American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis

Nutrition therapy in critically ill patients with severe acute pancreatitis

A significant proportion of patients (10%-20%) with acute pancreatitis develop severe acute pancreatitis characterized by pancreatic necrosis, systemic inflammation, and organ failure, commonly requiring intensive care unit (ICU) admission. In this specific population, nutrition therapy is more challenging than that in the general ICU population, primarily because of inevitable gastrointestinal involvement by pancreatic inflammation. In this review, we discussed several key aspects of nutrition therapy in this population, including key pathophysiology that may impede nutrition therapy, the timing and implementation of enteral nutrition and parenteral nutrition, the importance of specific nutrient supplements, and the long-term outcomes that may be addressed by nutrition therapy.

Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study

BACKGROUND

Delayed cholecystectomy in patients with symptomatic gallstone disease is associated with recurrence. Limited data on the recurrence patterns and the factors that determine them are available.

OBJECTIVE

We aimed to determine the pattern of relapse in each symptomatic gallstone disease (acute pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic) and determine the associated factors.

METHODS

RELAPSTONE was an international multicenter retrospective cohort study. Patients (n = 3016) from 18 tertiary centers who suffered a first episode of symptomatic gallstone disease from 2018 to 2020 and had not undergone cholecystectomy during admission were included. The main outcome was relapse-free survival. Kaplan-Meier curves were used in the bivariate analysis. Multivariable Cox regression models were used to identify prognostic factors associated with relapses.

RESULTS

Mean age was 76.6 [IQR: 59.7-84.1], and 51% were male. The median follow-up was 5.3 months [IQR 2.1-12.4]. Relapse-free survival was 0.79 (95% CI: 0.77-0.80) at 3 months, 0.71 (95% CI: 0.69-0.73) at 6 months, and 0.63 (95% CI: 0.61-0.65) at 12 months. In multivariable analysis, older age (HR = 0.57; 95% CI: 0.49-0.66), sphincterotomy (HR = 0.58, 95% CI: 0.49-0.68) and higher leukocyte count (HR = 0.79; 95% CI: 0.70-0.90) were independently associated with lower risk of relapse, whereas higher levels of alanine aminotransferase (HR = 1.22; 95% CI: 1.02-1.46) and multiple cholelithiasis (HR = 1.19, 95% CI: 1.05-1.34) were associated with higher relapse rates.

CONCLUSION

The relapse rate is high and different in each symptomatic gallstone disease. Our independent predictors could be useful for prioritizing patients on the waiting list for cholecystectomies.

Predicting the risk of early intensive care unit admission for patients hospitalized with acute pancreatitis using supervised machine learning

BACKGROUND

Acute pancreatitis (AP) is a complex and life-threatening disease. Early recognition of factors predicting morbidity and mortality is crucial. We aimed to develop and validate a pragmatic model to predict the individualized risk of early intensive care unit (ICU) admission for patients with AP.

METHODS

The 2019 Nationwide Readmission Database was used to identify patients hospitalized with a primary diagnosis of AP without ICU admission. A matched comparison cohort of AP patients with ICU admission within 7 days of hospitalization was identified from the National Inpatient Sample after 1:N propensity score matching. The least absolute shrinkage and selection operator (LASSO) regression was used to select predictors and develop an ICU acute pancreatitis risk (IAPR) score validated by 10-fold cross-validation.

RESULTS

A total of 1513 patients hospitalized for AP were included. The median age was 50.0 years (interquartile range: 39.0-63.0). The three predictors that were selected included hypoxia (area under the curve [AUC] 0.78), acute kidney injury (AUC 0.72), and cardiac arrhythmia (AUC 0.61). These variables were used to develop a nomogram that displayed excellent discrimination (AUC 0.874) (bootstrap bias-corrected 95% confidence interval 0.824-0.876). There was no evidence of miscalibration (test statistic = 2.88; P = 0.09). For high-risk patients (total score >6 points), the sensitivity was 68.94% and the specificity was 92.66%.

CONCLUSIONS

This supervised machine learning-based model can help recognize high-risk AP hospitalizations. Clinicians may use the IAPR score to identify patients with AP at high risk of ICU admission within the first week of hospitalization.

Innovative pathways allow safe discharge of mild acute pancreatitis from the emergency room

Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, resulting in 300000 admissions per year with an estimated cost of over $2.6 billion annually. The severity of AP is determined by the presence of pancreatic complications and end-organ damage. While moderate/severe pancreatitis can be associated with significant morbidity and mortality, the majority of patients have a mild presentation with an uncomplicated course and mortality rate of less than 2%. Despite favorable outcomes, the majority of mild AP patients are admitted, contributing to healthcare cost and burden. In this Editorial we review the performance of an emergency department (ED) pathway for patients with mild AP at a tertiary care center with the goal of reducing hospitalizations, resource utilization, and costs after several years of implementation of the pathway. We discuss the clinical course and outcomes of mild AP patients enrolled in the pathway who were successfully discharged from the ED compared to those who were admitted to the hospital, and identify predictors of successful ED discharge to select patients who can potentially be triaged to the pathway. We conclude that by implementing innovative clinical pathways which are established and reproducible, selected AP patients can be safely discharged from the ED, reducing hospitalizations and healthcare costs, without compromising clinical outcomes. We also identify a subset of patients most likely to succeed in this pathway.

A retrospective study of pregnant patients with acute pancreatitis

OBJECTIVE

Acute pancreatitis is a rare disease in pregnant patients. Although it may have serious maternal and fetal consequences, morbidity and mortality rates have decreased recently due to appropriate and rapid treatment with earlier diagnosis. The aim of this study was to evaluate pregnant patients diagnosed with acute pancreatitis.

METHODS

The study included pregnant patients diagnosed with acute pancreatitis who were admitted to Adana City Training and Research Hospital in Adana, Turkey, between January 2014 and January 2022. Patients' files were screened. Patients' demographics, acute pancreatitis etiology, severity, complications, and applied treatment, as well as maternal and fetal outcomes were evaluated.

RESULTS

The study included 65 pregnant patients with acute pancreatitis. The mean age was 26.6±5 (19-41) years. Acute pancreatitis was observed in the third trimester. The most common cause of acute pancreatitis was gallstones, and its severity was often mild. Only two patients required endoscopic retrograde cholangiopancreatography, and the remaining patients were treated medically. Maternal and infant death developed in a patient with necrotizing acute pancreatitis secondary to hyperlipidemia.

CONCLUSION

The most common etiology of acute pancreatitis in pregnancy was gallstones. Acute pancreatitis occurred in the third trimester. Most of the patients had mild acute pancreatitis. Maternal and fetal complications were rare. We think that the reasons for the low mortality rate were mild disease severity and biliary etiology, and most patients were in the third trimester, as well as early diagnosis and no delay in the intervention.

Exploring the Microbial Landscape: Gut Dysbiosis and Therapeutic Strategies in Pancreatitis-A Narrative Review

The gut microbiota is emerging as an important contributor to the homeostasis of the human body through its involvement in nutrition and metabolism, protection against pathogens, and the development and modulation of the immune system. It has therefore become an important research topic in recent decades. Although the association between intestinal dysbiosis and numerous digestive pathologies has been thoroughly researched, its involvement in pancreatic diseases constitutes a novelty in the specialized literature. In recent years, growing evidence has pointed to the critical involvement of the pancreas in regulating the intestinal microbiota, as well as the impact of the intestinal microbiota on pancreatic physiology, which implies the existence of a bidirectional connection known as the "gut-pancreas axis". It is theorized that any change at either of these levels triggers a response in the other component, hence leading to the evolution of pancreatitis. However, there are not enough data to determine whether gut dysbiosis is an underlying cause or a result of pancreatitis; therefore, more research is needed in this area. The purpose of this narrative review is to highlight the role of gut dysbiosis in the pathogenesis of acute and chronic pancreatitis, its evolution, and the prospect of employing the microbiota as a therapeutic intervention for pancreatitis.

