The incidence and case-fatality rates of acute biliary, alcoholic, and idiopathic pancreatitis in California, 1994-2001

Mortality following acute pancreatitis: social deprivation, hospital size and time of admission: record linkage study

Background

Very little is known about whether mortality following acute pancreatitis may be influenced by the following five factors: social deprivation, week day of admission, recruitment of junior doctors in August each year, European Working Time Directives (EWTDs) for junior doctors’ working hours and hospital size. The aim of this study was to establish how mortality following acute pancreatitis may be influenced by these five factors in a large cohort study.

Methods

Systematic record linkage of inpatient, mortality and primary care data for 10 589 cases of acute pancreatitis in Wales, UK (population 3.0 million), from 1999 to 2010. The main study outcome measure was mortality at 60 days following the date of admission.

Results

Mortality was 6.4% at 60 days. There was no significant variation in mortality according to social deprivation or the week day of admission. There was also no significant variation according to calendar month for acute pancreatitis overall or for gallstone aetiology, but for alcoholic acute pancreatitis, mortality was increased significantly by 93% for admissions during the months of August and September and 102% from August to October when compared with all other calendar months. Mortality was increased significantly for alcoholic aetiology in August 2004, the official month that the first EWTD was implemented, but there were no other increases following the first or second EWTDs. There were also indications of increased mortality in large hospitals when compared with small hospitals, for acute pancreatitis overall and for gallstone aetiology but not for alcoholic acute pancreatitis, although these increases in mortality were of quite marginal significance.

Conclusions

Although we found some evidence of increased mortality for patients admitted with alcoholic acute pancreatitis during August to October, in August 2004, and in large hospitals for acute pancreatitis overall and for gallstone aetiology, the study factors had limited impact on mortality following acute pancreatitis and no significant impact when adjusted for multiple comparisons.

Early phase of acute pancreatitis: Assessment and management

Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.

A population-based assessment of the burden of acute pancreatitis in the United States

OBJECTIVES

The aim of this study is to investigate the incidence and mortality of emergency department (ED) visits in the United States attributed to acute pancreatitis (AP) and quantify predictors of admission and mortality.

METHODS

Using the nationwide ED sample, all ED visits between 2006 and 2009 for AP were extracted. Multivariable analyses were fitted for prediction of admission and mortality.

RESULTS

A weighted sample of 1,224,121 patient visits with AP was captured. Of those, 75.4% resulted in admission and 0.7% died. Between 2006 and 2009, the incidence of AP ED visits increased from 9.9 to 10.6 per 10,000 person-years. Patients were more likely to be admitted if sicker (Charlson Comorbidity Index score ≥ 3; OR, 6.48; P < 0.001) and if the etiology of pancreatitis was alcoholic versus biliary (OR, 2.20; P < 0.001). They were more likely to die if sicker (Charlson Comorbidity Index score ≥ 3; OR, 1.51; P < 0.001) and covered with Medicare or Medicaid versus private insurance (OR, 1.40; P < 0.001 and OR, 1.45; P < 0.001, respectively).

CONCLUSIONS

Emergency department visits for AP represent a significant burden on US health care. Although mortality is lower than previously reported, significant disparities exist in patients presenting with AP with regard to admission and mortality rates. Further investigations are needed to assess these disparities.

Sudden Death and Chronic Alcoholism

Alcohol is a common factor in many deaths. Chronic alcoholics may die suddenly from trauma, intoxication, and from preexisting disease. In many cases, there is no obvious cause of death in chronic alcoholics following initial postmortem examination. Determining the cause of death in chronic alcoholics can be challenging. Such deaths in chronic alcoholics may be due to a number of mechanisms, including alcoholic ketoacidosis and disorders of cardiac rhythm. Alcoholic ketoacidosis has been recognized as a cause of death since the 1990s. It can be diagnosed by postmortem analysis of ketone bodies, including acetone and β-hydroxybutyrate. It has been recognized clinically that patients with alcoholic liver disease have prolongation of the QT interval and a risk of sudden death. This paper reviews sudden natural deaths in chronic alcoholics, discussing pathological processes and mechanisms of death, especially where the cause of death is not obvious on initial autopsy.

A population-based evaluation of readmissions after first hospitalization for acute pancreatitis

OBJECTIVE

This study aimed to evaluate the burden and pattern of pancreatitis-related readmissions after index hospitalization for acute pancreatitis (AP).

METHODS

We identified all unique white or black Allegheny County residents with first hospital admission for AP from 1996 to 2005 using the Pennsylvania Health Care Cost Containment Council data set. The final study population consisted of patients (n = 6010) who survived index admission and had follow-up data on readmissions. The etiology was determined using associated diagnosis codes. We analyzed pancreatitis-related readmissions until the third quarter of 2007 (median follow-up time, 39 months).

RESULTS

The absolute risk and total burden of readmissions were 21.9% and 2947 for primary AP, respectively, 5.8% and 812 for primary chronic pancreatitis (CP), respectively, and 32.3% and 6612 for any pancreatitis diagnosis, respectively. Patients with alcohol etiology (etiology on index admission in 20.3%; responsible for 41.6%-50.4% readmissions) and subsequent diagnosis of CP (any CP diagnosis, 12.8%; responsible for 73% readmissions) accounted for a disproportionately higher fraction of readmissions. Readmission risk decreased with increasing age. A small fraction of patients accounted for most readmissions.

CONCLUSIONS

Readmission after AP is influenced by demographics, etiology, and subsequent CP diagnosis. Future studies should focus on understanding the factors driving readmissions in high-risk individuals to develop strategies for reducing pancreatitis-related readmissions and health care costs.

Duration of injury correlates with necrosis in caerulein-induced experimental acute pancreatitis: implications for pathophysiology

Pancreatic acinar cell necrosis is indicative of severe pancreatitis and the degree of necrosis is an index of its outcome. We studied whether the dose and duration of injury correlates with severity, particularly in terms of necrosis, in caerulein-induced acute pancreatitis (AP) in Swiss albino mice. In addition to control group 1 (G1), groups 2 and 3 received four injections of caerulein every hour but were sacrificed at five hours (G2) and nine hours (G3) respectively, and group 4 received eight injections and was sacrificed at nine hours (G4). The severity of pancreatitis was assessed histopathologically and biochemically. The histopathological scores of pancreatitis in groups 3 and 4 were significantly higher than in groups 1 and 2 (4 vs. 1, 4 vs. 2, 3 vs. 1, 3 vs. 2; P < 0.05). TUNEL-positive apoptotic cells were significantly higher in groups 2 and 3 compared with groups 1 and 4 (P < 0.05). Necrosis was significantly more in group 4 than other groups (37.49% (4.68) vs. 19.97% (1.60) in G2; 20.36% (1.56) in G3; P = 0.006 for G 2 vs. 4 and P = 0.019 for G 3 vs. 4). Electron microscopy revealed numerous autophagosomes in groups 2 and 3 and mitochondrial damage and necrosis in group 4. The pancreatic and pulmonary myeloperoxidase activity in group 4 was significantly higher than that in the other groups (P < 0.01). Hence, severity of pancreatitis is a function of the dose of injurious agent, while inflammation is both dose and duration dependent, which may also explain the wide spectrum of severity of AP seen in clinical practice.

