101
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Berberich AJ, Ziada A, Zou GY, Hegele RA. Conservative management in hypertriglyceridemia-associated pancreatitis. J Intern Med 2019; 286:644-650. [PMID: 31077464 DOI: 10.1111/joim.12925] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Severe hypertriglyceridemia (serum triglyceride >10 mmol L-1 ) is implicated in ~9% of acute pancreatitis cases. Certain guidelines list severe hypertriglyceridemia as an indication for plasmapheresis. OBJECTIVE We assembled the natural trajectory of triglyceride levels in patients with acute pancreatitis due to severe hypertriglyceridemia who were managed conservatively without plasmapheresis to evaluate the effectiveness of this approach. METHODS A retrospective chart review was performed on 22 hospital admissions for acute pancreatitis episodes considered to be caused by severe hypertriglyceridemia. Patients were managed supportively, with cessation of oral intake (NPO) and intravenous hydration. Insulin infusion was used in 12 patients to manage concurrent hyperglycaemia. RESULTS Triglyceride levels for the group were evaluated using a mixed-effects model. The average triglyceride level fell from 45.4 mmol L-1 on presentation to 13.3 mmol L-1 within 48 h, corresponding to a mean 69.8% decrease. Regression analysis showed a triglyceride half-life of 30.6 h. Findings were similar for NPO-only and insulin infusion subgroups. CONCLUSION Patients with severe hypertriglyceridemia and acute pancreatitis can be conservatively managed safely and effectively without plasmapheresis.
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Affiliation(s)
- A J Berberich
- From the, Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - A Ziada
- From the, Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - G Y Zou
- From the, Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - R A Hegele
- From the, Department of Medicine and Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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102
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 760] [Impact Index Per Article: 152.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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103
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Relationships between Metabolic Comorbidities and Occurrence, Severity, and Outcomes in Patients with Acute Pancreatitis: A Narrative Review. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2645926. [PMID: 31687382 PMCID: PMC6800961 DOI: 10.1155/2019/2645926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/07/2019] [Indexed: 12/16/2022]
Abstract
Background. The population of patients with acute pancreatitis treated by the staff at our department of gastroenterology includes those with mild and self-limited disease ranging to those with severe and fatal disease. Early diagnosis and accurate prediction of the severity and outcome of this disease, which is commonly seen by our department, is important for a successful outcome. Metabolic comorbidities (e.g., diabetes mellitus, fatty liver, obesity, and metabolic syndrome) are relevant to the severity and progression of many diseases. The objective of this review was to examine clinical relationships between metabolic comorbidities and occurrence, severity, and outcome of acute pancreatitis.
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104
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Zhang R, Deng L, Jin T, Zhu P, Shi N, Jiang K, Li L, Yang X, Guo J, Yang X, Liu T, Mukherjee R, Singh VK, Windsor JA, Sutton R, Huang W, Xia Q. Hypertriglyceridaemia-associated acute pancreatitis: diagnosis and impact on severity. HPB (Oxford) 2019; 21:1240-1249. [PMID: 30885545 DOI: 10.1016/j.hpb.2019.01.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/16/2018] [Accepted: 01/31/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The level of hypertriglyceridaemia (HTG) at which the risk of acute pancreatitis (AP) increases and the impact of HTG on AP attributable to other aetiologies remains unclear. METHODS We compared clinical outcomes of patients admitted within 48 h of the onset of abdominal pain from a first episode of AP and admission serum triglyceride levels of either <5.65 mmol/l (<500 mg/dl) or ≥5.65 to <11.3 mmol/l (moderate HTG) or ≥11.3 mmol/l (≥1000 mg/dl, severe HTG). RESULTS Among a cohort of 1,233 patients with AP there were significant progressive increases in all major deleterious clinical outcomes including mortality (all Ptrend < 0.05) that were directly dependent on admission triglyceride levels. Outcomes were improved by earlier presentation (<24 h compared to 24-48 h from abdominal pain onset). Patients with severe HTG and a concomitant aetiology (n = 68) had significantly more persistent organ failure, pancreatic necrosis and longer hospital stays (P < 0.05) than those with severe HTG alone (n = 206). CONCLUSIONS There appears to be an association between HTG grade and the severity of AP. Severe HTG significantly increased the severity of AP, over AP attributable to other aetiologies. Moderate as well as severe HTG can be used as a criterion for the diagnosis of HTG-associated AP.
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Affiliation(s)
- Ruwen Zhang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Lihui Deng
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Tao Jin
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Ping Zhu
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Na Shi
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Kun Jiang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Lan Li
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Xinmin Yang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Jia Guo
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaonan Yang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Tingting Liu
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Rajarshi Mukherjee
- Liverpool Pancreatitis Research Group, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Vikesh K Singh
- Pancreatitis Centre, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - John A Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China.
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China.