Increase in acute pancreatitis, especially gallstone related, as the cause for emergency admissions: Temporal trend from Kashmir, India

BACKGROUND

The incidence of acute pancreatitis is increasing globally. Gallstones (GS) and ascariasis are the major causes for acute pancreatitis in the Kashmiri population. In recent years, we have observed an increase in the admission rate of acute pancreatitis. Many patients who present first time as gallstone pancreatitis have asymptomatic gallstones. We aimed at studying the etiology and yearly admission rate of acute pancreatitis with main focus on gallstone pancreatitis and the contribution of asymptomatic gallstones.

METHODS

This was a hospital-based, prospective, observational study from January 2015 to December 2019 for a period of five years. Patients of acute pancreatitis were evaluated for etiology and yearly admission rate. Patients of gallstone pancreatitis were evaluated in terms of clinical profile, risk factors, nature (symptomatic/asymptomatic, known/unknown gallstones), size of stones, treatment and outcome in terms of severity and mortality. The data was analyzed by Statistical Package for the Social Sciences (SPSS) version 20.0, as mean (SD), frequencies and percentages.

RESULTS

As many as 702 (8.5%) patients of acute pancreatitis were admitted among 8245 gastrointestinal emergencies in five years. The yearly admission rate of acute pancreatitis was 5.6%, 7.3%, 8.7%, 9.5% and 10.3%, respectively (p = 0.013). Gallstones, Ascariasis, alcohol and idiopathic acute pancreatitis were 47.7%, 6.9%, 1.2% and 33.7%, respectively. Gallstone pancreatitis increased from 31% in 2015 to 52.4% in 2019 (p = 0.045) and ascariasis-related acute pancreatitis declined from 14.4% to 1.6% (p = 0.034). Asymptomatic gallstones constituted 87.7% of cases. Known/unknown asymptomatic gallstones and symptomatic gallstones were 24.4%, 63.2% and 12.2%, respectively. Gallstones < 5 mm and > 5 mm were76.1% and 23.8% respectively (p = 0.027). Cholecystectomy rate in index admission was 4.7%. Mild, moderate and severe gallstone pancreatitis was 60.2%, 18.8% and 20.8%, respectively. Mortality in gallstone pancreatitis was 10.4%.

CONCLUSION

The incidence of acute pancreatitis is increasing due to gallstone pancreatitis. Ascariasis-related acute pancreatitis has declined. There is significant contribution of asymptomatic gallstones in patients who present for the first time as acute pancreatitis. Small gallstones < 5 mm are likely to be the risk factors for gallstone pancreatitis.

[Management of acute pancreatitis in the emergency department and the intensive care unit]

Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed.

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Buprenorphine Versus Diclofenac for Pain Relief in Acute Pancreatitis: A Double-Blinded Randomized Controlled Trial

BACKGROUND

Although both nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are used for analgesia in acute pancreatitis (AP), the analgesic of choice is not known. We compared buprenorphine, an opioid, and diclofenac, an NSAID, for analgesia in AP.

METHODS

In a double-blind randomized controlled trial, AP patients were randomized to receive intravenous diclofenac or intravenous buprenorphine. Fentanyl was used as rescue analgesia, delivered through a patient-controlled analgesia pump. Primary outcome was the difference in the dose of rescue fentanyl required. Secondary outcomes were the number of effective and ineffective demands of rescue fentanyl, pain-free interval, reduction in visual analogue scale (VAS) score, adverse events, and organ failure development.

RESULTS

Twenty-four patients were randomized to diclofenac and 24 to buprenorphine. The 2 groups were matched at baseline. The total amount of rescue fentanyl required was significantly lower in the buprenorphine group:130 μg, interquartile range (IQR), 80-255 vs 520 μg, IQR, 380-1065 (P < .001). The number of total demands was 32 (IQR, 21-69) in the diclofenac arm vs 8 (IQR, 4-15) in the buprenorphine arm (P < .001). The buprenorphine group had more prolonged pain-free interval (20 vs 4 hours; P < .001), with greater reduction in the VAS score at 24, 48, and 72 hours compared with the diclofenac group. These findings were confirmed in the subgroup of moderately severe/severe pancreatitis. Adverse events profile was similar in the 2 groups.

CONCLUSIONS

Compared with diclofenac, buprenorphine appears to be more effective and equally safe for pain management in AP patients, even in the subcohort of moderately severe or severe pancreatitis (Trial Registration number: CTRI/2020/07/026914).

Recent Treatment Strategies for Acute Pancreatitis

Acute pancreatitis (AP) is a leading gastrointestinal disease that causes hospitalization. Initial management in the first 72 h after the diagnosis of AP is pivotal, which can influence the clinical outcomes of the disease. Initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis, plays a fundamental role in AP treatment. Recent updates for fluid resuscitation, including treatment goals, the type, rate, volume, and duration, have triggered a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution. Evidence of the clinical benefit of early enteral feeding is becoming definitive. The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has recently been investigated to distinguish between inflammation and infection in patients with AP. Although urgent ERCP (within 24 h) should be performed for patients with gallstone pancreatitis and cholangitis, urgent ERCP is not indicated in patients without cholangitis. The management approach for patients with local complications of AP, particularly those with infected necrotizing pancreatitis, is discussed in detail, including indications, timing, anatomical considerations, and selection of intervention methods. Furthermore, convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is also important for improving the prognosis and preventing recurrence in patients with AP. This review focuses on recent updates on the initial and convalescent management strategies for AP.

Remission of organ failure in patients with predicted severe acute pancreatitis treated by somatostation, octreotide and cyclooxygenase-2 inhibitors

BACKGROUND

/Objectives: Persistent organ failure (OF) in severe acute pancreatitis (SAP) is caused by activation of cytokine cascades, resulting in inflammatory injury. Anti-inflammation may be helpful in OF remission in early SAP. To assess the efficacy of anti-inflammatory regimens for OF prevention and remission in patients with predicted SAP and display clinical doctors' acceptance of these strategies, we conducted this retrospective study in the real world.

METHODS

Clinical data of patients with predicted SAP from 2010 to 2017 were retrospectively reviewed. Cases were divided into conventional support (C), C+ somatostatin/octreotide (C + S/O), and C + S/O + Cyclooxygenase-2-inhibitors (C + S/O + COX-2-I). The occurrence of SAP, OF, changes of proportion for three strategies, length of hospital stay, meperidine injection, and cytokine levels were compared. The constituent ratios of the three schemes over eight years were evaluated.

RESULTS

A total of 580 cases (C = 124, C + S/O = 290, C + S/O + COX-2-I = 166) were included. The occurrences of SAP in the C + S/O (28.3 %) and C + S/O + COX-2-I (18.1 %) groups were significantly lower than that in C group (60.5 %, P < 0.001), mainly by reducing persistent respiratory failure (P < 0.001) and renal failure (P = 0.002). C + S/O and C + S/O + COX-2-I regimens significantly decreased new onset OF and enhanced OF amelioration within 48 h when compared with C treatment (P < 0.001) in patients with OF score <2 and ≥ 2 on admission, respectively. C + S/O and C + S/O + COX-2-I as compared with C group significantly decrease OF occurrences in a multivariate logistic regression analysis (P < 0.05).

CONCLUSIONS

Somatostatin or its analogs and cyclooxygenase-2 inhibitors are promising for OF prevention and remission in patients with predicted SAP. The acceptance of combined strategies in the real world has increased, and the occurrence of SAP has decreased annually.

The 2023 MANCTRA Acute Biliary Pancreatitis Care Bundle: A Joint Effort Between Human Knowledge and Artificial Intelligence (ChatGPT) to Optimize the Care of Patients With Acute Biliary Pancreatitis in Western Countries

OBJECTIVE

To generate an up-to-date bundle to manage acute biliary pancreatitis using an evidence-based, artificial intelligence (AI)-assisted GRADE method.

BACKGROUND

A care bundle is a set of core elements of care that are distilled from the most solid evidence-based practice guidelines and recommendations.

