Clinical practice guideline: management of acute pancreatitis

Morbidity and Mortality Trends of Pancreatitis: An Observational Study

Background: Pancreatitis accounts for more than $2.5 billion of healthcare costs and remains the most common gastrointestinal (GI) admission. Few contemporary studies have assessed temporal trends of incidence, complications, management, and outcomes for acute pancreatitis in hospitalized patients at the national level. Methods: We used data from one of the largest hospital-based databases available in the United States, the Healthcare Cost and Utilization Project's (HCUP) State Inpatient Database, from 10 states between 2008 and 2015. We included patients with a diagnosis of acute pancreatitis (ICD-9 CM 577.0). Patient- and hospital-level data were used to estimate incidence and inpatient mortality rates. Results: From 80,736,256 hospitalizations, 929,914 (1.15%) cases of acute pancreatitis were identified, 186,226 (20.2%) of which were caused by gallbladder disease). The median age was 53 years (interquartile range [IQR], 41-67) and 50.8% were men. In-hospital mortality was 2.5% and crude mortality rates declined from 2.9% to 2.0% over the study period. Admission year remained significant after adjusting for patient demographics and comorbidities (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.89-0.90; p < 0.001). Gallbladder disease was associated with decreased odds of mortality (OR, 0.60; 95% CI, 0.57-0.62). Median length of stay was four days (IQR, 2-7) and decreased over time. The rates of surgical and endoscopic interventions were highest in 2011 (peak incidence of 16.1% and 9.5%, respectively) and have been decreasing since. Surgical providers were, on average, more likely than medical providers to perform surgery in both those with and without gallbladder disease etiology (gallbladder disease OR, 7.11; 95% CI, 5.46-9.25; non-gallbladder disease OR, 20.50; 95% CI, 16.81-25.01), endoscopy (gallbladder disease OR, 1.22; 95% CI, 0.87-1.72; non-gallbladder disease OR, 1.60; 95% CI, 1.18-2.16), or both (gallbladder disease OR, 7.00; 95% CI, 5.22-9.37; non-gallbladder disease OR, 8.85; 95% CI, 5.61-13.96). Conclusions: The incidence of pancreatitis, from 2008 to 2015, has increased whereas inpatient mortality (i.e., case fatality) has decreased. Understanding temporal trends in outcomes and management along with provider, hospital, and regional variation can better identify areas for future research and collaboration in managing these patients.

A Case of Carbamazepine-Induced Acute Pancreatitis: A Rare Etiology

Carbamazepine-induced acute pancreatitis is rarely reported in the literature. A 49-year-old female presented with sudden onset of severe epigastric pain radiating to the back for the last five hours associated with nausea and two episodes of vomiting. She had been taking carbamazepine for trigeminal neuralgia for the last four weeks. On clinical examination, she was afebrile and had mild tenderness in the epigastrium. Serum chemistry revealed elevated levels of amylase, lipase, and total bilirubin. Her lipid profile was normal, and her abdominal ultrasonography was non-significant. Her abdominal CT revealed generalized pancreatic enlargement with imprecise borders and stranding edema of peripancreatic fat. A possible relationship between carbamazepine and acute pancreatitis was considered due to a lack of other possible causes. Carbamazepine was withdrawn and replaced by oxcarbazepine, and she was managed with bowel rest, isotonic fluids, antiemetics, and analgesics. Her condition improved gradually, and she was symptom-free on day six. She was discharged to her gastroenterology doctor for a follow-up. On her recent visit two weeks later, she was doing well.

Rare Complication of Necrotizing Pancreatitis: Extension of Retroperitoneal Abscess into Femoral Region

Distant abscesses are uncommon during the episode of acute pancreatitis (AP). However, these are possible sequalae of necrotizing pancreatitis and should be treated appropriately to prevent serious septic complications. We demonstrate a case of a 56-year-old male patient who presented with severe necrotizing pancreatitis and distant retroperitoneal abscess that reached femoral region and was detected on diagnostic imaging scans. Combination of surgical and supportive therapy was employed, and the patient recovered well with no permanent consequences. Our article highlights the importance of quick and accurate diagnosis and timely intervention in this rare type of pancreatitis complication.

Using a multidisciplinary team for the staged management and optimally minimally invasive treatment of severe acute pancreatitis

Severe acute pancreatitis (SAP) is a common critical disease with a high mortality rate that involves a complex, rapid change in condition and multiple organ systems. Therefore, a multidisciplinary team (MDT), including staff from the emergency department, intensive care unit, pancreatic surgery, gastroenterology , and imaging, is necessary for the early diagnosis, evaluation, and treatment of patients with SAP. This involves managing the systemic inflammatory response and maintaining organ function in the early stage and managing systemic infection and treatment of peripancreatic complications in the middle-to-late stages. The MDT should be led by departments corresponding to the clinical characteristics of each stage, and those departments should be responsible for the coordination and implementation of treatment by other relevant departments. In the late stage, pancreatic surgery and gastroenterology are the main departments that should manage peripancreatic complications. In line with the principle of minimally invasive treatment, the timely and reasonable selection of endoscopic or minimally invasive surgical debridement can achieve good therapeutic outcomes. Open surgery is also an effective method for treating an intractable massive hemorrhage in the abdominal cavity or necrotic cavity, intractable abdominal compartment syndrome, visceral perforation, and fistulae.

Mesenchymal stromal cell therapy for pancreatitis: Progress and challenges

Pancreatitis is a common gastrointestinal disease with no effective therapeutic options, particularly for cases of severe acute and chronic pancreatitis (CP). Mesenchymal stromal cells (MSCs) are multipotent cells with diverse biological properties, including directional migration, paracrine, immunosuppressive, and antiinflammatory effects, which are considered an ideal candidate cell type for repairing tissue damage caused by various pathogenies. Several researchers have reported significant therapeutic efficacy of MSCs in animal models of acute and CP. However, the specific underlying mechanisms are yet to be clarified and clinical application of MSCs as pancreatitis therapy has rarely been reported. This review mainly focuses on the potential and challenges in clinical application of MSCs for treatment of acute and CP, along with discussion of the underlying molecular mechanisms.

MiR-146b-3p protects against AR42J cell injury in cerulein-induced acute pancreatitis model through targeting Anxa2

Background

Acute pancreatitis (AP) is a common inflammatory disorder. MicroRNAs play crucial roles in the pathogenesis of AP. In this article, we explored the detailed role and molecular mechanisms of miR-146b-3p in AP progression.

Methods

The rat AR42J cells were treated with cerulein to establish the AP model in vitro. The miR-146b-3p and Annexin A2 (Anxa2) mRNA levels were assessed by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR). Cell viability and apoptosis were tested using the Cell Counting Kit-8 (CCK-8) and flow cytometry assays, respectively. Caspase-3 activity and the production of interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunosorbent assay and qRT-PCR. Targeted interaction between miR-146b-3p and Anxa2 was verified by the dual-luciferase reporter and RNA immunoprecipitation assays. Western blot analysis was performed to detect the expression of Anxa2 protein.

Results

Our data revealed that miR-146b-3p was significantly downregulated in AP samples. The enforced expression of miR-146b-3p alleviated cerulein-induced injury in AR42J cells, as evidenced by the promotion in cell viability and the repression in cell apoptosis, as well as the reduction in IL-1β, IL-6, and TNF-α production. Anxa2 was directly targeted and inhibited by miR-146b-3p. Moreover, the alleviative effect of miR-146b-3p overexpression on cerulein-induced AR42J cell injury was mediated by Anxa2.

Conclusions

The current work had led to the identification of miR-146b-3p overexpression that protected against cerulein-induced injury in AR42J cells at least in part by targeting Anxa2, revealing a promising target for AP diagnosis and treatment.

