Hematological Abnormalities in Cirrhosis: A Narrative Review

Liver cirrhosis remains a major public health issue. Liver fibrosis leading to cirrhosis is the terminal stage of various chronic liver diseases. Inflammatory cytokines are involved in the pathogenesis. Patients with cirrhosis often have hematological abnormalities, such as anemia and thrombocytopenia, which have multifactorial etiologies. Anemia in cirrhosis could be related to bleeding leading to iron deficiency anemia or other nutritional anemia such as vitamin B12 and folate deficiency. The pathophysiology of thrombocytopenia in liver cirrhosis has been postulated to range from splenic sequestration to bone marrow suppression from toxic agents, such as alcohol. It often complicates management due to the risk of bleeding with severely low platelets. This review aimed to highlight pathogenesis of liver cirrhosis, hematological abnormalities in liver cirrhosis, and their clinical significance.

Controversies in the management of acute pancreatitis: An update

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Drug Delivery Strategies for the Treatment of Pancreatic Cancer

Pancreatic cancer is fast becoming a global menace and it is projected to be the second leading cause of cancer-related death by 2030. Pancreatic adenocarcinomas, which develop in the pancreas' exocrine region, are the predominant type of pancreatic cancer, representing about 95% of total pancreatic tumors. The malignancy progresses asymptomatically, making early diagnosis difficult. It is characterized by excessive production of fibrotic stroma known as desmoplasia, which aids tumor growth and metastatic spread by remodeling the extracellular matrix and releasing tumor growth factors. For decades, immense efforts have been harnessed toward developing more effective drug delivery systems for pancreatic cancer treatment leveraging nanotechnology, immunotherapy, drug conjugates, and combinations of these approaches. However, despite the reported preclinical success of these approaches, no substantial progress has been made clinically and the prognosis for pancreatic cancer is worsening. This review provides insights into challenges associated with the delivery of therapeutics for pancreatic cancer treatment and discusses drug delivery strategies to minimize adverse effects associated with current chemotherapy options and to improve the efficiency of drug treatment.

Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges

Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.

Liu D, A. Müller C, A. Stuck B, Welge-Lüssen A, Hähner A. Olfactory Dysfunction: Etiology, Diagnosis, and Treatment

BACKGROUND

Disorders of the sense of smell have received greater attention because of the frequency with which they occur as a symptom of SARS-CoV-2 infection. Olfactory dysfunction can lead to profound reduction in quality of life and may arise from many different causes.

METHODS

A selective literature review was conducted with consideration of the current version of the guideline issued by the Association of the Scientific Medical Societies in Germany.

RESULTS

The cornerstones of diagnosis are the relevant medical history and psychophysical testing of olfactory function using standardized validated tests. Modern treatment strategies are oriented on the cause of the dysfunction. While treatment of the underlying inflammation takes precedence in patients with sinunasal dysosmia, olfactory training is the primary treatment option for other forms of the disorder. The prognosis is determined not only by the cause of the olfactory dysfunction and the patient's age, but also by the olfactory performance as measured at the time of diagnosis.

CONCLUSION

Options for the treatment of olfactory dysfunction are available but limited, depending on the cause. It is therefore important to carry out a detailed diagnostic work-up and keep the patient informed of the expected course and prognosis.

Dissection of pyroptosis-related prognostic signature and CASP6-mediated regulation in pancreatic adenocarcinoma: new sights to clinical decision-making

Recent studies have indicated that pyroptosis may participate in the regulation of tumorigenesis and immune microenvironment. However, the role of pyroptosis-related genes (PRGs) in pancreatic adenocarcinoma (PAAD) remains unclear. Through multiple bioinformatics analysis, we constructed a prognostic gene model and competing endogenous RNA network. The correlation between PRGs and prognosis, immune infiltration, immune checkpoints, and tumor mutational burden was analyzed by Kaplan-Meier curve, univariate Cox, multivariate regression, and Spearman's analysis in PAAD patients. The qRT-PCR, Western blotting, CCK-8, Wound healing, and Transwell assay were applied to examine the role of CASP6 in PANC-1 cell. Thirty-one PRGs were upregulated in PAAD. Functional enrichment analysis revealed that the PRGs were mainly involved in pyroptosis, NOD-like receptor signaling pathway, and response to bacteria. We established a novel 4-gene signature related to PRGs for evaluating the prognosis of PAAD patients. Patients with PAAD in the low-risk group had a better prognosis than those in the high-risk group. The nomogram suggested that the 1-, 3-, and 5-years survival probability exhibited robust predictive performance. Significant correlation was observed between prognostic PRGs and immune infiltration, immune checkpoints, and tumor mutational burden. We first identified the potential competing endogenous RNA regulatory axis in PAAD: lncRNA PVT1/hsa-miR-16-5p/CASP6/CASP8. Moreover, knockdown of CASP6 dramatically inhibited the proliferation, migration, and invasion ability of PANC-1 cell in vitro. In conclusion, CASP6 could be a potential biomarker, promoting the occurrence and progression in PAAD. The lncRNA PVT1/hsa-miR-16-5p/CASP6/CASP8 regulatory axis plays an vital role in regulating the anti-tumor immune responses for PAAD.

Timing of minimally invasive step-up intervention for symptomatic pancreatic necrotic fluid collections: A systematic review and meta-analysis

BACKGROUND AND AIMS

Minimally invasive step-up interventions are now the standard treatment recommended by current guidelines for symptomatic pancreatic necrotic fluid collections (PNFC); however, it is controversial whether delayed treatment after four weeks should always be used in patients who have failed conservative treatment and whose condition has not improved or worsened. The aim of this meta-analysis was to evaluate the impacts of the different timing of interventions on the clinical outcomes and prognosis of patients with symptomatic PNEC requiring intervention.

METHODS

We searched Embase, Cochrane Library, PubMed and Web of Science databases to identify comparative studies assessing the safety and efficacy of early and postponed interventions in treating symptomatic PNFC.

PRIMARY OUTCOME

Mortality. Secondary outcomes included some major complications, need for further minimally invasive necrosectomy and length of hospital stay.

RESULTS

This meta-analysis included ten studies (2 RCTs and 8 observational studies) with a total of 1178 symptomatic PNFC patients who required intervention. Pooled results showed that there was no significant difference between early minimally invasive intervention and postponed intervention in mortality(OR 1.41, 95%CI 0.93-2.12;p = 0.10) and the incidence of early and late complications, but the early intervention group had a significantly increased need for further minimally invasive necrosectomy compared with postponed intervention (OR 2.04,95%CI 1.04-4.03; p = 0.04). There was no increase in length of stay for patients who received early intervention compared to postponed drainage (MD 3.53, 95% CI -4.20, 11.27; p = 0.37).

CONCLUSION

Intervention before four weeks should be considered for patients with PNFC complicated by persistent organ failure or infections, who have been treated conservatively to the maximum extent possible.

Burden of bone disease in chronic pancreatitis: A systematic review and meta-analysis

BACKGROUND

Bone disease is an under-recognized cause of morbidity in chronic pancreatitis (CP). Over the past decade, publications of original studies on bone disease in CP has warranted synthesis of the evidence to ascertain the true burden of the problem.

AIM

To quantify the prevalence of osteopenia, osteoporosis, and fragility fractures in CP patients and investigate the associated clinical features and outcomes.

METHODS

A systematic search identified studies investigating bone disease in CP patients from Cochrane Library, Embase, Google Scholar, Ovid Medline, PubMed, Scopus, and Web of Science, from inception until October 2022. The outcomes included prevalence of osteopenia, osteoporosis, and fragility fractures, which were meta-analyzed using a random-effects model and underwent metaregression to delineate association with baseline clinical features.

