Acute pancreatitis: current perspectives on diagnosis and management

New markers in predicting the severity of acute pancreatitis in the emergency department: Immature granulocyte count and percentage

Background:

Acute pancreatitis (AP) may vary in severity, from mild, self-limiting pancreatic inflammation to rapidly progressive life-threatening clinical course. If the severity of AP can be predicted early and treated quickly, it may lead to a decrease in morbidity and mortality rates. There?fore, we aimed to investigate the clinical utility of immature granulocyte count (IGC) and IGC percentage (IG%) in showing the severity of AP in this study.

Methods:

Two hundred and twenty-seven patients who were admitted to our emergency department and diagnosed with AP between March 1 and September 30, 2019, were included in the study. The patients were divided into two groups as mild and severe AP (MAP and SAP) according to the severity of the disease. Demographic characteristics of the patients, disease etiology, disease severity, and inflammation markers [white blood cell count (WBC), IGC, IG%, neutrophil–lymphocyte ratio (NLR), and C-reactive protein (CRP)] were recorded. Differences between the groups were statistically analyzed.

Results:

Of the patients included in the study, 183 (80.7%) were in the MAP group and 44 (19.3%) were in the SAP group. The mean WBC, NLR, CRP, IGC, and IG% levels were significantly higher in the SAP group compared to the MAP group. The power of IGC and IG% in predicting SAP was higher than other inflammation markers (WBC, NLR, and CRP) [(AUC for IGC: 0.902; sensitivity: 78.2%; specificity: 92.8%); (AUC for IG%: 0.843; sensitivity: 72.7%; specificity: 84.6%)].

Conclusion:

IGC and IG% show the severity of AP more effectively than WBC, NLR, and CRP, which are traditional inflammation markers.

Shotgun metagenomics reveals significant gut microbiome features in different grades of acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) has a broad spectrum of severity and is associated with considerable morbidity and mortality. Dysbiosis of gut microbiota may be associated with AP severity.

AIMS

We aimed to evaluate the composition and functional effects of gut microbiota in different grades of AP severity.

METHODS

We carried out shotgun metagenomic sequencing on rectal swab samples from three patients with mild acute pancreatitis (MAP), three with moderately severe acute pancreatitis (MSAP), three with severe acute pancreatitis (SAP) and three normal control persons (NOR). Differences analysis in gut microbiota composition and functional enrichment was performed.

RESULTS

Gut microbiota in AP patients was characterized by decreased species richness. The most representative gut microbiota in mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP), and severe acute pancreatitis (SAP) was Streptococcus, Escherichia-coli, and Enterococcus, respectively. Each of the three AP-associated genera could differentiate AP from healthy control population. Representative pathways associated with the glutathione metabolism, lipopolysaccharide biosynthesis, and amino acid metabolism (valine, leucine and isoleucine degradation) were enriched in MAP, MSAP, and SAP, respectively.

CONCLUSIONS

The study shows a potential association of gut microbiome composition and function to the progression of AP severity.

A narrative review of the mechanism of acute pancreatitis and recent advances in its clinical management

Acute pancreatitis (AP) is a common gastrointestinal disease with a high risk of mortality. Recently, the exosome and its potential regulatory role in the progression of AP has garnered the interest of researchers. However, effective drug interventions and therapeutic targets for AP remain to be established. Treatment approaches for AP have undergone considerable changes in the recent years: there is a greater preference for minimally invasive therapy (as primary treatment), multidisciplinary participation and the step-up approach. We aimed to discuss AP mechanism and the recent advancement in its treatment strategies to manage AP better in clinical practice.

Early diagnosis of serum sICAM-1 and sRAGE in severe acute pancreatitis, and efficacy and prognosis prediction of glutamine combined with ulinastatin

Acute pancreatitis (AP) is a common gastrointestinal disease that can become severe, so that intensive care may be required. This study was to examine serum soluble intercellular adhesion molecule-1 (sICAM-1), and soluble receptor for advanced glycation end products (sRAGE) for efficacy and prognosis prediction of glutamine (Glu) combined with ulinastatin (UTI) on severe acute pancreatitis (SAP). Fifty-four mild acute pancreatitis (MAP) patients admitted to Yidu Central Hospital of Weifang were selected as the MAP group (MAPG), 80 with SAP were divided as the SAP group (SAPG), and 60 healthy individuals who came to Yidu Central Hospital of Weifang for physical examination during the same period were included to the normal group (NG). Serum sICAM-1 and sRAGE were measured and their predictive value of efficacy and prognosis were analyzed. In view of the treatment effectiveness and prognosis, the patients were divided into effective group (EG) and ineffective group (IG), good prognosis group (GPG) and poor prognosis group (PPG). The levels of D-lactate, diamine oxidase (DAO), endotoxin and T-lymphocyte subsets (CD3⁺, CD4⁺, CD8⁺ and CD4⁺/CD8⁺) were measured and the changes before and after treatment were analyzed. The AUC values of NG and MAPG, NG and SAPG, MAPG and SAPG were 0.857, 0.939 and 0.856, respectively, those of predicting efficacy were 0.920 and 0.874, respectively, and those of poor prognosis in the SAPG were 0.914 and 0.879, respectively. In the SAPG, D-lactate, DAO, endotoxin and CD8⁺ decreased markedly after treatment, but CD3⁺, CD4⁺, and CD4⁺/CD8⁺ were opposite. SICAM-1 and sRAGE were also independent risk factors for poor prognosis in the SAPG. Serum sICAM-1 and sRAGE have high predictive value for early diagnosis, efficacy and prognosis of Glu combined with UTI.

Resveratrol supplementation and acute pancreatitis: A comprehensive review

Resveratrol, a natural polyphenolic ingredient extracted from herbs, suppresses oxidative stress and inflammation. We performed a comprehensive review to find any evidence about the effects of Resveratrol on acute pancreatitis (AP). Resveratrol has been found to directly impact cytokine generation. As these factors play a crucial role in the pathophysiology of AP, resveratrol might attenuate AP and its complications. Mechanistically, resveratrol exerts its pharmacological effects through anti-inflammatory and antioxidant mechanisms via interaction with different signaling molecules and transcription factors. Indeed, resveratrol might prove to be an effective therapeutic component for AP treatment in the future. In this review, we shed light on potential most recent pathways through which resveratrol might impact the management and control of AP.

