reviewed patients who underwent resection for intraductal papillary mucinous neoplasm at a single institution between January 1990 and December 2023. Patients with and without acute pancreatitis as part of the clinical presentation were compared.

RESULTS

A total of 812 patients were reviewed. Of these, 156 patients (19.2%) had intraductal papillary mucinous neoplasms associated with acute pancreatitis, and in 92% of them pancreatitis was the symptom leading to the diagnosis. Half of the patients had a single episode of pancreatitis (n = 77, 49.4%), and 42 (26.9%) had had 3 or more episodes before diagnosis. Acute pancreatitis was significantly associated with high-grade dysplasia (odds ratio 2.07) but had a lower likelihood of invasive cancer (odds ratio 0.62). It was also significantly associated with main duct and mixed duct-type intraductal papillary mucinous neoplasm (odds ratio 1.97) and intestinal epithelial subtype (odds ratio 2.28). Median follow-up for all patients was 61 months, and the likelihood of recurrent pancreatitis after surgical resection was 9% (14 patients), whereas pancreatitis after resection in patients without prior history occurred in only 0.9% (6 patients, P < .001).

CONCLUSIONS

Almost 1 in 5 patients undergoing resection for intraductal papillary mucinous neoplasm have a history of acute pancreatitis and are twice as likely to have high-grade dysplasia, supporting its categorization as a worrisome feature. Recurrence of pancreatitis after resection was 9%.

Hypophosphatemia as a Predictor of Pancreatic Necrosis in Acute Alcohol-induced Pancreatitis

OBJECTIVE

Pancreatic necrosis is a catastrophic complication of acute pancreatitis and is associated with increased morbidity and mortality. While there is no objective means to predict pancreatic necrosis, recent studies have identified serum phosphate levels as a contributor to the disease process, with worse outcomes noted in patients with low serum phosphates. We aimed to determine if there was a relationship between low serum phosphate levels and the risk of developing pancreatic necrosis in patients with acute alcoholic pancreatitis (AAP).

METHODS

Health care records from patients admitted between January 2017 and December 2022 for acute alcoholic pancreatitis were retrospectively reviewed. These patients were categorized based on their phosphate levels within 48 hours of admission: normal phosphate levels (2.8-4.5 mg/dL) and hypophosphatemia (<2.8 mg/dL). Imaging findings from hospital stays were examined to identify cases of pancreatic necrosis. These cases were then compared across patients with normal and low phosphate levels.

RESULTS

Among the 207 patients admitted for acute alcoholic pancreatitis, 67 met the inclusion and exclusion criteria. Of these, 37 patients exhibited serum phosphate levels below 2.8 mg/dL, while 30 maintained levels between 2.8 and 4.5 mg/dL within the first 48 hours of admission. Of the patients in the hypophosphatemia group, 27.02% were noted to develop pancreatic necrosis during hospital stay compared to only 6.66% in the normal phosphate group ( P value: 0.029). In addition, those who developed necrosis had an overall lower mean phosphate level of 2.13 mg/dL compared to the mean phosphate level of 2.60 mg/dL ( P value: 0.0521) in patients without necrosis. The median duration of hospital stay ( P value: 0.65) and rate of intensive care unit (ICU) admission ( P value: 0.41) were similar in both groups.

CONCLUSIONS

Early hypophosphatemia during admission for AAP was associated with an increased risk of developing pancreatic necrosis; however, it may not affect the overall length of hospital stay or rate of ICU admission.

Metal versus plastic stents for EUS-guided walled-off necrosis drainage: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND & OBJECTIVE

The endoscopic step-up approach is the mainstay of walled-off necrosis management (WON). However, using metal stents versus plastic stents during WON drainage is debatable, with limited high-quality evidence. Therefore, we aim to investigate the comparative safety and efficacy of metal versus plastic stents for endoscopic ultrasound (EUS) guided WON drainage.

METHODS

A systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), retrieved by systematically searching PubMed, EMBASE, WOS, SCOPUS, and Cochrane through July 2024. Continuous and dichotomous outcome variables were pooled using mean difference (MD) and risk ratio (RR), with confidence interval (CI) using Stata MP v. 17. We assessed heterogeneity using the chi-square test and I2 statistic.

PROSPERO ID

CRD42024573859.

RESULTS

Six RCTs with 352 patients were included. There was no difference between both groups regarding clinical success (RR: 1.04 with 95% CI [0.88-1.23], p = 0.61), WON recurrence (RR: 1.46 with 95% CI [0.59-3.61], p = 0.41), the need of necrosectomy (RR: 0.96 with 95% CI [0.65-1.41], p = 0.84), the total number of necrosectomy sessions (MD: 1.03 with 95% CI [- 0.33, 2.40], p = 0.14), total number of interventions (MD: - 0.09 with 95% CI [- 0.72, 0.54], p = 0.79), mortality (RR: 0.87 with 95% CI [0.32-2.37], p = 0.79), bleeding (RR: 1.35 with 95% CI [0.58-3.12], p = 0.48), and stent migration (RR: 0.69 with 95% CI [0.28-1.71], p = 0.42). However, metal stents significantly decreased the procedure duration (MD: - 11.27 with 95% CI [- 17.69, - 4.86], p < 0.001).

CONCLUSION

There was no significant difference between metal and plastic stents in efficacy and safety outcomes during WON EUS-guided drainage, except for a shorter procedural duration with metal stents.

A systematic review on the prognostic role of radiologically-proven sarcopenia on the clinical outcomes of patients with acute pancreatitis

BACKGROUND

Sarcopenia is a known risk factor for poor prognosis in chronic pancreatitis, however the impact of sarcopenia in acute pancreatitis (AP) is unknown. This systematic review examines the prognostic impact of sarcopenia on clinical outcomes in patients with acute pancreatitis.

METHODS

A systematic literature of Medline, EMBASE, Cochrane, and the World Health Organisation International Clinical Trials Registry Platform was undertaken to identify articles relating to sarcopenia, AP, and computed tomography imaging. Data collected was related to studies' demographic population, presence of sarcopenia, sarcopenia assessment methodology, obesity, pancreatitis severity, and short- and long-term complications of AP.

RESULTS

A total of four out of 114 unique peer-review articles were included in this review, encompassing 947 patients in total. Of the analysable data, 200 patients had sarcopenia and 640 did not. There was marked heterogeneity in the determination of the presence of sarcopenia between studies. No significant association was found between sarcopenia and pancreatic necrosis, organ failure, venous thromboembolism, recurrent acute pancreatitis, or mortality.

CONCLUSION

Sarcopenia remains highly prevalent in patients suffering from acute pancreatitis. There is insufficient evidence to suggest sarcopenia is associated with poorer outcomes in patients with acute pancreatitis. More high-powered studies are required to further characterise the impact of sarcopenia on patients with acute pancreatitis.

Development and validation of a novel chronic pancreatitis pathological grade based on artificial intelligence

BACKGROUND

Effective chronic pancreatitis (CP) treatment requires accurate severity evaluation, but no histopathology grading system exists. This study aimed to develop and validate a novel CP pathological grade (Histopathology-derived CPpG) using quantified pathological and radiological characteristics through deep learning.

METHODS

Patients with pathologically/clinically confirmed CP or recurrent acute pancreatitis were retrospectively enrolled (2011-2023). Whole-slide CP images were automatically segmented and quantified via DeeplabV3+, followed by latent class analysis to develop Histopathology-derived CPpG. A deep learning radiomics score (DLRS) was created to predict Histopathology-derived CPpG using preoperative CT scans of patients with pathologically confirmed CP. CT-predicted CPpG was then validated in an independent group of patients with clinically confirmed CP and recurrent acute pancreatitis.

RESULTS

The study included 2054 patients with CP and recurrent acute pancreatitis, with 181 cases of pathologically confirmed CP. Histopathology-derived CPpG I had a higher proportion of acini, acinus-to-stroma ratio, acinus-to-islet ratio, islet-to-stroma ratio, and (acinus + islet)-to-stroma ratio, and a lower proportion of stroma and lymphocytes compared to CPpG II. The DLRS demonstrated high performance in the validation (AUC, 0.84; 95 % CI: 0.75-0.92) and test (AUC, 0.76; 95 % CI: 0.65-0.87) sets. In a large-scale clinical validation, CT-predicted grades were significantly associated with endocrine and exocrine function, as well as prognosis (P < .05).

CONCLUSION

This study developed a novel pathological classification, Histopathology-derived CPpG, which accurately reflects disease severity. Additionally, the non-invasive DLRS shows great potential for dynamically monitoring CP severity and evaluating pancreatic endocrine and exocrine function, as well as prognosis.

Autoimmune Pancreatitis: A Review

Autoimmune pancreatitis is a rare condition of pancreatic inflammation with two classic subtypes. The emergence of a third subtype, ICI-induced pancreatitis, highlights the need for knowledge of each type to ensure accurate diagnosis and treatment. Abbreviations: AIP-Autoimmune pancreatitis; AIP-1-Type 1 autoimmune pancreatitis, also known as lymphoplasmacytic sclerosing pancreatitis (LPSP); AIP-2-Type 2 autoimmune pancreatitis, also referred to as idiopathic duct-centric pancreatitis (IDCP); AIP-3-Type 3 autoimmune pancreatitis, also known as immune checkpoint inhibitor (ICI)-induced autoimmune pancreatitis; IgG4-RD-Immunoglobulin G4-related disease.

Parecoxib sequential with imrecoxib for occurrence and remission of severe acute pancreatitis: a multicentre, double-blind, randomised, placebo-controlled trial

BACKGROUND

There is no effective drug treatment for the organ failure (OF) caused by severe acute pancreatitis (SAP).

OBJECTIVE

We aimed to evaluate the efficacy of cyclooxygenase-2 inhibitors (COX-2-Is) on the treatment of SAP and its safety.

DESIGN

In this multicentre, double-blind, randomised, placebo-controlled, investigator-initiated trial, 348 patients with acute pancreatitis aged 18-75 years, <1 week from onset of illness to admission, and Acute Physiology and Chronic Health Evaluation II Score ≥7 or modified Marshall Score ≥2, were randomly assigned (1:1) to the COX-2-Is group (parecoxib sequential with imrecoxib) or the placebo group. SAP occurrence, duration of OF, local complications, clinical outcomes and serum inflammatory mediators were measured.