Whole exome sequencing identifies three novel gene mutations in patients with the triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis

BACKGROUND

This study aimed to analyze the genetics and treatments of the patients with the triad of diabetic ketoacidosis (DKA), hypertriglyceridemia, and acute pancreatitis (AP).

METHODS

We conducted a retrospective study of six patients with the triad of AP, hypertriglyceridemia, and DKA at our hospital. All patients underwent plasmapheresis as part of their treatment. The clinical characteristics of the patients were obtained from the hospital information system and analyzed. Whole exome sequencing was performed using samples of one patient (case 6) and his family members.

RESULTS

The average triglyceride level before plasmapheresis was 3282.17 ± 2975.43 mg/dL (range: 1646-9332 mg/dL). The triglyceride levels dropped by approximately 80% after plasmapheresis. None of the patients developed complications related from plasmapheresis. During follow-up, patients 5 and 6 developed recurrent pancreatitis for several times and showed the formation of pancreatic pseudocysts. We identified three novel heterozygous missense mutations in the family of patient 6, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD.

CONCLUSIONS

Three novel heterozygous missense mutations, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD were first identified in a patient with the triad of DKA, hypertriglyceridemia, and AP. The combination of plasmapheresis, hydration, and insulin therapy may have the greatest clinical benefits for these patients.

[Acute Pancreatitis]

Acute pancreatitis is one of the most common gastrointestinal diseases requiring acute hospitalization and its incidence is increasing. A particular challenge is the prediction and treatment of severe cases, which only affect a minority of patients, but are associated with mortality rates of up to 30 percent. In this review, we consider the diagnostic evaluation of the disease and provide an overview of current conservative and interventional treatment strategies.

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

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

The risk factors for acute respiratory distress syndrome in patients with severe acute pancreatitis: A retrospective analysis

Acute respiratory distress syndrome (ARDS) is very common in patients with severe acute pancreatitis (SAP), the early interventions are essential to the prognosis of SAP patients. We aimed to evaluate the risk factors for ARDS in SAP patients, to provide insights into the management of SAP.SAP patients treated in our hospital from June 1, 2018 to May 31, 2020 were included. The characteristics and lab test results were collected and compared, and we conducted the logistic regression analyses were conducted to identify the potential risk factors for ARDS in patients with SAP.A total of 281 SAP patients were included finally, the incidence of ARDS in patients with SAP was 30.60%. There were significant differences on the respiratory rate, heart rate, APACHE II and Ranson score between 2 groups (all P < .05). And there were significant differences on the polymorphonuclear, procalcitonin, C-reactive protein, serum creatinine, albumin and PO2/FiO2 between 2 groups (all P < .05), and no significant differences on the K+, Na+, Ca+, white blood cell, neutrophils, urine and blood amylase, trypsin, lipase, alanine aminotransferase, aspartate aminotransferase, total bilirubin, triglyceride, total cholesterol, total bilirubin, fasting blood glucose, and pH were found (all P > .05). Respiratory rate >30/min (odds ratio [OR]: 2.405, 95% confidence interval[CI]: 1.163-4.642), APACHE II score >11 (OR: 1.639, 95% CI: 1.078-2.454), Ranson score >5 (OR: 1.473, 95% CI: 1.145-2.359), polymorphonuclear >14 × 109/L (OR: 1.316, 95% CI: 1.073-2.328), C-reactive protein >150 mg/L (OR: 1.127, 95% CI: 1.002-1.534), albumin ≤30 g/L (OR: 1.113, 95% CI: 1.005-1.489) were the independent risk factors for ARDS in patients with SAP (all P < .05).The incidence of ARDS in SAP patients is relatively high, and it is necessary to carry out targeted early prevention and treatment for the above risk factors.

Appraisal of the diagnostic procedures of acute pancreatitis in the guidelines

OBJECTIVES

The purpose of this study was to comprehensively assess the heterogeneity of procedures in the diagnostic guidelines for acute pancreatitis and to identify gaps limiting knowledge in diagnosing this disease.

METHODS

A systematic search of a number of databases was performed to determine the guidelines for the diagnosis of acute pancreatitis in patients with severe pancreatitis. The guidelines for the diagnosis of severe pancreatitis were evaluated by AGREE II. The Measurement Scale of Rate of Agreement (MSRA) was used to assess the guidelines (2015-2020) and extract evidence supporting these recommendations for analysis.

RESULTS

Seven diagnostic guidelines for acute pancreatitis were included. Only the 2019 WSES Guidelines for the Management of Severe Acute Pancreatitis and the Japanese Guidelines for the Management of Acute Pancreatitis: Japanese Guidelines 2015 had a total score of more than 60%, which is worthy of clinical recommendation. The average scores of the Scope and Purpose domain and the Clarity and Expression domain were the highest at 71.62% and 75.59%, respectively, while the average score of the Applicability area was the lowest at 16.67%. The included guidelines were further analyzed to determine the heterogeneity of the diagnosis of acute pancreatitis. The main reasons for the heterogeneity were the citation of low-quality evidence, the presence of far too many indicators for the classification of acute pancreatitis, unclear depictions of the standard, and poorly comprehensive recommendations for the diagnosis of the aetiology in the primary diagnosis of acute pancreatitis, the severity classification, the aetiological diagnosis, and the diagnosis of comorbidities.

CONCLUSIONS

The quality of different diagnostic guidelines for severe pancreatitis is uneven. The recommendations are largely based on low-quality evidence, and the guidelines still have much room for improvement to reach a high level of quality. The diagnostic procedures for acute pancreatitis vary widely in different guidelines. There are large differences between them, and resolving the abovementioned reasons would be a very wise choice for guideline developers to revise and upgrade the guidelines in the future.

Efficacy of Xuebijing Injection for Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

METHODS

PubMed Medline, Embase, Cochrane Library, China National Knowledge Infrastructure, China Biology Medicine disc, VIP, and Wanfang databases were searched. The primary outcome was treatment response. The secondary outcomes included changes in clinical and laboratory indicators and incidence of AP-related complications. Meta-analyses were performed by using a random-effect model. Risk ratios (RRs) with 95% confidence intervals (CIs) or weighted mean differences (WMDs) with 95% CIs were calculated.

RESULTS

Overall, 23 RCTs were included. The rates of overall (RR = 1.16; 95% CI = 1.12 to 1.20; P < 0.00001) and complete (RR = 1.40; 95% CI = 1.30 to 1.50; P < 0.00001) responses were significantly higher in the Xuebijing injection group. After treatment, the levels of interleukin-6 (WMD = -18.22; 95% CI = -23.36 to -13.08; P < 0.00001), tumor necrosis factor-α (WMD = -16.44; 95% CI = -20.49 to -12.40; P < 0.00001), serum amylase (WMD = -105.61; 95% CI = -173.77 to -37.46; P=0.002), white blood cell (WMD = -1.51; 95% CI = -1.66 to -1.36; P < 0.00001), and C-reactive protein (WMD = -11.05; 95% CI = -14.32 to -7.78; P < 0.00001) were significantly lower in the Xuebijing injection group. Abdominal pain (WMD = -1.74; 95% CI = -1.96 to -1.52; P < 0.00001), abdominal distension (WMD = -1.56; 95% CI = -2.07 to -1.04; P < 0.00001), gastrointestinal function (WMD = -2.60; 95% CI = -3.07 to -2.13; P < 0.00001), body temperature (WMD = -2.16; 95% CI = -2.83 to -1.49; P < 0.00001), serum amylase level (WMD = -1.81; 95% CI = -2.66 to -0.96; P < 0.0001), and white blood cell (WMD = -2.16; 95% CI = -2.99 to -1.32; P < 0.00001) recovered more rapidly in the Xuebijing injection group. The incidence of multiple organ dysfunction syndrome (RR = 0.18; 95% CI = 0.05 to 0.62; P=0.006), pancreatic pseudocyst (RR = 0.17; 95% CI = 0.04 to 0.77; P=0.02), and renal failure (RR = 0.16; 95% CI = 0.05 to 0.60; P=0.006) was significantly lower in the Xuebijing injection group.

