Acute pancreatitis

Minimally invasive pancreatic necrosectomy; a technical pictorial review

Necrotizing pancreatitis is the most severe form of acute pancreatitis, which is associated with significant mortality and morbidity. Open necrosectomy has been one of the treatment modalities; however, it has been associated with high mortality rates and alternative minimally invasive procedures such as minimal invasive pancreatic necrosectomy (MIPN) were developed to improve on the outcomes. While current clinical evidence on MIPN showed significant advantages in terms of incidence of multiple organ failure, incisional hernias and new-onset diabetes there were no differences in terms of mortality rate. In this pictorial review we are presenting the technical details of MIPN as a minimally invasive procedure for the debridement of the necrotic pancreatic tissue and we will discuss the current evidence around the use of this procedure for the management of pancreatic necrosis.

Early enteral nutrition versus delayed enteral nutrition in acute pancreatitis: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Whether early enteral nutrition (EEN) administration is more beneficial than delayed enteral nutrition (DEN) for patients with acute pancreatitis remains controversial.

METHODS

This meta-analysis aimed to pool all relevant articles to evaluate the effects of EEN within 48 hours versus DEN beyond 48 hours on the clinical outcomes of patients with acute pancreatitis. We searched PubMed, Scopus, Embase, and Web of Science for all relevant studies and extracted the data concerning basic characteristics, complications, and mortality. We calculated the pooled risk ratio (RR), weighted mean difference, and the corresponding 95% confidential interval (95% CI) using STATA 12.0.

RESULTS

For complications, the pooled analysis showed that EEN was related to a reduced risk of multiple organ failure (RR = 0.67, 95% CI 0.46-0.99, P = .04), but not for necrotizing pancreatitis (RR = 0.95, 95% CI 0.81-1.12, P = .57). There was a tendency for decreased systemic inflammatory response syndrome in the EEN group, but the trend was not significant (RR = 0.85, 95% CI 0.71-1.02, P = .09). For mortality, no significant difference was found between the EEN and DEN groups (RR = 0.78, 95% CI 0.27-2.24, P = .64).

CONCLUSION

EEN within 48 hours is superior to DEN beyond 48 hours for patients with acute pancreatitis; however, more studies are required to verify this conclusion.

Mesenchymal stem cell transplantation for treatment of pancreatitis

Mesenchymal stem cells (MSCs) are one of the main cell resources of regenerative medicine. Recently, MSCs have been used to treat many diseases, such as Alzheimer's disease, inflammatory bowel disease and cirrhosis, with certain curative effects achieved. MSCs can not only secrete a variety of anti-inflammatory cytokines, but also reduce the secretion of inflammatory factors. Therefore, acute pancreatitis (AP) and chronic pancreatitis (CP) can be treated with MSCs. Several studies have investigated the effect of MSC therapy on acute and CP. MSCs exert a therapeutic effect on AP perhaps via two pathways: anti-inflammatory pathway and anti-apoptotic pathway. However, the mechanism for the therapeutic effect of MSCs on CP is unclear. In this review, we will summarize the progress in MSC treatment of AP and CP.

The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity?

BACKGROUND

Using revised Atlanta classification defined outcomes, we compare absolute values in C-reactive protein (CRP), with interval changes in CRP, for severity stratification in acute pancreatitis (AP).

METHODS

A retrospective study of all first incidence AP was conducted over a 5-year period. Interval change in CRP values from admission to day 1, 2 and 3 was compared against the absolute values. Receiver-operator characteristic (ROC) curve and likelihood ratios (LRs) were used to compare ability to predict severe and mild disease.

RESULTS

337 cases of first incidence AP were included in our analysis. ROC curve analysis demonstrated the second day as the most useful time for repeat CRP measurement. A CRP interval change >90 mg/dL at 48 h (+LR 2.15, -LR 0.26) was equivalent to an absolute value of >150 mg/dL within 48 h (+LR 2.32, -LR 0.25). The optimal cut-off for absolute CRP based on new, more stringent definition of severity was >190 mg/dL (+LR 2.72, -LR 0.24).

CONCLUSION

Interval change in CRP is a comparable measure to absolute CRP in the prognostication of AP severity. This study suggests a rise of >90 mg/dL from admission or an absolute value of >190 mg/dL at 48 h predicts severe disease with the greatest accuracy.