RESULTS

Compared with the placebo group, SAP occurrence was reduced by 20.7% (77.6% vs 61.5%, p=0.001) and the persistent OF duration in SAP was shortened by 2 days (p<0.001) after COX-2-Is treatment. For patients enrolled within or after 48 hours from symptom onset, SAP occurrence was reduced by 23.8% (p=0.001) and 8.5% (p=0.202), and the persistent OF duration in SAP was shortened by 3 days (p=0.001) and 2 days (p=0.010) after COX-2-Is treatment, respectively. The occurrence of local complications in the COX-2-Is group was significantly lower than those in the placebo group, 33.7% vs 49.1%, p=0.004. The serum levels of inflammatory mediators and 30-day mortality (from 8.6% to 3.4%) were significantly reduced after COX-2-Is treatment, p<0.05. The incidence of adverse events was similar between the two treatment groups.

CONCLUSION

Parecoxib sequential with imrecoxib was effective and well tolerated in reducing the occurrence and duration of SAP and local complications through suppression of systemic inflammatory response, leading to decreased morbidity.

Efficacy of DaXianXiong Decoction in Preventing the Progression of Acute Pancreatitis Severity: Protocol for a Randomized Controlled Trial

BACKGROUND

Low- and middle-income countries are facing an increase in the incidence of acute pancreatitis (AP)-characterized by rapid onset, fast progression, high rate of severity, and high mortality. Progression of AP into severe AP (SAP) results in a series of complications such as organ dysfunction, local abscesses, pseudocysts, and necrosis. Although the treatment of AP is primarily supportive, including fluid resuscitation and organ support, there is still a lack of consensus on the optimal management regimen for fluid therapy, and strategies to promote gastrointestinal recovery remain limited. As no effective intervention measure has yet been developed, supportive therapy remains the primary approach for the early treatment of AP. DaXianXiong decoction is a widely used traditional Chinese medicine formulation; however, limited research has been conducted on its clinical efficacy.

OBJECTIVE

This study aims to evaluate the efficacy and safety of DaXianXiong decoction in preventing AP from progressing to SAP, assessing its impact on SAP incidence, clinical severity scores, inflammation markers, and gastrointestinal function, and providing evidence for AP management.

METHODS

This study is a randomized, double-blind, placebo-controlled, single-center clinical trial. The primary outcomes will include the incidence of SAP, modified computed tomography severity index score, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, modified Marshall score, and levels of the inflammation factor. The secondary outcomes will include the effect of the gastrointestinal dysfunction treatment. Evaluations will be conducted at baseline; 24 hours after the intervention; and on days 3, 7, and 28 after the intervention in both groups. A total of 60 eligible patients will be randomly allocated in a 1:1 ratio to the intervention group and the control group. Both groups will receive standard Western medical treatment for pancreatitis. The intervention group will additionally receive DaXianXiong decoction, while the control group will receive a placebo similar to the decoction.

RESULTS

This study has been funded by the Performance Incentive Project of Scientific Research Institutions in Chongqing. The trial was registered in April 2024, and data analysis is expected to be completed by April 2025. The study results will be presented at both national and international conferences and published in peer-reviewed journals.

CONCLUSIONS

This trial will help us assess the effectiveness and safety of DaXianXiong decoction in patients with AP and provide clinical evidence on the efficacy and safety of DaXianXiong decoction in preventing the progression of AP to SAP. By evaluating its impact, the findings will contribute to the understanding of DaXianXiong decoction as an adjunct therapy in AP management and may offer a novel complementary treatment strategy for AP, potentially improving patient outcomes and reducing complications.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300076885; https://www.chictr.org.cn/showproj.html?proj=207084.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/67392.

Optimal timing for lumen-apposing metal stent removal following endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis

BACKGROUND

 Lumen-apposing metal stents (LAMSs) are widely used for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs). Safety is a major concern and the timing of LAMS removal is debated owing to the risk of adverse events (AEs). Previous studies showed early stent removal was associated with a reduced risk of AEs, but data are still conflicting. The aim of this systematic review with meta-analysis was to identify the optimal timing for LAMS removal.

METHODS

 Major databases were systematically searched until May 2024. The outcome assessed was the cumulative incidence of AEs related to the early (within 3-4 weeks) versus late (after 3-4 weeks) removal of the LAMS. A random-effects (DerSimonian-Laird) model was used to pool the results.

RESULTS

 Eight studies (1820 patients; mean age 54-61.6 years; 63 % men) were included in the analysis. PFCs included walled-off necrosis (WON; 58.2 %) and pseudocysts (41.8 %). Pooled LAMS-related AEs rate were similar in the late versus early removal groups (risk ratio [RR] 1.03, 95 %CI 0.47-2.28; P = 0.94). Sensitivity analysis, including only studies applying a 4-week cut-off, confirmed a comparable AEs rate (RR 0.80, 95 %CI 0.38-1.65; P = 0.59). The mean (SD) follow-up of the studies was 208 (88) days.

CONCLUSIONS

 The results of this meta-analysis showed no difference in the incidence of AEs between early and late removal of LAMSs in the presence of moderate heterogeneity across studies. Removal within 4 weeks is not warranted, and it may instead be planned on a clinical case-by-case basis according on the patient's condition.

Endoscopic interventions for managing pancreatic fluid collections associated with acute pancreatitis: A state-of-the-art review (with videos)

Acute pancreatitis is an acute inflammatory disease, which may be associated with pancreatic and peri-pancreatic necrosis and development of (peri)pancreatic fluid collections (PFCs). Interventions in acute pancreatitis have evolved over the years with a paradigm shift from open surgical drainage and necrosectomy to minimally invasive approaches. Depending on the presence of necrosis, the PFCs may be acute necrotic collections or acute pancreatic fluid collections, which evolve over a period of three to four weeks to walled-off necrosis and pseudocysts, respectively. Patients with symptomatic and infected PFCs require drainage. In general, drainage should be delayed beyond three to four weeks when the collection wall has matured and the necrotic debris is liquefied. However, some patients may merit early drainage (within the first three to four weeks), if they have suspected infected pancreatic necrosis and worsening organ dysfunction despite antibiotics and supporting therapy. Endoscopic transmural drainage and necrosectomy have now emerged as the most favored treatment modality in suitable pancreatic collections located predominantly in the lesser sac. Being minimally invasive, per-oral endoscopic direct necrosectomy is as effective as surgical necrosectomy in patients with infected necrotic collections but with fewer adverse events. Percutaneous endoscopic necrosectomy is an important addition to our armamentarium for laterally placed collections as an effective alternative to surgical video-assisted retroperitoneal debridement. The current review provides an overview of the evolution, indications, approaches, techniques and outcomes of endoscopic interventions in the management of pancreatic fluid collections associated with acute pancreatitis. Future direction for better outcomes has been highlighted.

Efficacy of modified pancreatic duct stent drainage during endoscopic retrograde cholangiopancreatography for common bile duct stones

BACKGROUND

Common bile duct stones pose a high risk of recurrence or disease progression if not promptly treated. However, there is still no optimal treatment approach.

AIM

To investigate the clinical efficacy of modified pancreatic duct stent drainage in endoscopic retrograde cholangiopancreatography (ERCP) for treating common bile duct stones.

METHODS

This retrospective study included 175 patients with common bile duct stones treated at Taizhou Fourth People's Hospital between January 1, 2021, and November 30, 2023. The patients were divided into three groups-the modified pancreatic duct stent drainage group (59 cases), the nasobiliary drainage group (58 cases), and the standard biliary drainage group (58 cases). Preoperative general clinical data, laboratory indicators, and the visual analog scale (VAS) at two time points (24 hours before and after surgery) were compared, along with postoperative complications across the three groups.

RESULTS

Serum levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyltransferase, total bilirubin, direct bilirubin, C-reactive protein, and amylase were significantly lower in the modified pancreatic duct stent drainage group and the standard biliary drainage group than those in the nasobiliary drainage group (P < 0.05). However, no statistically significant differences were observed in white blood cells, hemoglobin, or neutrophil levels among the three groups (P > 0.05). The standard biliary drainage group had significantly lower VAS scores [(4.36 ± 1.18) points] than those for the modified pancreatic duct stent drainage group [(4.92 ± 1.68) points] (P = 0.033), and the nasobiliary drainage group [(5.54 ± 1.24) points] (P = 0.017). There were no statistically significant differences in complication rates across the three groups (P > 0.05).

CONCLUSION

Compared to standard biliary drainage and nasobiliary drainage, the modified pancreatic duct stent used during ERCP for patients with bile duct stones significantly reduced hepatocyte injury, improved liver function parameters, alleviated inflammation and pain, enhanced patient comfort, and demonstrated superior safety.

Association of Visceral Adiposity and Sarcopenia with Geospatial Analysis and Outcomes in Acute Pancreatitis

Background: Radiological imaging has improved our insight into how obesity and sarcopenia impacts acute pancreatitis via several measured variables. However, we lack understanding of the association between social determinants of health and these variables within the acute pancreatitis population. Methods: This study included patients at a single tertiary care center between 1 January 2008 and 31 December 2021. Measurements of visceral adiposity (VA), subcutaneous adiposity (SA), the ratio of visceral to total adiposity (VA/TA), and degree of sarcopenia via psoas muscle Hounsfield unit average calculation (HUAC) were obtained on CT scans performed at presentation. Using geocoded patient data, we calculated the social vulnerability index (SVI) from CDC metrics. Descriptive and regression analyses were performed utilizing clinical and radiological data. Results: In 484 patients with 592 acute pancreatitis-related hospitalization, median (IQR) VA was 176 (100-251), SA was 209.5 (138.5-307), VA/TA ratio was 43.5 (32.3-55.3), and HUAC was 51.3 (44.4-58.9). For our primary outcome, geospatial analyses showed a reverse association between VA and SVI with a coefficient of -9.0 (p = 0.04) after adjustment for age, health care behaviors (i.e., active smoking and drinking), and CCI, suggesting residence in areas with higher SVI is linked to lower VA. However, VA/TA, SA, and HUAC showed no significant association with SVI. The SVI subdomain of socioeconomic status had significant association with VA (-39.78 (95% CI: -75.88--3.70), p = 0.03) after adjustments. For our secondary outcome, acute pancreatitis severity had significant association with higher VA (p ≤ 0.001), VA/TA (p ≤ 0.001), and lower HUAC (p ≤ 0.001). When comparing single vs. recurrent hospitalization patients, there was significantly higher median VA with recurrences (VA-single acute pancreatitis: 149 (77.4-233) vs. VA-recurrent acute pancreatitis: 177 (108-256); p = 0.04). Conclusions: In this study we found that patients residing in more socially vulnerable areas had lower visceral adiposity. This paradoxical result potentially conferred a protective effect against severe and recurrent acute pancreatitis; however, this was not found to be statistically significant.