CONCLUSIONS

Xuebijing injection added on the basis of conventional treatment has a potential benefit for improving the outcomes of AP.

An extremely rare complication of acute pancreatitis: Intraventricular thrombus

Acute pancreatitis is a frequent reason for emergency admission, which has seen its numbers increase over the years. This condition has systemic, local, and vascular complications. A 73-year-old male patient presented to our emergency department complaining of abdominal pain, nausea, and vomiting. During imaging, intraventricular thrombus was discovered, and following completion of diagnostic testing, he was diagnosed with acute pancreatitis. Herein, we present the first case of intraventricular thrombus related to acute pancreatitis prothrombotic process in the literature.

Dihydrokaempferol (DHK) ameliorates severe acute pancreatitis (SAP) via Keap1/Nrf2 pathway

Severe acute pancreatitis (SAP) is a non-bacterial inflammatory disease that clinically causes a very high rate of mortality. Dihydrokaempferol (DHK) is a natural flavonoid extracted from Bauhinia championii. Our research aimed to establish the treatment function of DHK on SAP-induced pancreas injury and delve into its potential mechanism. In this study, SAP was induced by caerulein (CER) and Lipopolysaccharide (LPS). DHK was administered orally at different doses of 20, 40, or 80 mg/kg. Results from serum amylase/lipase, pancreas hematoxylin-eosin staining technique, pancreas malondialdehyde (MDA), glutathione (GSH), and reactive oxygen species (ROS) showed the therapeutic effect of DHK in a mice SAP model. MTT revealed DHK alleviated CER + LPS induced cytotoxicity in a dose-dependent manner in the pancreatic acinar cells of mice. Next, we verified DHK suppressed the level of Keap1 and promoted transcriptional activation of nuclear Nrf2 in the presence of CER + LPS. The molecular docking study suggested that there is a potential interaction between DHK and Keap1. To further look at the role of Keap1 using in vitro and in vivo models, Keap1 overexpression adenovirus (ad-Keap1) was performed. The results revealed that ad-Keap1suppressed the nuclear translocation of Nrf2 which is enhanced by DHK, and suppressed the antioxidative functionality of DHK both in mice and cell models. Collectively, this research demonstrated that DHK bettered the SAP induced pancreas injury by regulating the Keap1/Nrf2 pathway and regulating oxidative stress injury.

Identification of Dysfunctional Gut Microbiota Through Rectal Swab in Patients with Different Severity of Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) has a wide spectrum of severity and can be associated with considerable morbidity and mortality. Whether gut microbiota dysbiosis is associated with AP severity remains obscure.

AIMS

We aim to investigate the differences in the alterations of gut microbiota in different grades of AP severity.

METHODS

We collected clinical information and rectal swab samples from 80 individuals. The gut microbiota was tested by 16S rRNA gene sequencing, gut microbiota species composition analysis, difference analysis, random forest model prediction analysis, and gut microbiota species correlation network analysis.

RESULTS

There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant species in mild, moderately severe, and severe AP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased species in mild AP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in moderately severe AP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in severe AP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for mild AP and Eubacterium_hallii and Anaerococcus for moderately severe AP. There was a positive interaction between Firmicutes and Bacteroidetes in mild AP.

CONCLUSIONS

The disturbed gut microbiota is different among grades of AP, suggesting their potential role in the progression of disease severity. There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant gut microbiota species in MAP, MSAP, and SAP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased gut microbiota species in MAP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in MSAP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in SAP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for MAP and Eubacterium_hallii and Anaerococcus for MSAP. There was a positive interaction between Firmicutes and Bacteroidetes in MAP.

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis with Mild Pancreatitis

The safety and feasibility of early laparoscopic cholecystectomy (LC) for acute cholecystitis with mild pancreatitis were explored. A total of 973 patients with acute pancreatitis, including 651 mild cases and 322 moderate or severe cases were retrospectively studied from July 2014 to December 2018 in our department. And 426 mild pancreatitis cases with acute cholecystitis were enrolled in this study, of which 328 patients underwent LC during the same-admission (early LC group), and 98 patients underwent LC a period of time after conservative treatment (delayed LC group). Clinical characteristics, operative findings and complications were recorded and followed up. The two groups were comparable in age, gender, the grade of American Society of Anesthesiologist (ASA), biochemical findings and Balthazar computer tomography (CT) rating (P>0.05). The operation interval and hospital stay in early LC group were significantly shorter than in delayed LC group (5.83±1.62 vs. 41.36±8.44 days; 11.38±2.43 vs. 16.49±3.48 days, P<0.01). There was no significant difference in the average operation time between the two groups. No preoperative biliary related events recurred in early LC group but there were 21 cases of preoperative biliary related events in delayed LC group (P<0.01). There was no significant difference in conversion rate (3.85 vs. 5.10%, P=0.41) and surgical complication rate (3.95 vs. 4.08%, P=0.95) between early LC group and delayed LC group. During the postoperative follow-up period of 375 cases, biliary related events recurred in 4 cases in early LC group and 3 cases in delayed LC group (P=0.37). The effect of early LC during the same-admission is better than delayed LC for acute cholecystitis with mild pancreatitis.

Endoscopic submucosal dissection as alternative to surgery for complicated gastric heterotopic pancreas

BACKGROUND

Gastric heterotopic pancreas (GHP) is generally asymptomatic and rarely features complications such as pancreatitis, pseudocysts, gastric outlet obstruction, bleeding, obstructive jaundice, or intussusception. However, the treatment of complicated GHP is challenging and often requires surgical resection.

AIM

To investigate the clinical outcomes of endoscopic submucosal dissection (ESD) as alternative to surgical resection for complicated GHP.

METHODS

This is a single-center, retrospective study. Between January 2013 and December 2017, a total of 5 patients underwent ESD for complicated GHP at Asan Medical Center. Patients who were diagnosed with complicated GHP were treated conservatively as with general practice for acute pancreatitis. After conservative management for resolving the acute phase of pancreatitis, ESD was performed as definitive treatment for complicated GHP. ESD was performed using the conventional method under conscious sedation. The clinical features of patients and tumors, procedure-related characteristics, and long-term outcomes were investigated.

RESULTS

The age of the 5 patients ranged from 28-43 years. Two of the patients were males. All lesions were located in the greater curvature of the antrum. On endoscopic ultrasonography during the pain episode, all lesions were located across the muscularis mucosa, submucosa, and proper muscle layers. The median lesion size was 20 [interquartile range (IQR), 18-35] during the pain episode at the time of the diagnosis of complicated GHP, and 15 mm (IQR, 9-33) at the time of ESD after conservative treatment. The procedure time ranged from 15-120 min. There were no procedure-related adverse events such as perforation or bleeding. The length of hospital stay after the procedure ranged from 2-4 d. All patients were symptom free during the median follow-up period of 46.0 mo (IQR, 39-60).

CONCLUSION

ESD appears to be a feasible and effective treatment option for complicated GHP based on the favorable clinical outcomes.

Endoscopic submucosal dissection as alternative to surgery for complicated gastric heterotopic pancreas

BACKGROUND

Gastric heterotopic pancreas (GHP) is generally asymptomatic and rarely features complications such as pancreatitis, pseudocysts, gastric outlet obstruction, bleeding, obstructive jaundice, or intussusception. However, the treatment of complicated GHP is challenging and often requires surgical resection.

AIM

To investigate the clinical outcomes of endoscopic submucosal dissection (ESD) as alternative to surgical resection for complicated GHP.