RESULTS

Twenty-one studies were included for systematic review and 18 studies were included for meta-analysis. The pooled prevalence of osteopenia and osteoporosis in CP patients was 41.2% (95%CI: 35.2%-47.3%) and 20.9% (95%CI: 14.9%-27.6%), respectively. The pooled prevalence of fragility fractures described among CP was 5.9% (95%CI: 3.9%-8.4%). Meta-regression revealed significant association of pancreatic enzyme replacement therapy (PERT) use with prevalence of osteoporosis [coefficient: 1.7 (95%CI: 0.6-2.8); P < 0.0001]. We observed no associations with mean age, sex distribution, body mass index, alcohol or smoking exposure, diabetes with prevalence of osteopenia, osteoporosis or fragility fractures. Paucity of data on systemic inflammation, CP severity, and bone mineralization parameters precluded a formal meta-analysis.

CONCLUSION

This meta-analysis confirms significant bone disease in patients with CP. Other than PERT use, we observed no patient or study-specific factor to be significantly associated with CP-related bone disease. Further studies are needed to identify confounders, at-risk population, and to understand the mechanisms of CP-related bone disease and the implications of treatment response.

Effect of Aggressive Intravenous Fluid Resuscitation Versus Nonaggressive Fluid Resuscitation in the Treatment of Acute Pancreatitis: A Systematic Review and Meta-Analysis

OBJECTIVES

Despite the need for active fluid therapy, fluid management of most acute pancreatitis (AP) cases is still supportive. The aim of this review is to compare the effect of aggressive versus nonaggressive intravenous (IV) fluid resuscitation in the treatment of acute pancreatitis.

METHODS

A systematic search of medical databases, such as Medline, Google Scholar, Science Direct, Cochrane Central, was conducted for publication until April 2022. We included randomized controlled trials or cohort (prospective and retrospective) studies reporting the outcomes of AP in patients that were managed with aggressive and nonaggressive IV fluid resuscitation. The primary outcome of interest was in-hospital mortality.

RESULTS

Fourteen trials involving 3423 acute pancreatitis patients were included in the review. We did not observe any differences in the risk of mortality, persistent organ failure, and systemic inflammatory response syndrome in both study groups. However, there was an increased risk of development of pancreatic necrosis, renal failure, and respiratory failure in the aggressive fluid therapy group compared with nonaggressive therapy. The funnel plot showed no publication bias.

CONCLUSIONS

Aggressive fluid therapy did not improve mortality rates in acute AP patients and was associated with an increased risk of acute renal failure, and respiratory failure.

Natural History of Asymptomatic Walled-off Necrosis in Patients With Acute Pancreatitis

Background and objectives Studies on the natural history of asymptomatic walled-off necrosis (WON) in acute pancreatitis (AP) are scarce. We conducted a prospective observational study to look for the incidence of infection in WON. Material and methods In this study, we included 30 consecutive AP patients with asymptomatic WON. Their baseline clinical, laboratory, and radiological parameters were recorded and followed up for three months. Mann Whitney U test and unpaired t-tests were used for quantitative data and chi-square and Fisher's exact tests were used for qualitative data analysis. A p-value <0.05 was considered significant. Receiver operating characteristic curve (ROC) analysis was done to identify the appropriate cutoffs for the significant variables. Results Of the 30 patients enrolled, 25 (83.3%) were males. Alcohol was the most common etiology. Eight patients (26.6%) developed an infection on follow-up. All were managed by drainage either percutaneously (n=4, 50%) or endoscopically (n=3, 37.5%). One patient required both. No patient required surgery and there was no mortality. Median baseline C-reactive protein (CRP) was higher in infection group 76 (IQR=34.8) mg/L vs asymptomatic group, 9.5 mg/dl (IQR=13.6), p<0.001. IL-6 and tumor necrosis factor (TNF)-alpha was also higher in the infection group. The size of the largest collection (157.50±33.59 mm vs 81.95±26.22 mm, P<0.001) and CT severity index (CTSI) (9.50±0.93 vs 7.82±1.37, p<0.01) were also higher in infection group as compared to the asymptomatic group. ROC curve analysis of baseline CRP (cutoff 49.5mg/dl), size of WON (cutoff 127mm) and CTSI (cutoff of 9) showed AUROC (area under ROC) of 1, 0.97, and 0.81 respectively for the future development of infection in WON. Conclusion Around one-fourth of asymptomatic WON patients developed an infection during three-months follow-up. Most patients with infected WON can be managed conservatively.

The optimal timing and intervention to reduce mortality for necrotizing pancreatitis: a systematic review and network meta-analysis

BACKGROUND

A series of randomized controlled trials have investigated the efficacy and safety of different timings of interventions and methods of intervention. However, the optimal treatment strategy is not yet clear.

METHODS

We searched PubMed, EMBASE, ClinicalTrials.gov and the Cochrane Library until November 30, 2022. A systematic review and Bayesian network meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Trials comparing different treatment strategies for necrotizing pancreatitis were included. This study was registered in the Prospective Register of Systematic Reviews (CRD42022364409) to ensure transparency.

RESULTS

We analyzed a total of 10 studies involving 570 patients and 8 treatment strategies. Although no statistically significant differences were identified comparing odds ratios, trends were confirmed by the surface under the cumulative ranking (SUCRA) scores. The interventions with a low rate of mortality were delayed surgery (DS), delayed surgical step-up approach (DSU) and delayed endoscopic step-up approach (DEU), while the interventions with a low rate of major complications were DSU, DEU and DS. According to the clustered ranking plot, DSU performed the best overall in reducing mortality and major complications, while DD performed the worst. Analysis of the secondary endpoints confirmed the superiority of DEU and DSU in terms of individual components of major complications (organ failure, pancreatic fistula, bleeding, and visceral organ or enterocutaneous fistula), exocrine insufficiency, endocrine insufficiency and length of stay. Overall, DSU was superior to other interventions.

CONCLUSION

DSU was the optimal treatment strategy for necrotizing pancreatitis. Drainage alone should be avoided in clinical practice. Any interventions should be postponed for at least 4 weeks if possible. The step-up approach was preferred.

Development of a Clinical Prediction Model for Diabetes in Chronic Pancreatitis: The PREDICT3c Study

OBJECTIVE

Diabetes that arises from chronic pancreatitis (CP) is associated with increased morbidity and mortality. Methods to predict which patients with CP are at greatest risk for diabetes are urgently needed. We aimed to examine independent risk factors for diabetes in a large cohort of patients with CP.

RESEARCH DESIGN AND METHODS

This cross-sectional study comprised 645 individuals with CP enrolled in the PROCEED study, of whom 276 had diabetes. We conducted univariable and multivariable regression analyses of potential risk factors for diabetes. Model performance was assessed by area under the receiver operating characteristic curve (AUROC) analysis, and accuracy was evaluated by cross validation. Exploratory analyses were stratified according to the timing of development of diabetes relative to the diagnosis of pancreatitis.

RESULTS

Independent correlates of diabetes in CP included risk factors for type 2 diabetes (older age, overweight/obese status, male sex, non-White race, tobacco use) as well as pancreatic disease-related factors (history of acute pancreatitis complications, nonalcoholic etiology of CP, exocrine pancreatic dysfunction, pancreatic calcification, pancreatic atrophy) (AUROC 0.745). Type 2 diabetes risk factors were predominant for diabetes occurring before pancreatitis, and pancreatic disease-related factors were predominant for diabetes occurring after pancreatitis.

CONCLUSIONS

Multiple factors are associated with diabetes in CP, including canonical risk factors for type 2 diabetes and features associated with pancreatitis severity. This study lays the groundwork for the future development of models integrating clinical and nonclinical data to identify patients with CP at risk for diabetes and identifies modifiable risk factors (obesity, smoking) on which to focus for diabetes prevention.

Incidence of bactibilia and related factors in patients who undergo cholecystectomy

Purpose

In general, bile is normally sterile. However, there are reports bactibilia may occur in certain instances, though the causal factors are unclear. We analyzed possible preoperative predictors of bactibilia upon cholecystectomy.