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105
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Pascual I, Sanahuja A, García N, Vázquez P, Moreno O, Tosca J, Peña A, Garayoa A, Lluch P, Mora F. Association of elevated serum triglyceride levels with a more severe course of acute pancreatitis: Cohort analysis of 1457 patients. Pancreatology 2019; 19:623-629. [PMID: 31229460 DOI: 10.1016/j.pan.2019.06.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 06/06/2019] [Accepted: 06/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous publications have reported an association between hypertriglyceridemia (HTG) and severity of acute pancreatitis, but this relationship remains somewhat controversial. OBJECTIVE To evaluate the outcome of acute pancreatitis according to serum triglyceride levels on admission. METHODS Retrospective analysis of prospectively collected data, which included all consecutive cases of acute pancreatitis admitted to a tertiary hospital (January 2002-December 2014). Acute pancreatitis patients were classified into 3 groups based on serum triglyceride levels (mg/dl) measured within 48 h from admission: normal triglycerides-mild HTG (<200); moderate HTG (200-749); severe HTG (≥750). Primary outcomes were the difference in organ failure, pancreatic necrosis, acute peripancreatic collections and mortality among the three groups. RESULTS A total of 1,457 cases were included: 1,335 with normal-mild HTG, 77 with moderate HTG and 45 with severe HTG. The rates of organ failure (11.2% in normal-mild HTG group, 15.6% in moderate HTG and 20.0% in severe HTG), persistent multiple organ failure (2.5% vs. 5.2% vs. 6.7%), pancreatic necrosis (9.2% vs. 14.3% vs. 26.7%) and acute collections (21.6% vs. 40.3% vs. 55.6%) increased significantly with hypertriglyceridemia severity grades. On multivariate analysis, triglycerides as a quantitative variable, evaluated in increments of 100 mg/dl, was independently associated with organ failure, pancreatic necrosis, acute collections and mortality (p < 0.05). CONCLUSIONS Elevated serum triglyceride levels are independently associated with a more severe course of pancreatitis. It must be highlighted the elevated frequency of local complications in patients with HTG that increases proportionally and significantly with HTG severity grades.
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Affiliation(s)
- Isabel Pascual
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain.
| | - Ana Sanahuja
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Natalia García
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Paola Vázquez
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Oswaldo Moreno
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Joan Tosca
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Andrés Peña
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Ana Garayoa
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Paloma Lluch
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Francisco Mora
- Department of Gastroenterology, Hospital Clínico Universitario, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
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106
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Koopal C, Bemelmans R, Marais AD, Visseren FL. Severe hypertriglyceridaemia and pancreatitis in a patient with lipoprotein lipase deficiency based on mutations in lipoprotein lipase (LPL) and apolipoprotein A5 (APOA5) genes. BMJ Case Rep 2019; 12:12/4/e228199. [PMID: 30948399 DOI: 10.1136/bcr-2018-228199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 44-year-old woman was admitted with pancreatitis caused by hypertriglyceridaemia (fasting triglycerides 28 mmol/L). She used oral contraceptives and ezetimibe 10 mg. She was overweight (body mass index 29.7 kg/m2). Diabetes mellitus was ruled out, as were nephrotic syndrome, alcohol abuse, hypothyroidism and dysbetalipoproteinaemia. Genetic analysis revealed mutations in two genes involved in triglyceride metabolism (apolipoprotein A5 and lipoprotein lipase [LPL]). The LPL activity was 45% compared with pooled healthy controls. The post-heparin triglyceride reduction was 6%, compared with a normal reduction of >20%. The patient was initially treated with gemfibrozil, but this was discontinued due to side effects. Dietary triglyceride restriction and discontinuation of the oral contraceptives lowered the plasma triglycerides within 2 weeks to 3.4 mmol/L. Hypertriglyceridaemia is a risk factor for pancreatitis and cardiovascular disease, and has a broad differential diagnosis including genetic causes. Patients can achieve near-normal triglyceride values with a low-fat diet only.
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Affiliation(s)
| | | | - A David Marais
- Division of Chemical Pathology, University of Cape Town Health Science Faculty, Cape Town, South Africa
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107
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Chen WW, Yang Q, Li XY, Shi XL, Pu N, Lu GT, Tong ZH, Chen JM, Li WQ. Identification of a novel and heterozygous LMF1 nonsense mutation in an acute pancreatitis patient with severe hypertriglyceridemia, severe obesity and heavy smoking. Lipids Health Dis 2019; 18:68. [PMID: 30885219 PMCID: PMC6421687 DOI: 10.1186/s12944-019-1012-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/08/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hypertriglyceridemia (HTG) is one of the most common etiologies of acute pancreatitis (AP). Variants in five genes involved in the regulation of plasma lipid metabolism, namely LPL, APOA5, APOC2, GPIHBP1 and LMF1, have been frequently reported to cause or predispose to HTG. METHODS A Han Chinese patient with HTG-induced AP was assessed for genetic variants by Sanger sequencing of the entire coding and flanking sequences of the above five genes. RESULTS The patient was a 32-year-old man with severe obesity (Body Mass Index = 35) and heavy smoking (ten cigarettes per day for more than ten years). At the onset of AP, his serum triglyceride concentration was elevated to 1450.52 mg/dL. We sequenced the entire coding and flanking sequences of the LPL, APOC2, APOA5, GBIHBP1 and LMF1 genes in the patient. We found no putative deleterious variants, with the exception of a novel and heterozygous nonsense variant, c.1024C > T (p.Arg342*; rs776584760), in exon 7 of the LMF1 gene. CONCLUSIONS This is the first time that a heterozygous LMF1 nonsense variant was found in a HTG-AP patient with severe obesity and heavy smoking, highlighting an important interplay between genetic and lifestyle factors in the etiology of HTG.