METHODS

This is a single-center, retrospective study. Between January 2013 and December 2017, a total of 5 patients underwent ESD for complicated GHP at Asan Medical Center. Patients who were diagnosed with complicated GHP were treated conservatively as with general practice for acute pancreatitis. After conservative management for resolving the acute phase of pancreatitis, ESD was performed as definitive treatment for complicated GHP. ESD was performed using the conventional method under conscious sedation. The clinical features of patients and tumors, procedure-related characteristics, and long-term outcomes were investigated.

RESULTS

The age of the 5 patients ranged from 28-43 years. Two of the patients were males. All lesions were located in the greater curvature of the antrum. On endoscopic ultrasonography during the pain episode, all lesions were located across the muscularis mucosa, submucosa, and proper muscle layers. The median lesion size was 20 [interquartile range (IQR), 18-35] during the pain episode at the time of the diagnosis of complicated GHP, and 15 mm (IQR, 9-33) at the time of ESD after conservative treatment. The procedure time ranged from 15-120 min. There were no procedure-related adverse events such as perforation or bleeding. The length of hospital stay after the procedure ranged from 2-4 d. All patients were symptom free during the median follow-up period of 46.0 mo (IQR, 39-60).

CONCLUSION

ESD appears to be a feasible and effective treatment option for complicated GHP based on the favorable clinical outcomes.

Recent advances in studies of molecular hydrogen in the treatment of pancreatitis

Pancreatitis is an inflammatory disease of the pancreas characterized by acinar cell injury and is associated with the abnormal release of trypsin, which results in high mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). The inflammatory response, impaired autophagic flux, endoplasmic reticulum stress (ERS) and their interactions are involved in the development of pancreatitis. Molecular hydrogen (H₂) is a novel antioxidant that possesses the features of selective scavenging of oxygen free radicals and nontoxic metabolites and has been shown to be efficacious for treating infection, injury, tumors, ischemia-reperfusion organ injury, metabolic disease and several other diseases. Recent studies have found that H₂ is also useful in the treatment of pancreatitis, which may be related to the mechanism of antioxidative stress, anti-inflammation, anti-apoptosis, regulation of immunity and regulation of molecular pathways. This review focuses on the pathogenesis of pancreatitis and the research progress and potential mechanisms of H₂ against pancreatitis to provide theoretical bases for future research and clinical application of H₂ therapy for pancreatitis.

A 5-Year Retrospective Cohort Study: Epidemiology, Etiology, Severity, and Outcomes of Acute Pancreatitis

OBJECTIVE

The aim of this study was to evaluate the epidemiology, etiology, severity, and outcomes of acute pancreatitis (AP) in the southern Sichuan region of China.

METHODS

All patients with first-attack AP between 2013 and 2018 in the Affiliated Hospital of Southwest Medical University were retrospectively identified. The etiology tendency was analyzed, and the relationship was defined with sex, aging, severity, length of stay, and mortality.

RESULTS

Three thousand twenty-eight patients were enrolled for analysis. Acute biliary pancreatitis had the highest incidence rate; the second and third most common causes were hypertriglyceridemic (14.4%) and alcoholic (14.2%), followed by idiopathic (13.6%), mixed etiology (12.9%), and miscellaneous (2.31%). Patients with alcoholic AP were more likely to be middle-aged males, whereas patients with acute biliary pancreatitis were more likely to be elderly females (P < 0.05). The overall mortality in the hospital was 1%, and there was no difference in each etiological groups (P > 0.05).

CONCLUSIONS

Biliary disease was the predominant etiology of AP in southern Sichuan of China, and hypertriglyceridemia ranked second. The proportion of hypertriglyceridemic AP and mixed etiology AP gradually increased, whereas idiopathic AP decreased. There were different etiology proportion of AP according age, sex, and severity.

Severe acute pancreatitis: eight fundamental steps revised according to the 'PANCREAS' acronym

Severe acute pancreatitis remains a life-threatening condition, responsible for many disorders of homeostasis and organ dysfunction. By means of a mnemonic 'PANCREAS', eight important steps in the management of severe acute pancreatitis are highlighted. These steps follow the principle of goal-directed therapy and should be borne in mind after diagnosis and during clinical treatment. The first step is perfusion: the goal is to reach a central venous pressure of 12-15mmHg, urinary output 0.5-1ml/kg/hour and inferior vena cava collapse index greater than 48%. Next is analgesia: multimodal, systemic and combined pharmacological agent and epidural block are possibilities. Third is nutrition: precocity, enteral feeding in gastric or post-pyloric position. Parenteral nutrition works best in difficult cases to achieve the individual total caloric value. Fourth is clinical: mild, moderate or severe pancreatitis according to the Atlanta criteria. Radiology is fifth: abdominal computed tomography on the fourth day for prognosis or to modify management. Endoscopy is sixth: endoscopic retrograde cholangiopancreatography (cholangitis, unpredicted clinical course and ascending jaundice); management of pancreatic fluid collection and 'walled-off necrosis'. Antibiotics come next: infectious complications are common causes of morbidity. The only rational indication for antibiotics is documented pancreatic infection. The last step is surgery: the dogma is represented by the 'three Ds' (delay, drain, debride). The preferred method is a minimally invasive step-up approach, which allows for gradually more invasive procedures when the previous treatment fails.

Consensus and controversy among severe pancreatitis surgery guidelines: a guideline evaluation based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool

The purpose of this study was to systematically evaluate guidelines for surgery in patients with severe pancreatitis and to identify gaps limiting evidence-based medicine practice. A systematic search of databases and related websites was conducted to identify surgical guidelines for patients with severe pancreatitis. The quality of the included guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The similarities among key recommendations were compared, and the evidence supporting them was extracted and analysed. Seven surgical guidelines for patients with severe pancreatitis were included. Only two guidelines, those of the World Society of Emergency Surgery (WSES) and the European Society of Gastrointestinal Endoscopy (ESGE), scored more than 60% for overall quality and were worthy of clinical recommendation. We found that the quality of the severe acute pancreatitis surgical guidelines have much room for improvement, especially in the field of application, the participation of stakeholders and editorial independence. The heterogeneity and causes of surgical recommendations were further analysed, and the latest evidence was retrieved. It was found that the surgical guidelines for severe pancreatitis lacked high-quality evidence, some of the recommendations were controversial, and evidence citation was unreasonable. The quality of surgical guidelines for patients with severe pancreatitis varies widely. In the past 5 years, the key recommendations of the surgical guidelines for severe pancreatitis have been somewhat consistent and controversial, and improvement in these existing problems and controversies will be an effective way for developers to upgrade the surgical guidelines for severe pancreatitis.

Comparison of pancreatic function and quality of life between patients with infected pancreatitis necrosis undergoing open necrosectomy and minimally invasive drainage: A long-term study

The present study aimed to determine whether a difference in pancreatic function and quality of life (QoL) is present between patients with infected pancreatitis necrosis (IPN) undergoing open necrosectomy (ON) and minimally invasive drainage (MID). The medical records of patients with IPN discharged from Jinling Hospital were retrospectively analyzed. Pancreatic function and QoL were compared between patients treated with ON and MID. Pancreatic endocrine and exocrine function were assessed using the oral glucose tolerance test and fecal elastase-1 (FE-1) test, respectively. The standard Short Form 36 health questionnaire was used to evaluate the QoL of patients. The analysis included 101 patients who underwent either ON (n=40, 39.6%) or MID (n=61, 60.4%). There were no significant differences in exocrine and endocrine pancreatic function between the two groups evaluated based on FE-1, fasting blood glucose, glycated hemoglobin and 2-h plasma glucose (P<0.05). The scores of the QoL questionnaire were significantly higher in patients treated with MID than in patients treated with ON, including the scores of general health perception (19.39±3.07 vs. 17.37±3.63, P=0.003), vitality (18.93±2.88 vs. 17.57±3.47, P=0.035), social role functioning (8.85±1.43 vs. 8.15±1.98, P=0.042), emotional role functioning (5.33±1.07 vs. 4.82±1.25, P=0.034), mental health (24.21±3.31 vs. 22.57±3.91, P=0.026) and the total QoL score (125.12±13.16 vs. 116.50±16.94, P=0.005). In conclusion, although the initial health of the patient may have influenced the treatment provided, patients with IPN who received MID achieved a better post-treatment QoL than those treated with ON. No significant differences between the two groups were observed regarding the endocrine and exocrine functions of the pancreas.