Methods

Bile samples were collected during cholecystectomies from November 2018 to November 2019. A total of 428 open or laparoscopic cholecystectomies were performed. Preoperative, intraoperative, and postoperative variables were compared between the culture-positive and culture-negative groups.

Results

One hundred fifty-seven patients (36.7%) were culture-positive. Gram-negative bacteria (95 [61.0%]) were more common. Escherichia coli (38 [40.0%]) and Enterobacter (22 [23.2%]) were the most common species. In univariate analysis, age of ≥70 years (P < 0.001), male sex (P < 0.001), high American Society of Anesthesiologists physical status grades (P = 0.001), diabetes mellitus (P = 0.002), jaundice (P = 0.007), high Tokyo Guideline grades (P = 0.008), percutaneous transhepatic gallbladder drainage (PTGBD; P < 0.001), endoscopic retrograde cholangiopancreatography (ERCP; P < 0.001) were identified as a risk factors for bactibilia. In multivariate analysis, age of ≥70 years (hazard ratio [HR], 2.874; 95% confidence interval [CI], 1.769-4.670; P = 0.001), ERCP (HR, 9.001; 95% CI, 4.833-16.75; P < 0.001), and PTGBD (HR, 2.866; 95% CI, 1.440-4.901; P = 0.002) were independent risk factors for bactibilia.

Conclusion

Among patients who underwent cholecystectomy, those who were elderly, symptomatic, and underwent preoperative drainage were more likely to have bactibilia. In such cases, surgeons should take care to prevent bile leakage during surgery and consider administering appropriate antibiotics.

Long non-coding RNA AL137789.1 promoted malignant biological behaviors and immune escape of pancreatic carcinoma cells

Our pre-investigation has revealed that long non-coding RNA (LncRNA) AL137789.1 has the potential to predict the survival of patients with pancreatic carcinoma (PCa). Accordingly, the mechanism underlying the implication of AL137789.1 in PCa is covered in the current study. The non-tumor and paired tumor tissues were collected. Kaplan-Meier curve was employed to estimate the survival of PCa patients with high or low expression of AL137789.1. The proliferation, migration, invasion, and cell cycle of PCa cells were determined, and the cytotoxicity of CD8⁺ T cells was evaluated as well. Levels of AL137789.1, E-cadherin, N-cadherin, and Vimentin were quantified. According to the experimental results, AL137789.1 was highly expressed in PCa and related to a poor prognosis of patients. Overexpressed AL137789.1 enhanced the proliferation, migration, and invasion of PCa cells, increased the cell population at G2/M and S phases yet decreased that in G0/G1 phase, and diminished the cytotoxicity of CD8⁺ T cells. Also, overexpressed AL137789.1 elevated levels of N-cadherin and Vimentin, while lessening E-cadherin levels. However, the silencing of AL137789.1 produced contrary effects. Collectively, lncRNA AL137789.1 plays a tumor-promotive role in PCa by enhancing the progression and immune escape.

The Evaluation of Inflammatory Biomarkers in Predicting Progression of Acute Pancreatitis to Pancreatic Necrosis: A Diagnostic Test Accuracy Review

Acute pancreatitis is the acute inflammation of the pancreas; 30% of cases may progress to pancreatic necrosis. The aim of this study was to assess the diagnostic accuracy of inflammatory biomarkers (C-reactive protein (CRP), procalcitonin (PCT), and lactate dehydrogenase (LDH)) in detecting pancreatic necrosis in adults with confirmed acute pancreatitis within 14 days of symptom onset and without organ failure. A systematic search was conducted across the Cumulative Index of Nursing and Allied Health (CINAHL), Cochrane, Embase, PubMed, and Web of Science until May 30, 2022, with the following keywords: acute disease, biomarkers, C-reactive protein, calcitonin, differential, diagnosis, lactate dehydrogenase, pancreatitis, acute necrotizing, necrosis, sensitivity, specificity. Statistical analysis was conducted in RevMan 5.4.1 (Cochrane). Five studies pooling 645 participants were included of which 59.8% were males, with a mean age of 49 years. CRP was the best cutoff at 279 mg/L (χ2 = 47.43, p < 0.001), followed by 200 mg/L (χ2 = 36.54, p < 0.001). LDH was cut off at 290 units/L (χ2 = 51.6, p < 0.001), whereas PCT did not display the most reliable results at 0.05 ng/mL. Inflammatory biomarkers are scalable diagnostic tools that may confer clinical value by decreasing the mortality of acute pancreatitis sequelae.

Changes in vitamin D and calcium-phosphorus metabolism in patients with severe acute pancreatitis

Objectives

The problem of predicting the course of acute pancreatitis and early diagnosis of its complications remains unresolved. This study aimed to determine changes in vitamin D and calcium-phosphorus metabolism in patients with severe acute pancreatitis.

Material and Methods

There were examined 72 people divided into two groups as healthy persons (comparison group) - males and females without pathology of the gastrointestinal tract and any other conditions or diseases that could affect the state of calcium-phosphorus metabolism (n= 36) and patients with acute pancreatitis (main group, n= 36). In addition, in order to determine the prognostic criteria for the severity of the disease, patients in the main group were divided into two subgroups. The first subgroup included patients with severe disease (n= 18), the second (n= 18) - with mild and moderate disease.

Results

Serum calcium value was lower in patients with severe acute pancreatitis comparison to healthy persons: 2.18 (2.12; 2.34) vs 2.36 (2.31; 2.43) mmol/L (p <0.0001), and the decrease of calcium levels was associated with an increase in the severity of acute pancreatitis. Therefore, hypocalcemia can be considered a reliable predictor of the severity of the disease. In patients with acute pancreatitis, the level of vitamin D was significantly low than in the healthy persons and was 13.8 (9.03; 21.34) and 28.4 (21.8; 32.3) ng/mL, respectively (p <0.0001).

Conclusion

For patients with acute pancreatitis, serum vitamin D levels≤ 13.28 ng/mL can be considered as a significant predictor of severe disease (sensitivity 83.3%, specificity 94.4%) regardless of calcium level.

Predicting need for intervention in acute necrotizing pancreatitis following discharge- A single center experience in 525 patients

BACKGROUND AND AIMS

The clinical course of necrotizing pancreatitis (NP) is variable and unpredictable, with some patients managed conservatively, but a significant proportion become symptomatic and needing intervention for drainage and/or necrosectomy. The aim of this study was to identify patients based on baseline clinical and imaging metrics who will likely need intervention and therefore closer follow-up.

METHODS

All NP patients managed in our institution between 2010 and 2019 were identified from a prospective database and those who did not undergo intervention during initial hospitalization were followed longitudinally post discharge until clinical and imaging resolution of necrosis. Patients were categorized into a conservative arm or intervention arm (endoscopic/percutaneous/surgical drainage and/or necrosectomy) for criteria defined according to IAP/APA guidelines. Clinical and imaging characteristics during initial presentation were analyzed between the two groups to identify independent predictors for eventual intervention using multivariable logistic regression. A nomogram was designed based on factors that were significant as defined by P value < 0.05.

RESULTS

Among 525 patients, 340 who did not meet criteria for intervention during initial admission were included for study and followed for an average 7.4 ± 11.3 months. 140 were managed conservatively and 200 needed intervention (168 within 6 months and 32 after 6 months). Independent predictors of need for eventual intervention were white race [OR 3.43 (1.11-10.62)], transferred status [OR 3.37 (1.81-6.27)], and need for TPN [OR 6.86 (1.63-28.9)], necrotic collection greater than 6 cm [OR 8.66 (4.10-18.32)] and necrotic collection with greater than 75% encapsulation [OR 41.3 (8.29-205.5)]. A prediction model incorporating these factors demonstrated an area under the curve of 0.88.