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Affiliation(s)
- Wei-Wei Chen
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210000, Jiangsu, China.,Department of Gastroenterology, Clinical Medical College, Yangzhou University, Yangzhou, 225000, Jiangsu, China
| | - Qi Yang
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210000, Jiangsu, China.
| | - Xiao-Yao Li
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210000, Jiangsu, China
| | - Xiao-Lei Shi
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210000, Jiangsu, China
| | - Na Pu
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210000, Jiangsu, China
| | - Guo-Tao Lu
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210000, Jiangsu, China
| | - Zhi-Hui Tong
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210000, Jiangsu, China
| | - Jian-Min Chen
- EFS, Univ Brest, Inserm, UMR 1078, GGB, F-29200, Brest, France
| | - Wei-Qin Li
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210000, Jiangsu, China.
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108
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He Y, Shi Y, Zhang A, Zhang X, Sun J, Tian L. Lipid-lowering and antioxidative effects of Apium graveolensL. root flavonoid extracts. RSC Adv 2019; 9:26757-26767. [PMID: 35528576 PMCID: PMC9070549 DOI: 10.1039/c9ra04481g] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/19/2019] [Indexed: 01/30/2023] Open
Abstract
Apium graveolensL. root flavone extract can improve hyperlipidemia induced by high-fat emulsion diet in rats.
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Affiliation(s)
- Yuan He
- College of Traditional Chinese Medicine
- Xinjiang Medical University
- Urumqi
- China
| | - Yang Shi
- Department of Editor
- Xinjiang Medical University
- Urumqi
- China
| | - Airong Zhang
- College of Traditional Chinese Medicine
- Xinjiang Medical University
- Urumqi
- China
| | - Xiaoxia Zhang
- College of Traditional Chinese Medicine
- Xinjiang Medical University
- Urumqi
- China
| | - Jing Sun
- College of Traditional Chinese Medicine
- Xinjiang Medical University
- Urumqi
- China
| | - Li Tian
- College of Traditional Chinese Medicine
- Xinjiang Medical University
- Urumqi
- China
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109
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Shemesh E, Zafrir B. Hypertriglyceridemia-Related Pancreatitis In Patients With Type 2 Diabetes: Links And Risks. Diabetes Metab Syndr Obes 2019; 12:2041-2052. [PMID: 31632114 PMCID: PMC6789969 DOI: 10.2147/dmso.s188856] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/15/2019] [Indexed: 12/11/2022] Open
Abstract
Disturbances in glucose and lipid homeostasis are cardinal features of the metabolic syndrome that affect millions of people worldwide. These conditions have multi-organ impact, and while cardiovascular effects are usually the core for studies and preventive measures, other systems may also be affected, including the pancreas. Acute pancreatitis related to severe hypertriglyceridemia is an under-recognized condition that could lead to significant morbidity and mortality. Therefore, when suspected, prompt diagnosis and treatment should be initiated to cover the various aspects of this disorder. Though commonly known to be associated with excess of alcohol use, hypertriglyceridemia-related pancreatitis is particularly observed in diabetics, especially when uncontrolled. Here, we portray the possible mechanisms and clinical features that link type 2 diabetes, hypertriglyceridemia and pancreatitis, and discuss their health-related outcomes and the current and novel treatment options for this unique disease.
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Affiliation(s)
- Elad Shemesh
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Barak Zafrir
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
- Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel
- Correspondence: Barak Zafrir Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal Street, Haifa3436212, IsraelTel +972-48250801Fax +972-48250916 Email
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110
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Adiamah A, Psaltis E, Crook M, Lobo DN. A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis. Clin Nutr 2018; 37:1810-1822. [PMID: 29056284 DOI: 10.1016/j.clnu.2017.09.028] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies. METHODS The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included. RESULTS Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis. CONCLUSION The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.
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Affiliation(s)
- Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Emmanouil Psaltis
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Martin Crook
- Department of Clinical Biochemistry, Guy's and St. Thomas' Hospital NHS Trust, London SE1 9RT, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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111
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Elevated triglycerides level in hospital stay as a risk factor of mortality in patients with severe acute pancreatitis. PLoS One 2018; 13:e0207875. [PMID: 30496237 PMCID: PMC6264831 DOI: 10.1371/journal.pone.0207875] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 11/06/2018] [Indexed: 02/05/2023] Open
Abstract
Hypertriglyceridaemia is one of the most common causes of severe acute pancreatitis (SAP). However, the association between elevated triglycerides (TG) level in hospital stay and outcome in SAP patients with normal TG level at admission has not been clearly demonstrated. This retrospective study assessed the serum TG levels of patients with SAP admitted to the intensive care unit (ICU) in 2017. Variables with a statistically significant association with the incidence of in-hospital TG elevation, as determined by univariate analysis, were analysed using a logistic regression model to predictors. Of the 99 patients included in the study, TG levels were within the normal range in 59 (59.59%) patients at admission. Among patients with normal TG level when admitted to ICU, 28 (47.46%) experienced at least one episode of TG level elevation during their ICU stay. Elevated TG level in hospitalization is associated with an increased length of ICU stay, as well as increased mortality. In addition to other factors, propofol usage was independently associated with the occurrence of in-hospital-TG elevation. To conclude, we retrospectively investigated the incidence, outcome, and risk factors for in-hospital TG elevation events in SAP patients admitted to the ICU. We found a high incidence of both preexisting and in-hospital-acquired TG elevation in SAP patients admitted to the ICU. The TG elevation that occurred during the ICU stay was associated with worse outcomes and long-term hospitalization of the ICU. Propofol usage was independently associated with the TG elevation occurrence in the ICU.