METHODS

The research questions were addressed in this bundle following the PICO criteria. The working group summarized the effects of interventions with the strength of recommendation and quality of evidence applying the GRADE methodology. ChatGPT AI system was used to independently assess the quality of evidence of each element in the bundle, together with the strength of the recommendations.

RESULTS

The 7 elements of the bundle discourage antibiotic prophylaxis in patients with acute biliary pancreatitis, support the use of a full-solid diet in patients with mild to moderately severe acute biliary pancreatitis, and recommend early enteral nutrition in patients unable to feed by mouth. The bundle states that endoscopic retrograde cholangiopancreatography should be performed within the first 48 to 72 hours of hospital admission in patients with cholangitis. Early laparoscopic cholecystectomy should be performed in patients with mild acute biliary pancreatitis. When operative intervention is needed for necrotizing pancreatitis, this should start with the endoscopic step-up approach.

CONCLUSIONS

We have developed a new care bundle with 7 key elements for managing patients with acute biliary pancreatitis. This new bundle, whose scientific strength has been increased thanks to the alliance between human knowledge and AI from the new ChatGPT software, should be introduced to emergency departments, wards, and intensive care units.

Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist

While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.

A Shift Toward Early Oral Feeding in Acute Pancreatitis

OBJECTIVES

The 2018 American Gastroenterological Association (AGA) guidelines strongly recommended early oral feeding as tolerated in patients with acute pancreatitis (AP). We compare early oral feeding rates in AP patients hospitalized in the periods before (2013-2016, Period A) and after (2019-2020, Period B) publication of the AGA guidelines, hypothesizing increased adherence in Period B.

METHODS

We performed a retrospective cohort study of AP patients presenting to the emergency department during each period. Early oral feeding was defined as diet initiation within the first 48 hours of presentation.

RESULTS

The cohort included 276 AP cases in period A and 104 in period B. A higher percentage of patients were offered early oral feeding during period B as compared to period A (70.2% vs. 43.5%). Similarly, more patients in period B were started on solid diet as compared to period A (34.6% vs. 20.3%). On multivariable regression analysis, the independent predictors of delayed oral feeding included early opioid analgesics use (OR 0.37), presence of pancreatic necrosis (OR 0.14), and organ failure (OR 0.33).

CONCLUSIONS

More AP patients were initiated on early oral feeding in the period following the publication of the AGA guidelines. Opioid analgesics use, pancreatic necrosis, and organ failure were associated with delayed oral feeding.

Faster discharge with lactated ringers than normal saline in first 72 h of acute pancreatitis: A multicenter randomized trial

OBJECTIVES

Data driven strategies for acute pancreatitis (AP) in pediatrics are limited; adult data suggests lactated ringers (LR) compared to normal saline (NS) resulted in favorable outcomes, but has not been studied in pediatrics. Our objective was to evaluate the efficacy of LR during the first 48 h of an AP episode compared with NS.

STUDY DESIGN

A multisite randomized controlled clinical trial, from 2015 to 2020 (Clinical Trials.gov NCT03242473). Patients were randomized to exclusively LR or NS for the first 48 h. Primary outcomes were serial C-reactive protein (CRP) values. Secondary outcomes included other lab values, time to feeds, length of stay (LOS), systemic inflammatory response syndrome (SIRS) development, and progression to severe AP (SAP).

RESULTS

We studied 76 patients (38 LR, 38 NS). CRP at 24 and 48 h were not significantly different between LR or NS group. Additionally, there were no differences in trends of BUN, amylase, lipase, SIRS status, or SAP development between the LR and NS group at 24 and 48 h. A higher proportion of LR patients (32%, 12/38) were discharged before 48 h compared to NS (13%, 5/38). The LR group had a significantly higher rate of discharge within the first 72 h compared to the NS group (p = 0.02).

CONCLUSION

The use of LR was associated with a faster rate of discharge during the intervention period and in the first 72 h, but no other differences compared to NS. This reduction in length of hospitalization has significant implications for patients and healthcare costs.

Dynamic nomogram for predicting infected pancreatic necrosis in female patients of childbearing age with hypertriglyceridemia-induced acute pancreatitis

BACKGROUND

Hypertriglyceridemia is a common cause of acute pancreatitis. Pregnant women are at risk of developing hypertriglyceridemia-induced acute pancreatitis (HTG-AP); however, whether pregnancy increases the risk of infected pancreatic necrosis (IPN) is unknown.

AIM

We aimed to assess the association between pregnancy and IPN.

METHODS

This 10-year retrospective cohort study was conducted at Jinling Hospital. Adult female patients of childbearing age with HTG-AP between January 2013 and September 2022 were screened. Logistic regression analyses were performed to assess the risk factors for IPN. Patients admitted within 7 days were assigned to the training and validation sets to develop a dynamic nomogram for IPN prediction.

RESULTS

489 patients were included, and 144 developed IPN. Logistic regression analyses revealed pregnancy (OR: 2.578 95% CI: 1.474-4.510) as an independent risk factor for IPN. Gestation weeks, ARDS, albumin level, and serum creatinine level were selected as the predictors of the dynamic nomogram for IPN prediction, with good discrimination in the training set (AUC 0.867 95% CI: 0.794-0.940) and validation set (AUC 0.957 95% CI: 0.885-1.000).

CONCLUSION

Pregnancy increases the risk of IPN in adult patients of childbearing age with HTG-AP, and the dynamic nomogram may help risk stratification for IPN.

Electroacupuncture at ST36 modulates the intestinal microecology and may help repair the intestinal barrier in the rat model of severe acute pancreatitis

Severe acute pancreatitis (SAP) onset and development are closely associated with intestinal barrier injury. Evidence from clinical practice and research has shown that electroacupuncture (EA) at the Zusanli (ST36) acupoint can improve intestinal barrier function and abdominal symptoms in patients with SAP; however, the specific mechanisms of action remain unclear. This study aimed to observe the changes in the intestinal microbiota and metabolites in SAP rats and to explore the effect of EA at ST36 on intestinal barrier injury in SAP rats. 16S rRNA gene sequencing combined with microbial diversity analysis, short-chain fatty acids (SCFAs)-targeted metabolomics, immunohistochemistry, immunofluorescence, western blotting, and other techniques were used to explore the mechanism of EA at bilateral ST36 acupoints on SAP-related intestinal barrier injury. Our results showed that EA at ST36 could repair intestinal barrier injury by modulating intestinal microecology, thereby reducing intestinal inflammation, restoring intestinal function, and ultimately alleviating the prognosis of SAP. Our study provides new insights into the mechanisms and treatment of intestinal barrier injury in patients with SAP from the perspectives of microbiota and SCFAs regulation.

β-Carotene Supplementation Improves Pancreas Function during Moderate Ethanol Consumption: Initial Characterization from a Morphological Overview

Alcohol is believed to harm acinar cells, pancreatic ductal epithelium, and pancreatic stellate cells. After giving ethanol and/or β-carotene to C57BL/6 mice, our goal was to evaluate their biochemistry, histology, and morpho-quantitative features. There were six groups of C57BL/6 mice: 1. Group C (control), 2. Group LA (low-dose alcohol), 3. Group MA (moderate-dose alcohol), 4. Group B (β-carotene), 5. Group LA + B (low-dose alcohol combined with β-carotene), and 6. Group MA + B (moderate-dose alcohol combined with β-carotene). After the animals were euthanized on day 28, each specimen's pancreatic tissue was taken. Lipase, uric acid, and amylase were assessed using biochemical assessment. Furthermore, the examination of the pancreatic structure was conducted using Ammann's fibrosis scoring system. Finally, the morpho-quantitative characteristics of the pancreatic islets and acinar cells were determined. In the serum of the MA + B group, there were higher amounts of total amylase (825.953 ± 193.412 U/L) and lower amounts of lipase (47.139 ± 6.099 U/L) (p < 0.05). Furthermore, Ammann's fibrosis punctuation in the pancreas revealed significant variations between the groups (p < 0.001). Finally, the stereological analysis of pancreatic islets showed that the groups were different (p < 0.001). These findings suggest that antioxidant treatments might help decrease the negative effects of ethanol exposure in animal models.