Admission hematocrit and fluctuating blood urea nitrogen levels predict the efficacy of blood purification treatment in severe acute pancreatitis patients

This study aimed to evaluate the prognostic significance of the levels of admission hematocrit (HCT) and the changes in the initial blood urea nitrogen (BUN) levels in predicting the efficacy of blood purification (BP) therapy in ameliorating severe acute pancreatitis (SAP) patients at admission. A retrospective study was conducted on 139 SAP patients from the People's Hospital of Guangxi Zhuang Autonomous Region from 2013 to 2022 and the data retrieved from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database for 346 SAP patients. The patients were stratified based on their HCT0 levels at admission; HCT < 44% (n = 93) and HCT ≥ 44% (n = 46) and ΔBUN levels within the first 24 h post-admission; ΔBUN ≤ 0 (n = 78) and ΔBUN > 0 (n = 61). Propensity score matching (PSM) was performed on factors such as age and gender to control for differences among the strata. The clinical outcomes of the patients receiving or not receiving BP therapy were compared based on the mentioned criteria. Patients with HCT0 ≥ 44%, who were treated with BP showed no significant difference in the 28-day mortality. However, a significant increase in hospital expenses and prolonged ICU stays was observed (P < 0.05). Conversely, patients with ΔBUN ≤ 0 who received BP therapy demonstrated relatively high 28-day mortality rates, prolonged ICU stays, increased hospital expenses, and low SOFA scores (P < 0.05). The analyses of MIMIC-IV database data corroborated these findings. The predictive efficacy of BP therapy in SAP patients was significantly influenced by the changes in BUN levels at 24 h post-admission compared to the initial levels of HCT on admission. Selecting SAP patients suitable for BP treatment should be based on the changes in BUN levels to enhance effective therapeutic outcomes.

Hepatic Portal Venous Gas in Acute Pancreatitis-A Critical Finding: A Systematic Review

BackgroundHepatic portal venous gas (HPVG) is an uncommon radiological finding in acute pancreatitis. This systematic review aims to consolidate existing literature on HPVG in acute pancreatitis and assess its clinical significance, particularly regarding surgical intervention. We also report a clinical case from our center.MethodsA systematic search was conducted across Medline, Scopus, Cochrane, and Google Scholar databases to identify studies reporting concurrent HPVG and pancreatitis. Data included demographics, clinical presentation, management, and outcomes. Descriptive statistics were employed for analysis, and methodological quality was assessed using established criteria.ResultsOut of 259 articles screened, 13 met inclusion criteria, yielding data on 17 patients (76.5% male; median age 62 years). Nonoperative management (NOM) was utilized in 75% of cases and was associated with a 54% mortality rate. In contrast, the surgical cohort (n = 4) experienced a similar overall mortality rate of 50%. Importantly, necrotic bowel was implicated in 44% of evaluable cases and was uniformly fatal. However, 2 patients who underwent early surgical resection of nonviable bowel survived the initial phase of their illness, suggesting that prompt operative intervention may confer an early survival advantage in selected patients. Fluid collections and pneumatosis intestinalis were significantly more prevalent in deceased patients (100% vs 17% in survivors; P < 0.0034). All deceased patients had either severe or necrotizing pancreatitis.ConclusionHPVG associated with severe acute pancreatitis appears to have a higher mortality than HPVG alone. It can be managed nonoperatively but when indicative of bowel necrosis, necessitates prompt surgical intervention.

The Multidisciplinary Approach to Acute Necrotizing Pancreatitis

Acute pancreatitis is a common gastrointestinal condition, primarily caused by gallstones and alcohol abuse, with other causes including hypertriglyceridemia, trauma, infections, etc. While most cases are mild and self-limiting, up to 20% of patients develop severe pancreatitis with pancreatic necrosis, increasing the risk of multi-organ failure and mortality. Conservative management involves fluid resuscitation, nutritional support, and antibiotics for infected peripancreatic fluid collections (PFCs). When PFCs are infected or symptoms persist, invasive interventions such as endoscopic ultrasound (EUS)-guided drainage or percutaneous drainage are recommended. Dual modalities (endoscopic and percutaneous drainage) offer better outcomes with fewer complications. Direct endoscopic necrosectomy is considered for patients who do not improve with drainage. A multidisciplinary team, including endoscopists, interventional radiologists, surgeons, and specialists, is essential for optimal management of severe necrotizing pancreatitis.

Fluid therapy in acute pancreatitis comparing balanced solutions and normal saline: A systematic review, meta-analysis and trial sequential analysis

BACKGROUND

Isotonic crystalloids are recommended as the first choice for fluid therapy in acute pancreatitis (AP), with normal saline (NS) and lactate Ringer's (LR) used most often. Evidence based recommendations on the type of fluid are conflicting and generally come from small single-center randomized controlled trials (RCTs). We therefore conducted a systematic review and meta-analysis to compare the effect of balanced solutions (BS) versus NS on patient-centered clinical outcomes in AP.

METHODS

From four databases searched up to October 2024, we included only RCTs of adult patients with AP that compared the use of BS (including LR, acetate Ringer's, etc.) with NS. The primary outcome was the disease advances from AP to moderately severe and severe AP (MSAP/SAP). Trial sequential analyses (TSA) were conducted to control for type-I and type-II errors and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence.

RESULTS

Six RCTs were identified and included, involving 260 patients treated with BS and 298 patients with NS. Patients who received the BS had less MSAP/SAP [odds ratio (OR) = 0.50, 95 % confidence interval (CI): 0.29 to 0.85, P = 0.01, I2 = 0 %; 5 studies, 299 patients], reduced need of ICU admission (OR = 0.60, 95 % CI: 0.39 to 0.93, P = 0.02, I2 = 0 %; 5 studies, 507 patients) and shorter length of hospital stay [mean difference (MD) = -0.88, 95 % CI:1.48 to -0.28, P = 0.004, I2 = 0 %; 6 studies, 558 patients; confirmed by TSA with high certainty] compared with those who received NS. The evidence for most of the clinical outcomes was rated as moderate to low due to the risk of bias, imprecision and inconsistency.

CONCLUSIONS

BS, compared with NS, was associated with improved clinical outcomes in patients with AP. However, given the moderate to low quality of evidence for most of the outcomes assessed, further trials are warranted.

Quality of Life and Psychological Functioning in Children with PFAPA Syndrome

BACKGROUND/OBJECTIVES

This study analyzes the impact of PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) on health-related quality of life (HRQoL) and the psychological functioning of children and adolescents aged 2 to 1 years.

METHODS

A cross-sectional descriptive study was conducted with 62 participants (31 males and 31 females) diagnosed with PFAPA. The Strengths and Difficulties Questionnaire (SDQ) and the Family Impact Module scale of Pediatric Quality of Life Inventory (PedsQL) were used to assess psychological functioning and HRQoL, respectively.

RESULTS

Participants exhibited predominantly low HRQoL, particularly in physical health and emotional functioning. School functioning was also affected. However, social functioning and family relationships showed more favorable scores. A positive correlation was observed between age and emotional symptoms. Family concern was the most significantly impacted aspect.

CONCLUSIONS

PFAPA syndrome has a significant impact on the HRQoL of affected children and adolescents, particularly in physical and emotional aspects. A holistic approach is necessary for disease management, considering not only physical symptoms but also psychosocial and academic factors, as well as the impact on the family.

Histologic Diagnosis of Pancreatic Cystic Lesions with Endoscopic Ultrasound Fine Needle Biopsy and Impact on Management Decisions

PURPOSE

Endoscopic ultrasound with fine needle biopsy (EUS-FNB) has not been well studied in pancreatic cystic lesions (PCLs). This study evaluates the diagnostic performance of EUS-FNB for PCLs and its impact on management decisions.

METHODS

We conducted a single-center, retrospective study of patients who had EUS-FNB between March 2016 and February 2024. We included patients with ≥ 6-month follow-up and excluded those with a solid pancreatic mass. We obtained clinical, radiologic, endoscopic, surgical, laboratory, and pathology data from chart review. We evaluated: (A) diagnostic yield; (B) predictors of diagnostic FNB; (C) diagnostic accuracy compared to surgical histopathology; (D) appropriateness of management decisions; and (E) adverse events. We compared the appropriateness of management decisions between diagnostic and non-diagnostic FNB.

RESULTS

100 subjects underwent EUS-FNB for PCLs (56% microcystic or with mural nodule). FNB yielded a histologic diagnosis in 60% of sampled lesions. Performing 2 or more needle passes was the only significant predictor of a diagnostic FNB (p = 0.02). Compared to surgical histopathology (n = 21), FNB needles highly accurately diagnosed specific cyst types (IPMN = 85.7%, MCN = 90.5%, SCA = 95.2%, NET = 95.2%, SPN = 100%) and malignant PCLs (accuracy = 81.0%; specificity = 100%; sensitivity = 72.7%). There was a 7.2-fold increase of appropriate management decisions when FNB was diagnostic vs. non-diagnostic (p < 0.001). This was due to improvement in surveillance discontinuation for benign cysts and in appropriate surgical resection for malignant PCLs (p < 0.001). Post-FNB pancreatitis occurred in 4% of patients.