CONCLUSIONS

Majority of NP patients do not need intervention during initial admission but may require drainage/necrosectomy mostly in the first 6 months following discharge. Need for subsequent intervention can be accurately predicted by a combination of clinical and imaging features on index admission.

Incidence of peripancreatic fluid collections in patients presenting with acute pancreatitis

OBJECTIVES

To calculate the incidence of acute peripancreatic fluid collection (APFC) in patients with acute pancreatitis. The secondary objective is to determine the underlying etiologies of acute pancreatitis in the Saudi population.

METHODS

A retrospective cohort study was carried out at King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. The study analyzed data from patients who were diagnosed with acute pancreatitis between January 2008 and January 202. A total of 327 were included in the study after applying the inclusion and exclusion criteria. Their medical records were subsequently reviewed for the presence or absence of APFC on follow-up imaging studies, evidence of biliary stones, prior endoscopic retrograde cholangiopancreatography (ERCP), a history of alcohol use, and demographic variables.

RESULTS

Of the 327 patients with acute pancreatitis, 158 (48.3%) developed APFC, while 169 (51.7%) did not. The majority of patients had an idiopathic etiology of acute pancreatitis (n=251; 76.8%); followed by a biliary etiology (n=51; 15.6%); post-ERCP complications (n=14; 4.3%), and other causes (n=11; 3.3%).

CONCLUSION

The incidence of APFC in patients presenting with acute pancreatitis between January 2008 and January 2021 was 48.3%. The most common etiology of acute pancreatitis in this tertiary care hospital was idiopathic, followed by biliary etiologies and post-ERCP complications. More studies targeting the local complications of pancreatitis are needed to reach more definitive findings.

Evidence-Based Approach to the Surgical Management of Acute Pancreatitis

Background  Acute pancreatitis is a significant challenge to health services. Remarkable progress has been made in the last decade in optimizing its management.

Methods  This review is a comprehensive assessment of 7 guidelines employed in current clinical practice with an appraisal of the underlying evidence, including 15 meta-analyses/systematic reviews, 16 randomized controlled trials, and 31 cohort studies.

Results  Key tenets of early management of acute pancreatitis include severity stratification based on the degree of organ failure and early goal-directed fluid resuscitation. Rigorous determination of etiology reduces the risk of recurrence. Early enteral nutrition and consideration of epidural analgesia have been pioneered in recent years with promising results. Indications for invasive intervention are becoming increasingly refined. The definitive indications for endoscopic retrograde cholangiopancreatography in acute pancreatitis are associated with cholangitis and common bile duct obstruction. The role of open surgical necrosectomy has diminished with the development of a minimally invasive step-up necrosectomy protocol. Increasing use of endoscopic ultrasound–guided intervention in the management of pancreatic necrosis has helped reduce pancreatic fistula rates and hospital stay.

Conclusion  The optimal approach to surgical management of complicated pancreatitis depends on patient physiology and disease anatomy, in addition to the available resources and expertise. This is best achieved with a multidisciplinary approach. This review provides a distillation of the recommendations of clinical guidelines and critical discussion of the evidence that informs them and presents an algorithmic approach to key areas of patient management.

Parathyroid adenoma presenting as chronic pancreatitis: A case report and literature review

BACKGROUND

Most patients with parathyroid adenomas are asymptomatic and rarely present with chronic pancreatitis (CP). Several studies have reported a positive association between primary hyperparathyroidism (PHPT) and pancreatitis. Parathyroidectomy is the definitive treatment for PHPT. IV bisphosphonates can be considered the drug of choice for bridge to surgery.

METHODS

We reported a 57-year-old female patient was admitted to the emergency room with left upper quadrant abdominal pain and a diagnosis of recurrent pancreatitis. Magnetic Resonance Cholangiopancreatography confirmed the diagnosis of CP. The patient had no common etiology of pancreatitis. Persistent hypercalcemia was noted despite administering intravenous fluids, and Calcitonin. Intravenous Pamidronate, a Bisphosphonate derivative, was also administered. Although calcium levels initially decreased, they were later found to rebound to previous levels.

RESULTS

A diagnosis of parathyroid adenoma and PHPT was made based on the elevated parathyroid hormone levels and cervical ultrasonography indicated right inferior parathyroid adenoma. Technetium-99m methoxy-isobutyl-isonitrile scintigraphy revealed a focal hot spot of tracer accumulation at the right lower thyroid bed. The patient underwent right lower parathyroidectomy smoothly and successfully. After right lower parathyroidectomy, she had normal serum calcium levels (9.2 mg/dL) and parathyroid hormone (16.1 pg/mL). There was no recurrent abdominal pain after the operation.

CONCLUSION

CP is a rare manifestation of parathyroid adenoma. When patients with a history of recurrent pancreatitis, without common causes of pancreatitis, present persistent elevated serum calcium levels, PHPT could be suspected.

Multiorgan Dysfunction With Severe Cardiac Injury Secondary to Septic Cellulitis Due to Vibrio parahaemolyticus

Vibrio parahaemolyticus infection commonly manifests as gastroenteritis, including diarrhea, abdominal pain, nausea, vomiting, and fever. Although uncommon, V. parahaemolyticus has also been associated with wound infection and septic shock. These two manifestations have not been well-reported in medical literature, yet may yield a high risk of death, thus requiring emergent interventions. We present a case of a 42-year-old patient who developed septic shock secondary to a bullous necrotic wound and diarrhea due to V. parahaemolyticus. Multi-organ dysfunction syndrome with extreme cardiac injury developed very early in the course of the disease, prompting ICU admission and management with antibiotics, fluid resuscitation, vasopressors, blood purification, and surgical debridement. The treatment achieved a good clinical outcome. To the best of our knowledge, this is the first case report of V. parahaemolyticus-induced cardiomyopathy. V. parahaemolyticus should be considered as one of the causative agents in patients with sepsis due to cellulitis, particularly in patients with a suggestive history, such as exposure to seawater or eating seafood.

A Systematic Review of Risk Factors for Hepatitis C Virus Infection Among Low-Risk Population in India

BACKGROUND

Identification of risk factors for hepatitis C virus (HCV) transmission will help in targeted screening of people who are at risk for HCV.

METHOD

Indian studies, published between January 1989 and June 2020, were systematically reviewed to identify the relevant studies. We searched electronic databases including PubMed/Medline, Embase, Scopus, and Google scholar to identify the original data published in English language. The full-text studies, published in any form, which reported data on risk factors for HCV transmission among low-risk population were selected. The studies which exclusively included high-risk groups were excluded.

RESULTS

Data were extracted from 31,176 participants included in 25 studies (median [range] 40 [7-20,113). The participants were HCV infected patients who visited the hospital (n = 10), community population (n = 6), pregnant women (n = 5), blood donors (n = 2), people with diabetes mellitus (n = 1), army recruits (n = 1), or slum dwellers (n = 1). These studies provided data on blood transfusion, use of unsafe injections, minor or major surgery, unsafe dental procedures, tattooing, body piercing, obstetrical procedures, unsafe shaving, intravenous drug use, and unsafe sexual practices as risk factors for HCV transmission.

CONCLUSION

Unsafe injections, body piercing, unsafe dental procedure, unsafe shaving, and tattooing were identified as major risk factors for reported by HCV population participants.More data are needed to identify the risk factors for HCV in Indian population. Risk-factor-targeted screening may increase the yield and reduce the cost of HCV screening in India.

Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review

Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.