Naldemedine-laxative combination: retrospective inpatient study

OBJECTIVES

The initiation of peripherally acting μ-opioid receptor antagonists (PAMORAs) should be considered 2 weeks after conventional laxatives have failed to achieve an adequate response, and affected patients should be evaluated every 2 weeks thereafter. However, this guidance is difficult to implement in acute care hospitals. This study aimed to examine how naldemedine (PAMORA) should be introduced in combination with other laxatives in the acute care setting.

METHODS

This retrospective study evaluated 93 inpatients who received at least four doses of naldemedine. We investigated changes in the average daily defecation counts during the first 7 days after compared with before naldemedine administration and the incidence of diarrhoea.

RESULTS

Daily defecation counts during the first 7 days after compared with before naldemedine administration were greater in both the naldemedine, magnesium oxide (MgO) and another laxative group, and in the naldemedine and another laxative other than MgO group than in the naldemedine only group. The incidence rates of diarrhoea were significantly higher in the naldemedine, MgO, and another laxative group, and in the naldemedine and another laxative other than MgO group than in the naldemedine only group.

CONCLUSIONS

The introduction of naldemedine alone or in combination with MgO should be considered.

Contemporary management of acute pancreatitis: What you need to know

ABSTRACT

Acute pancreatitis and management of its complications is a common consult for the acute care surgeon. With the ongoing development of both operative and endoscopic treatment modalities, management recommendations continue to evolve. We describe the current diagnostic and treatment guidelines for acute pancreatitis through the lens of acute care surgery. Topics, including optimal nutrition, timing of cholecystectomy in gallstone pancreatitis, and the management of peripancreatic fluid collections, are discussed. Although the management severe acute pancreatitis can include advanced interventional modalities including endoscopic, percutaneous, and surgical debridement, the initial management of acute pancreatitis includes fluid resuscitation, early enteral nutrition, and close monitoring with consideration of cross-sectional imaging and antibiotics in the setting of suspected superimposed infection. Several scoring systems including the Revised Atlanta Criteria, the Bedside Index for Severity in Acute Pancreatitis score, and the American Association for the Surgery of Trauma grade have been devised to classify and predict the development of the severe acute pancreatitis. In biliary pancreatitis, cholecystectomy prior to discharge is recommended in mild disease and within 8 weeks of necrotizing pancreatitis, while early peripancreatic fluid collections should be managed without intervention. Underlying infection or ongoing symptoms warrant delayed intervention with technique selection dependent on local expertise, anatomic location of the fluid collection, and the specific clinical scenario. Landmark trials have shifted therapy from maximally invasive necrosectomy to more minimally invasive step-up approaches. The acute care surgeon should maintain a skill set that includes these minimally invasive techniques to successfully manage these patients. Overall, the management of acute pancreatitis for the acute care surgeon requires a strong understanding of both the clinical decisions and the options for intervention should this be necessary.

Hypophosphatemia as a Predictor of Clinical Outcomes in Acute Pancreatitis: A Retrospective Study

OBJECTIVE

Phosphate is crucial for cellular repair after injury and may be important in recovery following acute pancreatitis (AP). This study aimed to evaluate the association between hypophosphatemia and severity of AP.

METHODS

Patients admitted with AP between 2014-2018 were identified and their records were retrospectively reviewed. Pancreatitis severity was defined using the modified Atlanta Criteria. Hypophosphatemia was defined as phosphate <2 mg/dL and was assessed at three time points: within one day, within two days, at any time during admission. The proportion of patients who developed severe AP was compared between patients with and without hypophosphatemia.

RESULTS

Of 312 patients, 30.1% (n = 94) developed severe AP. Hypophosphatemia occurred in 25.0% overall, within one day in 19.7%, and within two days in 20.0%. A higher proportion of patients with hypophosphatemia developed severe AP (overall: 47.4% vs. 24.4%, P < 0.001; one day: 47.4% vs. 23.9%, P = 0.004; two days: 42.9% vs. 24.5%, P = 0.01). Patients with hypophosphatemia within one day were also more likely to have ICU admission ( P < 0.001) and longer length of stay ( P < 0.001).

CONCLUSIONS

Early hypophosphatemia during an admission for AP was associated with increased AP severity, ICU admission, and longer length of stay.

Acute Pancreatitis Complicated by Thrombosis in the Right Brachiocephalic Veins and Superior Vena Cava: A Case Report

BACKGROUND

Acute pancreatitis (AP) is one of the most common digestive emergencies, and vascular complication is one of the primary reasons for death, with splanchnic venous thrombosis being the most common. Although extra-splanchnic venous thrombosis is rare, it carries the risk of life-threatening secondary pulmonary embolism.

CASE PRESENTATION

We have, herein, reported a case of AP complicated by rare brachiocephalic vein thrombosis and superior vena cava thrombosis. A 40 years old woman was diagnosed with severe AP for abdominal pain 21 days ago. The patient received symptomatic treatment, including acid suppression, enzyme suppression, lipid-lowering, fluid infusion, anti-infection, and continuous renal replacement therapy. The patient was discharged after symptomatic relief. Recently, the patient was admitted again for middle-upper abdominal pain and discomfort. On admission, her blood platelet, DDimer, fibrin degradation products (FDP), and triglyceride levels have been found to be increased; abdominal enhanced CT showed pancreatic necrosis and an accumulation of peripancreatic necrosis and fluid, while chest enhanced CT suggested thrombosis in the right brachiocephalic vein and superior vena cava. The patient, however, improved and was discharged after anticoagulation combined with insulin and trypsin inhibitors.

CONCLUSION

In diagnosing and treating AP, dynamic monitoring of D-dimer levels is necessary for the timely detection of the development of thrombotic complications.

Etiological Changes and Prognosis of Hospitalized Patients with Acute Pancreatitis Over a 15-Year Period

BACKGROUND

The worldwide incidence of acute pancreatitis (AP) is increasing, but the dominant etiology of AP may vary by country. Mixed etiologies are involved in the increase in the number of AP patients.

AIMS

This study was to analyze the etiological changes and prognosis of AP patients and explore the prognosis of AP patients with mixed etiologies.

METHODS

Using a retrospective analysis method, AP patients hospitalized from January 2007 to December 2021 were selected from a pancreatic center in Nanchang, China. Trends in the main etiologies were analyzed, and the severity and prognosis of different etiologies were compared.

RESULTS

A total of 10,071 patients were included. Cholelithiasis (56.0%), hyperlipidemia (25.3%), and alcohol (6.5%) were the top three etiologies. The proportion of acute biliary pancreatitis (ABP) showed a decreasing trend, while the proportion of hypertriglyceridemic pancreatitis (HTGP) and alcoholic AP showed an increasing trend (all ptrend < 0.001). The incidence of organ failure and necrotizing pancreatitis was higher in patients with HTGP than in those with AP induced by other etiologies (all p < 0.05). There was no statistically significant difference in mortality among patients with different etiologies. Patients with AP due to a mixed hypertriglyceridemia-alcoholic etiology had higher ICU admission rates and were more severe than those with AP induced by other mixed etiologies.

CONCLUSION

In the past 15 years, the proportion of ABP has trended downward, while those of HTGP and alcoholic AP have risen. Among patients with mixed etiologies, those with a mixed hypertriglyceridemia-alcoholic etiology had a worse prognosis.