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112
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Huang SP, Toh DE, Sue YM, Chen TH, Cheng SW, Cheng CY. Double filtration plasmapheresis in treatment of acute pancreatitis associated with severe hypertriglyceridemia: Three case reports. Medicine (Baltimore) 2018; 97:e12987. [PMID: 30383651 PMCID: PMC6221692 DOI: 10.1097/md.0000000000012987] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Severe hypertriglyceridemia is the 3rd-leading cause of acute pancreatitis. Current treatment option for hypertriglyceridemia associated with acute pancreatitis is mainly supportive measures, including adequate fluid supply, pain management, and broad-spectrum antibiotics if necessary. Extracorporeal method by mean of plasmapheresis is effective in reducing serum level of triglyceride. It has been proposed to have therapeutic potential in limited small sample studies. PATIENT CONCERNS A retrospective review of therapeutic effect of double filtration plasmapheresis in treating hypertriglyceridemia associated with acute pancreatitis was conducted by enlisting 3 patients who meet the criteria for the present study. DIAGNOSES Three patients met the criteria for hypertriglyceridemia (serum level >800 mg/dL) associated with acute pancreatitis (either with elevated serum level of lipase and/or amylase and/or with computed tomography evidence of acute pancreatitis). INTERVENTIONS Patients received double filtration plasmapheresis. OUTCOMES We found that an effective reduction of triglyceride was achieved on an average of 84.7% as a result of a single session of plasmapheresis. All 3 of our patients survived, but needed extended hospitalization. LESSONS A substantial clinical trial is required to further assess the effectiveness of plasmapheresis in managing of acute pancreatitis in the setting of hypertriglyceridemia.
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Affiliation(s)
- Shih-Ping Huang
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
| | - Ding-Ek Toh
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
| | - Yuh-Mou Sue
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
| | - Tso-Hsiao Chen
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
| | - Sheng-Wei Cheng
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Yi Cheng
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
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113
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Kiss L, Fűr G, Mátrai P, Hegyi P, Ivány E, Cazacu IM, Szabó I, Habon T, Alizadeh H, Gyöngyi Z, Vigh É, Erőss B, Erős A, Ottoffy M, Czakó L, Rakonczay Z. The effect of serum triglyceride concentration on the outcome of acute pancreatitis: systematic review and meta-analysis. Sci Rep 2018; 8:14096. [PMID: 30237456 PMCID: PMC6147944 DOI: 10.1038/s41598-018-32337-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/05/2018] [Indexed: 12/16/2022] Open
Abstract
Elevated serum triglyceride concentration (seTG, >1.7 mM or >150 mg/dL) or in other words hypertriglyceridemia (HTG) is common in the populations of developed countries. This condition is accompanied by an increased risk for various diseases, such as acute pancreatitis (AP). It has been proposed that HTG could also worsen the course of AP. Therefore, in this meta-analysis, we aimed to compare the effects of various seTGs on the severity, mortality, local and systemic complications of AP, and on intensive care unit admission. 16 eligible studies, including 11,965 patients were retrieved from PubMed and Embase. The results showed that HTG significantly elevated the odds ratio (OR = 1.72) for severe AP when compared to patients with normal seTG (<1.7 mM). Furthermore, a significantly higher occurrence of pancreatic necrosis, persistent organ failure and renal failure was observed in groups with HTG. The rates of complications and mortality for AP were significantly increased in patients with seTG >5.6 mM or >11.3 mM versus <5.6 mM or <11.3 mM, respectively. We conclude that the presence of HTG worsens the course and outcome of AP, but we found no significant difference in AP severity based on the extent of HTG.
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Affiliation(s)
- Lóránd Kiss
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Gabriella Fűr
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Péter Mátrai
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
- MTASZTE Translational Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Emese Ivány
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Irina Mihaela Cazacu
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Imre Szabó
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tamás Habon
- Department of Cardiology and Angiology, First Department of Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Hussain Alizadeh
- Department of Haematology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Gyöngyi
- Department of Public Health Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Éva Vigh
- Department of Radiology, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Adrienn Erős
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - Máté Ottoffy
- Institute for Translational Medicine and Szentagothai Research Center, Medical School, University of Pécs, Pécs, Hungary
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary.