Surfactin Mitigates a High-Fat Diet and Streptozotocin-Induced Type 2 Diabetes through Improving Pancreatic Dysfunction and Inhibiting Inflammatory Response

Surfactin from Bacillus amyloliquefaciens fmb50 was utilized to treat mice with type 2 diabetes (T2DM) induced by a high-fat diet/streptozotocin (HFD/STZ). Our group’s earlier research indicated that surfactin could lower blood glucose and mitigate liver dysfunction to further improve HFD/STZ-induced T2DM through modulating intestinal microbiota. Thus, we further investigated the effects of surfactin on the pancreas and colon in mice with T2DM to elucidate the detailed mechanism. In the present study, mice with HFD/STZ-induced T2DM had their pancreatic and colon inflammation, oxidative stress, and endoplasmic reticulum stress (ERS) reduced when given oral surfactin at a dose of 80 mg/kg body weight. According to further research, surfactin also improved glucose metabolism by activating the phosphatidylinositol kinase (PI3K)/protein kinase B (Akt) signaling pathway, further protecting islets β-cell, promoting insulin secretion, inhibiting glucagon release and mitigating pancreas dysfunction. Additionally, after surfactin treatment, the colon levels of the tight junction proteins Occludin and Claudin-1 of T2DM mice were considerably increased by 130.64% and by 36.40%, respectively. These findings revealed that surfactin not only ameliorated HFD/STZ-induced pancreas inflammation and dysfunction and preserved intestinal barrier dysfunction and gut microbiota homeostasis but also enhanced insulin sensitivity and glucose homeostasis in T2DM mice. Finally, in the further experiment, we were able to demonstrate that early surfactin intervention might delay the development of T2DM caused by HFD/STZ, according to critical biochemical parameters in serum.

Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Management of Necrotizing Pancreatitis

Necrotizing pancreatitis affects 10% to 15% of all patients with acute pancreatitis. Despite improved understanding of this complex disease, it is still attended by up to 15% mortality. Necrotizing pancreatitis provides the clinical challenges of working in a multi-disciplinary group, determining proper timing for intervention, and identifying appropriate intervention approaches. The step-up approach consists of supportive care initially. When there is documented infected necrosis, treatment begins with antibiotics, progressing to minimally invasive mechanical necrosis intervention, and reserving surgery as the final treatment modality. However, treatment must be tailored to the individual patient. This article provides an overview of necrotizing pancreatitis.

A new logistic regression model for early prediction of severity of acute pancreatitis using magnetic resonance imaging and Acute Physiology and Chronic Health Evaluation II scoring systems

BACKGROUND

The aim of this study was to develop a new model constructed by logistic regression for the early prediction of the severity of acute pancreatitis (AP) using magnetic resonance imaging (MRI) and the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system.

METHODS

This retrospective study included 363 patients with AP. The severity of AP was evaluated by MRI and the APACHE II scoring system, and some subgroups of AP severity were constructed based on a combination of these two scoring systems. The length of stay and occurrence of organ dysfunction were used as clinical outcome indicators and were compared across the different subgroups. We combined the MRI and APACHE II scoring system to construct the regression equations and evaluated the diagnostic efficacy of these models.

RESULTS

In the 363 patients, 144 (39.67%) had systemic inflammatory response syndrome (SIRS), 58 (15.98%) had organ failure, and 17 (4.68%) had severe AP. The AP subgroup with a high MRI score and a simultaneously high APACHE II score was more likely to develop SIRS and had a longer hospitalization. The model, which predicted the severity AP by combining extrapancreatic inflammation on magnetic resonance (EPIM) and APACHE II, was successful, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.912, which was higher than that of any single parameter. Other models that predicted SIRS complications by combining MRI parameters and APACHE II scores were also successful (all P<0.05), and these models based on EPIM and APACHE II scores were superior to other models in predicting outcome.

CONCLUSIONS

The combination of MRI and clinical scoring systems to assess the severity of AP is feasible, and these models may help to develop personalized treatment and management.

HBV Infection-Related PDZK1 Plays an Oncogenic Role by Regulating the PI3K-Akt Pathway and Fatty Acid Metabolism and Enhances Immunosuppression

Background and Aim. Chronic hepatitis B virus (HBV) infection is the leading global cause of hepatocellular carcinoma (HCC). Few studies have been conducted concerning the HBV infection-related genes and their function. Methods. We compared differentially expressed genes (DGEs) in HBV-positive and -negative tumor samples and conducted a Spearman correlation study between the DGEs and HBV titers within The Cancer Genome Atlas (TCGA). Moreover, we validated the results of our in-house samples. Results. In this study, we discovered a series of genes that correlated statistically with HBV infection based on the TCGA database. These genes were related to increased inflammation and some oncogenic signaling pathways via Gene Set Enrichment Analysis (GSEA). PDZK1 is an ideal gene, which mostly relates positively to HBV infection; moreover, it is overexpressed in human HCC, especially in those HBV-infected HCCs. After analyzing the TCGA data and performing a verification study using our own samples, PDZK1 expression was investigated to be significantly associated with PI3K-Akt signaling and fatty acid metabolism. Further, single-sample GSEA analysis of tumor immune cell infiltration gene sets revealed that high PDZK1expression in HCC tissues was significantly associated with increased tumor-associated macrophages (TAMs) and regulatory T cells(Tregs). Conclusions. PDZK1 is an HBV infection-related gene, which plays oncogenic roles, possibly due to enhancing PI3K-Akt, fatty acid usage in tumor cells and TAMs, and Treg-induced immunosuppression.

Endoscopic Versus Laparoscopic Drainage of Pancreatic Pseudocysts: a Cost-effectiveness Analysis

BACKGROUND

Both endoscopic and laparoscopic interventions have a high therapeutic success rate in the management of symptomatic pancreatic pseudocysts; however, neither has been established as the gold standard.

METHODS

A decision tree analysis was performed to examine the costs and outcomes of intervening on pancreatic pseudocysts endoscopically versus laparoscopically. Within the model, a theoretical patient cohort was separated into two treatment arms: endoscopic drainage and laparoscopic drainage. Variables within the model were selected from the published literature. Medicare reimbursements rates (US$) were used to represent costs accumulated during a 3-month perioperative period. Effectiveness was characterized by quality-adjusted life-years (QALYs). A willingness-to-pay of $100,000 per 1 year of perfect health (1 QALY) gained was used as the cost-effectiveness threshold. The model was validated using one-way, two-way, and probabilistic sensitivity analysis.

RESULTS

Endoscopic management of symptomatic pancreatic pseudocysts was the dominant strategy, producing 0.22 QALYs more while saving $23,976.37 in comparison to laparoscopic management. This result was further validated by one-way, two-way, and probabilistic sensitivity analysis.

CONCLUSIONS

For patients presenting with symptomatic pancreatic pseudocysts amenable to either endoscopic or laparoscopic management, endoscopic drainage should be considered first-line therapy.

Acute Myeloid Leukemia Masquerading as Decompensated Cirrhosis

Patients with known cirrhosis who present with anemia, thrombocytopenia, acute renal failure, and confusion are usually presenting with decompensated cirrhosis. We present a patient with known alcoholic cirrhosis presenting with the above abnormalities, initially thought to be decompensated cirrhosis but found to have acute myeloid leukemia (AML) with acute blast crisis. This case was presented as a poster at the American College of Gastroenterology Annual Scientific Meeting held on October 22-27, 2021.

A 59-year-old male with a history of compensated alcoholic cirrhosis presented with unresponsiveness. On physical exam, vitals were normal, he appeared lethargic with generalized pallor, and rectal exam demonstrated an empty rectal vault with no blood or stool noted. Labs were notable for hemoglobin 3.1 g/dL, platelet count 41,000/µL, creatinine 5.2mg/dL, aspartate aminotransferase (AST) 242 U/L, alanine aminotransferase (ALT) 138 U/L, bilirubin 0.8 mg/dL, lactic acid 8.5 mmol/L, international normalized ratio (INR) 1.8, ammonia 51µmol/L. Imaging with CT head was unremarkable and CT abdomen demonstrated cirrhotic morphology of the liver with a small amount of ascites. Upper endoscopy was performed with no evidence of varices. Paracentesis demonstrated a high serum-ascites albumin gradient with low total protein consistent with portal hypertension. He was intubated for airway protection due to worsening encephalopathy. A peripheral smear was performed which showed myeloblasts with no signs of hemolysis. Bone marrow biopsy was subsequently performed which revealed 38% myeloblasts and features of myelodysplastic syndrome suggestive of secondary AML. Chemotherapy was not initiated as he was acutely critically ill and he expired shortly thereafter. 