A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management

Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca²⁺) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.

Adherence to the evidence-based guidelines in the management of acute biliary pancreatitis: A case series

BACKGROUND

Acute pancreatitis (AP) is considered one of the most common gastrointestinal disorders; the annual worldwide incidence for AP is 4.9-73.4 cases / 100,000 people and the total mortality rate is 4-8%, increasing to 33% in patients with infected necrosis. This study aims to assess the outcome of providing standardized evidence-based care to patients with acute biliary pancreatitis.

METHODS

Thirty patients diagnosed with acute biliary pancreatitis, were enrolled in this study and managed according to the Japanese guidelines, 2015 with a complementary scope on other recent guidelines.

RESULTS

Out of 30 patients in the study, 60% were females. Twenty-five cases were presented in the early phase of the disease while the rest presented in the late phase. Gallstones were the commonest cause (80%). The complications encountered were a systemic complication in one case, organ failure in three cases, and the local complications in the form of fluid collections in (43.3%) of cases.Out of 30 patients, 6 patients had an intervention. The main approach was minimally invasive techniques (4 cases), Open approach was performed in 2 cases. The total mortality rate was 10%. Most mild cases were discharged within one week from admission. Cases readmitted with recurrent attacks of acute pancreatitis were 3 cases, one male and 2 females.

CONCLUSION

By applying guidelines in the management of acute biliary pancreatitis, we can reduce disease-related morbidity and mortality. Besides, we can reduce the costs of medical services with the proper investment of healthcare resources.

Heme Oxygenase-1 in Gastrointestinal Tract Health and Disease

Heme oxygenase 1 (HO-1) is the rate-limiting enzyme of heme oxidative degradation, generating carbon monoxide (CO), free iron, and biliverdin. HO-1, a stress inducible enzyme, is considered as an anti-oxidative and cytoprotective agent. As many studies suggest, HO-1 is highly expressed in the gastrointestinal tract where it is involved in the response to inflammatory processes, which may lead to several diseases such as pancreatitis, diabetes, fatty liver disease, inflammatory bowel disease, and cancer. In this review, we highlight the pivotal role of HO-1 and its downstream effectors in the development of disorders and their beneficial effects on the maintenance of the gastrointestinal tract health. We also examine clinical trials involving the therapeutic targets derived from HO-1 system for the most common diseases of the digestive system.

Drug-induced acute pancreatitis: Prevalence, Causative agents, and Outcomes

BACKGROUND

We sought to study the causative drugs, prevalence and outcomes of drug-induced acute pancreatitis (DIAP).

METHODS

Retrospective study of DIAP patients at a tertiary teaching hospital. The diagnosis and severity of pancreatitis were determined based on the Revised Atlanta Classification. The cases were further subclassified using the Badalov et al., 2008 classification, and Naranjo score to evaluate and determine the odds of drug-related adverse reaction as a causative factor for AP.

RESULTS

Out of 841 AP patients, a total of 31 patients (3.6%) with DIAP were included. The mean age was 52.9 years, 51.6% were male. The most common causative drugs are listed in Table 3. Most cases were mild in severity (87%), moderate AP occurred in 2 patients (6.5%) and severe AP in 2 patients (6.5%). 19.3% had systemic inflammatory response syndrome at presentation, but it persisted beyond 48 h in only 9.6%. 9.6% developed acute kidney injury. One patient with valproate induced DIAP had pancreatic necrosis, splenic vein thrombus, and sub occlusive superior mesenteric vein thrombus on abdominal imaging. Three patients had recurrent AP, and two (6.5%) of them eventually developed chronic pancreatitis. Notably, none of our patients developed complications such as shock, acute respiratory distress syndrome, bacteremia, or death. 1 patient had an acute peripancreatic fluid collection on initial imaging and another patient developed a pseudocyst on follow up imaging. None of them required drainage.

CONCLUSION

Our study showed a prevalence of DIAP of (3.6%) and hydrochlorothiazide, azathioprine, and doxycycline were the most common culprit drugs.

Biochemical Evaluation of the Antioxidant Effects of Hydroxytyrosol on Pancreatitis-Associated Gut Injury

Acute pancreatitis is a severe abdominal pathology often associated with several complications including gut dysfunction. Oxidative stress is one of the most important pathways involved in this pathology. Hydroxytyrosol (HT), a phenolic compound obtained from olive oil, has shown anti-inflammatory and antioxidant properties. We evaluated the effects of HT administration on pancreatic and intestinal injury induced by caerulein administration. CD1 female mice were administered caerulein (50 μg/kg) for 10 h. HT treatment (5 mg/kg) was performed 30 min after the first caerulein injection and for two consecutive hours afterwards. One hour after the last caerulein injection, mice were sacrificed and serum, colon and pancreatic tissue samples were collected. HT was able to reduce the serum hallmarks of pancreatitis (amylase and lipase), histological damage score in both pancreas and colon tissue, inflammatory cells recruitment (mast cells) in both injured tissues, intrapancreatic trypsin activity and overexpression of the adhesion molecules (Intercellular Adhesion Molecule-1 (ICAM-1) and P-selectin) in colon. Additionally, HT reduced cytokine (interleukin 1 beta (IL- 1β), interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α)) levels in serum, pancreas and colon tissue and chemokine release (monocyte chemotactic protein-1 (MCP1/CCL2)) in pancreas and colon tissue. HT decreased lipid peroxidation and oxidative stress (superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione reductase (GR) and glutathione S-transferase (GST) activity) by enhancing the nuclear factor erythroid 2-related factor 2 (Nrf2) and heme oxygenase 1 (HO-1) in both injured tissues. Moreover, HT preserved intestinal barrier integrity, as shown by the diamine oxidase (DAO) serum levels and tight junction (zonula occludens (ZO) and occludin) expression in pancreas and colon. Our findings demonstrated that HT would be an important therapeutic tool against pancreatitis-induced injuries in the pancreas and gut.