The effect of trimethazidine on mortality in an experimental acute pancreatitis model1

BACKGROUND/AIMS

Acute pancreatitis has a high morbidty and mortality. Its physiopathogenesis has not been enlightened up to the present. This study aims to investigate trimetazidine (antiischemic, antioxidant and cardioprotective agent) 's effects on the acute pancreatitis.

MATERIALS AND METHODS

In this study, four aqual groups are formed with 43 female Spraque-dawley type rats weighed between230-300 gr (mean 265 gr). 0.9% NaCl is injected intraperitoneally after laparotomy to the Group 1 (n=6). Group 2 (n=6) is control group that without any intervention. Acute pancreatitis is formed in Group 3 (n=16) via injection of Na-taurokolat in the common bile duct. Group 4 (n=15) is being formed pancreatitis and treated with Trimetazidine. In group 4 Trimetazidine 10 mg/kg/day drugs were given, 30 minutes, 24 and 72 hours after formation of acute pancreatitis, in three equal doses by orogastric way. In all groups, the rats have been laparatomised 72 hours later under general anesthesia and pancreas tissues has been extracted and studied histopathologically. Amylase, lipase, lactate dehydrogenase, aspartate transaminase, alanine tranaminase levels in the rats serum and superoxide dismutase, catalase, glutathione, malondialdehyde, nitric oxide, protein carbonyl, glutathione peroxidase levels in the rats tissue also have been looked up.

RESULTS

Serum and tissue findings and histopathologically examination of the pancreas tissues show significant decrease in the treatment group compare to study group.

CONCLUSION

Trimetazidine protects pancreas tissue and decreases the mortality by significantly lowering the biochemical and histopathological changes in the early stages of acute pancreatitis.

Taiwanese consensus recommendations for acute pancreatitis

The incidence of acute pancreatitis and related health care utilization are increasing. Acute pancreatitis may result in organ failure and various local complications with risks of morbidity and even mortality. Recent advances in research have provided novel insights into the assessment and management for acute pancreatitis. This consensus is developed by Taiwan Pancreas Society to provide an updated, evidence-based framework for managing acute pancreatitis.

LncRNA MEG3 Participates in Caerulein-Induced Inflammatory Injury in Human Pancreatic Cells via Regulating miR-195-5p/FGFR2 Axis and Inactivating NF-κB Pathway

Acute pancreatitis (AP) is a dysfunctional pancreas disease marked by severe inflammation. Long non-coding RNAs (lncRNAs) involving in the regulation of inflammatory responses have been frequently mentioned. The purpose of this study was to ensure the function and action mode of lncRNA maternally expressed gene 3 (MEG3) in caerulein-induced AP cell model. HPDE cells were treated with caerulein to establish an AP model in vitro. The expression of MEG3, miR-195-5p, and fibroblast growth factor receptor 2 (FGFR2) was measured using quantitative real-time polymerase chain reaction (qRT-PCR). Cell proliferation and apoptosis were detected by 3-(4, 5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) assay and flow cytometry assay, respectively. The expression of CyclinD1, B cell lymphoma/leukemia-2 (Bcl-2), Bcl-2-associated X protein (Bax), FGFR2, P65, phosphorylated P65 (p-P65), alpha inhibitor of nuclear factor kappa beta (NF-κB) (IκB-α), and phosphorylated IκB-α (p-IκB-α) at the protein level was quantified by western blot. The concentrations of tumor necrosis factor α (TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6) were monitored by enzyme-linked immunosorbent assay (ELISA). The targeted relationship between miR-195-5p and MEG3 or FGFR2 was forecasted by the online software starBase v2.0 and verified by dual-luciferase reporter assay and RNA immunoprecipitation (RIP) assay. As a result, the expression of MEG3 and FGFR2 was decreased in caerulein-induced HPDE cells, while the expression of miR-195-5p was increased. MEG3 overexpression inhibited cell apoptosis and inflammatory responses that were induced by caerulein. Mechanically, miR-195-5p was targeted by MEG3 and abolished the effects of MEG3 overexpression. FGFR2 was a target of miR-195-5p, and MEG3 regulated the expression of FGFR2 by sponging miR-195-5p. FGFR2 overexpression abolished miR-195-5p enrichment-aggravated inflammatory injuries. Moreover, the NF-κB signaling pathway was involved in the MEG3/miR-195-5p/FGFR2 axis. Collectively, MEG3 participates in caerulein-induced inflammatory injuries by targeting the miR-195-5p/FGFR2 regulatory axis via mediating the NF-κB pathway in HPDE cells.

MiR-92b-3p ameliorates inflammation and autophagy by targeting TRAF3 and suppressing MKK3-p38 pathway in caerulein-induced AR42J cells

Acute pancreatitis (AP) is an inflammatory disease with high morbidity and mortality. Dysregulation of microRNAs (miRNAs) was involved in human diseases, including AP. However, the effects of miR-92b-3p on AP process and its mechanism remain not been fully clarified. The expression levels of miR-92b-3p and tumor necrosis factor receptor-associated factor-3 (TRAF3) were measured by quantitative real-time polymerase chain reaction (qRT-PCR). The protein levels of TRAF3, tumor necrosis factor α (TNF-α) TNF-α, interleukin-6 (IL-6), phosphorylated mitogen-activated protein kinase kinase 3 (p-MKK3), MKK3, p38 and phosphorylated p38 (p-p38) were detected by western blot. The concentration of TNF-α and IL-6 in the medium was measured using ELISA kits. The possible binding sites of miR-92b-3p and TRAF3 were predicted by TargetScan and verified by dual-luciferase reporter assay and RNA immunoprecipitation (RIP) assay. The expression level of miR-92b-3p was decreased and TRAF3 expression was increased in AR42J cells stimulated with caerulein. Moreover, the protein levels of pro-inflammatory cytokines (TNF-α and IL-6) were markedly elevated, and the expression levels of autophagy-related markers Beclin1 as well as the ratio of LC3-II/I were obviously increased in AR42J cells treated with caerulein. In addition, overexpression of miR-92b-3p or knockdown of TRAF3 significantly suppressed the release of pro-inflammatory cytokines and autophagy in caerulein-induced AR42J cells. Furthermore, TRAF3 was a direct target of miR-92b-3p and its upregulation reversed the effects of miR-92b-3p overexpression on inflammatory response and autophagy. Besides, overexpression of miR-92b-3p inhibited the activation of the MKK3-p38 pathway by affecting TRAF3 expression. In conclusion, miR-92b-3p attenuated inflammatory response and autophagy by downregulating TRAF3 and suppressing MKK3-p38 pathway in caerulein-induced AR42J cells, providing a novel avenue for treatment of AP.