AML can present with symptomatic anemia, bleeding, mental status changes due to central nervous system involvement, organomegaly, and renal insufficiency. Diagnosing AML in the setting of decompensated liver cirrhosis can be difficult as the clinical presentations can be similar at times. Thus, hematological causes should be considered when there is profound anemia with no acute blood loss early in the course. 

Ward based goal directed fluid therapy (GDFT) in acute pancreatitis (GAP) trial: A feasibility randomised controlled trial

BACKGROUND

Goal-directed fluid therapy (GDFT) reduces complications in patients undergoing major general surgery. There are no reports of cardiac output evaluation being used to optimise the fluid administration for patients with acute pancreatitis (AP) in a general surgery ward.

METHOD

50 patients with AP were randomised to either ward-based GDFT (n = 25) with intravenous (IV) fluids administered based on stroke volume optimisation protocol or standard care (SC) (n = 25), but with blinded cardiac output evaluation, for 48-h following hospital admission. Primary outcome was feasibility.

RESULTS

50 of 116 eligible patients (43.1%) were recruited over 20 months demonstrating feasibility. 36 (72%) completed the 48-h of GDFT; 10 (20%) discharged within 48-h and 4 withdrawals (3 GDFT, 1 SC). Baseline characteristics were similar with only 3 participants having severe disease (6%, 1 GDFT, 2 SC). Similar volumes of IV fluids were administered in both groups (GDFT 5465 (1839) ml, SC 5211 (1745) ml). GDFT group had a lower heart rate, blood pressure and respiratory rate and improved oxygen saturations. GDFT was not associated with any harms. There was no evidence of difference in complications of AP (GDFT 24%, SC 32%) or in the duration of stay in intensive care (GDFT 0 (0), SC 0.7 [(Van DIjk et al., 2017) 33 days). Length of hospital stay was 5 (2.9) days in GDFT and 6.3 (7.6) in SC groups.

CONCLUSION

Ward-based GDFT is feasible and shows a signal of possible efficacy in AP in this early-stage study. A larger multi-site RCT is required to confirm clinical and cost effectiveness.

The Role of Antibiotics in Endoscopic Transmural Drainage of Post-Inflammatory Pancreatic and Peripancreatic Fluid Collections

BACKGROUND

Although endoscopic treatment of symptomatic post-inflammatory pancreatic and peripancreatic fluid collections (PPPFCs) is an established treatment method, some aspects of endotherapy and periprocedural management remain controversial. The role of antibiotics is one of the most controversial issues in interventional endoscopic management of local complications of pancreatitis.

METHODS

This study was a randomized, non-inferiority, placebo-controlled, and double-blinded clinical trial to investigate the role of antibiotic prophylaxis in endoscopic transmural drainage in patients with symptomatic non-infected PPPFCs and assess the influence of antibiotic treatment on the results of endotherapy in patients with symptomatic infected PPPFCs.This trial included 62 patients treated endoscopically for PPPFCs in 2020 at our medical center. Patients were divided into two groups; group 1 comprised patients who had received empirical intravenous antibiotic therapy during endotherapy and group 2 comprised patients who did not receive antibiotic therapy during endoscopic drainage of PPPFCs. The end points were clinical success and long-term success of endoscopic treatment.

RESULTS

Thirty-one patients were included in group 1 (walled-off pancreatic necrosis [WOPN, 51.6%; pseudocyst, 48.4%) and 31 patients in group 2 (WOPN, 58.1%; pseudocyst, 41.9%) (p=0.6098/nonsignificant statistical [NS]). Infection with PPPFCs was observed in 15/31 (48.39%) patients in group 1 and in 15/31 (48.39%) patients in group 2 (p=1.0/NS). The average time of active (with flushing through nasocystic drainage) drainage in group 1 was 13.0 (6 - 21) days and was 14.0 (7 - 25) days in group 2 (p=0.405/NS). The average total number endoscopic procedures on one patient was 3.3 (2 - 5) in group 1 and 3.4 (2 - 7) in group 2 (p=0.899/NS). Clinical success of PPPFCs was observed in 29/31 (93.5%) patients from group 1 and in 30/31 (96.8%) patients from group 2 (p=0.5540/NS). Complications of endotherapy were noted in 8/31 (25.8%) patients in group 1 and in 10/31 (32.3%) patients in group 2 (p=0.576/NS). Long-term success in group 1 and 2 was reported in 26/31 (83.9%) and 24/31 (77.4%) patients, respectively (p=0.520/NS).

CONCLUSIONS

The effective endoscopic drainage of sterile PPPFCs requires no preventive or prophylactic use of antibiotics. In infected PPPFCs, antibiotic therapy is not required for effective endoscopic transmural drainage.

Future therapies for pancreatic carcinoma: Insights into cancer precision medicine

Pancreatic carcinoma (PC) has one of the highest rates of cancer-related death worldwide. Except for surgery, adjuvant chemotherapy, chemoradiotherapy, and immunotherapy have shown various efficacies depending on the stage of the patient. We read the review "Current and emerging therapeutic strategies in pancreatic cancer: Challenges and opportunities" and offer some opinions that may improve its precision and completeness. This review presents a map of appropriate therapies for PC at different stages. Based on the clinical trial outcomes mentioned in the review, we evaluated the potential therapeutic options for PC and helped explain the contradictory efficacy between different programmed cell death protein 1/programmed cell death ligand 1 clinical trials, which may have resulted from the unique features of PC. Although R0 resection and adjuvant chemotherapy are still the gold standards for PC, new modalities, with or without clinical validation, are needed to establish more specific and precise treatments for PC.

The clinical outcome from early versus delayed minimally invasive intervention for infected pancreatic necrosis: a systematic review and meta-analysis

BACKGROUND

While the management of infected pancreatic necrosis (IPN) has evolved in the last two decades with the adoption of minimally invasive interventions (drainage ± debridement), it is unknown whether the principle of delaying intervention inherited from the open surgery era still applies. The aim of the current study was to investigate the impact of the timing of minimally invasive intervention on the outcomes of patients with IPN requiring intervention.

METHODS

PubMed, Embase, MEDLINE and Web of Science databases were searched for appropriate studies. The primary outcome of interest was hospital mortality, the secondary outcomes were the incidence of complications during the hospitalization, including new-onset organ failure, gastrointestinal fistula or perforation, bleeding and length of hospital or intensive care unit (ICU) stay.

RESULTS

Seven clinical studies were included with a total of 742 patients with IPN requiring intervention, of whom 321 received early intervention and 421 delayed intervention. Results from the meta-analysis showed that early minimally invasive intervention did not increase hospital mortality (odds ratio 1.65, 95% confidence interval 0.97-2.81; p = 0.06) but was associated with a remarkably prolonged hospital stay and an increased incidence of gastrointestinal fistula or perforation when compared with delayed intervention.

CONCLUSIONS

Although no firm conclusion can be drawn because of the quality of available studies, it does appear that timing of intervention is a risk factor for adverse outcomes and ought to be investigated more rigorously in prospective studies.

GAS41 mediates proliferation and GEM chemoresistance via H2A.Z.2 and Notch1 in pancreatic cancer

PURPOSE

GAS41 is a YEATS domain protein that binds to acetylated histone H3 to promote the chromatin deposition of H2A.Z in non-small cell lung cancer. The role of GAS41 in pancreatic cancer is still unknown. Here, we aimed to reveal this role.