Steroid-Induced Pancreatitis: Establishing an Accurate Association Poses a Challenge

The association between steroids and pancreatitis has been reported in the literature. However, due to its rarity, it can be challenging to make an early diagnosis. Hence, when diagnosing patients presenting with signs and symptoms of pancreatitis, there should be a high suspicion for medication-induced variants, after ruling out other common causes. In our report, we present the case of an individual with recurrent pancreatitis caused by the use of prednisone for musculoskeletal pain, the probable cause being steroids due to a high Naranjo score. The patient experienced clinical improvement with the resolution of pancreatitis after the steroids were discontinued.

A validated score predicting common bile duct stone in patients hospitalized with acute calculus cholecystitis: a multi-center retrospective study

BACKGROUND

Concomitant common bile duct (CBD) stone in the setting of acute calculous cholecystitis (ACC) should be suspected once abnormal liver indices are noticed.

AIM

We aimed to identify predictors of CBD stone in patients hospitalized with ACC.

METHODS

We performed a retrospective multi-center, case-controlled, study from 1st of January 2016 until the 31th of December 2018. Inclusion criteria included patients with an established diagnosis of ACC based on clinical, laboratory and radiological criteria and who had an endoscopic ultrasound (EUS) for suspected CBD stone. One-hundred and twelve patients were included, of these fifty-three patients (47.3%) were diagnosed with CBD stone by EUS.

RESULTS

In univariate analysis, Age (OR 1.038, P = 0.001), total bilirubin (mg/dl) (OR 1.429, P = 0.02) and CBD width (mm) by US (OR 1.314, P = 0.01) were statistically significant in predicting CBD stone and remained significant in multivariate regression analysis. We developed a diagnostic score that included these three parameters, with assignment of weights for each variable according to the coefficient estimate. A low cut-off score of 0 was associated with sensitivity of 100% for CBD stone, whereas a high cut-off score of 3 was associated with sensitivity of 10% and specificity of 96.6% with a positive predictive value of 67% (ROC of 0.7558). We validated this score with an independent cohort (ROC of 0.7416) with a sensitivity of 46.6%, a specificity of 91.5% and a PPV of 87.1%.

CONCLUSION

We recommend incorporating this score as an aid for stratifying patients with ACC into low or high probability for concomitant CBD stone.

Comparison of radiological scoring systems, clinical scores, neutrophil-lymphocyte ratio and serum C-reactive protein level for severity and mortality in acute pancreatitis

Comparison of radiological scoring systems, clinical scores, neutrophil-lymphocyte ratio and serum C-reactive protein level for severity and mortality in acute pancreatitis BACKGROUND/AIMS To compare radiological scoring systems, clinical scores, serum C-reactive protein (CRP) levels and the neutrophil-lymphocyte ratio (NLR) for predicting the severity and mortality of acute pancreatitis (AP). MATERIALS AND METHODS Demographic, clinical, and radiographic data from 80 patients with AP were retrospectively evaluated. The harmless acute pancreatitis score (HAPS), systemic inflammatory response syndrome (SIRS), bedside index for severity in acute pancreatitis (BISAP), Ranson score, Balthazar score, modified computed tomography severity index (CTSI), extrapancreatic inflammation on computed tomography (EPIC) score and renal rim grade were recorded. The prognostic performance of radiological and clinical scoring systems, NLR at admission, and serum CRP levels at 48 hours were compared for severity and mortality according to the revised Atlanta Criteria. The data were evaluated by calculating the receiver operator characteristic (ROC) curves and area under the ROC (AUROC). RESULTS Out of 80 patients, 19 (23.8%) had severe AP, and 9 (11.3%) died. The AUROC for the BISAP score was 0.836 (95%CI: 0.735-0.937), with the highest value for severity. With a cut-off of BISAP ≥2, sensitivity and specificity were 68.4% and 78.7%, respectively. The AUROC for NLR was 0.915 (95%CI: 0.790-1), with the highest value for mortality. With a cut-off of NLR >11.91, sensitivity and specificity were 76.5% and 94.1%, respectively. Of all the radiological scoring systems, the EPIC score had the highest AUROC, i.e., 0.773 (95%CI: 0.645-0.900) for severity and 0.851 (95%CI: 0.718-0.983) for mortality, with a cut-off value ≥6. CONCLUSION The BISAP score and NLR might be preferred as early determinants of severity and mortality in AP. The EPIC score might be suggested from the current radiological scoring systems.

Cholecystectomy outcomes after endoscopic sphincterotomy in patients with choledocholithiasis: a meta-analysis

Background

Endoscopic sphincterotomy (ES) is the standard treatment for common bile duct stones. The reported findings regarding complications, such as biliary pancreatitis and cholangitis, differ between cholecystectomy after ES. The purpose of this study is to compare cholecystectomy outcomes after endoscopic treatment of common bile duct stones whether or not the incidence of recurrent pancreatitis and cholangitis is reduced, especially in high-risk patients.

Methods

We analyzed 8 studies, including 7 randomized controlled trials retrieved from the PubMed (1990–2019), Embase (1990–2019), and Cochrane (1990–2019) databases for trials comparing the two strategies for treatment of gallstones after ES. A related study on gallbladder removal after ES was acquired, followed by analysis of each group using RevMan. Risk ratios (RRs) were calculated for categorical variables and differences in means were calculated for continuous variables.

Results

We retrieved a total of 8 studies, including seven randomized controlled trials and one retrospective study. A total of 12,717 patients were included in the study (4922 in the early cholecystectomy group and 7795 in the gallbladder in situ group). During the follow-up period, 41 patients had pancreatitis after ES in the cholecystectomy group and 177 patients in the wait-and-see group. The incidence of pancreatitis in the cholecystectomy group was significantly reduced (RR, 0.38; 95% CI, 0.27–0.53; P < 0.00001; I² = 0%). The incidence of cholangitis and jaundice in the cholecystectomy group was also less than the preserved gallbladder group (RR, 0.31; 95% CI, 0.26–0.38; P < 0.00001; I² = 0%). There was no significant difference in mortality between the two groups (RR, 0.73; 95% CI, 0.52–1.02; P = 0.07; I² = 14%). There was a significant difference in cholecystitis and biliary colic (RR, 0.28; 95% CI, 0.24–0.32; P < 0.00001; I² = 17%).