Persistent salmonellosis causes pancreatitis in a murine model of infection

Pancreatitis, a known risk factor for the development of pancreatic ductal adenocarcinoma, is a serious, widespread medical condition usually caused by alcohol abuse or gallstone-mediated ductal obstruction. However, many cases of pancreatitis are of an unknown etiology. Pancreatitis has been linked to bacterial infection, but causality has yet to be established. Here, we found that persistent infection of mice with the bacterial pathogen Salmonella enterica serovar Typhimurium (S. Typhimurium) was sufficient to induce pancreatitis reminiscent of the human disease. Specifically, we found that pancreatitis induced by persistent S. Typhimurium infection was characterized by a loss of pancreatic acinar cells, acinar-to-ductal metaplasia, fibrosis and accumulation of inflammatory cells, including CD11b+ F4/80+, CD11b+ Ly6Cint Ly6G+ and CD11b+ Ly6Chi Ly6G- cells. Furthermore, we found that S. Typhimurium colonized and persisted in the pancreas, associated with pancreatic acinar cells in vivo, and could invade cultured pancreatic acinar cells in vitro. Thus, persistent infection of mice with S. Typhimurium may serve as a useful model for the study of pancreatitis as it relates to bacterial infection. Increased knowledge of how pathogenic bacteria can cause pancreatitis will provide a more integrated picture of the etiology of the disease and could lead to the development of new therapeutic approaches for treatment and prevention of pancreatitis and pancreatic ductal adenocarcinoma.

Serum lipid levels are associated with the severity of acute pancreatitis

BACKGROUND/AIMS

Serum lipid concentrations react during acute disease. We sought to measure changes in the serum lipid profile during acute pancreatitis and ascertain whether these changes were associated with the severity of the disease.

METHODS

A total of 233 patients (71% male, median age 48 years) hospitalized for acute pancreatitis were included in the study. The most common etiology for acute pancreatitis was alcohol (n = 131, 56%), followed by biliary (n = 48, 21%) and idiopathic pancreatitis (n = 36, 16%). Serum lipid levels were measured enzymatically. We analyzed samples obtained during the first days of hospitalization and later follow-up samples to measure changes during the course of the disease.

RESULTS

We report profound changes in the serum lipid concentrations during acute pancreatitis. Serum total cholesterol, high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol concentrations measured within 2 days of admission (n = 203) were significantly lower in patients who developed severe pancreatitis (3.20 vs. 3.80 mmol/l, p = 0.001; 0.72 vs. 1.05 mmol/l, p < 0.000, and 1.60 vs. 2.14 mmol/l, p < 0.000, respectively). Low serum total cholesterol, HDL cholesterol and LDL cholesterol concentrations were moreover associated with in-hospital mortalities and longer hospitalization (p < 0.05). In the subgroup analysis, the findings remained statistically significant in patients with alcohol-induced acute pancreatitis.

CONCLUSION

Levels of serum total cholesterol, HDL cholesterol and LDL cholesterol are significantly lower in patients with severe acute pancreatitis and are associated with longer hospitalization.

Japanese severity score for acute pancreatitis well predicts in-hospital mortality: a nationwide survey of 17,901 cases

BACKGROUND

Early identification of severe cases of acute pancreatitis is necessary to reduce mortality. The Japanese severity score, which consists of nine prognostic factors, is reported to be useful for assessment of acute pancreatitis severity, but has not been validated by large-scale data.

METHODS

Data on adult patients with acute pancreatitis were collected between July 1, 2010, and September 30, 2011, from a national administrative database covering 1,032 Japanese hospitals. In-hospital mortality was analyzed to evaluate the predictive value of the Japanese severity score.

RESULTS

A total of 17,901 patients were included. Total in-hospital mortality was 2.6%, and mortality rates of non-severe and severe acute pancreatitis were 1.1 and 7.0%, respectively (P < 0.001). In multivariate analysis with adjustment for other baseline characteristics, the odds ratio for mortality significantly increased according to an increase in prognostic factor score. The odds ratio for mortality of computed tomography grade 3 was significantly higher than that of grade 1 (P < 0.001), but that of grade 2 was not (P = 0.149). In receiver operating characteristic curve analysis of the prognostic factor score for prediction of in-hospital mortality, the area under the curve was 0.798 (95% confidence interval 0.775-0.821), and the optimum cutoff level of the prognostic factors was 2, in accordance with the definition of the current scoring system.

CONCLUSIONS

The prognostic factor score has good predictive value for in-hospital mortality of acute pancreatitis, and thus is useful for severity assessment of acute pancreatitis at the early stage of hospital admission.

Incretin-mimetics associated pancreatitis: evidence from the spontaneous adverse drug reactions reporting in Italy

OBJECTIVE

New incretin-mimetics increased the treatment options for type 2 diabetes mellitus. Studies on the safety of incretin-based therapy showed a risk of hypersensitivity reactions, acute pancreatitis, renal failure, infection, thyroid and pancreas cancer. We contributed to safety assessment of these new drugs by evaluating the spontaneous adverse drug reactions (ADRs) reporting in Italy.

RESEARCH AND METHODS

Reports of suspected ADRs associated with incretin-mimetics were selected from the Italian Spontaneous ADR Reporting Database. For a subgroup of cases belonging to the Hospital of Cento (Ferrara), levels of pancreatic enzymes, amylase and lipase, before and after the therapy with the incretin-mimetics were available.

RESULTS

As of December 2012, the reports of ADR associated with hypoglycemic drugs (excluding insulin) were 2443, 1169 (47.85%) concerned the incretin-mimetics. A total of 90 reports described pancreatitis (44) and elevated pancreatic enzymes (46). Out of 90 cases, 34 were serious (37%). Data on amylase/lipase values for 10 patients were provided and an analysis of the published literature was performed.

CONCLUSIONS

Our data from the daily clinical practice add up and confirm the information available on the association between incretin-mimetics and pancreatic damage and suggest caution in the prescribing of these new drugs and a close monitoring of exposed patients.

A review of animal models of nonneoplastic pancreatic diseases

The nonneoplastic diseases of the human pancreas generally comprise the inflammatory and degenerative conditions that include acute and chronic pancreatitis, with cystic fibrosis being arguably one of the most important diseases that induce the condition. Both acute and chronic conditions vary in severity, but both can be life threatening; and because of this fact, the study of their progression, and their responsiveness to therapy, is largely conducted by indirect means using serum markers of damage and repair such as amylase and lipase activities that normally occur at very low levels in the circulation but can be significantly increased during inflammatory episodes. Progress in the understanding the pathogenesis of both conditions has therefore been largely due to time course studies in animal models of pancreatitis, and it is in this context that animal model development has been so significant. In general terms, the animal models can be divided into the invasive, surgical procedures, and those induced by the administration of chemical secretagogues that induce hypersecretion of the pancreatic enzymes. The former include ligation and/or cannulation of the biliopancreatic ducts with infusion of solutions of various kinds, or the formation of closed duodenal loops. Secretagogue administration includes administration of caerulein or l-arginine in various protocols. An additional model involves administration of dibutyltin dichloride, which induces a partial blockage of the pancreatic ducts to induce pancreatic disease through enzymic reflux into the gland. The models have been invaluable in generating testable hypotheses for the human diseases. These hypotheses for the production of cellular damage as the initiating events in the disease include (1) intracellular chemical activation, (2) pancreatic secretion reflux, (3) intracellular production of reactive oxygen species, and (4) intracellular production of free radicals.

The incidence of acute pancreatitis: impact of social deprivation, alcohol consumption, seasonal and demographic factors

BACKGROUND

The incidence of acute pancreatitis has increased sharply in many European countries and the USA in recent years.

AIM

To establish trends in incidence and mortality for acute pancreatitis in Wales, UK, and to assess how incidence may be linked to factors including social deprivation, seasonal effects and alcohol consumption.

METHODS

Use of record linked inpatient, mortality and primary care data for 10,589 hospitalised cases of acute pancreatitis between 1999 and 2010.