CONCLUSION

EUS-FNB accurately diagnoses different PCL types and their degree of neoplasia, leading to more appropriate management decisions. Future prospective studies are needed to confirm these findings.

Evaluation of scoring systems and hematological parameters in the severity stratification of early-phase acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is an emergency gastrointestinal disease that requires immediate diagnosis and urgent clinical treatment. An accurate assessment and precise staging of severity are essential in initial intensive therapy.

AIM

To explore the prognostic value of inflammatory markers and several scoring systems [Acute Physiology and Chronic Health Evaluation II, the bedside index of severity in AP (BISAP), Ranson's score, the computed tomography severity index (CTSI) and sequential organ failure assessment] in severity stratification of early-phase AP.

METHODS

A total of 463 patients with AP admitted to our hospital between 1 January 2021 and 30 June 2024 were retrospectively enrolled in this study. Inflammation marker and scoring system levels were calculated and compared between different severity groups. Relationships between severity and several predictors were evaluated using univariate and multivariate logistic regression models. Predictive ability was estimated using receiver operating characteristic curves.

RESULTS

Of the 463 patients, 50 (10.80%) were classified as having severe AP (SAP). The results revealed that the white cell count significantly increased, whereas the prognostic nutritional index measured within 48 hours (PNI48) and calcium (Ca2+) were decreased as the severity of AP increased (P < 0.001). According to multivariate logistic regression, C-reactive protein measured within 48 hours (CRP48), Ca2+ levels, and PNI48 were independent risk factors for predicting SAP. The area under the curve (AUC) values for the CRP48, Ca2+, PNI48, Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, BISAP, CTSI, and Ranson scores for the prediction of SAP were 0.802, 0.736, 0.871, 0.799, 0.783, 0.895, 0.931 and 0.914, respectively. The AUC for the combined CRP48 + Ca2+ + PNI48 model was 0.892. The combination of PNI48 and Ranson achieved an AUC of 0.936.

CONCLUSION

Independent risk factors for developing SAP include CRP48, Ca2+, and PNI48. CTSI, BISAP, and the combination of PNI48 and the Ranson score can act as reliable predictors of SAP.

Prognostic value of the measurement at admission of the inferior vena cava in acute pancreatitis

BACKGROUND

Identifying new early predictive markers for the development of severe forms in acute pancreatitis remains a major challenge. The aim of this study was to evaluate the performance of inferior vena cava (IVC) measurement to predict severe acute pancreatitis.

METHODS

We conducted a single-center retrospective study including patients consecutively hospitalized for acute pancreatitis between 2014 and 2019 who had an abdominal scan within 24 h after admission, before any significant fluid resuscitation. We calculated the ratio of inferior vena cava diameters (IVCR) by dividing the transverse diameter by the anteroposterior. Admission parameters associated with the occurrence of severe acute pancreatitis (persistent organ failure or necrosis infection) were identified by multivariate logistic regression.

RESULTS

Of the 404 included patients, 64 (15.8%) progressed to severe pancreatitis. IVCR in these patients was significantly higher (2.2 ± 0.6 vs. 1.7 ± 0.9, p < .001). In multivariate analysis, IVCR was independently associated with severe pancreatitis (OR = 2.27 95% CI [1.38-3.72], p = .001), as well as visual analog scale, creatinine, albumin, and bicarbonates. The areas under the Receiver Operating Characteristic (ROC) curve of IVCR was 0.67, inferior to systemic inflammatory response syndrome (0.76; p = .03) and Bedside Index for Severe Acute Pancreatitis (BISAP) (0.80; p = .002) in predicting severe acute pancreatitis.

CONCLUSIONS

IVCR is associated with the development of severe acute pancreatitis.

Automated machine learning for early prediction of systemic inflammatory response syndrome in acute pancreatitis

BACKGROUND

Systemic inflammatory response syndrome (SIRS) is a frequent and serious complication of acute pancreatitis (AP), often associated with increased mortality. This study aims to leverage automated machine learning (AutoML) algorithms to create a model for the early and precise prediction of SIRS in AP.

METHODS

This study retrospectively analyzed patients diagnosed with AP across multiple centers from January 2017 to December 2021. Data from the First Affiliated Hospital of Soochow University and Changshu Hospital were used for training and internal validation, while testing was conducted with data from the Second Affiliated Hospital. Predictive models were constructed and validated using the least absolute shrinkage and selection operator (LASSO) and AutoML. A nomogram was developed based on multivariable logistic regression (LR) analysis, and the performance of the models was assessed through receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Additionally, the AutoML model's effectiveness and interpretability were assessed through DCA, feature importance, SHapley Additive exPlanation (SHAP) plots, and locally interpretable model-agnostic explanations (LIME).

RESULTS

A total of 1,224 patients were included, with 812 in the training cohort, 200 in validation, and 212 in testing. SIRS occurred in 33.7% of the training cohort, 34.0% in validation, and 22.2% in testing. AutoML models outperformed traditional LR, with the deep learning (DL) model achieving an area under the ROC curve of 0.843 in the training set, and 0.848 and 0.867 in validation and testing, respectively.

CONCLUSION

The AutoML model using the DL algorithm is clinically significant for the early prediction of SIRS in AP.

YouTube and TikTok as sources of information on acute pancreatitis: a content and quality analysis

BACKGROUND

As one of the leading causes of hospitalization and huge medical expenses for gastrointestinal disorders, morbidity and mortality of acute pancreatitis continue to rise globally. Short videos are an important medium for population to achieve information about acute pancreatitis. We aimed to evaluate the content and quality of acute pancreatitis-related videos on TikTok and YouTube.

METHOD

A search was performed on the TikTok and YouTube platforms using the keyword "Acute pancreatitis". The sources of the videos were categorized as academic institutions, national institutions, physicians, healthcare professionals other than physicians, health information websites and others. The Journal of American Medical Association (JAMA), Global Quality Scale (GQS), and modified DISCERN scores were used to assess the quality of the included videos.

RESULT

A total of 75 TikTok videos and 79 YouTube videos were included and analyzed. Regarding modified DISCERN scale, the videos from national institutions scored highest on TikTok (p = 0.020). As for YouTube, healthcare professionals other than physicians had the highest averaged score judged by GQS score and JAMA score (p = 0.016 for JAMA score, p = 0.020 for GQS score). The duration of the videos on TikTok are significantly shorter than that on YouTube (71.5 vs. 361, respectively; p < 0.01). The length of the video was associated with higher JAMA score and DISCERN score (p < 0.01, r = 0.635 and 0.207, respectively).

CONCLUSION

According to TikTok and YouTube, basic information about acute pancreatitis was the main presentation of the videos. We recommend that video producers extend the length of their videos appropriately to flesh out the content, and national institutions, physicians, and healthcare professionals other than physicians are all great resource of getting to know the acute pancreatitis better for viewers.

Risk of and factors influencing the progression from acute to recurrent acute to chronic pancreatitis

OBJECTIVES & AIMS

Acute pancreatitis (AP) recurrence rates range from 11 to 36 % yet accurately predicting recurrent acute pancreatitis (RAP) and its progression to chronic pancreatitis (CP) after an initial episode remains challenging. Thus, this study explored the risk factors contributing to RAP and its progression to CP.

METHODS

This retrospective study included patients with AP from three tertiary medical centers between January 2010 and December 2017. The patients were followed up for up to 60 months. The primary endpoint was the incidence of RAP and CP; risk factors influencing these outcomes were also identified.

RESULTS

Overall, 501 patients were included, of which 164 (32.7 %) experienced RAP, and 71 (14.2 %) progressed to CP. The leading causes of AP were alcohol consumption (43.1 %), gallstones (41.5 %) and hypertriglyceridemia (4.4 %). Multivariate Cox regression analysis revealed that smoking (HR, 4.09; 95 % CI, 2.752-6.078, p < 0.001), and organ failure after 48 h of hospitalization (HR, 3.52; 95 % CI, 1.22-10.19, p < 0.02) were significant risk factors for RAP. Significant risk factors for progression to CP included age over 60 years (HR, 5.29; 95 % CI, 1.25-22.47, p = 0.024), smoking (HR, 2.50; 95 % CI, 1.04-6.01, p = 0.04), alcohol consumption (HR, 8.79; 95 % CI, 2.06-37.43, p = 0.003), computed tomography severity index (CTSI) (HR, 1.22; 95 % CI, 1.04-1.44, p = 0.015), and recurrence of AP (HR, 70.69; 95 % CI, 2.61-1914.86, p = 0.011). In alcohol-induced RAP patients, ≥3 recurrences (HR, 4.18; 95 % CI, 1.75-9.98, p = 0.001) was significant risk factor for progression to CP.

CONCLUSIONS

Alcohol consumption was the predominant cause of AP and RAP. The severity of the initial AP episode was the key determinant for RAP, and RAP was the most significant risk factor for the progression to CP. Therefore, smoking and alcohol cessation are important to prevent the development of recurrent AP and CP during long-term follow-up.

Comparison of Computed Tomography/Magnetic Resonance Imaging Characteristics of Acute Pancreatitis Between Cholecystectomy and Non-cholecystectomy Patients

OBJECTIVE

This study aimed to compare computed tomography (CT)/magnetic resonance imaging (MRI) characteristics of acute pancreatitis (AP) between patients with cholecystectomy and non-cholecystectomy and to validate the effect of prior cholecystectomy on the severity of subsequent pancreatitis.

METHODS

This retrospective study included 384 inpatients with AP at our hospital from January 1, 2020 to December 31, 2023. Based on their history of cholecystectomy, the patients were split into cholecystectomy and non-cholecystectomy groups. propensity score matching was applied, considering age and sex, in a 1:3 ratio. Demographic, clinical, laboratory, and CT/MRI parameters of each group were analyzed.