Conclusion

Early cholecystectomy after removal of common bile duct stones can effectively reduce biliary complications. This is still true for high-risk patients and has no significant effect on the mortality of patients. Laparoscopic cholecystectomy is recommended after ES.

Predicting common bile duct stones by non-invasive parameters

BACKGROUND

Common bile duct (CBD) stone affect about 10% of patients with symptomatic cholelithiasis. The American Society for Gastrointestinal Endoscopy (ASGE) published a strategy in 2010 for managing patients with suspected choledocholithiasis. This study aimed to assess the performance of different clinical parameters in predicting CBD stones.

METHODS

A total of 344 patients suspected to suffer from CBD stone and referred to endoscopic ultrasound (EUS) were included. Parameters were collected and their prediction power for CBD stones was assessed.

RESULTS

One hundred and sixty-seven patients without CBD stone according to EUS (group A) were compared to 177 patients with CBD stones (group B). Several predictive factors for CBD stone were identified on univariate analysis. In multivariate regression analysis, CBD width by US (OR = 1.224, 95% CI: 1.073-1.359; P = 0.0026), age (OR = 1.023, 95% CI: 1.011-1.035; P = 0.0002) and gamma glutamyl transferase (GGT) level (OR = 1.001, 95% CI: 1.000-1.002; P = 0.0018) were significantly correlated with CBD stone, with receiver operator characteristics (ROC) of 0.7259. We generated a diagnostic equation [age (yr) × 0.1 + CBD width (mm) by US × 1 + GGT (U/L) × 0.005] to predict CBD stone with ROC of 0.7287.

CONCLUSIONS

We suggest this score as a very strong predictor for CBD stones, and to reduce the strength of total bilirubin and transaminases as predictors.

Value of multidisciplinary collaboration in acute and chronic pancreatitis

Multidisciplinary collaboration (MDC) has been widely adopted in healthcare to optimize patient care. MDC brings several specialized healthcare providers to the table using several methods, including multidisciplinary meetings (MDMs), multidisciplinary clinics, teleconferences, and online multidisciplinary expert panels, to reach the goal of achieving the best diagnosis and treatment plan for complex diseases. Diagnosis and management of acute/chronic pancreatitis is complex which necessitates the development and utilization of MDC. The key members of pancreatitis MDM include gastroenterologists, radiologists, pathologists, hepatobiliary surgeons, chairperson, and a coordinator. After selection of admitted or referred patients, the availability of required information is reviewed, and then each case is discussed. The final diagnosis and treatment plan is confirmed by consensus, especially for complex cases that require endoscopic intervention or pancreatectomy and patients with the possibility of pancreatic adenocarcinoma. It has been shown that MDMs have improved the clinical outcome of patients with acute/chronic pancreatitis. In addition to MDM, the feasibility of multidisciplinary clinics, teleconferences, and online multidisciplinary expert panels for the management of pancreatic disorders has been investigated. Understanding structure, potential advantages, and limitations of MDC will help clinicians and healthcare systems in developing an optimized MDC to improve the management of acute/chronic pancreatitis. This narrative review summarized prior recommendations and explored the impact of MDC on clinical outcomes of patients with pancreatitis. Our recommendations offer a generalizable method that can be utilized by healthcare systems.

Bedside score predicting retained common bile duct stone in acute biliary pancreatitis

BACKGROUND

Retained common bile duct (CBD) stone after an acute episode of biliary pancreatitis is of paramount importance since stone extraction is mandatory.

AIM

To generate a simple non-invasive score to predict the presence of CBD stone in patients with biliary pancreatitis.

METHODS

We performed a retrospective study including patients with a diagnosis of biliary pancreatitis. One hundred and fifty-four patients were included. Thirty-three patients (21.5%) were diagnosed with CBD stone by endoscopic ultrasound (US).

RESULTS

In univariate analysis, age (OR: 1.048, P = 0.0004), aspartate transaminase (OR: 1.002, P = 0.0015), alkaline phosphatase (OR: 1.005, P = 0.0005), gamma-glutamyl transferase (OR: 1.003, P = 0.0002) and CBD width by US (OR: 1.187, P = 0.0445) were associated with CBD stone. In multivariate analysis, three parameters were identified to predict CBD stone; age (OR: 1.062, P = 0.0005), gamma-glutamyl transferase level (OR: 1.003, P = 0.0003) and dilated CBD (OR: 3.685, P = 0.027), with area under the curve of 0.8433. We developed a diagnostic score that included the three significant parameters on multivariate analysis, with assignment of weights for each variable according to the co-efficient estimate. A score that ranges from 51.28 to 73.7 has a very high specificity (90%-100%) for CBD stones, while a low score that ranges from 9.16 to 41.04 has a high sensitivity (82%-100%). By performing internal validation, the negative predictive value of the low score group was 93%.

CONCLUSION

We recommend incorporating this score as an aid for stratifying patients with acute biliary pancreatitis into low or high probability for the presence of CBD stone.

Picroside II Improves Severe Acute Pancreatitis-Induced Intestinal Barrier Injury by Inactivating Oxidative and Inflammatory TLR4-Dependent PI3K/AKT/NF-κB Signaling and Improving Gut Microbiota

Background

Picroside II exerts anti-inflammatory and antidiarrheal effects for treating the diseases associated with oxidative injury. However, its function on pancreatitis-induced intestinal barrier injury remains unclear. Hypothesis/Purpose. We hypothesized that picroside II will have protective effects against pancreatitis-induced intestinal barrier injury by affecting oxidative and inflammatory signaling (Toll-like receptor 4- (TLR4-) dependent phosphatidylinositol 3-kinase (PI3K), protein kinase B (AKT), and nuclear factor kappa B (NF-κB)). Study Design and Methods. A Sprague-Dawley (SD) rat model with severe acute pancreatitis (SAP) was induced via the injection of sodium taurocholate (4% wt/vol; 1 mL/kg). All rats were divided into 3 groups: sham (CG), SAP-induced intestinal barrier injury (MG), and picroside II (PG) groups. Intestinal barrier injury was assessed by scanning electron microscopy (SEM), hematoxylin and eosin staining, and pathological scores. We measured the levels of pancreatitis biomarkers (amylase and lipase), oxidative and inflammatory signaling (TLR4-dependent PI3K/AKT/NF-κB), oxidative stress marker (superoxidase dismutase (SOD), catalase (CAT), glutathione peroxidases (GPx), and malondialdehyde), and inflammatory markers (tumor necrosis factor α (TNFα), interleukin- (IL-) 1, IL-6, and IL-10) in serum and/or gut tissues. Gut microbiota composition in feces was measured by using 16S rRNA sequencing.