METHODS

GAS41 expression in pancreatic cancer tissues and cell lines was examined using qRT-PCR, Western blotting and immunohistochemistry. MTT, colony formation, spheroid formation and in vivo tumorigenesis assays were performed to assess the proliferation, tumorigenesis, stemness and gemcitabine (GEM) resistance of pancreatic cancer cells. Mechanistically, co-immunoprecipitation (co-IP) and chromatin immunoprecipitation (ChIP) assays were used to evaluate the roles of GAS41, H2A.Z.2 and Notch1 in pancreatic cancer.

RESULTS

We found that GAS41 is overexpressed in human pancreatic cancer tissues and cell lines, and that its expression increases following the acquisition of GEM resistance. We also found that GAS41 up-regulates Notch, as well as pancreatic cancer cell stemness and GEM resistance in vitro and in vivo. We show that GAS41 binds to H2A.Z.2 and activates Notch and its downstream mediators, thereby regulating stemness and drug resistance. Depletion of GAS41 or H2A.Z.2 was found to down-regulate Notch and to sensitize pancreatic cancer cells to GEM.

CONCLUSION

Our data indicate that GAS41 mediates proliferation and GEM resistance in pancreatic cancer cells via H2A.Z.2 and Notch1.

Vitamin D and Pancreatitis: A Narrative Review of Current Evidence

Emerging research indicates that vitamin D metabolic disorder plays a major role in both acute pancreatitis (AP) and chronic pancreatitis (CP). This has been demonstrated by studies showing that vitamin D deficiency is associated with pancreatitis and its anti-inflammatory and anti-fibrotic effects by binding with the vitamin D receptor (VDR). However, the role of vitamin D assessment and its management in pancreatitis remains poorly understood. In this narrative review, we discuss the recent advances in our understanding of the molecular mechanisms involved in vitamin D/VDR signaling in pancreatic cells; the evidence from observational studies and clinical trials that demonstrate the connection among vitamin D, pancreatitis and pancreatitis-related complications; and the route of administration of vitamin D supplementation in clinical practice. Although further research is still required to establish the protective role of vitamin D and its application in disease, evaluation of vitamin D levels and its supplementation should be important strategies for pancreatitis management according to currently available evidence.

Volume, but Not the Location of Necrosis, Is Associated with Worse Outcomes in Acute Pancreatitis: A Prospective Study

Background and Objectives: The course and clinical outcomes of acute pancreatitis (AP) are highly variable. Up to 20% of patients develop pancreatic necrosis. Extent and location of it might affect the clinical course and management. The aim was to determine the clinical relevance of the extent and location of pancreatic necrosis in patients with AP. Materials and Methods: A cohort of patients with necrotizing AP was collected from 2012 to 2018 at the Hospital of Lithuanian University of Health Sciences. Patients were allocated to subgroups according to the location (entire pancreas, left and right sides of pancreas) and extent (<30%, 30−50%, >50%) of pancreatic necrosis. Patients were reviewed for demographic features, number of performed surgical interventions, local and systemic complications, hospital stay and mortality rate. All contrast enhanced computed tomography (CECT) scans were evaluated by at least two experienced abdominal radiologists. All patients were treated according to the standard treatment protocol based on current international guidelines. Results: The study included 83 patients (75.9% males (n = 63)) with a mean age of 53 ± 1.7. The volume of pancreatic necrosis exceeded 50% in half of the patients (n = 42, 51%). Positive blood culture (n = 14 (87.5%)), multiple organ dysfunction syndrome (n = 17 (73.9%)) and incidences of respiratory failure (n = 19 (73.1%)) were significantly more often diagnosed in patients with pancreatic necrosis exceeding 50% (p < 0.05). Patients with >50% of necrosis were significantly (p < 0.05) more often diagnosed with moderately severe (n = 24 (41.4%)) and severe (n = 18 (72%)) AP. The number of surgical interventions (n = 18 (72%)) and ultrasound-guided interventions (n = 26 (65%)) was also significantly higher. In patients with whole-pancreas necrosis, incidence of renal insufficiency (n = 11 (64.7%)) and infected pancreatic necrosis (n = 19 (57.6%)) was significantly higher (p < 0.05). Conclusions: The clinical course and outcome were worse in the case of pancreatic necrosis exceeding 50%, rendering the need for longer and more complex treatment.

STING agonist cGAMP enhances anti-tumor activity of CAR-NK cells against pancreatic cancer

Activation of the stimulator of interferon gene (STING)-mediated innate immune response has been suggested as a promising therapeutic strategy for cancers. However, the effects of STING agonist on natural killer (NK) cell-mediated anti-tumor responses in pancreatic cancer remains unknown. Herein, we evaluated the effects of a classical STING agonist cyclic GMP-AMP (cGAMP) on NK cells in pancreatic cancer. We found that cGAMP could directly activate NK cells and enhance the sensitivity of pancreatic cancer cells to NK cell cytotoxicity, suggesting that cGAMP may become a potential adjuvant for NK cell therapy. In addition, combination of CAR-NK-92 cells targeting mesothelin and cGAMP displayed greater antitumor efficacy by inhibiting tumor growth and prolonging survival of the mouse model of pancreatic cancer. These results suggest that the combination of a STING agonist and NK cells may become a novel immunotherapy strategy for pancreatic cancer.

Evidence-Based Care Can Improve Treatment Compliance and Quality of Life of Patients with Acute Pancreatitis

Acute pancreatitis represents a disease characterized by acute necro-inflammatory changes in the pancreas, which is histologically characterized by destruction of alveolar cells. We aim to explore whether evidence-based care can improve treatment compliance and quality of life of patients with acute pancreatitis. The changes of hemoglobin (HGB), serum pre-albumin (PAB), and serum albumin (ALB) before and after care were observed, as well as the incidence of complications after care, total effective rate after care, disease severity (bedside index for severity in acute pancreatitis, BISAP) before and after care, and psychological scores of the two groups before and after care were observed. Patients' compliance after care, self-management scores after care, and quality of life after care were compared between the two groups. After care, HGB, PAB, and ALB increased significantly in both groups (p < 0.05) and were higher in OG than CG. Compared with CG, OG had significantly lower incidence of complications (p=0.009), significantly higher total effective rate (p=0.011), significantly lower disease severity (p < 0.05), significantly better psychological condition scores (p < 0.05), significantly higher compliance scores (p < 0.05), higher self-management scores (p < 0.05), and significantly higher quality of life (p < 0.001). Evidence-based care can improve treatment compliance of patients with acute pancreatitis and can effectively improve their quality of life.

Is NMDA-Receptor-Mediated Oxidative Stress in Mitochondria of Peripheral Tissues the Essential Factor in the Pathogenesis of Hepatic Encephalopathy?

Background: Hepatic encephalopathy (HE) is a neuropsychiatric syndrome of increased ammonia-mediated brain dysfunction caused by impaired hepatic detoxification or when the blood bypasses the liver. Ammonia-activated signal transduction pathways of hyperactivated NMDA receptors (NMDAR) are shown to trigger a cascade of pathological reactions in the brain, leading to oxidative stress. NMDARs outside the brain are widely distributed in peripheral tissues, including the liver, heart, pancreas, and erythrocytes. To determine the contribution of these receptors to ammonia-induced oxidative stress in peripheral tissues, it is relevant to investigate if there are any ammonia-related changes in antioxidant enzymes and free radical formation and whether blockade of NMDARs prevents these changes. Methods: Hyperammonemia was induced in rats by ammonium acetate injection. Oxidative stress was measured as changes in antioxidant enzyme activities and O2•− and H2O2 production by mitochondria isolated from the tissues and cells mentioned above. The effects of the NMDAR antagonist MK-801 on oxidative stress markers and on tissue ammonia levels were evaluated. Results: Increased ammonia levels in erythrocytes and mitochondria isolated from the liver, pancreas, and heart of hyperammonemic rats are shown to cause tissue-specific oxidative stress, which is prevented completely (or partially in erythrocyte) by MK-801. Conclusions: These results support the view that the pathogenesis of HE is multifactorial and that ammonia-induced multiorgan oxidative stress-mediated by activation of NMDAR is an integral part of the disease and, therefore, the toxic effects of ammonia in НЕ may be more global than initially expected.