Heparanase in Acute Pancreatitis

Acute pancreatitis (AP) is one of the most common diseases in gastroenterology, affecting 2% of all hospitalized patients. Nevertheless, neither the etiology nor the pathophysiology of the disease is fully characterized, and no specific or effective treatment has been developed. Heparanase (Hpa) is an endoglycosidase that cleaves heparan sulfate (HS) side chains of heparan sulfate proteoglycans (HSPGs) into shorter oligosaccharides, activity that is highly implicated in cell invasion associated with cancer metastasis and inflammation. Given that AP is a typical inflammatory disease, we investigated whether Hpa plays a role in AP. Our results provide keen evidence that Hpa expression and activity are significantly increased following cerulein-induced AP in wild type mice. In parallel to the classic manifestations of AP, namely elevation of amylase and lipase levels, pancreas edema and inflammation as well as induction of cytokines and signaling molecules, have been detected in this experimental model of the disease. Noteworthy, these features were far more profound in transgenic mice overexpressing heparanase (Hpa-Tg), suggesting that these mice can be utilized as a model system to reveal the molecular mechanism by which Hpa functions in AP. Further support for the involvement of Hpa in the pathogenesis of AP emerged from our observation that treatment of experimental AP with PG545 or SST0001(= Ronepastat), two potent Hpa inhibitors, markedly attenuated the biochemical, histological and immunological manifestations of the disease. Hpa, therefore, emerges as a potential new target in AP, and Hpa inhibitors are hoped to prove beneficial in AP along with their promising efficacy as anti-cancer compounds.

COVID-19 Induced Acute Pancreatitis: A Case Report and Literature Review

A 49-year-old female with no history of past medical illness presented to the emergency department with complaints of fever, dry cough, and shortness of breath. Initial evaluation revealed a temperature of 101°F, and on auscultation, the patient had scattered wheezing and rales in left lung fields. CT of the chest revealed pneumonic patches in the upper and lower segment of the left lung. Her COVID-19 testing came positive. On the second day of hospital admission, the patient experienced nausea, vomiting, and severe epigastric pain radiating to back. Laboratory analysis revealed a marked elevation of lipase and amylase. CT of the abdomen showed an edematous pancreas with diffuse enlargement. She was diagnosed with acute pancreatitis due to COVID-19 after carefully ruling out other causes. She was managed symptomatically, and improvement in her clinical condition was observed and was discharged with outpatient follow-up. Although acute pancreatitis is rare in patients with COVID-19, it should be considered as a differential diagnosis in patients with severe epigastric pain and respiratory symptoms.

Cocaine-Induced Acute Pancreatitis: A Rare Etiology

An 18-year-old male with a medical history of trigeminal neuralgia presented to the emergency department with complaints of severe abdominal pain associated with nausea, projectile vomiting, and watery diarrhea with no fever, rigors, and chills. The abdominal examination was unremarkable. His lab results showed elevated serum lipase and amylase. Gallstones were ruled out by abdominal ultrasonography. His computed tomography (CT) revealed pancreatic enlargement with ill-defined borders. He reported cocaine use but had no history of alcohol abuse. A urine drug screen was positive for cocaine. He was managed conservatively with a possible diagnosis of acute pancreatitis due to cocaine abuse after carefully ruling out other causes. The patient was symptom-free on day 7 and discharged from hospital on day 8 with follow-up with his gastroenterology doctor and drug counseling service. Although cocaine-induced pancreatitis is rare, it should be considered a differential diagnosis in patients with a history of cocaine use.

The early predictive value of routine laboratory tests on the severity of acute pancreatitis patients in pregnancy: a retrospective study

Acute pancreatitis in pregnancy (APIP) varies in severity from a self-limiting mild condition to a severe life-threatening condition, and its severity is significantly correlated with higher risks of maternal and foetal death. This study evaluated the early predictive value of routine laboratory tests on the severity of APIP patients. We enrolled 100 patients with APIP in West China Hospital. Initial routine laboratory tests, including the biochemistry and hematologic tests were collected within 48 hours after the onset of APIP. For predicting SAP in AP, LDH had the highest specificity of 0.879. RDW was a suitable predictive marker as it had the sensitivity of 0.882. Lower levels of triglycerides (<4.72 mmol/L) predicted mild AP of APIP, with an area under the curve (AUC) of 0.724, and a negative predictive value of 0.80. Furthermore, a risk score was calculated based on white blood cells, neutrophils, RDW, LMR and LDH, as an independent marker (adjusted odds ratio = 3.013, 95% CI 1.893 to 4.797, P < 0.001), with the highest AUC of 0.906, a sensitivity of 0.875 and a specificity of 0.828. In conclusion, the risk score we recommended was the powerful marker to aid in the early prediction of the severity of APIP patients.

Recent Advances in Diagnosis and Severity Assessment of Acute Pancreatitis

The incidence and prevalence of acute pancreatitis (AP) is increasing over time. The diagnosis of acute pancreatitis is established by revised Atlanta criteria (2012). Multiple criteria and scoring systems have been used for assessment of severity of AP. Majority of acute pancreatitis cases (80%) are mild, the challenge remains in early diagnosis, severity assessment and treatment of severe AP and its complications. Assessment of severity of AP is important part of management because line of treatment depends on aetiology and severity of acute pancreatitis. In this article a comprehensive review of recent advances in diagnosis and severity assessment of acute pancreatitis has been described.

Impact of prior antibiotics on infected pancreatic necrosis microbiology in ICU patients: a retrospective cohort study

Background

Recent guidelines advise against prophylactic antibiotics in patients with necrotizing pancreatitis, advocating instead a step-up drainage and necrosectomy strategy with antibiotics as dictated by microbiological findings. However, prompt antibiotic therapy is recommended in patients with sepsis or septic shock, a possible presentation of infected pancreatic necrosis (IPN). Consequently, in many critically ill patients with IPN, pancreatic samples are collected only after broad-spectrum antibiotic therapy initiation. Whether this prior antibiotic exposure alters the microbiological findings is unknown. The main objective was to determine whether prior antibiotic exposure sterilized the samples collected during procedures for suspected IPN in patients admitted to the intensive care unit (ICU) for acute pancreatitis with suspected IPN. We retrospectively studied 56 consecutive ICU patients admitted with suspected IPN. We collected details on the microbiological samples and antimicrobials used. A definite diagnosis of IPN was given when bacteria were identified in pancreatic samples.

Results

In all, 137 pancreatic samples were collected, including 91 (66.4%) after antibiotic therapy initiation. IPN was confirmed in 48 (86%) patients. The proportion of positive samples was 74 (81.3%) in antibiotic-exposed patients and 32/46 (69.5%) in unexposed patients (p = 0.58). Of the 74 positive samples from exposed patients, 62 (84%) had organisms susceptible to the antibiotics used. One-third of samples contained more than one organism. Among patients with IPN, 37.5% had positive blood cultures. Multidrug- or extensively drug-resistant bacteria were identified at some point in half the patients. Enterobacter cloacae complex was more frequent in the exposed group (p = 0.02), as were Gram-negative anaerobic bacteria (p = 0.03).

Conclusion

Antibiotic exposure before sampling did not seem to affect culture positivity of pancreatic samples to confirm IPN, but may affect microbiological findings. Our results suggest that, in patients with sepsis and suspected IPN, antibiotics should be started immediately and pancreatic samples obtained as soon as possible thereafter. In other situations, antibiotics can be withheld until the microbiological results of pancreatic samples are available, to ensure accurate targeting of the spectrum to bacterial susceptibility patterns.

ClinicalTrials.gov number NCT03253861

Outcome of acute pancreatitis in octogenarians: A retrospective study

Background and Aim

Acute pancreatitis (AP) is a common disease, but data on outcomes in octogenarians are scarce in the literature. The aim of this study is to analyze results from patients aged 80 years old and over who were treated for AP at a single center.

Methods

Patients aged 80 years and older diagnosed with AP from April 2010 to October 2015 were considered. Demographics, American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), serum biochemistry at 24 and 48 h after admission, and revised Atlanta severity score were analyzed and correlated with hospital mortality rate and length of stay using the multiple regression and Kaplan–Meier tests.