RESULTS

There were 200 (52.1%) males and 184 (47.9%) females, with a mean age of 53.55 ± 13.86 years (range: 18-98 y). Ninety-six patients were in the cholecystectomy group that had previously undergone cholecystectomy, and 288 in the non-cholecystectomy group. Creatinine and C-reactive protein levels were lower in the patients with cholecystectomy than in patients with non-cholecystectomy (P1 = 0.001, P2 = 0.049). In the prevalence of biliary pancreatitis, the cholecystectomy patients are 27.1%, whereas the non-cholecystectomy patients are 45.8% (P = 0.005). The non-cholecystectomy patients had a significantly higher mean CT/MRI severity index score (3.57 ± 1.72 points) than the cholecystectomy group (3.00 ± 1.58 points; P < 0.001). Regarding local complications, In the groups that underwent cholecystectomy and those that did not, the prevalence of acute peripancreatic fluid collection was 40.4% and 21.9%, respectively. (P < 0.001).

CONCLUSIONS

AP following cholecystectomy exhibits unique imaging characteristics. Cholecystectomy reduces the severity and acute peripancreatic fluid collection rate of subsequent pancreatitis on CT/MRI.

Neutrophil CD64 index: a novel biomarker for risk stratification in acute pancreatitis

Objective

Effective early diagnosis and timely intervention in acute pancreatitis (AP) are essential for improving patient outcomes. This study aims to evaluate the clinical utility of the neutrophil CD64 index (nCD64) in stratifying patients with SAP and assessing mortality risk.

Methods

A total of 302 AP patients were enrolled and divided into a training cohort (n = 226) and a validation cohort (n = 76). Venous blood samples were collected within 24 hours of admission, and the nCD64 index was measured via flow cytometry. Other clinical parameters, including C-reactive protein (CRP) and procalcitonin (PCT), were also recorded. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to assess the diagnostic value of the nCD64 index and its capacity to predict mortality risk.

Results

ROC curve analysis identified a cutoff value of 1.45 for the nCD64 index. Patients with nCD64 > 1.45 had significantly higher risks of complications, including systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), multiple organ failure (MOF), and death. Over 65% of patients with acute pancreatitis (AP) can be effectively risk-stratified at a low cost, and it has been demonstrated that AP patients with an nCD64 value ≤ 1.45 have an extremely low mortality rate (no mortality in present training and validation cohort). Kaplan-Meier survival analysis revealed a significant survival difference between high-risk (nCD64 > 1.45) and low-risk groups (p < 0.001).

Conclusion

The nCD64 index is an effective tool for early identification of SAP patients, allowing for the classification of over 65% of cases as low-risk for mortality.

The impact of the novel EUS scope and ultrasonographic system for diagnosis and therapy in patients with pancreatobiliary diseases (videos)

PURPOSE

We evaluated the diagnostic and therapeutic capabilities of endoscopic ultrasonography (EUS) in pancreaticobiliary diseases. We aimed to validate the efficiency of detective flow imaging (DFI), shear wave elastography (SWE), and other advanced imaging techniques.

METHODS

We used new EUS scopes (EG-740 UT and G-580UR) and the latest ultrasound equipment (ARIETTA 850) (Fujifilm Healthcare, Kanagawa, Japan). Diagnostic procedures were performed in 16 cases, including pancreatic cancer and intraductal papillary mucinous neoplasms, and therapeutic procedures in eight cases, involving complex biliary and pancreatic interventions. The utility of SWE in assessing tissue stiffness was quantified by measuring the shear wave velocity (SWV) in pancreatic cancer and autoimmune pancreatitis.

RESULTS

We found no significant difference in SWVs among different pancreatic conditions; however, significant variations were observed in the net percentage of effective SWV. Interventional EUS had a 100% technical and clinical success rate, demonstrating the efficacy of new imaging techniques and equipment in enhancing procedural safety and diagnostic accuracy.

CONCLUSIONS

The integration of advanced EUS imaging technologies, particularly DFI, contrast-enhanced EUS, and SWE, significantly enhances the diagnosis and treatment of pancreaticobiliary diseases.

Managing complicated pancreatitis with more knowledge and a bigger toolbox!

Acute pancreatitis (AP) is a heterogeneous inflammation of the pancreas, most frequently attributable to gallstones or alcohol. AP accounts for an estimated 300 000 patients admitted each year in the USA, and an estimated US$2.6 billion/year in hospitalization costs. Disease severity is classified as mild, moderate, or severe, dependent on the presence or degree of concomitant organ failure. Locally, pancreatitis may be complicated by fluid collections, necrosis, infection, and hemorrhage. Infection of necrotizing pancreatitis (NP) is associated with a doubling of mortality risk. The modern management of AP is evolving. Recent data suggest a shift from normal saline to lactated Ringer's solution, and from aggressive to more judicious volume resuscitation. Similarly, while historical wisdom advocated keeping patients nothing by mouth to 'rest the pancreas', recent data convincingly show fewer complications and reduced mortality with early enteral nutrition, when tolerated by the patient. The use of antibiotics in NP is controversial. Current recommendations suggest reserving antibiotics for cases with highly suspected or confirmed infected necrosis, as well as in patients with biliary pancreatitis complicated by acute cholecystitis or cholangitis. Regarding the management of local complications, control of acute hemorrhage can be attained either endovascularly or via laparotomy. Abdominal compartment syndrome is associated with a mortality risk of 50%-75%. Routine monitoring of intra-abdominal pressure is recommended in patients at high risk. Pancreatic pseudocysts require intervention in symptomatic patients or those with infection or other complications. Endoscopic transmural drainage may be considered as the first step when technically feasible. Necrotizing pancreatitis without suspicion of infection is often managed medically, while the delay, drain, debride approach remains the standard of care for the vast majority of infected pancreatic necrosis. Robotic surgery, in appropriately selected patients, allows for a one-step approach, and merits further study to explore its initially promising results.

A systematic review of the predictive factors for the recurrence of acute pancreatitis

PURPOSE

Acute Pancreatitis (AP) is a prevalent clinical pancreatic disorder characterized by acute inflammation of the pancreas, frequently associated with biliary or alcoholic events. If not treated with cholecystectomy after the first episode, patients may experience a recurrence of AP, with consequent need for emergency surgery and increased risk of death. Analyzing the risk factors that may contribute to the recurrence of Biliary and Alcoholic Pancreatitis (BAP and AAP), future research can be driven toward new solutions for preventing and treating this pancreatic disease.

METHODS

A systematic review was conducted selecting studies from BiomedCentral, PubMed, Scopus and Web of Science by two independent reviewers. Publications were considered only if written in English in the time interval between January 2000 and June 2024 and investigated the risk factors for the recurrence of BAP and AAP. At the end of the selection, a quality assessment phase was conducted using the PROBAST tool.

RESULTS

In this systematic review, 8 articles were selected out of 6.945, involving a total sample of 11.271 patients of which 38.77% developed recurrence episodes. 37.5% of the included studies focus on recurrent acute biliary pancreatitis (RBAP), while 62.5% are dedicated to recurrent acute alcoholic pancreatitis (RAAP). The risk factors for the recurrence of AP showed a clear differentiation between the alcoholic and biliary etiology. Most of the considered studies adopted a retrospective design, characterized by a susceptibility to potential methodological biases. However, the trend indicated a more recent increase in prospective studies, together with a greater focus on identifying and understanding the possible risk factors associated with the recurrence of acute pancreatitis (RAP). This result highlighted the progress in the scientific approach toward a more rigorous and systematic assessment of the causes and dynamics that influence the recurrence of the disease.

CONCLUSION

Studies highlighted the importance of lifestyle factors, clinical complications, and surgical interventions that can impact the risk of biliary or alcoholic recurrent acute pancreatitis. Increased and systematic adoption of artificial intelligence-based tools could significantly impact future knowledge relating to the risks of recurrence and relative possibilities of prevention.

Acute Pancreatitis in Children: It's Not Just a Simple Attack

Acute pancreatitis (AP) in children presents unique challenges distinct from adult manifestations, requiring specialized diagnostic and therapeutic approaches. Compared with adults, pediatric AP has lower mortality rates but still carries significant morbidity and potential long-term complications. This review examines current evidence on pediatric AP, highlighting recent advances in diagnosis, risk stratification, and management strategies. Current diagnostic approaches use serum lipase and amylase testing, along with various imaging modalities that have different diagnostic values. Recent research has identified promising biomarkers for predicting severe AP, including blood urea nitrogen, C-reactive protein, and specific cytokine signals. Emerging evidence suggests a role of gut microbiome dysbiosis in disease pathogenesis, opening new therapeutic possibilities targeting the gut-pancreas axis. Genetic factors, specifically pancreatitis risk genes, influence disease progression to recurrent and chronic pancreatitis. In this review, we summarize the consequences of an isolated AP episode in children. Our review highlights for the first time how AP can lead to significant long-term sequelae, including exocrine/nutritional deficiencies, endocrine pancreatic dysfunction, diabetes, recurrent pain, and decreased quality of life compared with healthy population controls. The goal of this review is to summarize advances in understanding of pediatric AP and to emphasize the importance of early recognition, appropriate risk stratification, and comprehensive follow-up after the first pediatric AP episode, while highlighting areas requiring future research to optimize patient outcomes.

Clinical Value of Circulating Angiopoietin-like Protein 8/Betatrophin Levels in Patients with Acute Pancreatitis

Background and Objectives: Acute pancreatitis (AP) is an inflammatory disorder of the pancreas, with severe cases linked to a higher mortality rate. The prognosis of AP is influenced by factors such as necrosis, secondary infections, and organ failure. Tissue damage in AP is driven by the activation of leukocytes and the release of inflammatory mediators. Angiopoietin-like protein 8 (ANGPTL8), also known as betatrophin, is a recently discovered protein that regulates lipid metabolism. This study aimed to investigate the relationship between ANGPTL8 levels and disease severity in AP patients, and to explore the potential of ANGPTL8 as a biomarker. Materials and Methods: This prospective study included 50 patients diagnosed with AP who were admitted to the Department of Internal Medicine at Dr. Cemil Taşcıoğlu City Hospital between September 2021 and February 2022. Additionally, 39 healthy volunteers who underwent a check-up at the same hospital served as the control group. The Glasgow-Imrie (GI) score was used to assess the severity of pancreatitis. Results: ANGPTL8 levels were found to be significantly lower in the AP group compared to the control group, with a statistically significant correlation between ANGPTL8 levels and the severity of AP (p < 0.05). The cut-off level of ANGPTL8 based on the GI score was determined to be 70.9 ng/L. The GI score for ANGPTL8 was 0.749 (95% CI: 0.606-0.861) (p < 0.001). The overall cut-off value for ANGPTL8 was 179.2 ng/L, with an overall classification rate of 0.936 (95% CI: 0.864-0.977) (p < 0.001). Conclusions: This study demonstrates that ANGPTL8 levels vary between patients with and without AP, with lower levels observed in AP patients. Our research is the first to identify decreased ANGPTL8 levels as an independent predictor of AP severity. ANGPTL8 may play a crucial role in regulating inflammation or metabolic dysfunction in AP. However, further studies are needed to confirm these findings in larger populations and investigate ANGPTL8's mechanistic role in AP. Longitudinal studies could help determine whether ANGPTL8 levels act as a biomarker for disease progression or treatment response, potentially paving the way for targeted therapies to improve outcomes for AP patients.