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114
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Martinolich J, Midura D, Benton M, Ata A, Stain SC, Beyer TD. Hypertriglyceridemia-Induced Pancreatitis: A Case Series of 56 Patients from One Institution. Am Surg 2018. [DOI: 10.1177/000313481808400917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Devin Midura
- Department of Surgery Albany Medical College Albany, New York
| | - Michaela Benton
- Department of Surgery Albany Medical College Albany, New York
| | - Ashar Ata
- Department of Surgery Albany Medical College Albany, New York
| | - Steven C. Stain
- Department of Surgery Albany Medical College Albany, New York
| | - Todd D. Beyer
- Department of Surgery Albany Medical College Albany, New York
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115
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Epidemiology and Etiology of Acute Pancreatitis in Urban and Suburban Areas in Shanghai: A Retrospective Study. Gastroenterol Res Pract 2018; 2018:1420590. [PMID: 30158961 PMCID: PMC6109519 DOI: 10.1155/2018/1420590] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/14/2018] [Accepted: 05/24/2018] [Indexed: 01/30/2023] Open
Abstract
Aim To investigate the epidemiology, etiology, and severity of acute pancreatitis (AP) in urban and suburban areas of Shanghai in 2011 and 2016. Methods A retrospective study of patients admitted to Shanghai General Hospital (urban and suburban campuses) with AP in 2011 and 2016 was undertaken. Patients were divided into acute biliary pancreatitis (ABP), hypertriglyceridemic pancreatitis (HTGP), alcoholic pancreatitis, and pancreatitis of other causes according to etiology. Severity of AP was divided into mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP). Results AP patients in the suburban area increased more rapidly than those in the urban area. The mean onset age of AP in the urban area in 2016 was older than that in the suburban area (p < 0.05). The suburban patients in 2016 have significantly younger mean onset age than those in 2011 (p < 0.05). HTGP incidence in suburban patients increased from 2011 to 2016, which changed little in the urban area. Urban females were more likely to develop HTGP than suburban ones in 2011, which reversed in 2016. As to the male patients, the incidence of HTGP increased in both urban and suburban areas. Nonelderly (<60 years old) patients had higher HTGP incidence than elderly ones in both 2011 and 2016. The descending trend of SAP in the suburban area was more obvious than that in the urban area. The length of hospitalization decreased from 2011 to 2016, especially in SAP patients. Conclusions AP patients increased more rapidly in the suburban area of Shanghai with younger onset age. The incidence of HTGP increased significantly in the suburban area, reminding of the prevention and screening of HTG.
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116
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Moulin P, Dufour R, Averna M, Arca M, Cefalù AB, Noto D, D'Erasmo L, Di Costanzo A, Marçais C, Alvarez-Sala Walther LA, Banach M, Borén J, Cramb R, Gouni-Berthold I, Hughes E, Johnson C, Pintó X, Reiner Ž, van Lennep JR, Soran H, Stefanutti C, Stroes E, Bruckert E. Identification and diagnosis of patients with familial chylomicronaemia syndrome (FCS): Expert panel recommendations and proposal of an “FCS score”. Atherosclerosis 2018; 275:265-272. [DOI: 10.1016/j.atherosclerosis.2018.06.814] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/23/2018] [Accepted: 06/13/2018] [Indexed: 12/31/2022]
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117
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Management of Hypertriglyceridemia Induced Acute Pancreatitis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4721357. [PMID: 30148167 PMCID: PMC6083537 DOI: 10.1155/2018/4721357] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/01/2018] [Accepted: 07/12/2018] [Indexed: 02/06/2023]
Abstract
Hypertriglyceridemia is an uncommon but a well-established etiology of acute pancreatitis leading to significant morbidity and mortality. The risk and severity of acute pancreatitis increase with increasing levels of serum triglycerides. It is crucial to identify hypertriglyceridemia as the cause of pancreatitis and initiate appropriate treatment plan. Initial supportive treatment is similar to management of other causes of acute pancreatitis with additional specific therapies tailored to lower serum triglycerides levels. This includes plasmapheresis, insulin, heparin infusion, and hemofiltration. After the acute episode, diet and lifestyle modifications along with hypolipidemic drugs should be initiated to prevent further episodes. Currently, there is paucity of studies directly comparing different modalities. This article provides a comprehensive review of management of hypertriglyceridemia induced acute pancreatitis. We conclude by summarizing our treatment approach to manage hypertriglyceridemia induced acute pancreatitis.
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118
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Mandalia A, Wamsteker EJ, DiMagno MJ. Recent advances in understanding and managing acute pancreatitis. F1000Res 2018; 7. [PMID: 30026919 DOI: 10.12688/f1000research.14244.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 12/16/2022] Open
Abstract
This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.
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Affiliation(s)
- Amar Mandalia
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
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119
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Abstract
This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.
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Affiliation(s)
- Amar Mandalia
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Erik-Jan Wamsteker
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
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120
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Rawla P, Sunkara T, Thandra KC, Gaduputi V. Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies. Clin J Gastroenterol 2018; 11:441-448. [PMID: 29923163 DOI: 10.1007/s12328-018-0881-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 06/14/2018] [Indexed: 12/22/2022]
Abstract
Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis (AP) comprising up to 7% of the cases. The clinical course of HTG-induced pancreatitis (HTGP) is highly similar to that of AP of other etiologies with HTG being the only distinguishing clinical feature. However, HTGP is often correlated with higher severity and elevated complication rate. At present, no approved treatment guideline for the management of HTGP is available, although different treatment modalities such as insulin, heparin, fibric acids, and omega 3 fatty acids have been successfully implemented to reduce serum triglycerides (TG). Plasmapheresis has also been used to counteract elevated TG levels in HTGP patients. However, it has been associated with complications. Following the management of acute phase, lifestyle modifications including dietary adjustments and drug therapy are essential in the long-term management of HTGP and the prevention of its relapse. Results from studies of small patient groups describing treatment and prevention of HTGP are not sufficient to draw solid conclusions resulting in no treatment algorithm being available for effective management of HTGP. Therefore, prospective randomized, active-controlled clinical studies are required to find a better treatment regimen for the management of HTGP. Until date, one randomized clinical trial has been performed to compare clinical outcomes of different treatment approaches for HTGP. However, further studies are required to outline a generalized and efficient treatment regimen for the management of HTGP.