Lactated Ringer Solution Is Superior to Normal Saline Solution in Managing Acute Pancreatitis: An Updated Meta-analysis of Randomized Controlled Trials

GOAL

The goal of this study was to further determine the role of lactated Ringer (LR) compared with normal saline (NS) in managing acute pancreatitis (AP) as a consideration of fluid resuscitation.

BACKGROUND

Fluid resuscitation play a critically important role in managing AP, and NS and LR solutions were common selection in clinical practice. However, it remains debate about which regime may be more better for patients with AP.

MATERIALS AND METHODS

The PubMed, Embase, and the Cochrane library were searched to find eligible randomized controlled trials focusing on the comparative efficacy and safety of LR and NS for the management of patients with AP.

RESULTS

Four eligible randomized controlled trials involving 248 patients to perform meta-analysis finally. Meta-analysis suggested no statistical difference between LR and NS groups in reducing the incidence of systemic inflammatory response syndrome at 24 hours [risk ratio (RR)=0.66, 95% confidence interval (CI)=0.33-1.31, P=0.24], 48 hours (RR=0.70, 95% CI=0.29-1.68, P=0.42), and 72 hours (RR=0.68, 95% CI=0.37-1.25, P=0.22). Meanwhile, no statistical difference was detected between LR and NS groups in terms of in-hospital mortality, incidence of local complications, pancreatic necrosis, organ failure, and developing moderate-to-severe AP, and the length of hospital stay. However, incidence of intensive care unit admission in LR group was significantly lower than that in NS group (RR=0.39, 95% CI=0.18-0.85; P=0.02).

CONCLUSION

The current updated meta-analysis indicates that LR may be superior to NS in managing patients with AP because of LR has a potential advantage in decreasing the incidence of pancreatic necrosis and intensive care unit admission compared with NS.

Anemia in cirrhosis: An underestimated entity

Anemia in a patient with cirrhosis is a clinically pertinent but often overlooked clinical entity. Relevant guidelines highlight the algorithmic approach of managing a patient of cirrhosis presenting with acute variceal hemorrhage but day-to-day management in hospital and out-patient raises multiple dilemmas: Whether anemia is a disease complication or a part of the disease spectrum? Should iron, folic acid, and vitamin B complex supplementation and nutritional advice, suffice in those who can perform tasks of daily living but have persistently low hemoglobin. How does one investigate and manage anemia due to multifactorial etiologies in the same patient: Acute or chronic blood loss because of portal hypertension and bone marrow aplasia secondary to hepatitis B or C viremia? To add to the clinician's woes the prevalence of anemia increases with increasing disease severity. We thus aim to critically analyze the various pathophysiological mechanisms complicating anemia in a patient with cirrhosis with an emphasis on the diagnostic flowchart in such patients and proposed management protocols thereafter.

Early endoscopic treatment of symptomatic pancreatic necrotic collections

EUS-guided transmural endoscopic drainage is commonly used in the treatment of WOPN in the late phase of ANP. The role of endoscopic intervention remains unclear in the early phase of ANP. This study aimed to prospectively evaluate early endoscopic treatment of ANCs compared with endoscopic drainage of WOPN. Overall, 71 patients with ANP who underwent transmural endoscopic drainage for necrotic collections were included. Endoscopic intervention was performed within the first four weeks of ANP in 25 (35.21%) patients with ANC (Group 1) and in 46 (64.79%) patients after four weeks since the onset of ANP with WOPN (Group 2). The overall mean age of patients was 49.9 (22-79) years and 59 of them were males. The mean time of active drainage and duration of total endoscopic treatment was 26.8 and 16.9 days (P = 0.0001) and 270.8 and 164.2 days (P = 0.0001) in Groups 1 and 2, respectively. The average total number of endoscopic interventions was 9.5 and 4.5 in Groups 1 and 2, respectively (P = 0.0001). The clinical success rate, frequency of complications of endoscopic interventions, long-term success rate, and recurrence rate were not significantly different between the groups (P > 0.05 for each). Transmural endoscopic drainage is effective method of treatment of early ANCs within the first four weeks of ANP. However, compared with endoscopic intervention in WOPN, more interventions and longer duration of drainage are required.

Association of Organochlorine Pesticides With Genetic Markers of Endoplasmic Reticulum Stress in Type 2 Diabetes Mellitus: A Case-Control Study Among the North-Indian Population

BACKGROUND

Organochlorine pesticides (OCPs) have been long linked to type 2 diabetes mellitus (T2DM); however, this relation at the molecular level has not been explored yet. Endoplasmic reticulum (ER) stress and pro-inflammatory pathways are considered vital ones in the pathogenesis of T2DM. We aimed to investigate the existence of any association between OCPs, ER stress, and pro-inflammatory pathways in subjects with known T2DM.

METHODS

Seventy subjects each with T2DM and normal glucose tolerance were recruited from the surgery department. Their visceral adipose tissue was collected intraoperatively. OCP concentration, ER stress, and pro-inflammatory markers were analyzed and compared between two study groups.

RESULTS

We found 18 OCPs and their metabolites in visceral adipose tissue samples of study participants. The levels of δ-HCH, heptachlor, endrin, and p,p'DDT were significantly higher in the T2DM group and were also positively correlated with fasting and postprandial plasma glucose levels (p < 0.01). We observed a positive association of δ-HCH (p < 0.01), heptachlor (p < 0.05), and endrin (p < 0.05) with central adiposity and ER stress markers. However, we failed to establish the correlation of OCPs with any of the pro-inflammatory markers.

CONCLUSION

The existence and simultaneous complex correlation of OCPs with ER stress may explain their role in the pathogenesis of T2DM, revealing the persistence of the gene-environment interaction in the etiology of T2DM.

Pancreatogenic Diabetes in Children With Recurrent Acute and Chronic Pancreatitis: Risks, Screening, and Treatment (Mini-Review)

Up to 9% of children with acute recurrent pancreatitis (ARP) or chronic pancreatitis have pancreatogenic diabetes mellitus (DM), and this risk likely increases as they age into adulthood. Risk factors for pancreatogenic DM in children vary depending on the clinical cohort but may include pancreatic atrophy, exocrine insufficiency, pancreatic calcifications, obesity/metabolic syndrome features, or autoimmune diseases. Knowledge regarding disease pathology is extrapolated nearly entirely from studies in adults. Insulin deficiency is the primary defect, resulting from islet loss associated with pancreatic fibrosis and cytokine-mediated β-cell dysfunction. Beta cell autoimmunity (type 1 diabetes) should also be considered as markers for this have been identified in a small subset of children with pancreatogenic DM. Hepatic insulin resistance, a deficient pancreatic polypeptide state, and dysfunctional incretin hormone response to a meal are all potential contributors in adults with pancreatogenic DM but their significance in pediatrics is yet unknown. Current guidelines recommend yearly screening for diabetes with fasting glucose and hemoglobin A1c (HbA1c). Insulin in the first-line pharmacologic therapy for treatment of pancreatogenic DM in children. Involvement of a multidisciplinary team including a pediatric endocrinologist, gastroenterologist, and dietitian are important, and nutritional health and exocrine insufficiency must also be addressed for optimal DM management.

Evidence-based clinical practice guidelines for chronic pancreatitis 2021

BACKGROUND

Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress.

METHODS

The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions.

RESULTS

Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition.

CONCLUSIONS

These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.