Results

A total of 100 consecutive patients were included in the study. There were 52 women, and the mean age was 87.5 years (range 80–95). Gallstones were the most common cause of AP (69.7%). The ASA score was ≥III in 51 patients. Eight patients had severe, disease and all of them died in hospital. A CCI > 4 was associated with higher disease severity and mortality (P < 0.00001). The median hospital stay was 9 days (range 1–59). Longer hospital stay was associated with serum C‐reactive protein ≥242 mg/L (P = 0.01) and serum albumin ≤30 g/L (P = 0.01) at 48 h. Over a 5‐year period, 22% of patients were readmitted to hospital with recurrent AP. Gallstones were the main cause of disease (63.6%).

Conclusions

AP in octogenarians has low mortality. Higher death rate is associated with disease severity. In the presence of gallstone disease, cholecystectomy is recommended whenever possible as the risk of disease recurrence is significant.

Reduction of intra-abdominal pressure after percutaneous catheter drainage of pancreatic fluid collection predicts survival

OBJECTIVE

Intra-abdominal hypertension (IAH) can adversely affect the outcome in patients of acute pancreatitis (AP). Effect of percutaneous drainage (PCD) on IAH has not been studied. We studied the effect of PCD on IAH in patients with acute fluid collections.

MATERIAL AND METHODS

Consecutive patients of AP undergoing PCD between Jan 2016 and May 2018 were evaluated for severity markers, clinical course, hospital and ICU stay, and mortality. Patients were divided into two groups: with IAH and with no IAH (NIAH). The two groups were compared for severity scores, organ failure, hospital and ICU stay, reduction in IAP and mortality.

RESULTS

Of the 105 patients, IAH was present in 48 (45.7%) patients. Patients with IAH had more often severe disease, BISAP ≥2, higher APACHE II scores and computed tomography severity index (CTSI). IAH group had more often OF (87.5% vs. 70.2%, p = 0.033), prolonged ICU stay (12.5 vs. 6.75 days, p = 0.007) and higher mortality (52.1% vs. 15.8%, p < 0.001). After PCD, IAP decreased significantly more in the IAH group (21.85 ± 4.53 mmHg to 12.5 ± 4.42 mmHg) than in the NIAH group (12.68 ± 2.72 mmHg to 8.32 ± 3.18 mmHg), p = <0.001. Reduction of IAP in patients with IAH by >40% at 48 h after PCD was associated with better survival (63.3% vs. 36.7%, p = 0.006).

CONCLUSION

We observed that patients with IAH have poor outcome. PCD decreases IAP and a fall in IAP >40% of baseline value predicts a better outcome after PCD in patients with acute fluid collections.

Characteristics and outcome of patients presenting with acute Pancreatitis: A one-year descriptive study from a tertiary care center in Lebanon

AIM

To determine the aetiology, hospital course, and outcome of patients diagnosed with acute pancreatitis (AP) presenting to the Emergency Department (ED) of a tertiary care center in Lebanon.

PATIENTS AND METHODS

Using a retrospective cross-sectional study design, records of all patients presenting to the ED with elevated lipase over one calendar year (2016) were reviewed. Patients diagnosed with AP according to the revised Atlanta classification were identified.

RESULTS

Over one year, a total of 24,133 adult patients visited the ED and 4,976 had serum lipase determination. Of those, 75 patients (mean age 59.4 ± 16.1; range 20-95; M:F 2.1) had confirmed AP accounting for 0.3% of adult ED visits. The most common etiologies were biliary (36%), idiopathic (16%), drugs (13%), and alcohol (11%). Intake of drugs known to be associated with AP was identified in 26% of patients. Alcoholic pancreatitis was more common in males, while biliary pancreatitis was more common in females (p less than 0.05 in both). 63 patients (84%) required regular hospital admission and only 1 (1.3%) required intensive care unit admission and passed away after multiorgan failure. Mean hospital stay was 4.0 ± 4.0 days (range 0-23) with mean hospital charges of $6,637 ± 8,496.

CONCLUSION

Acute pancreatitis accounts for a relatively small number of emergency visits in Lebanon. Leading etiologies are biliary and drugs, with a low contribution of alcohol compared to the West. The economic burden of AP is important, but outcomes appear largely favorable with an overall mortality of less than 2%.

Value of multidisciplinary collaboration in acute and chronic pancreatitis

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

Prophylactic low-molecular-weight heparin administration protected against severe acute pancreatitis partially by VEGF/Flt-1 signaling in a rat model

BACKGROUND

The present study was aimed to explore the effects and the underlying mechanism of prophylactic low-molecular-weight heparin (LMWH) treatment on taurocholate-induced severe acute pancreatitis (SAP) in a rat model.

METHODS

Rat SAP model was induced by injection of 4% sodium taurocholate into the pancreatic duct. LMWH was applied half an hour before the induction of pancreatitis at the dose of 200 IU/kg subcutaneous injection. The rats were euthanized at 1 h, 6 h, and 12 h after taurocholate-induced SAP. The inflammatory and oxidative response markers were assessed. And the vascular endothelial growth factor (VEGF) and Fms-related tyrosine kinase 1 (Flt-1) expression were evaluated by immunohistochemistry (IHC) and western blot methods.

RESULTS

The expression of inflammatory and oxidative response markers increased after induction of SAP. IHC and western blot results showed the VEGF and Flt-1 expression were increased in SAP group. Prophylactic LMWH administration reduced the inflammatory and oxidative response markers expression and decreased the expression of VEGF and Flt-1.

CONCLUSIONS

This study suggested that prophylactic LMWH treatment mitigated the severity of pancreatitis in rat SAP model by anti-inflammation and oxidative response. The underlying mechanism may result from downregulating VEGF/Flt-1 signaling of LMWH in SAP rat model.

Hepatobiliary Adverse Events

Immune checkpoint inhibitors (ICIs) are increasingly used for multiple cancer types. Hepatotoxicity is a reported adverse event of ICI treatment. It can present as asymptomatic elevation of aspartate transaminase and alanine transaminase or symptomatic hepatitis with fever, malaise, and even death in rare cases. The diagnosis of ICI-induced hepatitis is made after exclusion of other etiologies based on medical history, laboratory evaluation, and imaging and histological findings. Treatment of ICI-induced hepatitis consists of ICI discontinuation and immunosuppression in severe cases. Pancreatic injury as asymptomatic lipase elevation or acute pancreatitis-like disease with abdominal pain and evidence on imaging has been documented as a toxicity of ICI therapy. Appropriate treatment of pancreatitis still needs further investigation. Few cases, reports, and series documented cholecystitis and cholangitis as possible adverse events related to ICI therapy as well.

The impact of obesity on acute pancreatitis outcomes in older patients

PURPOSE

Although obesity is an established risk factor for a number of diseases, several epidemiological studies have demonstrated that older obese patients have better survival rates than non-obese old patients in various disease states. In this context, the relationship between obesity and acute pancreatitis outcome in older patients is controversial. Therefore, the authors aimed to investigate the impact of obesity on acute pancreatitis outcomes in older patients.

METHODS

Patients aged > 65 years who had been hospitalized for acute pancreatitis were retrospectively analyzed. Among them, 190 patients were included. The median age was 73 (68-79) years, and 118 (62.1%) were women. Obesity was assessed according to body mass index, and patients were classified as either obese or non-obese. The primary endpoint of the study was in-hospital major adverse events (major in-hospital complications and death). The secondary endpoints were acute pancreatitis recurrence, 30-day all-cause mortality, and long-term all-cause mortality.

RESULTS

A total of 77 (40.5%) patients were obese. In-hospital major adverse events were observed in 40 (21.1%) patients. There was no statistical difference in major in-hospital adverse events between the two groups (27 [23.9%] in non-obese patients vs. 13 [16.9%] in obese patients, p = 0.24). Further, the 30-day mortality, long-term survival, and acute pancreatitis recurrence rates were similar (all p > 0.05). The median follow-up time was 18 (0-80) months.

CONCLUSION

Obesity does not result in higher mortality or complications in older patients with acute pancreatitis. Although the underlying mechanism needs to be elucidated, the deleterious effect of obesity seems to be diminished in older patients.