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Affiliation(s)
- Prashanth Rawla
- Department of Internal Medicine/Hospitalist, SOVAH Health, 320 Hospital Dr, Martinsville, VA, 24115, USA.
| | - Tagore Sunkara
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, New York, NY, 11201, USA
| | | | - Vinaya Gaduputi
- Division of Gastroenterology, SBH Health System, Bronx, NY, 19457, USA
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121
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Greer JW, Beck WC, Bhavaraju A, Davis B, Kimbrough MK, Jensen J, Privratsky A, Robertson R, Taylor JR, Sexton KW. Dilated cardiomyopathy secondary to acute pancreatitis caused by hypertriglyceridemia. J Surg Case Rep 2018; 2018:rjy104. [PMID: 29876048 PMCID: PMC5961335 DOI: 10.1093/jscr/rjy104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/01/2018] [Indexed: 11/30/2022] Open
Abstract
A 30-year-old male presented to an outside facility with acute pancreatitis and triglycerides of 1594. He was transferred to our facility after becoming febrile, hypoxic and in acute renal failure with triglycerides of 4243. CT scan performed showed wall-off pancreatic necrosis. He underwent continuous renal replacement therapy and his acute renal failure resolved. He was treated with broad spectrum antibiotics and discharged. He developed a fever to 101 a week later and was found to have a large infected pancreatic pseudocyst. This was managed with an IR placed drain. This was continued for 6 weeks. He came to the emergency department several weeks later with shortness of breath and 3+ edema to bilateral lower extremities and lower abdomen. TTE performed showed an EF of 15%. He was diuresed 25 L during that stay. His heart failure was medically managed. We present this case of dilated cardiomyopathy secondary to acute pancreatitis.
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Affiliation(s)
- Jordan W Greer
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - William C Beck
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Avi Bhavaraju
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Ben Davis
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Mary K Kimbrough
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Joseph Jensen
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Anna Privratsky
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Ronald Robertson
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - John R Taylor
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Kevin W Sexton
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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122
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Wang Y, Fuentes HE, Attar BM, Jaiswal P, Demetria M. Evaluation of the prognostic value of neutrophil to lymphocyte ratio in patients with hypertriglyceridemia-induced acute pancreatitis. Pancreatology 2017; 17:893-897. [PMID: 29030078 DOI: 10.1016/j.pan.2017.10.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/23/2017] [Accepted: 10/03/2017] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Recent studies attribute promising prognostic values to various inflammatory biomarkers in acute pancreatitis, including the following: the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and red cell distribution width (RDW). We aimed to determine the performance of these biomarkers for detecting disease severity in patients with hypertriglyceridemia-induced acute pancreatitis (HTG-AP). METHODS We retrospectively reviewed 110 patients with HTG-AP and compared the NLR, PLR, and RDW in different severity groups. We performed receiver-operating characteristic (ROC) analysis to identify the optimal cut-off value for NLR to predict severe AP. RESULTS NLR was significantly higher in patients with severe AP than mild and moderately severe AP (14.6 vs. 6.9, p < 0.001), and higher with organ failure upon presentation (9.1 vs. 7.1, p = 0.026). After dichotomization by the optimal cut-off value of 10 as determined by the ROC curve, the high-NLR group had a significantly longer length of stay (9.1 vs. 6.6 days, p = 0.001), duration of nil per os (4.9 vs. 3.7 days, p = 0.007), and higher rates of complications, including systemic inflammatory response syndrome (81.5% vs. 44.6%, p = 0.001) and persistent acute kidney injury (25.9% vs. 3.6%, p < 0.001). High NLR independently predicted severe acute pancreatitis in multivariate analysis (Odds ratio 6.71, p = 0.019). CONCLUSION NLR represents an inexpensive, readily available test with a promising value to predict disease severity in HTG-AP. Among the three inflammatory biomarkers, NLR has the highest discriminatory capacity for severe HTG-AP, with an optimal cut-off value of 10.
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Affiliation(s)
- Yuchen Wang
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, United States.
| | - Harry E Fuentes
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, United States
| | - Bashar M Attar
- Department of Gastroenterology, Rush University Medical Center, Chicago, IL, United States; Division of Gastroenterology and Hepatology, John H Stroger Hospital of Cook County, Chicago, IL, United States
| | - Palash Jaiswal
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, United States
| | - Melchor Demetria
- Division of Gastroenterology and Hepatology, John H Stroger Hospital of Cook County, Chicago, IL, United States
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123
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Kim YJ, Kim DB, Chung WC, Lee JM, Youn GJ, Jung YD, Choi S, Oh JH. Analysis of factors influencing survival in patients with severe acute pancreatitis. Scand J Gastroenterol 2017; 52:904-908. [PMID: 28388866 DOI: 10.1080/00365521.2017.1310291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Acute pancreatitis (AP) ranges from a mild and self-limiting disease to a fulminant illness with significant morbidity and mortality. Severe acute pancreatitis (SAP) is defined as persistent organ failure lasting for 48 h. We aimed to determine the factors that predict survival and mortality in patients with SAP. METHODS We reviewed a consecutive series of patients who were admitted with acute pancreatitis between January 2003 and January 2013. A total of 1213 cases involving 660 patients were evaluated, and 68 cases with SAP were selected for the study. Patients were graded based on the Computer Tomography Severity Index (CTSI), the bedside index for severity (BISAP), and Ranson's criteria. RESULTS The frequency of SAP was 5.6% (68/1213 cases). Among these patients, 17 died due to pancreatitis-induced causes. We compared several factors between the survivor (n = 51) and non-survivor (n = 17) groups. On multivariate analysis, there were significant differences in the incidence of diabetes mellitus (p = .04), Ranson score (p = .03), bacteremia (p = .05) and body mass index (BMI) (p = .02) between the survivor and non-survivor groups. CONCLUSIONS Bacteremia, high Ranson score, DM, and lower BMI were closely associated with mortality in patients with SAP. When patients with SAP show evidence of bacteremia or diabetes, aggressive treatment is necessary. For the prediction of disease mortality, the Ranson score might be a useful tool in SAP.