RESULTS

The incidence of acute pancreatitis was 30.0 per 100,000 population overall, mortality was 6.4% at 60 days. Incidence increased significantly from 27.6 per 100,000 in 1999 to 36.4 in 2010 (average annual increase = 2.7% per year), there was little trend in mortality (0.2% average annual reduction). The largest increases in incidence were among women aged <35 years (7.9% per year) and men aged 35-44 (5.7%) and 45-54 (5.3%). Incidence was 1.9 times higher among the most deprived quintile of patients compared with the most affluent (3.9 times higher for alcoholic acute pancreatitis and 1.5 for gallstone acute pancreatitis). Acute pancreatitis was increased significantly during the Christmas and New Year weeks by 48% (95% CI = 24-77%) for alcoholic aetiology, but not for gallstone aetiology (9%). Alcoholic admissions were increased with higher consumption of spirits and beer, but not wine.

CONCLUSIONS

The study shows an elevated rate of alcoholic acute pancreatitis during the Christmas and New Year period. Acute pancreatitis continues to rise, most rapidly for young women, while alcoholic acute pancreatitis is linked strongly with social deprivation.

Acute pancreatitis: a prospective study on incidence, etiology, and outcome

BACKGROUND AND AIMS

Prospective and population-based studies on the incidence of acute pancreatitis (AP) are lacking. Alcohol consumption has increased considerably in Iceland during the last decade. We aimed to determine the incidence, etiology, severity, and complications of AP and compare the results with a previous study on AP in Iceland.

METHODS

A prospective population-based study of patients diagnosed with AP at the National University Hospital of Iceland during 1 year (2010-2011). Information on symptoms, etiology, and complications was registered.

RESULTS

During the study period, 134 patients were diagnosed with AP, 78 men (58%), median age 57 years (interquartile range 42-71). Overall, 89/104 (86%) patients had their first attack of pancreatitis, yielding a crude incidence of 40/100 000 inhabitants/year. The major etiological groups were as follows: gallstones, 52 cases (42%); alcohol 29, (23%); postendoscopic retrograde cholangio-pancreatography in 12 (9.5%); medications in eight (6.3%); and idiopathic in 15 (12%). Alcohol was more often the cause in men (25 vs. 4, P<0.05) but the incidence of gallstone-induced pancreatitis was similar in men and women (26 vs. 27). Seven patients had severe complications, three had pancreatic necrosis, two had pseudocysts, and one developed renal failure. Another patient developed acute respiratory distress syndrome and was admitted to the ICU. No patient died of AP during the study period.

CONCLUSION

The incidence of AP has not increased significantly in Iceland in the last decade. Alcohol-induced pancreatitis has not increased proportionally despite increased alcohol consumption in Iceland. In a population-based setting, the vast majority of AP is of mild severity.

Effect of obesity and decompressive laparotomy on mortality in acute pancreatitis requiring intensive care unit admission

Background

Controversy still exists on the effect that obesity has on the morbidity and mortality in severe acute pancreatitis (SAP). The primary purpose of this study was to compare the mortality rate of obese versus nonobese patients admitted to the ICU for SAP. Secondary goals were to assess the potential risk factors for abdominal compartment syndrome (ACS) and to investigate the performance of validated scoring systems to predict ACS and in-hospital mortality.

Methods

A retrospective cohort of adults admitted to the ICU for SAP was stratified by their body mass index (BMI) as obese and nonobese. The rates of morbidity, mortality, and ACS were compared by univariate and multivariate regression analyses. Areas under the curve (AUC) were used to evaluate the discriminating performance of severity scores and other selected variables to predict mortality and the risk of ACS.

Result

Forty-five patients satisfied the inclusion criteria and 24 (53 %) were obese with similar characteristics to nonobese patients. Among all the subjects, 11 (24 %) died and 16 (35 %) developed ACS. In-hospital mortality was significantly lower for obese patients (12.5 vs. 38 %; P = 0.046) even though they seemed to develop ACS more frequently (41 vs. 28 %; P = 0.533). At multivariable analysis, age was the most significant factor associated with in-hospital mortality (odds ratio (OR) = 1.273; 95 % confidence interval (CI) 1.052–1.541; P = 0.013) and APACHE II and Glasgow-Imrie for the development of ACS (OR = 1.143; 95 % CI 1.012–1.292; P = 0.032 and OR = 1.221; 95 % CI 1.000–1.493; P = 0.05) respectively. Good discrimination for in-hospital mortality was observed for patients’ age (AUC = 0.846) and number of comorbidities (AUC = 0.801). ACS was not adequately predicted by any of the clinical severity scores (AUC = 0.548–0.661).

Conclusions

Patients’ age was the most significant factor associated with mortality in patients affected by SAP. Higher APACHE II and Glasgow-Imrie scores were associated with the development of ACS, but their discrimination performance was unsatisfactory.

Lack of consensus on the role of endoscopic retrograde cholangiography in acute biliary pancreatitis in published meta-analyses and guidelines: a systematic review

OBJECTIVES

Several randomized controlled trials studied the role of endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy (ES) in acute biliary pancreatitis (ABP). No study assessed whether these trials resulted in international consensus in published meta-analyses and treatment guidelines.

METHODS

A systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, of meta-analyses and guidelines on ERCP in ABP was performed in PubMed until August 2011.The methodological quality of the meta-analysis and guidelines was assessed by a validated quality assessment tool.

RESULTS

Eight meta-analyses and 12 guidelines fulfilled the inclusion criteria. There is consensus that ERCP is indicated in case of ABP with coexistent cholangitis and/or persistent cholestasis. By exception of the first meta-analysis, all included studies disapproved early ERCP in predicted mild ABP. Consensus is lacking regarding the role of early ERCP in predicted severe ABP, as 3 meta-analyses and 1 guideline do not advice this strategy. Routine early ERCP in predicted severe ABP is recommended in 7 of the 11 guidelines.

CONCLUSIONS

There is consensus in guidelines and meta-analyses that ERCP/ES is indicated in patients with ABP and coexisting cholangitis and/or persistent cholestasis. Consensus is lacking on the role of routine early ERCP/ES in patients with predicted severe ABP.

Is alcoholic pancreatitis associated with enteroviral infection?

AIM: To investigate whether enteroviral infection might trigger acute pancreatitis in patients made susceptible due to high alcohol consumption.

METHODS: Patients with alcohol-induced acute pancreatitis were analyzed for signs of simultaneous or preceding enteroviral infection. We studied the serum samples of 40 patients hospitalized for alcohol-induced acute pancreatitis and 40 controls recruited from an alcohol detoxification center. Reverse transcription-polymerase chain reaction (RT-PCR) was used to detect enterovirus RNA and diagnose acute viremia. Immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM) enteroviral antibodies were measured using enzyme immunoassay to detect subacute and previous infections. The samples were considered positive when the antibody titers were ≥ 15 IU. Furthermore, using RT-PCR, we studied pancreatic biopsy samples obtained during surgery from nine patients with chronic pancreatitis, one patient with acute pancreatitis and ten control patients with pancreatic carcinoma for evidence of persisting enteroviral RNA in the pancreatic tissue.