Inulin-Type Fructans Modulates Pancreatic-Gut Innate Immune Responses and Gut Barrier Integrity during Experimental Acute Pancreatitis in a Chain Length-Dependent Manner

Acute pancreatitis (AP) is a common abdominal inflammatory disorder and one of the leading causes of hospital admission for gastrointestinal disorders. No specific pharmacological or nutritional therapy is available but highly needed. Inulin-type fructans (ITFs) are capable of modifying gut immune and barrier homeostasis in a chemistry-dependent manner and hence potentially applicable for managing AP, but their efficacy in AP has not been demonstrated yet. The current study aimed to examine and compare modulatory effects of ITFs with different degrees of fermentability on pancreatic-gut immunity and barrier function during experimentally induced AP in mice. BALB/c mice were fed short (I)- or long (IV)-chain ITFs supplemented diets for up to 3 days before AP induction by caerulein. Attenuating effects on AP development were stronger with ITF IV than with ITF I. We found that long-chain ITF IV attenuated the severity of AP, as evidenced by reduced serum amylase levels, lipase levels, pancreatic myeloperoxidase activity, pancreatic edema, and histological examination demonstrating reduced pancreatic damage. Short-chain ITF I demonstrated only partial protective effects. Both ITF IV and ITF I modulated AP-associated systemic cytokine levels. ITF IV but not ITF I restored AP-associated intestinal barrier dysfunction by upregulating colonic tight junction modulatory proteins, antimicrobial peptides, and improved general colonic histology. Additionally, differential modulatory effects of ITF IV and ITF I were observed on pancreatic and gut immunity: ITF IV supplementation prevented innate immune cell infiltration in the pancreas and colon and tissue cytokine production. Similar effects were only observed in the gut with ITF I and not in the pancreas. Lastly, ITF IV but not ITF I downregulated AP-triggered upregulation of IL-1 receptor-associated kinase 4 (IRAK-4) and phosphor-c-Jun N-terminal kinase (p-JNK), and a net decrease of phosphor-nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) p65 (p-NF-κB p65) nuclear translocation and activation in the pancreas. Our findings demonstrate a clear chain length-dependent effect of inulin on AP. The attenuating effects are caused by modulating effects of long-chain inulin on the pancreatic-gut immunity via the pancreatic IRAK-4/p-JNK/p-NF-κBp65 signaling pathway and on prevention of disruption of the gut barrier.

Gastroduodenal Artery Psuedoaneurysm Bleed through a Spontaneous Pancreaticoduodenal Fistula as a Result of Acute Necrotizing Pancreatitis

Spontaneous pancreaticoduodenal fistulization and arterial psuedoaneurysm formation are both complications of acute pancreatitis. We present a 27-year-old man with hematemesis who was found to be bleeding from a gastroduodenal artery psuedoaneurysm through a spontaneous pancreaticoduodenal fistula as a result of severe alcohol-related necrotizing pancreatitis. This is the first reported case in the literature to describe this occurrence.

Immunology of pancreatitis and environmental factors

PURPOSE OF REVIEW

This report reviews recent aspects of pancreatitis immunology and environmental factors that link to development and progression of disease.

RECENT FINDINGS

Limited human and animal model studies have recently attempted to understand immune mechanisms that lead to the pathogenesis of acute and chronic pancreatitis. Based on these studies innate immune responses emerge as critical elements in disease pathogenesis and severity of inflammation. The immune basis for environmental factors such as smoking, which are highly associated with disease progression highlight novel cross talk mechanisms between immune and nonimmune pancreatic cells such as the pancreatic stellate cells.

SUMMARY

Better understanding of immune responses and signaling pathways are emerging as important contributors in pancreatitis development and progression. Such mechanisms are likely to offer future targetable therapies that can either halt or reverse disease progression.

The Prognosis of Severe Acute Pancreatitis Varies According to the Segment Presenting With Low Enhanced Pancreatic Parenchyma on Early Contrast-Enhanced Computed Tomography: A Multicenter Cohort Study

OBJECTIVE

The aim of this study was to investigate the outcomes of severe acute pancreatitis (SAP) according to the segment presenting with low enhanced pancreatic parenchyma (LEPP) on early contrast-enhanced computed tomography.

METHODS

This was a post hoc analysis of a multicenter, retrospective study conducted at 44 institutions in Japan. Patients diagnosed as having SAP according to the Japanese Severity Score between January 2009 and December 2013 were included. We compared the effect of LEPP in each segment on mortality.

RESULTS

A total of 1097 patients were assessed. The numbers of patients with LEPP in the pancreatic head (Ph), body (Pb), or tail (Pt) were 272, 273, and 204 (with some overlaps), respectively. In multivariate analysis, LEPP in Ph and Pt was significantly related to mortality (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.11-3.40 [P < 0.05], for LEPP in Ph; OR, 2.44; 95% CI, 1.27-4.67 [P < 0.05], for LEPP in Pt), but LEPP in Pb was unrelated to mortality (OR, 0.70; 95% CI, 0.35-1.37; P = 0.30).