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Affiliation(s)
- Yeon Ji Kim
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Dae Bum Kim
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Woo Chul Chung
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Ji Min Lee
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Gun Jung Youn
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Yun Duk Jung
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Sooa Choi
- a Department of Internal Medicine , St. Vincent's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
| | - Jung Hwan Oh
- b Department of Internal Medicine , St. Paul's Hospital, College of Medicine, The Catholic University of Korea , Seoul , Korea
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Goyal H, Guerreso K, Smith B, Harper K, Patel S, Patel A, Parikh P. Severity and outcomes of acute alcoholic pancreatitis in cannabis users. Transl Gastroenterol Hepatol 2017; 2:60. [PMID: 28815220 PMCID: PMC5539398 DOI: 10.21037/tgh.2017.06.03] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/01/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cannabis is the most commonly and widely used illicit drug in the world and is also the most commonly used drug of abuse in alcohol drinkers. Experimental studies have shown conflicting results of the effects of cannabis on the severity of acute pancreatitis (AP). The purpose of this study is to ascertain the clinical effects of simultaneous alcohol and cannabis use on severity at presentation and outcomes of acute alcoholic pancreatitis (AAP). METHODS A retrospective review was conducted on the patients discharged with principle or secondary diagnosis of AP using ICD-9 & ICD-10 codes during the time period from January 2006 to December 2015 at a large community-based hospital in Central Georgia. Patients with alcoholic pancreatitis with cannabis (CB+) and without cannabis (CB-) use were identified and were matched with sex and age. RESULTS Our study findings showed that a greater percentage of CB+ patients did not have a systemic inflammatory response syndrome (SIRS) score (P=0.043), had a lower BISAP score (P=0.031), and had a significantly lower BUN level (P=0.033), but there was no difference in the Balthazar Index and revised Atlanta classification severity between the two groups. CB+ patients tended to need less ICU care than CB- patients (P=0.059). CONCLUSIONS Based on our findings, we found that CB+ patients had less severe presentation of AAP indicating that cannabis could modulate the inflammatory effect of alcohol on the pancreas. Further large scale prospective studies are needed to confirm our results.
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Affiliation(s)
- Hemant Goyal
- Mercer University School of Medicine, Macon, GA, USA
| | | | - Betsy Smith
- Mercer University School of Medicine, Macon, GA, USA
| | | | - Sheetal Patel
- Mercer University School of Medicine, Macon, GA, USA
| | - Akash Patel
- Mercer University School of Medicine, Macon, GA, USA
| | - Puja Parikh
- Mercer University School of Medicine, Macon, GA, USA
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125
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Wu C, Zou L, Shi S, Tong Z, Shen X, Yang D, Ke L, Li W, Li J. The role of hypertriglyceridemia for acute kidney injury in the course of acute pancreatitis and an animal model. Pancreatology 2017. [PMID: 28647101 DOI: 10.1016/j.pan.2017.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the role of hypertriglyceridemia for acute kidney injury (AKI) in the course of acute pancreatitis. METHODS Patients with acute pancreatitis were retrospectively divided into four groups according to admission triglyceride: normal group, mild HTG group, moderate HTG group and severe HTG group. Clinical characteristics were compared among these groups. Wild type (WT) mice and Human ApoC III transgenic (ApoCIIItg) mice were used in the next animal experiments. Severe acute pancreatitis (SAP) model was established by retrograde injection of 0.5% sodium taurocholate (0.1 ml/100 g) from duodenum to pancreatic duct. Histological scores, serum amylase, creatinine, usea nitrogen were compared between WT mice and ApoCIIItg mice. RESULTS Two hundred and sixty-two patients were classified into 4 groups: normal TG (104, 39.7%), mild HTG (72, 27.5%), moderate HTG (47, 17.9%), and severe HTG (39, 14.9%) groups. The proportions of AKI were 13.5% (14/104, normal), 13.9% (10/72, mild), 21.3% (10/47, moderate), and 38.5% (15/39, severe), respectively. After establishing SAP model, the levels of serum amylase (P < 0.05) and pancreatic histological score (P < 0.05) of ApoCIII-SAP-9h group were significantly higher than that of WT-SAP-9h group, respectively. ApoCIII-SAP-9h group had significantly higher levels of serum creatinine (P < 0.001), usea nitrogen (P < 0.001), and kidney histological score (P < 0.05) than that of WT-SAP-9h group, respectively. CONCLUSIONS Mild HTG has little adverse impact on disease severity of acute pancreatitis; severe HTG can aggravate kidney injury in the course of acute pancreatitis. ApoCIII-SAP mice have more serious pancreatic damage and kidney injury than WT-SAP mice.