RESULTS: No enterovirus RNA indicating acute viremia was detected by RT-PCR in the serum samples of any patient or control. A high incidence of positive antibody titers was observed in both study groups: IgM antibodies had positive titers in 5/40 (13%) vs 4/40 (10%), P = 0.723; IgG in 15/40 (38%) vs 19/40 (48%), P = 0.366; and IgA in 25/40 (63%) vs 33/40 (83%), P = 0.045, patients and controls, respectively. Ten (25%) patients had severe pancreatitis and two (5%) required treatment in intensive care. The median length of hospitalization was 7 d (range: 3-47 d). The severity of acute pancreatitis or the length of hospitalization was not associated with enteroviral IgM, IgG or IgA antibodies. Five pancreatic biopsy samples tested positive with RT-PCR, three (8%) in the control group and two (5%) in the patient group (P = 0.64).

CONCLUSION: The rate of enteroviral infection is not increased in patients with alcohol-induced acute pancreatitis when compared to alcoholics with similar high alcohol use.

Clinical management of patients with acute pancreatitis

Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. As rates of hospitalization for acute pancreatitis continue to increase, so does demand for effective management. We review approaches to best manage patients with acute pancreatitis, covering diagnosis, risk and prognostic factors, treatment, and complications, considering recommendations from current practice guidelines.

The epidemiology of pancreatitis and pancreatic cancer

Acute pancreatitis is one of the most frequent gastrointestinal causes of hospital admission in the United States. Chronic pancreatitis, although lower in incidence, significantly reduces patients' quality of life. Pancreatic cancer is associated with a high mortality rate and is one of the top 5 causes of death from cancer. The burden of pancreatic disorders is expected to increase over time. The risk and etiology of pancreatitis differ with age and sex, and all pancreatic disorders affect the black population more than any other race. Gallstones are the most common cause of acute pancreatitis, and early cholecystectomy eliminates the risk of future attacks. Alcohol continues to be the single most important risk factor for chronic pancreatitis. Smoking is an independent risk factor for acute and chronic pancreatitis, and its effects could synergize with those of alcohol. Significant risk factors for pancreatic cancer include smoking and non-O blood groups. Alcohol abstinence and smoking cessation can alter the progression of pancreatitis and reduce recurrence; smoking cessation is the most effective strategy to reduce the risk of pancreatic cancer.

Incidence and mortality of acute and chronic pancreatitis in the Netherlands: A nationwide record-linked cohort study for the years 1995-2005

AIM: To analyze trends in incidence and mortality of acute pancreatitis (AP) and chronic pancreatitis (CP) in the Netherlands and for international standard populations.

METHODS: A nationwide cohort is identified through record linkage of hospital data for AP and CP, accumulated from three nationwide Dutch registries: the hospital discharge register, the population register, and the death certificate register. Sex- and age-group specific incidence rates of AP and CP are defined for the period 2000-2005 and mortality rates of AP and CP for the period 1995-2005. Additionally, incidence and mortality rates over time are reported for Dutch and international (European and World Health Organization) standard populations.

RESULTS: Incidence of AP per 100000 persons per year increased between 2000 and 2005 from 13.2 (95%CI: 12.6-13.8) to 14.7 (95%CI: 14.1-15.3). Incidence of AP for males increased from 13.8 (95%CI: 12.9-14.7) to 15.2 (95%CI: 14.3-16.1), for females from 12.7 (95%CI: 11.9-13.5) to 14.2 (95%CI: 13.4-15.1). Irregular patterns over time emerged for CP. Overall mean incidence per 100000 persons per year was 1.77, for males 2.16, and for females 1.4. Mortality for AP fluctuated during 1995-2005 between 6.9 and 11.7 per million persons per year and was almost similar for males and females. Concerning CP, mortality for males fluctuated between 1.1 (95%CI: 0.6-2.3) and 4.0 (95%CI: 2.8-5.8), for females between 0.7 (95%CI: 0.3-1.6) and 2.0 (95%CI: 1.2-3.2). Incidence and mortality of AP and CP increased markedly with age. Standardized rates were lowest for World Health Organization standard population.

CONCLUSION: Incidence of AP steadily increased while incidence of CP fluctuated. Mortality for both AP and CP remained fairly stable. Patient burden and health care costs probably will increase because of an ageing Dutch population.

Extracorporeal life support for pancreatitis-induced acute respiratory distress syndrome

OBJECTIVE

Adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis is associated with a poor prognosis. We hypothesized that extracorporeal life support (ECLS) may be an effective treatment option for the most severe cases of pancreatitis-induced ARDS.

METHODS

We reviewed 8 cases of pancreatitis-induced ARDS that were treated with ECLS at our institution. We collected data on demographics, comorbidities, hemodynamic parameters, and ventilatory support used before ECLS. Our outcome measures for this study included survival to discharge, length of ECLS run, days undergoing mechanical ventilation, days in an intensive care unit, total length of hospital stay, adjunct therapies and procedures, and complications.

RESULTS

Overall, 5 of the 8 patients (63%) survived to discharge. Seven of the 8 patients underwent venovenous ECLS, and 1 underwent venoarterial ECLS. The overall mean length of ECLS was 9.7 ± 10.7 days. However, the mean ECLS run length in survivors was 4.3 ± 1.8 days and the longest ECLS run in a survivor was 7.25 days. Two of the 3 patients who died had very long run lengths (28.8 and 24.7 days, respectively), whereas 1 patient had a short run (2.4 days). Five of the 8 patients (63%), including all of the 3 who died, experienced a bleeding complication of some kind. Two patients required continuous venovenous hemofiltration, 1 of whom died and 1 of whom survived. Six patients underwent tracheostomy on ECLS, 1 patient already had undergone tracheostomy, and 1 patient did not undergo tracheostomy.

CONCLUSIONS

ECLS is useful in treating severe pancreatitis-induced ARDS. Pancreatic debridement can be performed during ECLS, using a comprehensive protocol to minimize bleeding complications.

Outcome assessment in acute pancreatitis patients

Early diagnosis and severity evaluation in patients with acute pancreatitis (AP) are very important due to its potential morbidity and mortality. Several clinical, laboratory, and radiologic factors, and many scoring systems have been proposed for outcome prediction. Although the Ranson and Acute Physiology and Chronic Health Evaluation II scoring systems have been widely used for decades, the cumbersome components partly limit their predictability. Recently, the Bedside Index for Severity in AP scoring system and series blood urea nitrogen changes, which are simple and convenient to evaluate within 24 hours after admission, have been validated for accuracy by several large-cohort studies. The presence of organ failure and systemic inflammatory response syndrome are also helpful to evaluate the severity of AP. Herein we review recent advances of the predictive methods for AP to provide an up-to-date perspective on outcome assessment of AP.

The impact of early goal-directed fluid management on survival in an experimental model of severe acute pancreatitis

PURPOSE

Severe acute pancreatitis (SAP) remains a life-threatening disease with classic etiology of systemic inflammatory response and mortality between 30 and 50 %. The aim of the present study is to compare two different treatment strategies of goal-directed hemodynamic management and evaluate their impact on survival, microcirculation, tissue oxygenation, and histopathologic damage in acute pancreatitis in a prospective animal study.

METHODS

Thirty-four domestic pigs were randomly assigned to two different treatment groups. After induction of acute pancreatitis, in group 1 volume administration was guided by central venous pressure (CVP >12 mmHg) and mean arterial pressure (MAP). In group 2, hemodynamic management was guided primarily by left-ventricular stroke volume variation (SVV <10 %), MAP, and cardiac output (CO). Treatment according to randomization was performed for 6 h, and tissue oxygen tension in the pancreas and pancreatic microcirculation were evaluated. Thereafter, animals were observed for 7 days and then sacrificed. Standardized tissue specimens were taken post mortem, and histopathologic scoring was performed.