A qualitative study to explore the patient experience of hypertriglyceridemia-related acute pancreatitis

BACKGROUND

Hypertriglyceridemia (HTG) is a common cause of acute pancreatitis (AP) and can be exacerbated by acquired metabolic conditions or rare inherited disorders (eg, familial chylomicronemia syndrome [FCS]), leading to HTG-induced AP (HTG-AP). HTG-AP is associated with severe abdominal pain typically requiring hospitalization and significantly impacts health-related quality of life (HRQoL).

OBJECTIVE

To understand patients' perspectives on the HRQoL impacts of HTG-AP.

METHODS

Interviews were conducted with adults with severe/very severe HTG and/or FCS, experiencing ≥1 HTG-AP episode in the past 2 years requiring an overnight hospitalization. An interview guide, developed with patient and clinical expert input, explored symptoms, long-term HRQoL impacts, and management of HTG-AP. Participants completed a background questionnaire, the EQ-5D-5L and select items from the PROMIS Profile v1.0-FCS 28 prior to interview. Interview transcripts were analyzed using thematic and content analysis.

RESULTS

Twelve participants completed the study (aged 32-66 years), 3 with genetically confirmed FCS. Participants described a sudden onset of HTG-AP episodes and a gradual recovery following medical intervention (up to several weeks). Participants described substantial symptomatic burden during episodes, including severe abdominal pain, fatigue, gastrointestinal symptoms, fever, and appetite loss. These impacted psychological wellbeing, relationships, and daily activities. Many of the symptoms and impacts on HRQoL (eg, pain, work impacts) persisted between episodes and had long-term effects. Participants reported substantial lifestyle restrictions (eg, dietary) to manage symptoms.

CONCLUSION

HTG-AP has a substantial symptomatic and HRQoL burden during episodes, which can persist postrecovery. Treatments that reduce the incidence of HTG-AP have potential to improve HRQoL.

A nomogram for predicting risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit

AimTo investigate the incidence and risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit.DesignA retrospective study.MethodsFour hundred and one elderly patients (defined as aged ≥60 years) with severe traumatic brain injury who had undergone surgery and were admitted to the intensive care unit were enrolled in this study. We collected data on the incidence of lower extremity deep vein thrombosis and analyzed its influencing factors. Binary logistic regression analysis was employed to assess the associations between these factors and the occurrence of DVT. A nomogram was developed, and calibration curves were utilized to evaluate the model's accuracy. Additionally, a receiver operating characteristic curve was employed to assess the model's clinical discriminatory power.ResultsThe incidence of lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit was 25.69%. The final nomogram included age, intraoperative hypothermia, intraoperative bleeding volume, surgery time, D-dimer level, any organ failure, and body mass index as independent risk factors. The standard curve fit well with the calibrated prediction curve. The area under the receiver operating characteristic curve was 0.976 (95% CI: 0.958-0.994), and the model had good discrimination ability and reliability.ConclusionsThe risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit can be preliminarily assessed via the nomogram prediction model. This information may help guide medical staff in making reasonable decisions regarding the management of deep vein thrombosis prophylaxis.Patient or Public ContributionElderly postoperative patients with severe traumatic brain injury in the intensive care unit participated in the retrospective investigation of this study.

Imaging-based biomarkers in acute pancreatitis: the predictive value of adrenal contrast ratios for intensive care unit admission

BACKGROUND

Early risk stratification is crucial in acute biliary pancreatitis (ABP) to optimize patient management and guide intensive care unit (ICU) admission decisions. Traditional biomarkers and scoring systems have limitations in early severity assessment. This study aimed to evaluate the predictive value of adrenal contrast ratios on contrast-enhanced CT (CECT) as imaging-based biomarkers for ICU admission and prolonged hospitalization in ABP patients.

METHODS

This retrospective study included 288 ABP patients who underwent CECT within 24 h of admission. Adrenal-to-inferior vena cava (IVC) and adrenal-to-spleen contrast ratios were measured from portal venous phase images. The predictive performance of these ratios for ICU admission was assessed using receiver operating characteristic (ROC) analysis, and their correlation with clinical outcomes was evaluated through regression analysis.

RESULTS

ICU-admitted patients had significantly higher adrenal contrast ratios compared to non-ICU patients (adrenal-to-IVC ratio: 1.15 vs. 0.99, p < 0.001; adrenal-to-spleen ratio: 0.97 vs. 0.75, p < 0.001). ROC analysis demonstrated strong predictive accuracy (AUC = 0.74 for adrenal-to-IVC, AUC = 0.81 for adrenal-to-spleen). Additionally, adrenal contrast ratios correlated significantly with prolonged hospital stay (r = 0.49-0.55, p < 0.001).

CONCLUSION

Adrenal contrast ratios serve as promising imaging-based biomarkers for early ICU admission prediction and risk stratification in ABP patients. Their integration into clinical decision-making may enhance early management strategies. Further prospective validation is warranted.

STANDARDIZATION OF THE WHITE TEST IN OPEN LIVER RESECTION: TOWARD NEAR-ZERO CLINICALLY SIGNIFICANT BILE LEAKAGE

BACKGROUND

Biliary fistula is one of the most common complications after liver resection and is associated with significant morbidity and mortality. One of the methods used to evaluate biliary fistulas is the White test, which consists of injecting a lipid emulsion into the bile duct. However, no standard technique for performing the White test has been published.

AIMS

The aim of this study was to standardize the technique for performing the White test in patients undergoing hepatectomies, with and without previous cholecystectomy, and to assess the preliminary results.

METHODS

Patients over 18 years of age who were submitted to open hepatectomy were included in the study. The primary outcome was the rate of biliary fistula. Secondary outcomes were the incidence of acute pancreatitis and overall morbidity, measured by the Clavien-Dindo classification.

RESULTS

The standard technique for the White test was performed on 17 patients. In total, three patients had previous cholecystectomy, and two had low insertion of the cystic duct, requiring cannulation of the hepatocholedochal duct. None of the patients developed clinically significant biliary leaks. Acute pancreatitis did not occur in any patient. One patient developed pneumonia requiring mechanical ventilation (Clavien-Dindo IV). All others had minor or no complications.

CONCLUSIONS

The standardized technique for performing the White test suggests an appropriate strategy to maximize the detection of intraoperative biliary leaks.

Management of acute pancreatitis in the "no man's land"

Acute pancreatitis (AP) is an inflammatory disease that can represent a challenge for clinicians, in fact, the early determination of its severity in the first 72 h is crucial for prognosis, recognizing the etiology and carrying out risk stratification to determine a more specific therapy. No accurate early prognostic scores for disease severity have been published, so the severity of AP often cannot be properly defined in the first few hours of the disease. This initial phase represents a "no man's land", in which there is no certainty in the stratification of the damage, prognosis is difficult to establish, therapy must be started promptly, although there is still no effective medical therapy against pancreatic enzymatic activation. Therefore, it is very difficult at this stage to make the correct decisions to achieve the best outcome for the patient with AP. Literature search was carried out using the PubMed database by entering early management of acute pancreatitis [title] or therapy of acute pancreatitis [title] and selecting the most relevant articles for the diagnosis and therapy of acute pancreatitis in clinical practice. This document provides suggestions on managing the key clinical decisions for patients suffering from AP before disease severity is defined, to achieve the best outcomes for patients with AP.

Maternal and fetal death associated with acute pancreatitis during pregnancy: A case report

BACKGROUND

Acute pancreatitis in pregnancy is a rare but serious condition that can lead to high maternal mortality and fetal loss. Instances of pregnancy complicated by severe acute pancreatitis, particularly with subsequent respiratory and cardiac arrest, are rarely reported.

CASE SUMMARY

We present the case of a 35-year-old woman, at 36 + 5 weeks of gestation, who presented with paroxysmal epigastric pain accompanied by low back pain, nausea, and vomiting. According to the clinical symptoms, B-ultrasound imaging and biochemical indicators, the patient was diagnosed with acute pancreatitis and initially managed conservatively. However, 3 hours after admission, the patient experienced respiratory and cardiac arrest, and the fetus died. In this case, the adverse outcomes occurred due to the lack of aggressive fluid resuscitation and an active surgical intervention.

CONCLUSION

Implementing aggressive fluid resuscitation to sustain tissue perfusion, alongside the proactive evaluation of pharmacological agents that suppress gastric acid secretion and inhibit pancreatic enzyme activity, may be beneficial in mitigating the risk of a severely adverse prognosis. Effective management of acute pancreatitis during pregnancy requires careful timing of surgical intervention, a thorough evaluation of the risks and benefits regarding the continuation or termination of pregnancy, and a focus on safeguarding both maternal and fetal health.

Qingyi decoction and its active ingredients ameliorate acute pancreatitis by regulating acinar cells and macrophages via NF-κB/NLRP3/Caspase-1 pathways

BACKGROUND AND PURPOSE

Macrophage infiltration and activation is a critical step during acute pancreatitis (AP). NLRP3 inflammasomes in macrophages plays a critical role in mediating pancreatic inflammatory responses. Qing-Yi Decoction(QYD)has been used for many years in clinical practice of Nankai Hospital combined with traditional Chinese and western medicine treatment of acute pancreatitis. Although QYD has a well-established clinical efficacy, little is known about its bioactive ingredients, how they interact with different therapeutic targets and the pathways to produce anti-inflammatory effects. Here, we elucidate the therapeutic effects of QYD against acute pancreatitis and reveal its mechanism of action.