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Affiliation(s)
- Congye Wu
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China; Department of Oncology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lei Zou
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Shujing Shi
- Department of Oncology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhihui Tong
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Xiao Shen
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Dongliang Yang
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Lu Ke
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Weiqin Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China.
| | - Jieshou Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
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126
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Joglekar K, Brannick B, Kadaria D, Sodhi A. Therapeutic plasmapheresis for hypertriglyceridemia-associated acute pancreatitis: case series and review of the literature. Ther Adv Endocrinol Metab 2017; 8:59-65. [PMID: 28507728 PMCID: PMC5415006 DOI: 10.1177/2042018817695449] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 02/02/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe hypertriglyceridemia (HTG) is the third leading cause of acute pancreatitis (AP) in the United States. The current standard of care includes management of HTG using pharmacological therapy. More recently, plasmapheresis has been proposed as a therapeutic tool for decreasing triglyceride (TG) levels, especially in critically ill patients. Few studies are available to ascertain overall benefits of plasmapheresis over traditional management. OBJECTIVE To analyze the outcomes of patients treated with plasmapheresis for severe HTG-associated pancreatitis. METHODS We conducted a retrospective chart review of three patients with severe HTG- associated (TGs greater than 1000 mg/dl; 11.29 mmol/l) AP at the Methodist University Hospital. All the patients underwent plasmapheresis as part of their treatment. RESULTS The average TG level before plasmapheresis was 3532 mg/dl (range: 2524-4562 mg/dl; 39.9 mmol/l; range: 28.5-51.6 mmol/l). All patients made a full recovery, with a significant improvement in TG levels after plasmapheresis. The mean number of sessions was 1.3 (range 1-2), and mean TG level after plasmapheresis was 1051 mg/dl (range: 509-1771 mg/dl; 11.9 mmol/l; range: 5.8-20 mmol/l). After the first session, the average reduction of TG level was 2481 mg/dl (range 753-3750 mg/dl; 28 mmol/l; range: 8.5-42.4 mmol/l) or approximately 70%. None of the patients developed complications related to plasmapheresis. CONCLUSIONS Plasmapheresis can be an effective and rapid treatment option in patients with severe HTG and complications. However, further research, including randomized controlled studies, is necessary.
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Affiliation(s)
- Kiran Joglekar
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Ben Brannick
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Dipen Kadaria
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Tennessee Health Sciences Center, Memphis, TN, USA
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127
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Xiang H, Wang G, Qu J, Xia S, Tao X, Qi B, Zhang Q, Shang D. Yin-Chen-Hao Tang Attenuates Severe Acute Pancreatitis in Rat: An Experimental Verification of In silico Network Target Prediction. Front Pharmacol 2016; 7:378. [PMID: 27790147 PMCID: PMC5061810 DOI: 10.3389/fphar.2016.00378] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 09/28/2016] [Indexed: 12/12/2022] Open
Abstract
Yin-Chen-Hao Tang (YCHT) is a classical Chinese medicine compound that has a long history of clinical use in China for the treatment of inflammatory diseases. However, the efficacy and mechanisms of YCHT for the treatment of severe acute pancreatitis (SAP) are not known. The current study investigated the pharmacological properties of YCHT against SAP and its underlying mechanisms. A computational prediction of potential targets of YCHT was initially established based on a network pharmacology simulation. The model suggested that YCHT attenuated SAP progress by apoptosis inducement, anti-inflammation, anti-oxidation and blood lipid regulation. These effects were validated in SAP rats. YCHT administration produced the following results: (1) significantly inhibited the secretion of pancreatic enzymes and protected pancreatic tissue; (2) obviously increased the number of in situ terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL)-positive cells and induced apoptosis; (3) markedly inhibited neutrophil infiltration to the impaired pancreas and reduced the inflammatory reaction; (4) notably enhanced the activities of antioxidant enzymes and decreased the nitric oxide synthase levels; (5) significantly reduced the levels of triglycerides, total cholesterol and low-density lipoprotein and increased high-density lipoprotein; and (6) significantly up-regulated peroxisome proliferator-activated receptor-γ (PPARγ) and down-regulated nuclear factor-kappa B (NF-κB). In summary, these results demonstrated that YCHT attenuated SAP progress by inducing apoptosis, repressing inflammation, alleviating oxidative stress and regulating lipid metabolism partially via regulation of the NF-κB/PPARγ signal pathway.
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Affiliation(s)
- Hong Xiang
- College (Institute) of Integrative Medicine, Dalian Medical University Dalian, China
| | - Guijun Wang
- Department of General Surgery, The First Affiliated Hospital of Jinzhou Medical University Jinzhou, China
| | - Jialin Qu
- Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University Dalian, China
| | - Shilin Xia
- Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University Dalian, China
| | - Xufeng Tao
- College of Pharmacy, Dalian Medical University Dalian, China
| | - Bing Qi
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University Dalian, China
| | - Qingkai Zhang
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University Dalian, China
| | - Dong Shang
- College (Institute) of Integrative Medicine, Dalian Medical UniversityDalian, China; Department of General Surgery, The First Affiliated Hospital of Dalian Medical UniversityDalian, China
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