Crawling toward obsolescence: The extended lifespan of amylase for pancreatitis

The correlation between hyperamylasemia and acute pancreatitis was discovered in 1929, yet another test, lipase, was shown to provide better diagnostic performance in the late 1980s and early 1990s. Subsequent studies demonstrated co-ordering amylase with lipase did not provide additional benefit, only added cost. We sought to investigate the impact of studies advocating for the obsolescence of amylase on its clinical demand. We reviewed 1.3 million reportable results for amylase over 14 years (2009-2022). The trend in utilization of amylase over this period declined by 66% along a linear trajectory (R2 = 0.97). Despite demand for amylase decreasing by an average of 17,003 tests per year, the last year of the study (2022) recorded over 100,000 results for amylase. By interpolating the decline of amylase until the utilization reached zero, we calculated amylase orders will continue for 6 more years until 2028. Tests for creatinine and lipase changed <3% over the same period. Despite a multitude of studies advocating for the obsolescence of amylase, robust demand continues. Many important clinical guidelines, a source many practicing physicians rely on, have yet to acknowledge the preference for lipase over amylase. They frequently treat the two tests as equivalent, neglecting their head-to-head comparison studies and subsequent studies advocating against co-ordering both tests simultaneously. To expedite the obsolescence of amylase, which we anticipate lasting 46 years in our case study from its initial call for obsolescence to the last orders placed, metrics created specifically to monitor the utilization of unnecessary tests are also needed.

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

What should be measured and reported in clinical trials for the treatment of patients with acute pancreatitis? A study protocol for establishing a core outcome set

INTRODUCTION

Acute pancreatitis (AP) is characterised by inflammation of the exocrine pancreas, which potentially leads to local complications and organ failure resulting in significant morbidity and mortality. A long-term follow-up by an experienced team is needed. Currently, a variety of outcome measures are used in clinical trials for patients with AP. However, due to heterogeneous and selective outcome reporting across trials of interventions, it is hard to combine or compare the trial results compromising systematic evaluations of effectiveness and safety. A core outcome set is demanded to standardise reporting for the management of AP in clinical trials, so as to conduct systematic reviews and to improve the quality of the existing evidence base on the management of AP. We designed a study to establish a core outcome set (COS) on what indicators should be measured and reported in clinical trials of patients with AP (COS-AP).

METHODS AND ANALYSIS

This study protocol outlines the following five phases: Phase I will be a systematic review of randomised control trials and semistructured interviews with patients to initially establish a preliminary list of potential outcomes. Phase II will be the recruitment of key stakeholders' groups comprising experts in pancreatic disease, clinical researchers, methodologists, journal editors and patients. Phase III will be two rounds of the Delphi surveys with key stakeholder groups. Phase IV will be a consensus on the outcomes that should be included in a final COS-AP. Phase V will be dissemination of COS-AP.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Biomedical Research Ethics Committee (BREC) of West China Hospital of Sichuan University (2020 No.691). The findings will be disseminated in peer-reviewed journals and meetings.

TRIAL REGISTRATION

This study was registered with Core Outcome Measures in Effectiveness Trials (COMET) database as study 2573.

The 2022 top 10 list of endoscopy topics in medical publishing: an annual review by the American Society for Gastrointestinal Endoscopy Editorial Board

Using a systematic literature search of original articles published during 2022 in Gastrointestinal Endoscopy and other high-impact medical and gastroenterology journals, the 10-member Editorial Board of the American Society for Gastrointestinal Endoscopy composed a list of the 10 most significant topic areas in GI endoscopy during the study year. Each Editorial Board member was directed to consider 3 criteria in generating candidate lists-significance, novelty, and global impact on clinical practice-and subject matter consensus was facilitated by the Chair through electronic voting. The 10 identified areas collectively represent advances in the following endoscopic spheres: artificial intelligence, endoscopic submucosal dissection, Barrett's esophagus, interventional EUS, endoscopic resection techniques, pancreaticobiliary endoscopy, management of acute pancreatitis, endoscopic environmental sustainability, the NordICC trial, and spiral enteroscopy. Each board member was assigned a consensus topic area around which to summarize relevant important articles, thereby generating this précis of the "top 10" endoscopic advances of 2022.

Lactated Ringers Use in the First 24 Hours of Hospitalization Is Associated With Improved Outcomes in 999 Patients With Acute Pancreatitis

INTRODUCTION

Recent pilot trials in acute pancreatitis (AP) found that lactated ringers (LR) usage may result in decreased risk of moderately severe/severe AP compared with normal saline, but their small sample sizes limit statistical power. We investigated whether LR usage is associated with improved outcomes in AP in an international multicenter prospective study.

METHODS

Patients directly admitted with the diagnosis of AP were prospectively enrolled at 22 international sites between 2015 and 2018. Demographics, fluid administration, and AP severity data were collected in a standardized prospective manner to examine the association between LR and AP severity outcomes. Mixed-effects logistic regression analysis was performed to determine the direction and magnitude of the relationship between the type of fluid administered during the first 24 hours and the development of moderately severe/severe AP.

RESULTS

Data from 999 patients were analyzed (mean age 51 years, female 52%, moderately severe/severe AP 24%). Usage of LR during the first 24 hours was associated with reduced odds of moderately severe/severe AP (adjusted odds ratio 0.52; P = 0.014) compared with normal saline after adjusting for region of enrollment, etiology, body mass index, and fluid volume and accounting for the variation across centers. Similar results were observed in sensitivity analyses eliminating the effects of admission organ failure, etiology, and excessive total fluid volume.

DISCUSSION

LR administration in the first 24 hours of hospitalization was associated with improved AP severity. A large-scale randomized clinical trial is needed to confirm these findings.

Acupuncture for gastrointestinal diseases

Acupuncture, an important component of traditional Chinese medicine, has gained growing attention around the world in the past decades. Both manual and electroacupuncture are commonly used in clinical practice, especially by patients with gastrointestinal disorders seeking symptoms control due to disease signs recurrence and/or lack of effective treatments. Currently, patients with functional gastrointestinal disorders, constipation, gastroesophageal reflux disease, inflammatory bowel disease, ileus, acute pancreatitis, and gastroparesis may benefit from acupuncture treatment, as clinically evident, and the most frequently used acupoints are chosen from the large intestine, stomach, bladder, and spleen meridian. The underlying mechanisms of acupuncture involve the neuromodulation, adjustment of gastrointestinal motility and visceral hypersensitivity, anti-inflammation, repairment of gut microbiota, and intestinal barrier. As methodology advanced, cumulative number of well-designed clinical trials has been established, which might help elevating clinicians and gastroenterologists' awareness and perception toward application of acupuncture for gastrointestinal diseases management.

No role for protease inhibitors as a mitigation strategy for postpancreatectomy acute pancreatitis (PPAP): Propensity score matching analysis

BACKGROUND

While the use of protease inhibitor gabexate mesylate (GM) is still controversial in acute pancreatitis, it has never been tested for postpancreatectomy acute pancreatitis (PPAP). This study aims to assess the impact of GM on postoperative serum hyperamylasaemia (POH) or PPAP after pancreatoduodenectomy (PD).

METHODS

Consecutive patients developing POH after PD between 2016 and 2021 were included. According to GM administration, patients were divided into GM-treated and control (CTR) groups. GM was administered from postoperative day 1-3 in POH patients who underwent surgery before 2017. A 2:1 propensity matching was used to minimize the risk of bias.

RESULTS

Overall, 264 patients with POH were stratified in the GM (59 patients) and CTR (104 patients) cohorts, which showed balanced baseline characteristics after matching. No difference in postoperative complications was observed between the groups (all p > 0.05), except for PPAP occurrence, which was significantly higher in the GM group (37% vs. 22%, p = 0.037). A total of 45 patients (28%) evolved to PPAP. Comparing PPAP patients in the GM and CTR groups, no significant differences in POPF, relaparotomy, and mortality (all p > 0.09) were found. No difference in intravenous crystalloid administration was found in patients with PPAP, whether or not they developed major complications or pancreatic fistula (p > 0.05) CONCLUSION: Protease inhibitor seems ineffective in preventing a PPAP after PD once a POH has occurred. Further studies are needed to achieve benchmarks for treating PPAP and identify mitigation strategies to prevent the evolution of POH into additional morbidity.