Results

SEM showed that intestinal barrier injury was caused with the loss of intestinal villi and mitochondria destruction, and pathological scores were increased in the MG group. The levels of amylase, lipase, malondialdehyde, TNFα, IL-1, IL-6, TLR4, PI3K, AKT, and NF-κB were increased, and the levels of SOD, GPx, CAT, and IL-10 was reduced in the MG group when compared with CG group (P < 0.05). Picroside II treatment inhibited the symptoms in the MG group and showed antioxidant and anti-inflammatory activities. The serum levels of picroside II had strong correlation with the levels of inflammatory and oxidative stress biomarkers (P < 0.05). Picroside II treatment increased the proportion of Lactobacillus and Prevotella and decreased the proportion of Helicobacter and Escherichia_Shigella in the model.

Conclusions

Picroside II improved the SAP-induced intestinal barrier injury in the rat model by inactivating oxidant and inflammatory signaling and improving gut microbiota.

Clinical review of acute, recurrent, and chronic pancreatitis: Recent updates of 2013-2019 literature

The increasing prevalence of pancreatic disorders worldwide has provided challenges in its clinical care and management. This review was aimed to evaluate recent literature on diagnosis, treatment, and management of acute pancreatitis (AP), recurrent acute pancreatitis (RAP), as well as chronic pancreatitis (CP) documented during the past 5–6 years. An extensive literature review was carried out based on studies within the last 6 years (2013–2019). Articles were selected based on updates and therapeutic management. Critical appraisal of literature was performed using the Mixed Methods Appraisal Tool (MMAT), and a PRISMA flowchart was used to avoid bias. The study identified recent updates on the prophylactic treatment in preventing RAP. The risk factors and the therapeutic management options were evaluated and discussed. The findings show that although many lifesaving new protocols are available for implementation in clinical practice, current literature lacks detailed and comprehensive guidelines that cover special populations and comorbidities. The literature evaluated showed that eight genes were involved in pancreatitis, CASR, CFTR, CLDN2, CPA1, CTRC, PRSS1, SBDS, and SPINK1, but the most common gene implicated was found to be CFTR, at 11%. Therefore, it is recommended that a comprehensive guideline should be formulated to facilitate the diagnosis, management, treatment, and prophylactic measures of pancreatic disease. This could in turn reduce disease complications and hospitalization time, and improve clinical practice for management of pancreatitis.

Cordycepin protects against acute pancreatitis by modulating NF-κB and NLRP3 inflammasome activation via AMPK

Acute pancreatitis (AP) is a noninfectious inflammatory disease with high morbidity and mortality, which is characterized by severe inflammation and tissue necrosis. Cordycepin (CRD), derived from Cordyceps militaris, possesses anti-inflammatory effects and immunomodulation properties. Here, we investigated the protective effects of CRD on pancreatic injury and clarified potential mechanisms in AP model. There were established caerulein-induced AP and CRD pretreatment models in vivo and in vitro, as showed by serum enzymes, histopathological alterations and pro-inflammatory cytokines. Pretreatment with CRD notably downregulated the serum amylase and lipase levels and apparently reduced pancreatic histopathological alterations in AP mice. Meanwhile, the MPO staining confirmed that CRD pretreatment modulated the infiltration of neutrophils in AP mice. Furthermore, CRD markedly decreased the levels of pro-inflammatory factors (IL-6, IL-1β, and TNF-α) though inhibiting the activation of nuclear factor-κB (NF-κB) and NLR family pyrin domain-containing protein 3 (NLRP3) inflammasome in AP mice. In pancreatic acinar cancer cell 266-6, CRD pretreatment decreased cholecystokinin(CCK)-induced inflammatory response was consistent with those in vivo. Mechanistically, CRD was also revealed to activate activated protein kinase (AMPK) and attenuated inflammation both in vivo and in vitro. On the whole, this study indicated that CRD protects mice from pancreatic inflammatory process and damage by suppressed NF-κB and NLRP3 inflammasome activation via AMPK, which probably contributed to the potential therapy for AP.

Comparison of Scoring Systems in Predicting Severity and Prognosis of Hypertriglyceridemia-Induced Acute Pancreatitis

BACKGROUND

In China, hyperlipidemia is the second major reason of acute pancreatitis.

AIMS

Comparison of Scoring Systems in identification patients at risk for severe acute pancreatitis (SAP), pancreatic necrosis (PNec), and infected pancreatic necrosis (IPN) early in the course of hypertriglyceridemia-induced acute pancreatitis (HTG-AP).

METHODS

Predictive accuracy of scoring systems was measured by the area under the receiver operating characteristic curve (AUC) in a retrospective study. Pairwise AUC comparisons were performed to calculate the difference between scoring systems.

RESULTS

A total of 238 patients diagnosed with HTG-AP were included. Sixty patients (25.2%) were classified as SAP. Twenty-nine patients (12.2%) had evidence of PNec. Nine patients (3.8%) were diagnosed with IPN. One patient (0.4%) died during hospitalization. In predicting SAP in HTG-AP, the AUCs of APACHE-II, SOFA, SIRS, Ranson's, BISAP, and MMS were 0.77, 0.83, 0.73, 0.88, 0.83, and 0.85, respectively; in predicting PNec, were 0.75, 0.77, 0.75, 0.86, 0.80, and 0.75, respectively; and in predicting IPN, were 0.92, 0.86, 0.76, 0.85, 0.84, and 0.87, respectively. Pairwise AUC comparisons revealed that Ranson's, MMS, BISAP, and SOFA had higher accuracy than SIRS, Ranson's and MMS had higher accuracy than APACHE-II in predicting SAP; Ranson's had the same accuracy with BISAP, but higher than other four criteria in predicting PNec; APACHE-II had higher accuracy than SIRS in predicting IPN.