RESULTS

Survival after 7 days was 29.4 % in group 2 versus 11.8 % in group 1 (p < 0.05). Pancreatic oxygen tension (138.0 ± 89.5 mmHg versus 71.1 ± 35.3 mmHg; p < 0.05) and pancreatic microcirculation (1,209.9 ± 630 AU versus 732 ± 315 AU; p < 0.05) were significantly higher in group 2. Significantly less histopathologic damage within the pancreas could be analyzed post mortem in group 2.

CONCLUSIONS

Goal-directed hemodynamic management guided by stroke volume variation led to improved survival, tissue oxygenation, and microcirculatory perfusion, as well as less histopathologic damage in an animal model of severe acute pancreatitis.

Medical resource use and costs associated with chylomicronemia

BACKGROUND

The prevalence of severe hypertriglyceridemia (TG > 1000 mg/dl) is estimated at 150-400 per 100,000 individuals in North America. Severe hypertriglyceridemia in the fasting state is associated with increased acute pancreatitis risk and is a sign of chylomicronemia which reflects the accumulation in the bloodstream of chylomicrons, the large lipoprotein particles produced in the gut after a meal.

OBJECTIVE

To assess medical resource use and costs associated with chylomicronemia.

METHODS

Patients with chylomicronemia of different causes (≥2 diagnoses with ICD-9 code 272.3) were identified from a large US claims database (years 2000 to 2009) and matched 1:1 to controls free of chylomicronemia based on age, gender, demographics, comorbidities, and use of lipid lowering drugs. During a 1-year study period, medical resource use and costs associated with chylomicronemia or acute pancreatitis were compared between matched cases and controls.

RESULTS

Among 6472 matched pairs, annual per-patient medical costs, calculated independently of the occurrence of acute pancreatitis, were significantly greater by $808 for chylomicronemia cases vs controls ($8029 vs $7220, p < 0.01), half of which was attributable to chylomicronemia-related services (p < 0.01). Chylomicronemia cases with a history of acute pancreatitis (n = 46) had greater rates of inpatient visits (p < 0.05) and greater average costs for subsequent acute pancreatitis or abdominal pain (p < 0.01) as well as greater total medical costs ($33,587 vs $4402, p < 0.01) vs matched controls. The average episode of acute pancreatitis (n = 104 episodes) generated medical costs of $31,820, almost entirely due to inpatient stays.

LIMITATIONS

Triglyceride levels were not available to characterize disease severity.

CONCLUSIONS

Patients with chylomicronemia, and especially those with a history of acute pancreatitis, incurred significantly greater total medical costs compared with individuals without chylomicronemia but with an otherwise comparable health profile.

The epidemiology of idiopathic acute pancreatitis, analysis of the nationwide inpatient sample from 1998 to 2007

OBJECTIVE

The study aimed to better define the epidemiology of idiopathic acute pancreatitis (IAP).

METHODS

We identified admissions with primary diagnosis of acute pancreatitis (AP) in Nationwide Inpatient Sample between 1998 and 2007. Idiopathic AP was defined as all cases after excluding International Classification of Diseases, Ninth Revision, codes for other causes of AP (including biliary, alcoholic, trauma, iatrogenic, hyperparathyroidism, hyperlipidemia, etc).

RESULTS

Among the primary admissions for AP, 26.9% had biliary pancreatitis, 25.1% alcoholic, and 36.5% idiopathic. Idiopathic AP had estimated 81,8025 admissions with a mean hospitalization of 5.6 days. Patients with IAP accounted for almost half of the fatalities among the cases of AP (48.2%) and had a higher mortality rate than both patients with biliary pancreatitis and patients with alcoholic pancreatitis (1.9%, 1.5%, and 1.0%, respectively, P < 0.01). Forty-six percent of patients with biliary pancreatitis underwent cholecystectomy during the index hospitalization, compared with 0.42% of patients with IAP. Patients with IAP had a demographic distribution similar to that of patients with biliary AP (female predominant and older), which was distinct from patients with alcoholic pancreatitis (male predominant and younger). There was a gradual but steady decrease in the incidence of IAP, from 41% in 1998 to 30% in 2007.

CONCLUSIONS

Despite improving diagnostics, IAP remains a common clinical problem with a significant mortality. Standardization of the clinical management of these patients warrants further investigation.

Canadian Digestive Health Foundation Public Impact Series 5: Pancreatitis in Canada. Incidence, prevalence, and direct and indirect economic impact

The Canadian Digestive Health Foundation initiated a scientific program to assess the incidence, prevalence, mortality and economic impact of digestive disorders across Canada in 2009. The current article presents the updated findings from the study concerning pancreatitis.

Age-dependent vulnerability to experimental acute pancreatitis is associated with increased systemic inflammation and thrombosis

The severity and mortality rates of acute pancreatitis (AP) are significantly elevated in the elderly population. However, due to a lack of appropriate animal models, the underlying mechanisms for this age-dependent vulnerability remain largely unknown. The purpose of this study was to characterize a murine model of AP, which displays age-associated severity, and to use this model to identify pathophysiologies that are distinctive of the aged with AP. AP was induced in young (4-5 months), middle-aged (12-13 months), and aged (23-25 months) C57BL/6 mice by repeated injection of caerulein, a homologue of the gastrointestinal hormone cholecystokinin. Approximately 10% of aged mice died during AP, while young and middle-aged mice showed no mortality. Although both young and aged mice exhibited early signs of edema and inflammation in the pancreas, kidney, and lung, young mice showed signs of recovery within 24 h, while aged mice exhibited increasingly severe tissue damage and cell death. There was a significant age-dependent increase in pancreatic neutrophil activation and systemic inflammation as assessed by pancreatic myeloperoxidase and plasma interleukin-6 (IL-6) concentration, respectively. Importantly, aged but not young mice with AP showed significantly elevated thrombosis in the lung and kidney as well as a marked increase in plasma concentration of plasminogen activator inhibitor-1 (PAI-1), a primary inhibitor of the fibrinolytic system. These results demonstrate that aging is associated with increased severity of AP characterized by augmented and prolonged pancreatic inflammation and the presence of multiple extra-pancreatic sequelae including thrombosis.

[Clinical characteristics of acute pancreatitis in Mexico]

BACKGROUND

Acute pancreatitis (AP) etiology and frequency vary in relation to geographic region.

AIMS

To determine the etiology, frequency, and mortality of AP in a Mexican population.

PATIENTS AND METHODS

We carried out a prospective study of first episode AP patients over a period of 6 years.

RESULTS

A total of 605 patients with a mean age of 40 years were included in the study. Sixty-four percent of them presented with overweight and/or obesity determined through BMI. Etiology was biliary in 66.60%, it was due to alcohol consumption in 15.90%, hypertriglyceridemia in 7.80%, it was post-endoscopic retrograde cholangiopancreatography (ERCP) in 2.10%, and was undetermined in 7.20%. Pancreatic infection was suspected in 70 patients and they underwent CT-guided fine needle aspiration. Thirty-two of those patients were diagnosed with pancreatic infection in which Staphylococcus spp was the most common microorganism. Overall mortality was 5.00% (2.60% < 30 years and 10.00% > 70 years). Necrosis, pancreatic infection, and mortality were more frequent in the cases in which etiology was due to alcohol ingestion.

CONCLUSIONS

The most frequent AP etiology was biliary, but that caused by alcohol presented with more complications. Overall mortality was 5.00% and was higher in the elderly patients.

Risk of development of acute pancreatitis with pre-existing diabetes: a meta-analysis

OBJECTIVES

It is well established that acute pancreatitis (AP) often causes diabetes mellitus. However, whether pre-existing diabetes is associated with the development of AP remains unknown. To clarify the association of pre-existing diabetes and the development of AP, we carried out a meta-analysis of observational studies.