Treatment and diagnosis of hyperlipidemia acute pancreatitis in pregnancy associated with pre‑pregnancy obesity and diabetes: A case report

Hyperlipidemia acute pancreatitis (HLAP) is a specific type of pancreatitis mainly caused by elevated serum triglyceride (TG) levels. Therefore, knowledge of patients' medical history is crucial to the identification of those at high risk of HLAP. Diabetes and obesity are associated with high levels of triglycerides, a risk factor for the development of HLAP, which should be controlled before pregnancy. Moreover, HLAP is associated with additional diagnostic and management challenges related to hyperlipidemia (HL) and pregnancy. HLAP during pregnancy has a rapid onset and rapid progression, and complications are more likely to damage the function of multiple organs. HLAP is more common after 28 weeks of pregnancy, the cause is mostly high TG and the serum TG of the patient is often >1,000 mg/d1. Clinicians should be alert to the occurrence of server acute pancreatitis (AP). Therefore, clinicians need to identify and implement effective treatment in a timely manner to control the progression of HLAP during pregnancy and improve pregnancy outcomes. The present study reported the case of a 26-year-old pregnant patient who was hospitalized for epigastric pain at 35 weeks and 2 days of gestation. Medical and family history reported previous diagnoses of diabetes and obesity (weight before pregnancy, 103 kg; BMI, 36.40 kg/m2). Laboratory tests demonstrated high levels of lipase and amylase, a notable systemic inflammatory response, HL, coagulopathy, hypoproteinemia and hyperglycemia. Abdominal ultrasonography demonstrated a hypoechoic pancreatic head. A clinical diagnosis of AP was confirmed using CT scanning. Initial interventions for HLAP included aggressive intravenous hydration, bowel rest, pain control and a combination of heparin and insulin. Lipid-lowering agents were administered to reduce serum lipid levels. Hemoperfusion and continuous renal replacement therapy were also used to rapidly counteract the elevated lipid levels. Antibiotics were administered in the present case because inflammatory markers such as leukocytes, neutrophils and C-reactive protein were elevated. The patient and newborn were discharged 11 days after hospitalization, with an improvement in maternal clinical health and the infant was healthy. When evaluating pregnant patients with pre-obesity and diabetes presenting with abdominal pain, obstetricians should consider HLAP. Timely diagnosis and multi-team precision treatment are effective for good outcomes for mother and baby.

Systematic Appraisal of Guidelines for the Diagnosis and Treatment of Choledocholithiasis

BACKGROUND

To systematically evaluate the methodological quality of the current up-to-date guidelines pertaining to choledocholithiasis, we conducted a comprehensive analysis of key recommendations and corresponding evidence, focusing on the heterogeneity among these guidelines.

METHOD

Systematic searches across various databases were performed to identify the latest guidelines. The identified guidelines, which met the inclusion criteria, underwent evaluation using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The key recommendations and evidence from the included guidelines were extracted and reclassified using the Oxford Centre for Evidence-Based Medicine (OCEBM) grading system, and the obtained results were analyzed.

RESULTS

Nine guidelines related to choledocholithiasis were included in this study, out of which 4 achieved an overall standardized score of more than 60%, indicating their suitability for recommendation. Upon closer examination of the main recommendations within these guidelines, we discovered significant discrepancies concerning the utilization of similar treatment techniques for different diseases or different treatment methods under comparable conditions, and discrepancies in the recommended treatment duration. High-quality research evidence was lacking, and some recommendations either failed to provide supporting evidence or cited inappropriate and low-level evidence.

CONCLUSION

The quality of guidelines pertaining to choledocholithiasis is uneven. Recommendations for the treatment of choledocholithiasis demonstrate considerable disparities among the guidelines, particularly regarding the utilization of endoscopic retrograde cholangiopancreatography as a treatment method and the management approaches for difficult stone cases. Improvements by guideline developers for these factors contributing to the heterogeneity would be a reasonable approach to further update the guidelines for cholangiolithiasis.

Identification of optimal reference genes in golden Syrian hamster with ethanol- and palmitoleic acid-induced acute pancreatitis using quantitative real-time polymerase chain reaction

BACKGROUND

Acute pancreatitis (AP) is a severe disorder that leads to high morbidity and mortality. Appropriate reference genes are important for gene analysis in AP. This study sought to study the expression stability of several reference genes in the golden Syrian hamster, a model of AP.

METHODS

AP was induced in golden Syrian hamster by intraperitoneal injection of ethanol (1.35 g/kg) and palmitoleic acid (2 mg/kg). The expression of candidate genes, including Actb, Gapdh, Eef2, Ywhaz, Rps18, Hprt1, Tubb, Rpl13a, Nono, and B2m, in hamster pancreas at different time points (1, 3, 6, 9, and 24 h) posttreatment was analyzed using quantitative polymerase chain reaction. The expression stability of these genes was calculated using BestKeeper, Comprehensive Delta CT, NormFinder, and geNorm algorithms and RefFinder software.

RESULTS

Our results show that the expression of these reference genes fluctuated during AP, of which Ywhaz and Gapdh were the most stable genes, whereas Tubb, Eef2, and Actb were the least stable genes. Furthermore, these genes were used to normalize the expression of TNF-α messenger ribonucleic acid in inflamed pancreas.

CONCLUSIONS

In conclusion, Ywhaz and Gapdh were suitable reference genes for gene expression analysis in AP induced in Syrian hamster.

Prolonged course of eravacycline leading to acute pancreatitis

Eravacycline is the newest member of the broad-spectrum class of tetracycline antimicrobials. Pancreatitis has been previously associated with the tetracycline class of antibiotics, but, to our knowledge, we believe that this is the first reported case of eravacycline-induced pancreatitis. We describe a 46-year-old male who received eravacycline for treatment of a perirectal abscess. While the patient had slightly elevated lipase levels at baseline post-cardiopulmonary arrest, he developed abdominal pain and a further increase in lipase levels following 10 days of eravacycline, consistent with pancreatitis. Based on the Naranjo adverse drug reaction probability scale, eravacycline was the probable etiology of acute pancreatitis given improvement immediately after discontinuation. Clinicians should be aware of this potential adverse effect of eravacycline and should not initiate eravacycline in those with risk factors for acute pancreatic injury. However, acute pancreatitis should be suspected in all patients complaining of symptoms followed by immediate discontinuation of eravacycline.

Fluid resuscitation in the early management of acute pancreatitis - evidence from a systematic review and meta-analysis

BACKGROUND

Third space fluid loss is one of the hallmarks of the pathophysiology of acute pancreatitis (AP) contributing to complications, including organ failure and death. We conducted a systematic review of literature to determine the ideal fluid resuscitation in the early management of AP, primarily comparing aggressive versus moderate intravenous fluid resuscitation (AIR vs MIR).

METHODS

A systematic review of major reference databases was undertaken. Meta-analysis was performed using random-effects model. Bias was assessed using Cochrane risk of bias and ROBINS-I tools for randomized and non-randomised studies, respectively.

RESULTS

Twenty studies were included in the analysis. Though there was no significant difference in mortality between AIR and MIR groups (8.3% versus 6.0%; p = 0.3), AIR cohort had significantly higher rates of organ failure (p = 0.009), including pulmonary (p = 0.02) and renal (p = 0.01) complications. Similarly, there was no difference in mortality between normal saline (NS) and Ringer's lactate (RL) (3.17% versus 3.01%; p = 0.23), though patients treated with NS had a significantly longer length of hospital stay (LOS) (p = 0.009).

CONCLUSIONS

Current evidence appears to support moderate intravenous resuscitation (level of evidence, low) with RL (level of evidence, moderate) in the early management of AP.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

BACKGROUND

Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.

METHODS

The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.

RESULTS

The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.

CONCLUSIONS

RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

Association of Cardiovascular Disease and Pancreatitis: What Came First, the Chicken or the Egg?