CONCLUSIONS

Presence of LEPP in Ph and Pt on early contrast-enhanced computed tomography was independently associated with increased mortality in SAP. These patients require close observation to ensure timely and adequate intervention.

Elevated Serum Triglycerides in the Prognostic Assessment of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Hypertriglyceridemia has been positively associated with the risk of acute pancreatitis (AP), but whether increased triglyceride (TG) levels are associated with the severity of AP remains unknown. To this, a meta-analysis was conducted to assess the effect of elevated serum TG on the prognosis of AP.

METHODS

We searched PubMed, EMBASE, and the Cochrane library to identify all eligible studies (up to September 2016). We pooled the odds ratios (ORs) or standardized mean difference from individual studies using a random-effects model to investigate associations between levels of TG and the prognosis of AP.

RESULTS

A total of 15 studies were included in the meta-analysis, including a total of 1564 patients with triglyceride-related acute pancreatitis (TGAP) and 5721 patients with nontriglyceride-related acute pancreatitis (NTGAP). The occurrence of renal failure [OR=3.18; 95% confidence interval (CI): 1.92, 5.27; P<0.00001], respiratory failure (OR=2.88; 95% CI: 1.61, 5.13; P<0.0001), and shock (OR=3.78; 95% CI: 1.69, 8.44; P<0.0001) was statistically significantly higher in TGAP group than in NTGAP group. Furthermore, mortality (OR=1.90; 95% CI: 1.05, 3.45; P<0.01), systemic inflammatory response syndrome (OR=2.03; 95% CI: 1.49, 2.75; P<0.00001), and Acute Physiology and Chronic Health Evaluation (APACHE-II) scores (standardized mean difference=2.72; 95% CI: 1.00, 4.45; P<0.001) were also statistically significantly higher in TGAP group than in NTGAP group.

CONCLUSION

Elevated serum TGs are related to a worse prognosis of AP.

Selective inhibition of BET proteins reduces pancreatic damage and systemic inflammation in bile acid- and fatty acid ethyl ester- but not caerulein-induced acute pancreatitis

OBJECTIVES

To evaluate the therapeutic potential of I-BET-762, an inhibitor of the bromodomain and extra-terminal (BET) protein family, in experimental acute pancreatitis (AP).

METHODS

AP was induced by retrograde infusion of taurolithocholic acid sulphate into the biliopancreatic duct (TLCS-AP) or 2 intraperitoneal (i.p.) injections of ethanol and palmitoleic acid 1 h apart (FAEE-AP) or 12 hourly i.p. injections of caerulein (CER-AP). In all treatment groups, I-BET-762 (30 mg/kg, i.p.) was administered at the time of disease induction and again 12 h later. AP severity was assessed at 24 h by serum biochemistry, multiple cytokines and histopathology.

RESULTS

TLCS-AP, FAEE-AP and CER-AP resulted in characteristic elevations in serum amylase and cytokine levels, increased pancreatic trypsin and myeloperoxidase activity, typical pancreatic histopathological changes and lung injury. Treatment with I-BET-762 significantly reduced biochemical, cytokine and histopathological responses in TLCS-AP and FAEE-AP, but not CER-AP.

CONCLUSIONS

These results suggest that in different forms of AP there are significant differences in the epigenetic control of gene transcription contributing to the severity of disease responses. There is therapeutic potential in targeting bromodomains for the treatment of gallstone- and alcohol-related pancreatitis.

Assessment of Pancreas Safety in the Development Program of Once-Weekly GLP-1 Receptor Agonist Dulaglutide

OBJECTIVE

To assess the risk of acute pancreatitis during treatment with glucagon-like peptide 1 receptor agonist dulaglutide, placebo, and active comparators across phase 2/3 dulaglutide trials.

RESEARCH DESIGN AND METHODS

A total of 6,005 patients with type 2 diabetes participated (dulaglutide group N = 4,006 [dose range 0.1-3.0 mg]; active comparator group [metformin, sitagliptin, exenatide twice daily, insulin glargine] N = 1,541; placebo group N = 703; 245 placebo-treated patients subsequently received dulaglutide or sitagliptin and were also included in these groups) for up to 104 weeks. The following events were adjudicated: investigator-reported pancreatitis, adverse events (AEs) of severe or serious abdominal pain of unknown etiology, and confirmed asymptomatic increases in pancreatic enzymes ≥3× the upper limit of normal range.