METHODS

A computerized literature search was performed in MEDLINE (from 1 January 1966) and EMBASE (from 1 January 1974), through 31 January 2012. We also searched the reference lists of relevant articles. Summary relative risks with their corresponding 95% confidence intervals (CIs) were calculated using a random-effects model. Between-study heterogeneity was assessed using Cochran's Q statistic and the I 2.

RESULTS

A total of seven articles (10 523 incident cases of AP) were included in this meta-analysis. Analysis of seven studies indicated that, compared with nondiabetic individuals, diabetic individuals had a 92% increased risk of development of AP (95% CI 1.50-2.47). There was significant evidence of heterogeneity among these studies (P heterogeneity<0.001, I 2=93.0%). These increased risks were independent of alcohol use, gallstones, and hyperlipidemia.

CONCLUSION

Although the current evidence supports a positive link between pre-existing diabetes and an increased risk of development of AP, additional studies, with a perfect design, are required before definitive conclusions can be drawn.

Liraglutide: a review of its use in the management of type 2 diabetes mellitus

Liraglutide (Victoza®) is a subcutaneously administered glucagon-like peptide-1 (GLP-1) receptor agonist produced by recombinant DNA technology and used as an adjunct to diet and exercise in the treatment of adults with type 2 diabetes mellitus. This article reviews the clinical efficacy and tolerability of liraglutide in adults with type 2 diabetes, and provides a summary of its pharmacological properties. Recently published pharmacoeconomic studies of liraglutide are also reviewed. Administered subcutaneously, liraglutide (usually 1.2 or 1.8 mg once daily) generally produced greater improvements in glycaemic control than active comparators or placebo when administered as monotherapy or in combination with one or two oral antidiabetic drugs (OADs) to adults with type 2 diabetes in numerous randomized, controlled phase III trials. These included six trials in the LEAD trial programme that was designed to evaluate the efficacy and safety of liraglutide across a continuum of antihyperglycaemic management for patients with type 2 diabetes. Liraglutide was generally well tolerated, with a low risk of hypoglycaemia evident, in the phase III trials. The most common adverse events were gastrointestinal and included nausea and diarrhoea; most events were mild to moderate in severity and decreased in incidence over time. In conclusion, liraglutide has an important place in the management of adults with type 2 diabetes across a continuum of care. As well as providing effective glycaemic control, liraglutide improves pancreatic β-cell function and leads to bodyweight loss, thereby addressing some of the unmet needs of patients treated with traditional OADs.

Natural history following the first attack of acute pancreatitis

OBJECTIVES

Data on natural history following a sentinel attack of acute pancreatitis (AP) are limited. The objective of this study was to determine the risk of recurrent AP (RAP) and subsequent chronic pancreatitis (CP) diagnosis after the first attack of AP.

METHODS

Using the Pennsylvania Health Care Cost Containment Council (PHC4) data set, we identified all unique White and Black Allegheny County residents who received a first-time primary inpatient discharge diagnosis of AP from 1996 through 2005. AP etiology was determined using associated diagnoses codes. We also checked whether any of these patients were readmitted for AP and/or received inpatient CP diagnosis until third quarter of 2007.

RESULTS

In all, 7,456 unique residents (mean age 58±20 years, 45% male, 80% White) with incident AP admission were identified. Common etiologies included biliary (28%), alcohol (19%), and idiopathic (36%). Compared with other causes, alcoholic AP patients were significantly younger and more likely to be male and Black. Among survivors (98.1%) and those without pancreatic cancer, follow-up (median 40 months, interquartile range 18, 69) was available for 84% of patients. Readmission for primary or any AP was recorded for 22 and 29%; subsequent primary or any CP diagnosis was assigned to 6 and 12.8%, respectively. Significant independent predictors for RAP were alcohol etiology and tobacco abuse and for CP were RAP and tobacco abuse. RAP risk in biliary AP increased with the duration between AP and cholecystectomy.

CONCLUSIONS

Readmissions following a sentinel attack of AP are common. Progression to CP is infrequent and usually occurs in the setting of RAP, alcohol, and smoking. Cholectstectomy should be considered as soon as feasible after an attack of biliary AP. Natural history of CP may be altered through early behavioral intervention.

Epidemiology of first-attack acute pancreatitis in Taiwan from 2000 through 2009: a nationwide population-based study

OBJECTIVES

This study aimed to describe a 10-year epidemiological trend of patients with first-attack acute pancreatitis (AP) in Taiwan.

METHODS

We analyzed 107,349 patients with first-attack AP from the Taiwan National Health Insurance Research Database between 2000 and 2009. Severe cases were defined according to a modified Atlanta classification. Incidence rates were standardized by direct method.

RESULTS

During the study period, the median age of the patients increased from 49 to 55 years and the proportion of men decreased from 66.8% to 62.3%. The averaged annual incidence of first-attack AP was estimated at 36.9 per 100,000 persons and changed only slightly. Stratified analyses showed that the incidence increased in children (<15 years), elderly people (≥ 65 years), and patients with biliary cause, but decreased in young to middle-aged men (15-64 years). The prevalence of severe cases increased from 21.0% to 22.3%, which was mainly caused by an increase of acute organ dysfunction (from 9.7% to 14.1%). Despite that, hospital mortality decreased from 4.3% to 3.3% for all cases and from 18.5% to 13.3% for severe ones.

CONCLUSIONS

The overall incidence of first-attack AP changed slightly in Taiwan, which differs from the increasing trend observed in most Western countries. Although more patients had severe attacks in recent years, hospital mortality declined.

Analyses of hospital administrative data that use diagnosis codes overestimate the cases of acute pancreatitis

BACKGROUND & AIMS

Although widely used, little information exists on the validity of using hospital administrative data to code acute pancreatitis (AP). We sought to determine if discharge diagnosis codes accurately identify patients whose clinical course met the standard for AP diagnosis.

METHODS

We analyzed data from 401 unique patients admitted through the emergency department who received a primary inpatient discharge diagnosis of AP at 2 University of Pittsburgh Medical Center hospitals in the years 2000, 2002, and 2005. Each patient was matched with a control patient who was admitted with abdominal pain and then discharged without a diagnosis of AP. Patients were matched based on demographics, testing for serum levels of pancreatic enzymes, year of visit to the emergency department, admission to the intensive care unit, and performance of abdominal computed tomography scan. The standard used to diagnose AP was the presence of 2 of 3 features (abdominal pain, ≥ 3-fold increase in serum levels of pancreatic enzymes, and positive results from imaging analysis).

RESULTS

The median age of AP cases was 53 years (interquartile range, 41.5-67 years); 47.1% were male, 85% were white. The most common etiologies were biliary (33.4%), alcohol-associated (16.2%), and idiopathic (24.2%). Serum levels of pancreatic enzymes were increased by any amount, and by ≥ 3-fold, in 95.3% and 68.6% of patients diagnosed with AP and in 16.2% and 2.2% of controls, respectively. The standard for diagnosis of AP was met in 80% of cases diagnosed with this disorder; they had no history of pancreatitis. The sensitivity, specificity, and positive and negative predictive values of the AP diagnosis code were 96%, 85%, 80%, and 98%, respectively.

CONCLUSIONS

Approximately 1 of 5 patients diagnosed with AP upon discharge from the hospital do not meet the guidelines for diagnosis of this disorder. Efforts should be made to more consistently use guidelines for AP diagnosis.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis

BACKGROUND

The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis remains controversial. A number of clinical trials and meta-analyses have provided conflicting evidence.