METHODS

The main components of QYD were identified using UHPLC-Q-Orbitrap MS. Network pharmacology was employed to predict potential therapeutic targets and their mechanisms of action. C57BL/6 mice were randomly divided into control group, model group, low, medium and high dose (6, 12, 24 g/kg) QYD groups, with 10 mice in each group. The therapeutic effect of QYD on cerulein-induced acute pancreatitis. (CER-AP) was evaluated by histopathological score, immunohistochemistry, serum amylase and cytokines detection by ELISA. The protein expressions of MyD88/NF-κB/NLRP3 signaling pathway were detected by Western blotting. Along with molecular docking of key bioactive compounds and targets, RAW264.7 cells stimulated with 1μg/ml LPS is used to screen components with more potent effects on target proteins. AR42 J cells were stimulated with 100 nM dexamethasone (dexa) combined with 10 nM cerulein (CN) as s a cell-culture model of acute pancreatitis. Inhibitory effects of the main chemical composition Wogonoside on NLRP3 inflammasomes were analyzed by qRT-PCR and Western blots.

RESULTS

Using UHPLC-Q-Orbitrap MS, 217 compounds were identified from QYD, including Wogonoside, Catechins, Rhein, etc. A visualization network of QYD-compounds-key targets-pathways-AP show that QYD may modulate PI3K-Akt signaling pathway, NOD-like receptor signaling pathway, MAPK signaling pathway, Ras signaling pathway and Apoptosis signaling pathway by targeting TNF, IL1β, AKT1, TP53 and STAT3 exerting a therapeutic effect on AP. QYD administration effectively mitigated CER-induced cytokine storm, pancreas edema and serum amylase. QYD (12 mg/kg) showed better effect. The protein expression levels of MyD88, NF-κB, NLRP3, Caspase-1 and GSDMD in pancreatic tissue were significantly decreased. Through molecular docking and LPS-RAW264.7 inflammation model, the selected Wogonoside significantly decreased IL-1β mRNA. The expression levels of NLRP3/Caspase-1/GSDMD pathway-related proteins were also decreased on AR42J-AP.

CONCLUSION

The results of network pharmacology indicate that QYD can inhibit AP through multiple pathways and targets. This finding was validated through in vivo tests, which demonstrated that QYD can reduce AP by inhibiting NLRP3 inflammasomes, additionally, it should be noted that 12mg/kg was a relatively superior dose. One of the main chemical compositions Wogonoside regulated NLRP3 inflammasome activation to protect against AP. This study is the first to verify the intrinsic molecular mechanism of QYD in treating AP by combining network pharmacology and animal experiments. The findings can provide evidence for subsequent clinical research and drug development.

A Case of Severe Acute Gallstone Pancreatitis With Black Ascites in a Patient Without Underlying Diseases

In acute pancreatitis, ascitic fluid is typically pale yellow and exudative due to inflammation. We report a rare case of black ascitic fluid associated with gallstone-induced severe acute pancreatitis in a 71-year-old man with no underlying disease. The patient initially presented to a local hospital with acute-onset abdominal pain. Abdominal computed tomography (CT) revealed a common bile duct stone, and he was diagnosed with acute cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and endoscopic nasobiliary drainage (ENBD) was performed. On the following day, his abdominal pain worsened, and further evaluation revealed elevated pancreatic enzyme levels and peripancreatic inflammatory changes on CT. He was subsequently diagnosed with acute pancreatitis. Despite four days of treatment with fluid resuscitation and antibiotics, his condition deteriorated, and he was transferred to our facility on Day 0. Upon arrival, he was intubated and started on mechanical ventilation due to respiratory failure. Continuous hemodiafiltration (CHDF) was initiated on Day 1 for metabolic acidosis and worsening renal function. On Day 3, abdominal CT revealed newly developed ascites, and paracentesis was performed due to concern for increased intra-abdominal pressure. The ascitic fluid appeared black. Laboratory analysis revealed a mildly elevated total bilirubin level and markedly elevated amylase and lipase levels, consistent with pancreatic ascites. Despite drainage and intensive supportive care, the patient developed multiple organ dysfunction syndrome (MODS), including refractory shock, respiratory failure, and renal insufficiency. He died on Day 5 of hospitalization. This case highlights an extremely rare presentation of pancreatic ascites with black discoloration in the early phase of acute pancreatitis. The black color was most likely due to pancreatic duct disruption and enzyme-mediated hemorrhagic changes. To our knowledge, this is the first reported case of black pancreatic ascites secondary to acute pancreatitis. Awareness of this rare manifestation may aid in the timely recognition and management of similar cases in the future.

Hypertriglyceridemia-Induced and Alcohol-Induced Acute Pancreatitis-A Severity Comparative Study

Background: Alcohol use and hypertriglyceridemia are the second and third common causes of acute pancreatitis after choledocholithiasis. Still, few studies directly compare the severity and outcomes of these two groups, which share pathophysiology pathways. Methods: In our study, we compared the biologic profile, severity according to the Atlanta classification and Balthazar index, intensive care unit admissions, and mortality between patients with hypertriglyceridemia-induced pancreatitis (HTGP) and alcohol-induced acute pancreatitis (AAP). A total of 78 patients were included in this study, 37.17% of which had HTGP, and 62.82% had AAP. Results: HTGP was more severe in terms of the Atlanta revised classification severity assessment (82.76% vs. 46%, p = 0.014), led to more extended hospitalizations (p = 0.024), and resulted in similar serum CRP levels among patients, with a significant difference regarding median serum fibrinogen values (739 vs. 563 mg/dL, p = 0.030) and necrotizing forms (24.13% vs. 10.20%). Hyponatremia was more significant in HTGP patients compared with AAP patients (130 vs. 137 mmol/L, p < 0.000). No differences were found in other inflammation indexes such as NLR (neutrophil count/lymphocyte count), PLR (platelet count/lymphocyte count), MLR (monocyte/lymphocyte count), SII (systemic immune-inflammation index), or SIRI (systemic inflammation response index). Conclusions: The pattern of acute pancreatitis is related to its etiology and may have different grades of severity. In our study, we found that hypertriglyceridemia-induced pancreatitis required twice as many admissions to the intensive care unit and was associated with lower serum sodium levels, and almost twice as many patients with HTGP had moderate or severe forms of acute pancreatitis compared to alcohol-induced pancreatitis cases.

Red Blood Cell Distribution Width-to-Platelet Count Ratio as a Prognostic Marker for Predicting Severity and Various Outcomes in Acute Pancreatitis

INTRODUCTION

The natural course of acute pancreatitis is quite variable, where most patients with mild acute pancreatitis usually follow a self-limiting course, whereas the mortality is quite higher in severe acute pancreatitis. Hence, early prediction of severity is essential for proper triaging. The study aimed to assess the diagnostic accuracy of red blood cell distribution width (RDW)-to-platelet count ratio (RPR) as a prognostic marker in acute pancreatitis.

METHODS

It was a prospective, observational study conducted on consecutive patients with acute pancreatitis. All participants were subjected to routine laboratory investigations and radiological evaluation using transabdominal ultrasound at the time of admission and a contrast-enhanced CT scan after 96 hours. All the parameters, including RPR, and various severity scores, such as the Systemic Inflammatory Response Syndrome (SIRS) score, Ranson score, Bedside Index for Severity in Acute Pancreatitis (BISAP) score, and Modified Marshall score, were compared between patients with mild or moderate to severe acute pancreatitis by using standard statistical tests.

RESULTS

A total of 200 patients diagnosed with acute pancreatitis were enrolled in this study, out of which the most common etiologies of acute pancreatitis were alcohol abuse (88 (44%)) and gallstones (57 (28.5%)). The overall mortality in our patients was seven (3.5%), which occurred only in severe acute pancreatitis. The mean RPR of patients with mild and moderately severe to severe acute pancreatitis were 0.07 ± 0.02 and 0.12 ± 0.09, respectively (p < 0.05), whereas the mean RPR of patients who survived and those who did not were 0.09 ± 0.06 and 0.12 ± 0.05, respectively (p < 0.05).

CONCLUSION

RPR calculated at the time of admission is found to be an independent prognostic marker in acute pancreatitis with the potential to identify individuals at risk for developing severe acute pancreatitis as well as mortality.

Serum Trypsin Is a Reliable Biomarker of Pancreas Function

ABSTRACT

Pancreatic diseases pose significant diagnostic and therapeutic challenges necessitating robust biomarkers for accurate diagnosis, management, and monitoring of pancreas function.Pancreas function can be measured with direct (invasive) and indirect tests. However, neither approach allows for continuous disease monitoring to identify disease progression or therapeutic response. We demonstrate literature evidence suggesting that trypsin, an important pancreatic digestive enzyme, holds promise as a continuous biomarker. On one hand, assessment of trypsin concentration in the serum sensitively and specifically detects pancreas inflammation; whereas on the other hand, declining trypsin levels in serum show good correlation with direct pancreatic function tests to identify exocrine pancreatic insufficiency. With this comprehensive review, we aimed to evaluate the existing evidence on the utility of trypsin as a continuous biomarker, spanning from acute to chronic pancreatitis and pancreas function, highlighting its potential in monitoring disease evolution on an individual patient level.

Circulating Biomarkers of Macrophage Activation in Different Stages of Chronic Pancreatitis: A Pilot Study

OBJECTIVES

Activation of type M2 macrophages has been implicated in the pathogenesis of chronic pancreatitis (CP). In a clinical pilot study, we investigated blood-based markers of macrophage activation at different stages of CP.

MATERIALS AND METHODS

We performed a cross-sectional analysis of prospectively collected plasma samples from healthy controls and patients with suspected or definitive CP according to the M-ANNHEIM criteria. Plasma concentrations of soluble CD163 (sCD163), soluble CD206 (sCD206), and monocyte chemoattractant protein-1 (MCP-1) were analyzed using enzyme-linked immunosorbent assays. Group and pairwise comparisons of analytes were performed using regression models and area under the receiver operating curves (AUC-ROC).