(1) Background: Recent studies suggest an association between pancreatitis and cardiovascular disease. This article aims to review the available evidence linking cardiovascular disease with acute and chronic pancreatitis. (2) Methods: A comprehensive search was conducted on the PubMed/MEDLINE database from inception to April 2022 using Medical Subject Heading and keywords related to pancreatitis and cardiovascular disease. The search was limited to English-language literature involving human subjects, and various study types, including observational studies, case-control studies, cohort studies, and clinical trials, were screened for eligibility. Following data extraction, the authors conducted a narrative synthesis of the studies. (3) Results: Longitudinal studies indicate that a history of acute pancreatitis is associated with an increased risk of acute atherosclerotic cardiovascular disease and acute coronary syndrome. Elevated triglyceride levels (>2000 mg/dL) have a temporal relationship with acute pancreatitis. Cross-sectional studies have shown that acute pancreatitis is associated with cardiac injury during the acute phase. Based on longitudinal studies, chronic pancreatitis is associated with an increased risk of cerebrovascular diseases. However, data regarding the relationship between chronic pancreatitis and myocardial infarction are conflicting. (4) Conclusions: Based on the available evidence, having a history of acute pancreatitis appears to increase the risk of acute atherosclerotic cardiovascular disease. However, there is insufficient evidence to conclude whether chronic pancreatitis is associated with cardiovascular disease, and no definitive studies have yielded conflicting results.

Cardiometabolic Index (CMI), Lipid Accumulation Products (LAP), Waist Triglyceride Index (WTI) and the risk of acute pancreatitis: a prospective study in adults of North China

OBJECTIVE

To investigate the correlation between anthropometric indexes [cardiometabolic index (CMI), lipid accumulation products (LAP), waist triglyceride index (WTI), and body mass index (BMI)] and acute pancreatitis (AP) in a Chinese adult population.

METHODOLOGY

The present investigation consisted of a prospective group including 117,326 subjects who were enrolled in the Kailuan investigation. The individuals were categorized into quartiles based on their baseline levels of CMI, LAP, and WIT. BMI was categorized into three distinctive groups: normal weight group (BMI < 24 kg/m2), overweight group (BMI 24-28 kg /m2), and obesity group (BMI ≥ 28 kg/m2). The data were subjected to analysis in order to investigate the correlation between these anthropometric indexes and the incidence of AP. Cox regression models were employed to assess the relative risk of AP while accounting for known risk factors through appropriate adjustments.

OUTCOMES

Over the course of a median follow-up duration of 12.59 ± 0.98 years, we documented 401 incident AP cases. Incidence density and cumulative incidence rates of AP increased with the increase of CMI, LAP, and WTI. After multivariate adjustment, the fourth quartile of CMI, LAP, and WTI exhibited the greatest risk of AP [CMI: hazard ratio (HR) 1.93, 95% confidential interval (CI) (1.45-2.57); LAP: HR 2.00, 95% CI(1.49-2.68); WTI: HR 2.13,95% CI (1.59-2.83)]. In comparison to the normal weight group, the obesity group (BMI ≥ 28 kg/m2) had an elevated risk of AP (HR = 1.58, 95% CI: 1.21-2.05). Furthermore, the incremental effect of BMI combined with CMI on the prognostic value of AP was greater than that of BMI alone (the C statistics demonstrated a result of 0.607 versus 0.546; the integrated discrimination improvement revealed a result of 0.321%; net reclassification improvement was 1.975%).

CONCLUSION

We found that CMI, LAP, and WTI were positively and independently connected to the risk of AP. Additionally, CMI demonstrates a superior prognostic capacity than other indexes in anticipating AP.

The clinical characteristics of focal acute pancreatitis based on imaging diagnosis: comparison with non-localized acute pancreatitis- a preliminary result

BACKGROUND

Focal acute pancreatitis is a special type of acute pancreatitis, which diagnosis is based on image showing a focal mass formation in the pancreas. For acute pancreatitis with or without focal inflammatory enlargement, little is known on differences between them. Our purpose was to find differences between focal acute pancreatitis and non-localized acute pancreatitis.

METHODS

We reviewed the medical records of a total of 24 patients diagnosed with focal acute pancreatitis by imaging and clinical diagnosis, and 27 cases of acute pancreatitis which manifest non-localized pancreas inflammation were selected as the control group. The differences of the two groups were compared to describe their clinical characteristics.

RESULTS

Differences in bloating (4.2% VS 29.6%,P = 0.026), abdominal tenderness (58.3% VS 85.2%,P = 0.032), peripheral blood neutrophil ratio (60.1 ± 23.3VS 75.9 ± 12.6,P = 0.004), serum D-Dimer (0.40(0.25,0.98) VS 1.59(0.49,4.63),P = 0.008), serum GGT (40(25,91) VS120(22,383),P = 0.046), serum amylase(435(241,718) VS 591(394,1333),P = 0.044) and lipase(988(648,1067) VS 1686(525,2675),P = 0.027) between focal acute pancreatitis and non-localized acute pancreatitis groups were statistically significant. However, difference of the severity of two groups was not statistically significant (P = 1.000).

CONCLUSION

Compared with non-localized acute pancreatitis, changes in symptoms, signs and laboratory indicators of focal acute pancreatitis are non-obvious, however, there was no significant difference in the severity of two groups, indicating that we should pay more attention to diagnosis of focal acute pancreatitis in clinical practice.

There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis

BACKGROUND

Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP).

STUDY DESIGN

Retrospective analysis of the Nationwide Readmissions Database (2017). All frail geriatric (65 years or older) patients with ABP were included. Patients were grouped by treatment at index admission: CCY vs NOM with endoscopic retrograde cholangiopancreatography. Propensity score matching was performed in a 1:2 ratio. Primary outcomes were 6-month readmissions, mortality, and length of stay. Secondary outcomes were 6-month failure of NOM defined as readmission for recurrent ABP, unplanned pancreas-related procedures, or unplanned CCY. Subanalysis was performed to compare outcomes of unplanned CCY vs early CCY.

RESULTS

A total of 29,130 frail geriatric patients with ABP were identified and 7,941 were matched (CCY 5,294; NOM 2,647). Patients in the CCY group had lower 6-month rates of readmission for pancreas-related complications, unplanned readmissions for pancreas-related procedures, overall readmissions, and mortality, as well as fewer hospitalized days (p < 0.05). NOM failed in 12% of patients and 7% of NOM patients were readmitted within 6 months to undergo CCY, of which 56% were unplanned. Patients who underwent unplanned CCY had higher complication rates and hospital costs, longer hospital lengths of stay, and increased mortality compared with early CCY (p < 0.05).

CONCLUSIONS

For frail geriatric patients with ABP, early CCY was associated with lower 6-month rates of complications, readmissions, mortality, and fewer hospitalized days. NOM was unsuccessful in nearly 1 of 7 within 6 months; of these, one-third required unplanned CCY. Early CCY should be prioritized for frail geriatric ABP patients when feasible.

Determinants and impact of splanchnic vein thrombosis in acute pancreatitis

BACKGROUND

Splanchnic vein thrombosis (SVT) is a well-recognised though little-studied complication in acute pancreatitis (AP). SVT risk factors, its clinical consequences and the role of anticoagulation (AC) therapy is scarce.

AIMS

To evaluate the incidence and natural history of SVT in AP.

METHODS

Post hoc analysis of a prospective multicentre cohort study involving 23 hospitals in Spain. AP complications were identified by computer tomography, and patients with SVT were re-evaluated after two years.

RESULTS

A total of 1655 patients with AP were included. The overall incidence of SVT was 3.6%. SVT was significantly associated with male gender, younger age and alcoholic aetiology. Every local complication increased SVT incidence, and this risk rose gradually with larger extension and infection of necrosis. These patients had a longer hospital stay and underwent a greater number of invasive treatments, regardless of AP severity. Forty-six patients with SVT were followed up. SVT resolution rate was 54.5% in the AC group and 30.8% in the non-AC group with lower thrombotic complications in the SVT resolution group (83.3% vs 22.7%; p<0.001). No AC-related adverse events occurred.

CONCLUSION

This study identifies the risk factors and negative clinical impact of SVT in AP. Our results justify future trials to demonstrate the role of AC in this clinical scenario.