OBJECTIVES

To systematically review evidence from randomized controlled trials (RCTs) assessing the clinical effectiveness and safety of the early routine ERCP strategy compared to the early conservative management with or without selective use of ERCP strategy, based on all important, clinically relevant and standardized outcomes including mortality, local and systemic complications as defined by the Atlanta Classification (Bradley 1993) and by authors of the primary study, and ERCP-related complications in unselected patients with acute gallstone pancreatitis.

SEARCH METHODS

We searched the CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and LILACS databases and major conference proceedings up to January 2012, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions.

SELECTION CRITERIA

RCTs comparing the early routine ERCP strategy versus the early conservative management with or without selective use of ERCP strategy in patients with suspected acute gallstone pancreatitis. We included studies in which the population with acute gallstone pancreatitis was a subgroup within a larger group of patients. We only included studies involving only a selected subgroup of patients with acute gallstone pancreatitis (actual severe pancreatitis) in subgroup analyses.

DATA COLLECTION AND ANALYSIS

Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test and I² statistic. To explore sources of heterogeneity, we conducted a priori subgroup analyses according to predicted severity of pancreatitis, cholangitis, biliary obstruction, time to ERCP in routine ERCP strategy, use of selective ERCP in conservative management strategy, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed versus random-effects), and per-protocol analysis. We performed influence analysis by exclusion of each study.

MAIN RESULTS

Five RCTs comprising 644 participants were included in the main analyses. Two additional RCTs, comprising only patients with actual severe acute gallstone pancreatitis, were included only in subgroup analyses. There was statistical heterogeneity among trials for mortality, but not for other outcomes. In unselected patients with acute gallstone pancreatitis, there were no statistically significant differences between the two strategies in mortality (RR 0.74, 95% CI 0.18 to 3.03), local and systemic complications as defined by the Atlanta Classification (RR 0.86, 95% CI 0.52 to 1.43; and RR 0.59, 95% CI 0.31 to 1.11 respectively) and by authors of the primary study (RR 0.80, 95% CI 0.51 to 1.26; and RR 0.76, 95% CI 0.53 to 1.09 respectively). The results were robust to sensitivity and influence analyses except for systemic complications as defined by the Atlanta Classification. There was no evidence to suggest that the results were dependent on predicted severity of pancreatitis. Among trials that included patients with cholangitis, the early routine ERCP strategy significantly reduced mortality (RR 0.20, 95% CI 0.06 to 0.68), local and systemic complications as defined by the Atlanta Classification (RR 0.45, 95% CI 0.20 to 0.99; and RR 0.37, 95% CI 0.18 to 0.78 respectively) and by authors of the primary study (RR 0.50, 95% CI 0.29 to 0.87; and RR 0.41, 95% CI 0.21 to 0.82 respectively). Among trials that included patients with biliary obstruction, the early routine ERCP strategy was associated with a significant reduction in local complications as defined by authors of the primary study (RR 0.54, 95% CI 0.32 to 0.91), and a non-significant trend towards reduction of local and systemic complications as defined by the Atlanta Classification (RR 0.53, 95% CI 0.26 to 1.07; and RR 0.56, 95% CI 0.30 to 1.02 respectively) and systemic complications as defined by authors of the primary study (RR 0.59, 95% CI 0.35 to 1.01). ERCP complications were infrequent.

AUTHORS' CONCLUSIONS

In patients with acute gallstone pancreatitis, there is no evidence that early routine ERCP significantly affects mortality, and local or systemic complications of pancreatitis, regardless of predicted severity. Our results, however, provide support for current recommendations that early ERCP should be considered in patients with co-existing cholangitis or biliary obstruction.

Retrospective study of patients with acute pancreatitis: is serum amylase still required?

OBJECTIVES

To assess the role of serum amylase and lipase in the diagnosis of acute pancreatitis. Secondary aims were to perform a cost analysis of these enzyme assays in patients admitted to the surgical admissions unit.

DESIGN

Cohort study.

SETTING

Secondary care.

PARTICIPANTS

Patients admitted with pancreatitis to the acute surgical admissions unit from January to December 2010 were included in the study.

METHODS

Data collated included demographics, laboratory results and aetiology. The cost of measuring a single enzyme assay was £0.69 and both assays were £0.99.

RESULTS

Of the 151 patients included, 117 patients had acute pancreatitis with gallstones (n=51) as the most common cause. The majority of patients with acute pancreatitis had raised levels of both amylase and lipase. Raised lipase levels only were observed in additional 12% and 23% of patients with gallstone-induced and alcohol-induced pancreatitis, respectively. Overall, raised lipase levels were seen in between 95% and 100% of patients depending on aetiology. Sensitivity and specificity of lipase in the diagnosis of acute pancreatitis was 96.6% and 99.4%, respectively. In contrast, the sensitivity and specificity of amylase in diagnosing acute pancreatitis were 78.6% and 99.1%, respectively. Single lipase assay in all patients presenting with abdominal pain to the surgical admission unit would result in a potential saving of £893.70/year.

CONCLUSIONS

Determining serum lipase level alone is sufficient to diagnose acute pancreatitis and substantial savings can be made if measured alone.

Hospitalizations for chronic pancreatitis in Allegheny County, Pennsylvania, USA

BACKGROUND/AIMS

Population-based estimates for chronic pancreatitis (CP) are scarce. We determined incident CP hospitalization rates and the risk of pancreatitis-related readmissions in Allegheny County, Pennsylvania, USA.

METHODS

We used Pennsylvania Health Care Cost Containment Council (PHC4) dataset to identify all unique White and Black Allegheny County residents with incident hospitalization for CP from years 1996-2005. We noted presence of alcoholism codes (from one year before index hospitalization until last contact) and pancreatitis-related readmissions until the third quarter of 2007. Age-, sex-, and race-adjusted (to US 2000 population) rates/100,000 were calculated.

RESULTS

988 unique County residents with incident hospitalization for CP were identified. Of these, 37.6% also received alcoholism codes. Overall hospitalization rate was 7.75/100,000 (95% CI 7.26-8.24), which remained stable throughout the study period. Patients with alcoholism codes were significantly younger (47.2 vs. 58.0 years), more likely to be male (71.4 vs. 36.6%), and Black (38.5 vs. 17.7%). Hospitalization rates were significantly higher (2.4-fold) in Blacks (vs. Whites), particularly for those with alcoholism codes. During follow-up (median 45 months), pancreatitis-related readmissions were common, significantly more so for patients with alcoholism codes.

CONCLUSIONS

CP hospitalization rates over a one-decade period were stable. Readmissions were highest among patients with a diagnosis of alcoholism. and IAP.

An assessment of the severity of interstitial pancreatitis

BACKGROUND & AIMS

There is limited information on the incidence of and factors associated with severe disease among patients with interstitial pancreatitis (IP). We evaluated a large cohort of patients with IP and compared data with those from patients with extrapancreatic necrosis (EXPN).

METHODS

We evaluated 149 consecutive patients with IP admitted over a 2.5-year period. Transferred patients were excluded. We collected data on age, Charlson comorbidity score (CCI), measures of severity on admission or within 24 hours (Acute Physiology and Chronic Health Evaluation II, bedside index for severity of acute pancreatitis scores), persistent (>48 h) systemic inflammatory response syndrome, persistent organ failure, need for intensive care unit, length of hospital stay (in days), and mortality. We also analyzed levels of severity among those with IP and EXPN. Statistical analysis was performed using SAS version 9.1 (Cary, NC).