CONCLUSIONS

APACHE-II had high performance in predicting IPN, and all other score systems had medium performance in predicting SAP, PNec, and IPN in HTG-AP. Each score has its merit and weakness; BISAP may be the best criterion in predicting severity and prognosis of HTG-AP.

The relationship between serum triglyceride levels and acute pancreatitis in an animal model and a 14-year retrospective clinical study

Objectives

The aim of the current study was to evaluate influence of serum triglyceride levels on the course of acute pancreatitis (AP).

Methods

Rats models of hypertriglyceridemic were used in animal experiments. Following induction of acute pancreatitis, amylase, and pancreas histological scores were all compared. In addition, in a clinical study, clinical data were collected from 1681 AP patients admitted from 2003 to 2016 who were divided into 4 groups based on their serum triglyceride (TG) levels. The clinical features among these 4 groups were compared, and a receiver operating characteristic (ROC) curve analysis was also performed on TG values to estimate their relationship with severity.

Results

In animal experiments, the hypertriglyceridemic pancreatitis (HTGP) group had markedly higher serum amylase, and histological scores relative to the other animal groups. In the clinical study, we identified significant differences in gender, age, body mass index (BMI), cost, and incidence of partial complications among the 4 TG-based groups. Importantly, the TG levels on day 3–4 after admission could be used to accurately predict disease severity.

Conclusions

Hypertriglyceridemia (HTG) can aggravate pancreatic injury, and hypertriglyceridemia patients are more likely to suffer from severe pancreatic injury with a higher possibility of complications. In addition, triglyceride levels are correlated with the severity of AP positively.

Management of Severe Acute Pancreatitis

Acute pancreatitis is one of the most common causes of hospitalisation from gastrointestinal diseases. The causes of pancreatitis vary between countries. Acute pancreatitis is classified based on Revised Atlanta classification 2013 as mild, moderately severe and severe acute pancreatitis. Acute pancreatic severity can be stratified by scoring systems such as Ranson's score, BISAP score, APACHE-II score, SOFA score. In severe acute pancreatitis, to diagnose, abdominal pain raised amylase or lipase, supported imaging finding and organ failure. Organ failure can be diagnosed by using Modified Marshall Scoring System. Management is started conservatively, which are fluid resuscitation, enteral nutrition, analgesics, and antibiotics. Surgical management is indicated when infected pancreas necrosis is detected. In this review, we will discuss the current management based on recent research.

Effects of curcumin on oxidative stress, inflammation and apoptosis in L-arginine induced acute pancreatitis in mice

Background and purpose

Curcumin, an active constituent of rhizomes of Curcuma longa Linn, exhibits a variety of biological activities such as anti-inflammation and anti-oxidant. The present study aims to examine the effects of curcumin on oxidative stress, inflammation and apoptosis in L-arginine induced acute pancreatitis (AP) in mice.

Methods

Male ICR mice were randomly divided into 4 groups. Control group received intraperitoneal injection (i.p.) of 1% DMSO as a vehicle. AP group received two doses of i.p. L-arginine (L-Arg) 450 mg/100 g body weight (BW) at 1-hour interval. AP plus low-dose curcumin group received i.p. curcumin 50 mg/kg BW 1 hour before L-Arg injection and then once daily for 3 days. AP plus high-dose curcumin group received i.p. curcumin 200 mg/kg BW 1 hour before L-Arg injection and then once daily for 3 days. All mice were sacrificed at 72 hours. Pancreatic tissue was obtained for histological evaluation, immunohistochemical studies for nuclear factor-kappa beta (NF-kβ), apoptosis and myeloperoxidase (MPO), and Western blot analyses for 4-Hydroxynonenal (4-HNE). Blood samples were collected for amylase analysis.

Results

Mean body weight was significantly lower in AP group than in control group, while in curcumin group, body weight was maintained. The serum amylase, number of MPO positive cells, NF-kB positive cells, TUNEL positive cells, and 4-HNE expression significantly increased in AP group when compared with control group, but decreased in low and high-dose curcumin groups. Mice in AP group developed severe pancreatic inflammation, edema and fat necrosis. While mice in low and high-dose curcumin groups showed a significant improvement in histopathological scores. There was no significant difference between low and high doses of curcumin.

Conclusion

Curcumin could attenuate acute pancreatitis via anti-oxidant, anti-inflammation and anti-apoptosis property leading to the improvement in pancreatic damage.

Murine Models of Acute Pancreatitis: A Critical Appraisal of Clinical Relevance

Acute pancreatitis (AP) is a severe disease associated with high morbidity and mortality. Clinical studies can provide some data concerning the etiology, pathophysiology, and outcomes of this disease. However, the study of early events and new targeted therapies cannot be performed on humans due to ethical reasons. Experimental murine models can be used in the understanding of the pancreatic inflammation, because they are able to closely mimic the main features of human AP, namely their histologic glandular changes and distant organ failure. These models continue to be important research tools for the reproduction of the etiological, environmental, and genetic factors associated with the pathogenesis of this inflammatory pathology and the exploration of novel therapeutic options. This review provides an overview of several murine models of AP. Furthermore, special focus is made on the most frequently carried out models, the protocols used, and their advantages and limitations. Finally, examples are provided of the use of these models to improve knowledge of the mechanisms involved in the pathogenesis, identify new biomarkers of severity, and develop new targeted therapies.

Complications of endoscopic retrograde cholangiopancreatography: an imaging review

Endoscopic retrograde cholangiopancreatography (ERCP) has currently become an inseparable tool in the gastroenterologist's armamentarium for treatment of pancreaticobiliary disorders. Given the increase in number of therapeutic ERCP procedures today, the need for prompt and correct diagnosis of its complications is pivotal. This review discusses the mechanisms, risk factors, imaging findings and general management aspects of common and rare complications of ERCP. Furthermore, the review elaborates on imaging indications, recommended protocol and normal imaging findings post ERCP.