RESULTS

In total, 73 subjects with CP (28 suspected CP and 45 definitive CP) and 40 controls were included. Compared to controls, the median plasma concentrations of sCD163 ( P  = 0.019) and sCD206 ( P  = 0.033) were elevated in patients with definitive CP. sCD206 was also elevated in patients with definitive CP ( P  = 0.042) compared to suspected CP. ROC analysis revealed the optimal sCD163 cutpoint to distinguish definitive CP from controls was 1.84 mg/mL (AUC-ROC 0.65; 95% confidence interval [CI], 0.54-0.77). The optimal sCD206 cutpoint to distinguish definitive CP from controls was 0.24 mg/mL (AUC-ROC 0.66; 95% CI, 0.54-0.78). MCP-1 concentrations showed no differences across subgroups.

CONCLUSION

Our study demonstrates that subjects with definitive CP, sampled during a clinically quiescent phase, exhibited increased levels of sCD163 and sCD206. This indicates the presence of activated M2 macrophages in patients with CP at advanced, but not early, clinical stages.

The Effect of Epidural Analgesia on In-hospital Outcomes in Patients With Acute Pancreatitis: A Systematic Review and Meta-analysis of Randomized Clinical Trials

OBJECTIVES

Acute pancreatitis (AP) can lead to severe complications and high mortality. Previous studies suggest that epidural analgesia (EA) may improve outcomes in AP. This systematic review and meta-analysis aimed to evaluate the efficacy of EA on in-hospital outcomes in AP patients.

METHODS

Electronic databases (PubMed, Medline-Ovid, Scopus, CINAHL, Web of Science) were systematically searched until May 2024 for RCTs comparing EA with other pain strategies in AP patients. Variables were pooled using weighted mean difference (WMD) or risk ratio (RR) with 95% confidence intervals (CIs). Data analysis employed random-effects the Mantel-Haenszel method and I 2 statistic was used for heterogeneity.

RESULTS

Five RCTs with 260 participants were included. Meta-analysis showed no significant differences in in-hospital mortality (RR, 0.69; 95% CI [0.29-1.65]; P  = 0.40), mechanical ventilation (RR, 0.82; 95% CI [0.61-1.10]; P  = 0.19), sepsis (RR, 0.88; 95% CI [0.42-1.86]; P  = 0.74), hospital/ICU stay (WMD, 0.49 days; 95% CI [-1.13 to 2.10]; P  = 0.55), and pain score (WMD, 1.49; 95% CI [-0.42 to 3.40]; P  = 0.13). Opioid requirements were significantly lower, with one study reporting MME of 15 mg/d compared to 52 mg/d in the control group ( P  = 0.001). Heterogeneity was low to moderate for most outcomes but high for pain score ( I2  = 92%). Small number of studies, risk of bias, and sample size limited overall certainity.

CONCLUSIONS

EA did not significantly improve in-hospital outcomes in AP patients. However, findings suggested potential benefits in pain management. High-quality randomized trials are needed to understand the potential benefits of EA in this population.

Comparison of acute pancreatitis and acute on chronic pancreatitis: a retrospective cohort study

BACKGROUND

Acute on chronic pancreatitis (ACP) shares a similar clinical presentation with acute pancreatitis (AP) and is often diagnosed and treated in the same way. However, these two conditions may have distinct clinical risk profiles and prognoses. There is currently limited evidence available regarding the specific characteristics of ACP.

METHODS

This retrospective cohort study included all adult patients admitted with a diagnosis of AP or ACP between 2017 and 2019 at two tertiary referral centers. The primary outcome was disease severity as defined by the Atlanta classification. Secondary outcomes included the presence of local and systemic complications, organ failure, ICU admission, and mortality. Differences in outcomes between ACP and AP were compared using multivariate logistic regression models, with results presented as odds ratios (ORs).

RESULTS

We included 1163 patients, 90% of whom had AP and 10% had ACP. ACP patients were predominantly male (81 vs. 46%; P  < 0.001), whereas AP patients were older (mean age 62.6 vs. 56.5 years, P  < 0.001). ACP patients had lower amylase and lipase levels ( P  < 0.001). Multivariate analysis showed no difference in the risk of moderate or severe pancreatitis (OR, 1.15; 95% CI, 0.66-1.98; P  = 0.615). ACP patients had a higher risk of local complications (predominantly pseudocysts) (OR, 1.71; 95% CI, 1.00-2.92; P  = 0.049) and a lower risk of organ failure ( P  = 0.019) and ICU admission ( P  = 0.005).

CONCLUSION

Our study confirms previous observations that ACP has a more favorable in-hospital prognosis than AP and extends these findings to a modern European setting.

Machine Learning-Guided Fluid Resuscitation for Acute Pancreatitis Improves Outcomes

INTRODUCTION

Ariel Dynamic Acute Pancreatitis Tracker (ADAPT) is an artificial intelligence tool using mathematical algorithms to predict severity and manage fluid resuscitation needs based on the physiologic parameters of individual patients. Our aim was to assess whether adherence to ADAPT fluid recommendations vs standard management impacted clinical outcomes in a large prospective cohort.

METHODS

We analyzed patients consecutively admitted to the Los Angeles General Medical Center between June 2015 and November 2022 whose course was richly characterized by capturing more than 100 clinical variables. We inputted these data into the ADAPT system to generate resuscitation fluid recommendations and compared with the actual fluid resuscitation within the first 24 hours from presentation. The primary outcome was the difference in organ failure in those who were over-resuscitated (>500 mL) vs adequately resuscitated (within 500 mL) with respect to the ADAPT fluid recommendation. Additional outcomes included intensive care unit admission, systemic inflammatory response syndrome (SIRS) at 48 hours, local complications, and pancreatitis severity.

RESULTS

Among the 1,083 patients evaluated using ADAPT, 700 were over-resuscitated, 196 were adequately resuscitated, and 187 were under-resuscitated. Adjusting for pancreatitis etiology, gender, and SIRS at admission, over-resuscitation was associated with increased respiratory failure (odd ratio [OR] 2.73, 95% confidence interval [CI] 1.06-7.03) as well as intensive care unit admission (OR 2.40, 1.41-4.11), more than 48 hours of hospital length of stay (OR 1.87, 95% CI 1.19-2.94), SIRS at 48 hours (OR 1.73, 95% CI 1.08-2.77), and local pancreatitis complications (OR 2.93, 95% CI 1.23-6.96).

DISCUSSION

Adherence to ADAPT fluid recommendations reduces respiratory failure and other adverse outcomes compared with conventional fluid resuscitation strategies for acute pancreatitis. This validation study demonstrates the potential role of dynamic machine learning tools in acute pancreatitis management.

Redox signaling in the pancreas in health and disease

This review addresses oxidative stress and redox signaling in the pancreas under healthy physiological conditions as well as in acute pancreatitis, chronic pancreatitis, pancreatic cancer, and diabetes. Physiological redox homeodynamics is maintained mainly by NRF2/KEAP1, NF-κB, protein tyrosine phosphatases, peroxisome proliferator-activated receptor-γ coactivator 1α (PGC1α), and normal autophagy. Depletion of reduced glutathione (GSH) in the pancreas is a hallmark of acute pancreatitis and is initially accompanied by disulfide stress, which is characterized by protein cysteinylation without increased glutathione oxidation. A cross talk between oxidative stress, MAPKs, and NF-κB amplifies the inflammatory cascade, with PP2A and PGC1α as key redox regulatory nodes. In acute pancreatitis, nitration of cystathionine-β synthase causes blockade of the transsulfuration pathway leading to increased homocysteine levels, whereas p53 triggers necroptosis in the pancreas through downregulation of sulfiredoxin, PGC1α, and peroxiredoxin 3. Chronic pancreatitis exhibits oxidative distress mediated by NADPH oxidase 1 and/or CYP2E1, which promotes cell death, fibrosis, and inflammation. Oxidative stress cooperates with mutant KRAS to initiate and promote pancreatic adenocarcinoma. Mutant KRAS increases mitochondrial reactive oxygen species (ROS), which trigger acinar-to-ductal metaplasia and progression to pancreatic intraepithelial neoplasia (PanIN). ROS are maintained at a sufficient level to promote cell proliferation, while avoiding cell death or senescence through formation of NADPH and GSH and activation of NRF2, HIF-1/2α, and CREB. Redox signaling also plays a fundamental role in differentiation, proliferation, and insulin secretion of β-cells. However, ROS overproduction promotes β-cell dysfunction and apoptosis in type 1 and type 2 diabetes.

Endoscopic retrograde cholangiopancreatography and endoscopic cystogastrostomy in very young children (aged <5 years): Feasibility, success, and safety

Objectives

Paucity of data and concerns about potential lower effectiveness and more adverse events limit the use of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic cystogastrostomy in younger children even in high-volume centers. We retrospectively analyzed indications, success rates, and adverse events of all the children (<18 years) who underwent ERCP and endoscopic cystogastrostomy between January 2010 to May 2024 at our center.

Methods

Data, including patient demographics, indications for the procedure, technical details, and adverse events, were collected from our prospectively kept database and compared according to age groups (<1 year, 1-5 years, 5-10 years, and 10-18 years).

Results

A total of 286 ERCP (273 therapeutic and 13 diagnostic) and 57 endoscopic cystogastrostomy were performed in 222 (138 boys) and 55 children (32 boys), respectively, during the study period with 20% ERCP procedures in under-five children. In children <5 years, the majority of the ERCPs were for biliary diseases (87%), while pancreatic duct procedures (39.5%) were done in higher numbers in children >5 years. For biliary ERCP, choledochal cyst (15, 33%) was the most common etiology in under-five children and choledocholithiasis (60, 34%) in children >5 years. Cannulation and technical success rates were 95% and 92%, respectively with no significant difference across age groups. Adverse events were noted in 36 (16%) with post-ERCP pancreatitis (8%) being the most common. All adverse events were managed conservatively with no mortality.

Conclusion

ERCP can safely be performed in all children, including those under five with various hepato-pancreato-biliary diseases with high technical success rates.