RESULTS

Among the patients with IP, the median CCI score was 1, the median Acute Physiology and Chronic Health Evaluation II score was 7, and the median bedside index for severity of acute pancreatitis score was 1. In addition, the median length of hospital stay was only 4 days; only 1% had persistent organ failure and only 1% to 2% required intervention. The mortality rate of IP was 3%; it was associated significantly with comorbidity (the median CCI scores of nonsurvivors and survivors was 4 and 1, respectively, P = .003). Patients with EXPN had greater levels of disease severity, compared with patients with IP.

CONCLUSIONS

IP is severe in only 1% to 3% of patients; mortality of IP is associated strongly with comorbidity. EXPN is more frequently severe than IP; EXPN must be distinguished from IP in clinical studies.

Incidence of acute pancreatitis does not increase during Oktoberfest, but is higher than previously described in Germany

BACKGROUND & AIMS

Increased alcohol consumption can lead to acute pancreatitis (AP). We investigated whether the incidence of alcohol-induced AP increased during the Munich Oktoberfest in 2008, at which 6.6 million liters of beer were sold within 16 days.

METHODS

We performed a multicenter, prospective study of 188 patients with AP (36.7% alcohol-induced, 34.6% biliary), treated at 27 hospitals in the greater area of Munich, Germany (2,970,000 inhabitants) during the 2008 Oktoberfest. Data were compared with that from two 18-day control periods.

RESULTS

During the Oktoberfest, the overall incidence of AP was 42.8/100,000 person-years, which is 117% higher than previously reported. The incidence of acute attacks of alcoholic pancreatitis (AAP) did not increase during the Oktoberfest, compared with control periods. AAP was independently associated with repeated episodes of AP (P = .001), high levels of chronic alcohol intake (P = .001), low body-mass index (P = .007), male gender (P = .033), and acute alcohol excess (P = .037). Biliary AP was associated with increased levels of alanine-aminotransferase and aspartate-aminotransferase (P = .003), old age (P = .014), and low levels of chronic alcohol intake (P = .032). Death (5/188 patients) was associated with baseline levels of blood urea nitrogen, receiver operating characteristic-area under the curve (ROC-AUC = 0.918), alkaline phosphatase (ROC-AUC = 0.861), and C-reactive protein (ROC-AUC = 0.855).

CONCLUSIONS

The incidence of AP does not increase during the Oktoberfest, compared with other time periods; the incidence of AP in Munich is higher than previously described in Germany. AAP was associated with long-term, heavy alcohol exposure rather than short-term, excessive alcohol drinking. Levels of blood urea nitrogen were associated with mortality.

Risk of acute pancreatitis in type 2 diabetes and risk reduction on anti-diabetic drugs: a population-based cohort study in Taiwan

OBJECTIVES

The objective of this study was to assess the risk of acute pancreatitis among patients with type 2 diabetes mellitus (DM) and identify the roles of co-morbidities and anti-diabetic drugs.

METHODS

From claims data of one million enrollees randomly sampled from a population covered by the Taiwan National Health Insurance, 19,518 adults with type 2 DM diagnosed between 2000 and 2005 were identified. In addition, 78,072 DM-free persons, frequency matched with sex, age, and index year for comparison were identified. Subjects were followed up until the end of 2008 or censored to ascertain incident acute pancreatitis cases and associations with co-morbidities and anti-diabetic drugs.

RESULTS

Patients with type 2 DM had 1.95-fold greater incidence of acute pancreatitis compared with non-diabetics (27.7 vs. 14.2 per 10,000 person-years), with an adjusted hazard ratio (HR) of 1.89 (95% confidence interval (CI)=1.65-2.18) based on multivariable Cox regression analysis. Additive Poisson regression analysis revealed an absolute risk increase of 14.4 per 10,000 person-years (95% CI=13.4-15.5) among type 2 DM patients. Co-morbid alcoholism, hepatitis C infection, and gallstones yielded additional risk of acute pancreatitis among type 2 DM patients (absolute risk increase ranges 86.3, 41.1, and 23.5 per 10,000 person-years, respectively). Patients taking anti-diabetic drugs had a reduced risk of acute pancreatitis, however. The adjusted HR decreased to 0.31 (95% CI=0.18-0.56) among patients who took five different anti-diabetic drugs.

CONCLUSIONS

Patients with type 2 DM are at an elevated risk of acute pancreatitis. Alcoholism, hepatitis C infection, and gallstones increase the risk further. However, anti-diabetic drugs reduce the risk as the number of drugs used increases and as the duration of treatment increases.

Decreased mortality in acute pancreatitis related to early aggressive hydration

OBJECTIVE

Early aggressive intravenous hydration is believed to prevent morbidity and mortality by preventing intravascular volume depletion and maintaining perfusion of the pancreas possibly preventing pancreatic necrosis. The following study was initiated to determine the relationship between the observed decrease in mortality and the role of early aggressive hydration.

METHODS

A consecutive series of patients with acute pancreatitis from a single community hospital in 1998 were compared to a consecutive series of patients with acute pancreatitis from the same institution in 2008.

RESULTS

Significantly more patients developed pancreatic necrosis; 26 (15%) of 173 patients in 1998 compared to 4 (4%) of 113 patients in 2008. The mean rate of hydration was significantly higher in 2008 compared with that in 1998 (P = 0.02). In 1998, hydration was provided at 184 mL/h during the first 6 hours and 188 mL/h during the first 12 hours compared with 284 mL/h during the first 6 hours and 221 mL/h during the first 12 hours in 2008. There was a significant decrease in mortality in 2008 compared with that in 1998 (3.5% vs 12%, P = 0.03).

CONCLUSIONS

The decrease in mortality seen in patients with acute pancreatitis during the last decade may be related to the increased aggressive hydration preventing pancreatic necrosis.

Relationship of serum pancreatic enzyme testing trends with the diagnosis of acute pancreatitis

OBJECTIVE

The reasons for increasing incidence of acute pancreatitis (AP) are not completely understood. We hypothesized that the rate of serum pancreatic enzyme (PE) testing is increasing, and it correlates with AP diagnosis.

METHODS

We retrieved electronic patient data for all emergency department visits at 2 University of Pittsburgh Medical Center hospitals (UPMC Presbyterian [PUH] from 1996 to 2005, N = 422,745; UPMC St Margaret Hospital [SMH] from 1999 to 2005, N = 202,171). We evaluated the trends for serum PE testing (amylase, lipase, or both) and correlated this with the proportion of visits resulting in an inpatient discharge diagnosis of AP.

RESULTS

Serum PE testing increased significantly from 4.6% (95% CI, 4.4-4.9) in 1996 to 9.5% (95% CI, 9.3-9.7) in 2005. On multivariate modeling, the rates for serum PE testing were higher at SMH (vs PUH: OR, 1.53; 95% CI, 1.50-1.57), among females (vs males: OR, 1.30 [95% CI, 1.28-1.33]), and increased with age (OR, 1.06 [95% CI, 1.05-1.06] for each 10 years). The proportion of ED visits resulting in an inpatient discharge diagnosis of AP increased significantly during the study period and correlated highly with the rate of PE testing.

CONCLUSIONS

The rate of serum PE testing is increasing. Increased serum PE testing may be contributing to the increase in the incidence of AP.

Alcoholic acute pancreatitis: pathogenesis and clinical characteristics

Animal and clinical studies have shown that alcohol and its metabolic products, endotoxin, viral infection, drinking pattern, smoking, obesity, genetic variability, and gene polymorphisms were very important in the pathogenesis of alcoholic acute pancreatitis (AAP). The morbidity of AAP has been increased in the past decade, and male gender is strongly associated with increased risk of AAP. The mortality of AAP is high, while the quality of life of survivors of severe AAP is low. In this paper, we review the pathogenesis and clinical characteristics of AAP.