Electroacupuncture for abdominal pain relief in patients with acute pancreatitis: A three-arm randomized controlled trial

BACKGROUND

Electroacupuncture (EA) may reduce the severity of acute pancreatitis (AP) and provide additional pain relief in patients with chronic pancreatitis. However, the ability of EA to relieve pain in patients with AP has not been well documented.

OBJECTIVE

This study was undertaken to compare the pain-relieving effects of EA and conventional treatment in patients with AP.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This study was conducted using a randomized, controlled, three-arm, parallel-group and multi-center design. Patients diagnosed with AP were randomly and equally assigned to EA1, EA2 or control groups. All participants received conventional standard-of-care therapy for AP. Local EA alone was administered in EA1, and local plus distal EA was given in EA2. Local EA included two abdominal acupoints, while distal EA included twelve peripheral acupoints. EA groups underwent one session of EA daily for 4 days (days 1-4), or until pain was resolved or discharged.

MAIN OUTCOME MEASURES

The primary outcome measure was the change in the visual analogue scale (VAS; 0-100) pain score between baseline and day 5.

RESULTS

Eighty-nine participants were randomized into EA1, EA2 and control groups, and 88 (EA1, 30; EA2, 29; control, 29) were included in the full-analysis set. VAS score change (median [interquartile range]) on day 5 was (12.3 ± 22.5) in the EA1 group, (10.3 ± 21.5) in the EA2 group, and (8.9 ± 15.2) in the control group. There were not significant differences in the change in VAS score among treatments (P = 0.983). However, time to food intake was significantly shorter in the EA group (EA1 + EA2) than in the control group (median 2.0 days vs 3.0 days), with a hazard ratio of 0.581 (P = 0.022; 95% CI, 0.366-0.924). No significant adverse events occurred.

CONCLUSION

EA treatment did not significantly reduce pain after 4 days of treatment in patients with AP-associated abdominal pain but significantly reduced time to first food intake.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03173222. Please cite this article as: Jang DK, Lee JK, Jung CY, Kim KH, Kang HR, Lee YS, Yoon JH, Joo KR, Chae MK, Baek YH, Seo BK, Lee SH, Lim C. Electroacupuncture for abdominal pain relief in patients with acute pancreatitis: A three-arm randomized controlled trial. J Integr Med. 2023; 21(6): 537-542.

Low molecular weight heparin decreases mortality and major complication rates in moderately severe and severe acute pancreatitis-a systematic review and meta-analysis

Background

Routine anticoagulation therapy in acute pancreatitis (AP) is not recommended by the guidelines in the field, although it is frequently used in clinical practice.

Objectives

We aimed to analyze the efficacy and safety of adding anticoagulants therapy to AP management.

Methods

The systematic search was performed in three databases on the 14th of October 2022 without restrictions. Randomized controlled trials (RCTs) and observational studies that reported the differences in the outcomes of AP for patients receiving anticoagulants (intervention group) in addition to the standard of care (SOC), compared to patients managed by SOC alone (control group), were eligible. A random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding 95%-confidence intervals (CI). We performed subgroup analysis for study design and disease severity, among other criteria.

Results

Of the 8,223 screened records, we included eight in the meta-analysis. Except one, all studies reported on low-molecular-weight heparin (LMWH). Both RCTs and observational studies reported results in favor of the LMWH group. Subgroup RCTs' analysis revealed significantly decreased odds of mortality [OR 0.24; 95%CI 0.17-0.34] and multiple organ failure [OR 0.32; 95%CI 0.17-0.62] in the intervention group. Moreover, the need for endoscopic or surgical interventions [OR 0.41; 95%CI 0.28-0.61] were significantly reduced by LMWH. The subgroup analyzes for moderate and severe cases, respectively, yielded similar results. Due to limited data, we could no perform subgroup analysis for mild cases.

Conclusion

LMWH therapy reduces major complication rates in moderate and severe AP. Across all identified RCTs, LMWH were initiated early after AP diagnosis and improved its prognosis.

The anti-inflammatory effect of dimethyl trisulfide in experimental acute pancreatitis

Various organosulfur compounds, such as dimethyl trisulfide (DMTS), display anti-inflammatory properties. We aimed to examine the effects of DMTS on acute pancreatitis (AP) and its mechanism of action in both in vivo and in vitro studies. AP was induced in FVB/n mice or Wistar rats by caerulein, ethanol-palmitoleic acid, or L-ornithine-HCl. DMTS treatments were administered subcutaneously. AP severity was assessed by pancreatic histological scoring, pancreatic water content, and myeloperoxidase activity measurements. The behaviour of animals was followed. Pancreatic heat shock protein 72 (HSP72) expression, sulfide, and protein persulfidation were measured. In vitro acinar viability, intracellular Ca2+ concentration, and reactive oxygen species production were determined. DMTS dose-dependently decreased the severity of AP. It declined the pancreatic infiltration of leukocytes and cellular damage in mice. DMTS upregulated the HSP72 expression during AP and elevated serum sulfide and low molecular weight persulfide levels. DMTS exhibited cytoprotection against hydrogen peroxide and AP-inducing agents. It has antioxidant properties and modulates physiological but not pathophysiological Ca2+ signalling. Generally, DMTS ameliorated AP severity and protected pancreatic acinar cells. Our findings indicate that DMTS is a sulfur donor with anti-inflammatory and antioxidant effects, and organosulfur compounds require further investigation into this potentially lethal disease.

Hypertriglyceridemia-Associated Pancreatitis: New Concepts and Potential Mechanisms

BACKGROUND

Triglycerides are a major source of energy, while high plasma triglycerides are a risk factor for various diseases and premature death. Severely elevated plasma triglycerides are a well-established cause of acute pancreatitis with high mortality, likely due to the presence of elevated levels of chylomicrons and large very low-density lipoproteins in plasma. As markedly elevated levels of these very large lipoproteins are not generally found in mild to moderate hypertriglyceridemia, this was previously not regarded as a cause or marker of increased risk of acute pancreatitis. However, mild to moderate hypertriglyceridemia may identify individuals who at a later timepoint develop severe hypertriglyceridemia and acute pancreatitis.

CONTENT

We describe measurement of plasma triglycerides and studies on plasma triglycerides and risk of acute pancreatitis. Further, we summarize current European and American guidelines for the prevention of acute pancreatitis and, finally, the potential for future prevention of acute pancreatitis through lowering of plasma triglycerides.

SUMMARY

Recent observational and genetic studies indicate that mild to moderate hypertriglyceridemia is causally related to increased risk of acute pancreatitis, most likely as a marker of future severe hypertriglyceridemia. Current guidelines do not mention individuals with mild to moderate hypertriglyceridemia, even though newer evidence suggests an unmet medical need. Treatment could include plasma triglyceride-lowering therapy targeting the pathway for lipoprotein lipase as the main triglyceride degrading enzyme in plasma. Angiopoietin-like 3 and apolipoproteinC-III are inhibitors of lipoprotein lipase, and blocking of these 2 inhibitors is showing promising results in relation to marked triglyceride-lowering and could perhaps be used to prevent acute pancreatitis in the future.

The role of apheresis and insulin therapy in hypertriglyceridemic acute pancreatitis-a concise review

Severe hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP) and is involved in its pathogenesis. Chylomicrons increase blood viscosity and induce ischemia, while free fatty acids induce inflammation and distant organ damage. Conservative treatment options include fasting and insulin; limited evidence shows their comparable efficacy. Plasma exchange might provide more rapid lowering of triglycerides and amelioration of systemic effects of severe AP. Available data from controlled studies show only moderately faster lowering of triglycerides with apheresis (about 70% vs. 50% with conservative treatment within 24 h) and limited data from non-randomized studies show no improvement in clinical outcomes. New evidence is expected soon from ongoing large randomized trials. Until then, insulin may be used in mild HTG-AP and plasma exchange should be considered only in severe HTG-AP, especially if the decline of triglycerides with conservative treatment is slow, and in HTG-AP during pregnancy.

Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.