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

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

Nasogastric versus nasojejunal tube feeding for severe acute pancreatitis

BACKGROUND

Nutrition is an important aspect of management in severe acute pancreatitis. Enteral nutrition has advantages over parenteral nutrition and is the preferred method of feeding. Enteral feeding via nasojejunal tube is often recommended, but its benefits over nasogastric feeding are unclear. The placement of a nasogastric tube is technically simpler than the placement of a nasojejunal tube.

OBJECTIVES

To compare the mortality, morbidity, and nutritional status outcomes of people with severe acute pancreatitis fed via nasogastric tube versus nasojejunal tube.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS on 17 October 2019 without using any language restrictions. We also searched reference lists and conference proceedings for relevant studies and clinical trial registries for ongoing trials. We contacted authors for additional information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing enteral feeding by nasogastric and nasojejunal tubes in participants with severe acute pancreatitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, assessed risk of bias of the included studies, and extracted data. This information was independently verified by the other review authors. We used standard methods expected by Cochrane to assess the risk of bias and perform data synthesis. We rated the certainty of evidence according to GRADE.

MAIN RESULTS

We included five RCTs that randomised a total of 220 adult participants from India, Scotland, and the USA. Two of the trial reports were available only as abstracts. The trials differed in the criteria used to rate the severity of acute pancreatitis, and three trials excluded those who presented in severe shock. The duration of onset of symptoms before presentation in the trials ranged from within one week to four weeks. The trials also differed in the methods used to confirm the placement of the tubes and in what was considered to be nasojejunal placement. We assessed none of the trials as at high risk of bias, though reporting of methods in four trials was insufficient to judge the risk of bias for one or more of the domains assessed. There was no evdence of effect with nasogastric or nasojejunal placement on the primary outcome of mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.36 to 1.17; I² = 0%; 5 trials, 220 participants; very low-certainty evidence due to indirectness and imprecision). Similarly, there was no evidence of effect on the secondary outcomes for which data were available. These included organ failure (3 trials, 145 participants), rate of infection (2 trials, 108 participants), success rate (3 trials, 159 participants), complications associated with the procedure (2 trials, 80 participants), need for surgical intervention (3 trials, 145 participants), requirement of parenteral nutrition (2 trials, 80 participants), complications associated with feeds (4 trials, 195 participants), and exacerbation of pain (4 trials, 195 participants). However, the certainty of the evidence for these secondary outcomes was also very low due to indirectness and imprecision. Three trials (117 participants) reported on length of hospital stay, but the data were not suitable for meta-analysis. None of the trials reported data suitable for meta-analysis for the other secondary outcomes of this review, which included days taken to achieve full nutrition requirement, duration of tube feeding, and duration of analgesic requirement after feeding tube placement.

AUTHORS' CONCLUSIONS

There is insufficient evidence to conclude that there is superiority, inferiority, or equivalence between the nasogastric and nasojejunal mode of enteral tube feeding in people with severe acute pancreatitis.

Progress in research of liver injury induced by acute biliary pancreatitis

Acute biliary pancreatitis (ABP) not only causes acute inflammation of the pancreas, but also leads to obstruction or infection of the biliary system. Liver injury is one of the most common complications of ABP. The pathological mechanisms mainly include infection and endotoxin, cholestasis, pancreatic enzyme damage, microcirculatory disorders, and oxidative stress, and the research conclusions are mostly derived from animal experiments. On the basis of routine medical treatment of ABP, active anti-infective treatment and rapid relief of biliary obstruction can promote the recovery of ABP-related liver injury.

Cost of Unnecessary Amylase and Lipase Testing at Multiple Academic Health Systems

OBJECTIVES

To determine adherence to Choosing Wisely recommendations for using serum lipase to diagnose acute pancreatitis rather than amylase, avoiding concurrent amylase/lipase testing and avoiding serial measurements after the first elevated test as both are ineffective for tracking disease course.

METHODS

Deidentified laboratory data from four large health systems were analyzed to determine concurrent testing rates, serial testing rates, and provider-ordering patterns.

RESULTS

While most providers adhered to recommendations with 58,693 lipase-only tests ordered and performed, 86% of amylase tests were performed concurrently with lipase. Ambulatory, inpatient, and emergency department settings revealed concurrent rates of 51%, 41%, and 8%, respectively. Services with order sets containing both amylase and lipase were associated with higher rates of concurrent testing.

CONCLUSIONS

Concurrent amylase/lipase testing is an area of opportunity to improve compliance, especially in ambulatory settings. Revision of order sets and provider education could be interventions to reduce unnecessary testing and save costs.

Assessment of prophylactic antibiotics administration for acute pancreatitis: a meta-analysis of randomized controlled trials

BACKGROUND

Recent evidence has shown that prophylactic antibiotic treatment in patients with acute pancreatitis is not associated with a significant decrease in mortality or morbidity. The use and efficacy of prophylactic antibiotic treatment in acute pancreatitis remain controversial. This meta-analysis was conducted to assess whether antibiotic prophylaxis is beneficial in patients with acute pancreatitis.

METHODS

We searched randomized controlled trials (RCTs) of prophylactic use of antibiotics using Medline (PubMed), Embase, the Cochrane Library, and Web of Science. The data were analyzed using Review Manager 5.3 software. We performed pooled analyses for infected pancreatic necrosis, mortality, surgical intervention, and non-pancreatic infection. Odds ratios (ORs) from each trial were pooled using a random or fixed effects model, depending on the heterogeneity of the included studies. Sub-group analysis or sensitivity analysis was conducted to explore potential sources of heterogeneity, when necessary.

RESULTS

Totally, 11 RCTs involving 747 participants were included, with an intervention group (prophylactic use of antibiotics, n = 376) and control group (n = 371). No significant differences were found regarding antibiotic prophylaxis with respect to incidence of infected pancreatic necrosis (OR, 0.74; 95% confidence interval [CI], 0.50-1.09; P = 0.13), surgical intervention (OR, 0.92; 95% CI, 0.62-1.38; P = 0.70), and morality (OR, 0.71; 95% CI, 0.44-1.15; P = 0.16). However, antibiotic prophylaxis was associated with a statistically significant reduction in the incidence of non-pancreatic infection (OR, 0.59; 95% CI, 0.42-0.84; P = 0.004).

CONCLUSIONS

Prophylactic antibiotics can reduce the incidence of non-pancreatic infection in patients with AP.

Effect of clinical pharmacist intervention on the treatment of acute pancreatitis

Background The participation of clinical pharmacists in the treatment of acute pancreatitis has rarely been reported. Objective The aim of this study was to retrospectively evaluate the impact of intervention of clinical pharmacists on the treatment of acute pancreatitis. Setting An academic teaching hospital in Taizhou, Jiangsu, China. Method Two hundred and twenty-eight patients with acute pancreatitis were retrospectively enrolled from July 2017 to July 2018 and divided into an intervention group (n = 119) and a control group (n = 109) according to whether a clinical pharmacist was involved. No significant differences in the baseline clinical characteristics were found between the groups. Clinical pharmacists participated in drug formulation and adjustment, pharmaceutical care, and follow-up. Main outcome measure Clinical outcomes, average hospital stays, costs, incidence of adverse drug reactions, 1-month subsequent visit rate, and patient satisfaction between the two groups were measured. Results The clinical symptoms of patients in both groups were relieved after treatment. There were no significant differences between the groups in computed tomography grades after treatment, incidence of adverse drug reactions, or average hospital stays. However, the intervention group had lower total costs of hospitalization, drugs and antibiotics but higher rates of 1-month subsequent visits and satisfaction compared with the control group. Conclusion The intervention of clinical pharmacists in the treatment of acute pancreatitis can effectively reduce costs of hospitalization, drug and antibiotics and improve follow-up compliance and patient satisfaction.