Serum apolipoprotein B-to-apolipoprotein A1 ratio is independently associated with disease severity in patients with acute pancreatitis

Early identification of severe acute pancreatitis (SAP) is critical for clinical decision-making. The apolipoprotein B-to-apolipoprotein A1 ratio (ApoB/A1 ratio) reflects the balance between pro-inflammation and anti-inflammation in vivo. This study investigated the association between serum ApoB/A1 ratio at admission and acute pancreatitis (AP) severity. A total of 375 patients with first attack of AP were retrospectively recruited from January 2014 to December 2017. The severity of AP was assessed at admission based on the 2012 revised Atlanta Classification. Serum lipids levels were tested on the first 24 h of hospitalization, of which the correlations with clinical features or scoring systems were also measured. The ApoB/A1 ratio markedly increased across disease severity of AP. The ApoB/A1 ratio, expressed as both quartile and continuous variables, was significantly associated with a high risk of SAP, even after adjustment for other conventional SAP risk factors. The ApoB/A1 ratio positively correlated with the revised 2012 Atlanta Classification, Ranson score, Bedside Index for Severity in AP score, Modified Computed Tomography Severity Index score, and Acute Physiology and Chronic Health Evaluation II score for AP severity. The optimal cut-off value of ApoB/A1 ratio for detecting SAP was 0.88, with a sensitivity of 83.08% and a specificity of 69.03%. Serum ApoB/A1 ratio at admission is closely correlated with disease severity in patients with AP and can serve as a reliable indicator for SAP in clinical setting.

Melatonin treatment of pigs with acute pancreatitis reduces inflammatory reaction of pancreatic tissue and enhances fitness score of pigs: experimental research

Background

Severe acute pancreatitis is associated with high morbidity and mortality. Melatonin is known as the activator of antioxidant enzymes. The main purpose of this study was to evaluate the clinical effect of melatonin treatment in a pig model with induced acute pancreatitis.

Methods

In this study, acute pancreatitis was induced in 38 German domestic pigs (German Hybrid). After induction of acute pancreatitis, 18 animals were treated with melatonin. Intraoperative clinical data, postoperative blood parameters, fitness, and Porcine Well-being (PWB) score, and post-mortal histopathological data were analyzed in both study groups.

Results

The matching procedure created two groups (melatonin group and control group) which were very similar. The fitness and PWB score were postoperative significantly enhanced in the melatonin group as compared to the control group (p = 0.005 and p = 0.003). Additionally, histological analysis revealed that acinar necrosis, fat tissue necrosis, and edema were significantly reduced in the melatonin group as compared to the non-melatonin group (p = 0.025, p = 0.003, and p = 0.028).

Conclusions

Pigs, which were treated with melatonin, were characterized by higher fitness and PWB scores than those of the control group. Moreover, melatonin treatment reduces the acinar necrosis, fat tissue necrosis, and edema of pancreatic tissue. Thus, melatonin might be a useful therapeutic option in severe acute pancreatitis.

Risk Stratification and Early Conservative Treatment of Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a potentially life-threatening common gastrointestinal disorder with increasing incidence around the globe. Although the majority of cases will take an uneventful, mild course, a fraction of patients is at risk of moderately severe or severe pancreatitis which is burdened with substantial morbidity and mortality. Early identification of patients at risk of a severe disease course and an adopted treatment strategy are crucial to avoid adverse outcomes.

SUMMARY

In this review we summarize the most recent concepts of severity grading in patients diagnosed with AP by adopting recommendations of current guidelines and discussing them in the context of the available literature. The severity of AP depends on the presence of local and/or systemic complications and organ failure. To predict the severity early in the disease course, host-specific factors (age, comorbidities, body mass index), clinical risk factors (biochemical and physiological parameters and scoring systems), as well as the response to initial therapy need to be considered and revisited in the short term. Depending on the individual risk and comorbidity the initial treatment can be guided, which will be discussed in the second part of this review.

KEY MESSAGE

Predicting the severity of AP and adapting the individual treatment strategy requires multidimensional risk assessment and close observation during the early phase of AP development.

Elevated serum neopterin concentration increases mortality risk in patients with acute pancreatitis

Background The aim of this study was to investigate serum neopterin levels in patients with acute pancreatitis (AP) and its predictive value for mortality in cases of severe acute pancreatitis (SAP).

Methods Eighty-two patients with confirmed acute pancreatitis (AP) were included and divided into two groups, mild acute pancreatitis (MAP, n=51) and severe acute pancreatitis (SAP, n=31) according to severity of disease. From the SAP group, 8 cases went on to develop multiple organ dysfunction syndrome (MODS) and 6 subsequently died. Thirty healthy subjects from routine medical examination were included as the control group. The neopterin serum concentrations were determined and compared between groups.

Results Serum neopterin concentrations from control, MAP, SAP, SAP_Non-MODS, MODS_survival and MODS_death groups were 6.85±2.42 (nmol/L), 0.91±4.83(nmol/L), 33.11±11.67(nmol/L), 30.39±9.97(nmol/L), 36.40±4.48(nmol/L) and 41.75±15.64(nmol/L) respectively, with statistical significant difference (p<0.05). The sensitivity and specificity for mortality risk were 66.67% (95%CI:22.28-95.67%) and 88.00%(95%CI:68.78-97.45%) respectively, with area under the ROC curve (AUC) of 0.71(95%CI:0.50-0.9), under the cut off value of 40.18.

Conclusion: Serum neopterin levels in patients with acute pancreatitis were significantly elevated and correlated with the severity of disease. Neopterin may also be used a serological biomarker of mortality risk in patients with SAP.

Gut Microbiota in Alcoholic Hepatitis is Disparate from Those in Acute Alcoholic Pancreatitis and Biliary Disease

BACKGROUND

Alcoholic hepatitis (AH) is associated with gut dysbiosis. Comparative gut microbial profiles of acute alcoholic pancreatitis (AAP) and acute biliary disease (ABD) are not demonstrated. We aimed to compare gut microbiota of AH, AAP, and ABD patients with each other and with their respective healthy controls (HCs).

METHODS

From December 2016 to September 2017, consecutive patients with AH, AAP, and ABD (acute cholecystitis, acute biliary pancreatitis, and choledocholithiasis with cholangitis) were included in the study. Qualitative and functional stool microbiota comparative analysis was performed between groups, with AH as the reference comparator.

RESULTS

Of 3564, 882, and 224 patients with liver disease, pancreatic disease, and biliary disease, respectively, after exclusion, 29 patients with AH and 7 patients each with AAP and ABD and their corresponding HCs were included in the study analysis. The alpha diversity between patients with AH and AAP was found to be significantly different. Significant relative abundance (RA) of Acinetobacter and Moraxella was noted among patients with AAP. Enterobacter, Atopobium, Synergistia, and Devosia were significantly higher in patients with ABD compared to patients with AH, in whom Faecalibacterium and Megamonas were higher. Functional pathways associated with carbohydrate metabolism, phenylpropanoid biosynthesis, and ethylbenzene degradation were significantly higher in AAP when compared to AH. Fatty acid and inositol phosphate metabolism and dioxin degradation were significantly upregulated in patients with ABD while lipid and fatty acid biosynthetic pathways and pathways associated with immune processes were upregulated in patients with AH.

CONCLUSIONS

Differential gut dysbiosis is evident in both patients with AH, AAP, and ABD and also in comparison to HCs. The differential microbiota among patients with AH and AAP maybe important in promotion and progression of liver or pancreatic disease among alcohol users and may be a potential therapeutic target, which needs to be confirmed in larger multicenter studies.

Acute Pancreatitis as a Complication of Sickle Cell Anaemia

A common cause of abdominal pain is acute pancreatitis, with the majority of cases being attributed to gallstones and excess alcohol. Sickle cell anaemia (SCA) is an autosomal recessive disease causing the production of abnormal haemoglobin. Physiological changes can lead to vaso-occlusion in sickle cell anaemia. Cholelithiasis is frequently seen in patients with SCA and complications from this can increase patient morbidity. We present a rare case of acute pancreatitis inducing a vaso-occlusive crisis.

Isoliquiritigenin Protects Against Pancreatic Injury and Intestinal Dysfunction After Severe Acute Pancreatitis via Nrf2 Signaling

Severe acute pancreatitis (SAP) is a digestive system disease that is associated with a range of complications including intestinal dysfunction. In this study, we determined that the chalcone compound, isoliquiritigenin (ISL), reduces pancreatic and intestinal injury in a mouse model of SAP. These effects were achieved by suppressing oxidative stress and the inflammatory responses to SAP. This was evidenced by a reduction in histological score, and malondialdehyde (MDA), interleukin (IL)-6, tumor necrosis factor (TNF)-α and cleaved-caspase-3 (c-caspase-3) protein along with an increase in Nrf2, hemeoxygenase-1 (HO-1), quinone oxidoreductase 1 (NQO1), and superoxide dismutase (SOD). We then used Nrf2^-/- mice to test the protective effect of Nrf2 during ISL treatment of SAP. Our results indicated that Nrf2^-/- mice had greater pancreatic injury and intestinal dysfunction than wild-type mice. They also had reduced adherens junctions (P120-catenin) and tight junctions (occludin), and increased activated nuclear factor-κB (NF-κB) protein. In Nrf2^-/- mice, ISL was less effective at these functions than in the WT mice. In conclusion, this study demonstrated that ISL exerts its protective effects against oxidative stress and inflammatory injury after SAP via regulation of the Nrf2/NF-κB pathway. It also showed that the efficacy of ISL in repairing the intestinal barrier damage caused by SAP is closely related to the Nrf2 protein. Our findings demonstrated that Nrf2 is an important protective factor against SAP-induced injuries in the pancreas and intestines.

Association between HLA-DR Expression and Multidrug-resistant Infection in Patients with Severe Acute Pancreatitis

Multidrug-resistant (MDR) bacterial infection is a common complication of severe acute pancreatitis (SAP). This study aimed to explore the association between human leukocyte antigen-antigen D-related (HLA-DR) expression and multidrug-resistant infection in patients with SAP. A total of 24 SAP patients who were admitted to Nanjing Drum Tower Hospital between May 2015 and December 2016 were enrolled in the study. The percentages of CD4+, CD8+, natural killer (NK), and HLA-DR (CD14+) cells and the CD4+/CD8+ cell ratio on days 1,7,14, and 28 after admission were determined by flow cytometry. Eighteen patients presented with the symptoms of infection. Among them, 55.6% patients (10/18) developed MDR infection. The most common causative MDR organisms were Enterobacter cloacae and Acinetobacter baumannii. The CD4+/CD8+ cell ratio and the percentage of NK cells were similar between patients with non-MDR and patients with MDR infections. In patients without infection, the HLA-DR percentage was maintained at a high level throughout the 28 days. Compared to the patients without any infection, the HLA-DR percentage in patients with non-MDR infection was reduced on day 1 but increased and reached similar levels on day 28. In patients with MDR infection, the HLA-DR percentage remained below normal levels at all-time points. It was concluded that persistent down-regulation of HLA-DR expression is associated with MDR bacterial infection in patients with SAP.

Eruptive xanthoma in the setting of hypertriglyceridemia and pancreatitis

BACKGROUND

Undifferentiated dermatologic complaints are often encountered in the emergency department. While a patient's exposures, risk factors, and comorbidities may help guide emergency department evaluation, the accurate diagnosis of dermatologic findings is critical to allowing rapid identification and treatment of disease.

CASE

In this vignette we discuss a case of eruptive xanthoma in a 33-year-old male with diabetic ketoacidosis and pancreatitis.

DISCUSSION

Dermatologic complaints pose a unique challenge to the emergency physician. Many dermatologic findings are benign; however, some may represent underlying serious disease even in young, otherwise healthy appearing patients. Eruptive xanthomas are cutaneous lesions often indicating severe hypertriglyceridemia and uncontrolled diabetes. Likely presentations and risk factors for eruptive xanthomas will be discussed as well as ED evaluation and management.