RESULTS

Overall, 203 events from 151 patients underwent adjudication (dulaglutide group n = 108; comparator group including placebo n = 43). Acute pancreatitis was confirmed by adjudication in seven patients (dulaglutide n = 3, placebo n = 1, sitagliptin n = 3). Exposure-adjusted incidence rates were as follows: dulaglutide group 0.85 patients/1,000 patient-years, placebo group 3.52 patients/1,000 patient-years, sitagliptin group 4.71 patients/1,000 patient-years. No events of pancreatitis were confirmed by adjudication in patients treated with exenatide twice daily, metformin, or glargine. Increases in median values of lipase and pancreatic amylase within the normal range were observed with all treatments except glargine. These changes were not associated with AEs.

CONCLUSIONS

The exposure-adjusted incidence rate of acute pancreatitis in dulaglutide-treated patients was similar to the rates with placebo, with few reported cases during the entire program.

Prediction of acute pancreatitis in the earliest stages – role of biochemical parameters and histopathological changes

For many years, there has been a search for a set of biochemical parameters that could facilitate the assessment of severity, prognosis, and administration of early and appropriate treatment in acute pancreatitis. Administration of treatment within the first 48 hours since admission is associated with many problems of distinguishing patients with a mild form of acute pancreatitis (AP) from those with a severe form of acute pancreatitis. Study aim: To assess the relationship between the extent of change in the concentration of 10 selected biochemical indicators: amylase, lipase, total bilirubin, creatinine, uric acid, aspartate transaminase, alanine transaminase, glucose, magnesium, and iron and histopathological lesions in the pancreas within 2 and 6 hours since induction of AP. The selected time periods correspond to the first and the second day of the disease in people, respectively. Material and methods: The experiments were conducted in 110 male Wistar rats weighing from 250 to 300 g. Experimental animals were divided into three groups: Z – a group in which the ranges of the studied factors and histological structure were established; K – a group of animals operated on which were injected with 0.9% NaCl into the biliary-pancreatic duct; E – a group of animals operated on in which acute pancreatitis was induced by an injection of 5% sodium taurocholate into the biliary-pancreatic duct. Animals from the K and E groups were randomly assigned to one of five subgroups from which the material for biochemical and histological examinations was collected at 2 h and 6 h since the induction of AP. Whole pancreases were dissected for histological examinations, and the samples were dyed with hematoxylin and saturated alcoholic eosin solution. The degree of pancreatic lesions was assessed according to the Spormann score. Quantitative variables were characterized by arithmetic means, standard deviations, medians, minimum and maximum values, and 95% CIs. Results: In histological preparations from rats from the E group, after 2 hours, edematous lesions, neutrophilic infiltrations in the pancreatic parenchyma, together with single petechiae started to appear and were observed. After 6 hours, the lesions became more intense, and minor foci of coagulation necrosis and minor foci of purulent inflammation in the fatty tissue appeared. Within 2 hours, statistically significant differences in the amount of four markers: creatinine, ALT, amylase, and magnesium were observed. After six hours, statistically significant differences in the amount of two markers: AST and glucose were seen. The correlations between histological assessments according to the Spormann scale and biochemical indicators were investigated, and it was observed that within 2 hours the intensity of pancreatitis increased together with an increase in AST. In group K, within 6 hours, the intensity of inflammatory infiltration increased together with an increase in creatinine concentration (correlation coefficient 0.95; p=0.0138). In group E, in the period of 2 hours, lesion intensity in the form of inflammatory infiltration increased together with an increase in the AST level (correlation coefficient 0.90; p=0.0063) and an increase in the iron level (correlation coefficient 0.78; p=0.0399). In the same group and in the same period, an increase in the AST level (correlation coefficient 0.79; p=0.0343) was associated with an increase in lesion intensity in the form of ecchymoses. Inflammatory infiltration increased (correlation coefficient -0.87; p=0.0117) within 6 hours, whereas the creatinine level decreased. Interesting results were obtained with the use of regression analysis – forward stepwise regression. In the period of 2 hours, if the creatinine level increased by 1, the intensity of lesions in acute pancreatitis decreased by 9.02, according to the Spormann score, while the other variables remained at a stable level. However, if ALT level increased by 1, the intensity of lesions in acute pancreatitis increased by 0.02, according to the Spormann score; and if the amylase level increased by 1, the intensity of lesions in acute pancreatitis increased by 0.01, according to the Spormann score, while the other variables remained at a stable level. Conclusions: Histopathological lesions occurred prior to changes in laboratory test results, whereas significant correlations with Spormann scores were seen in the case of changes in AST and creatinine levels. The study results confirm the fact that diagnostics in acute pancreatitis is very difficult and requires monitoring of many laboratory parameters.

D-二聚体在急性胰腺炎中的特点

目的

回顾性分析无锡101医院近2年来急性胰腺炎(acute pancreatitis, AP)患者D-二聚体(D-dimer, DD)值与临床特点, 探讨DD与病情严重程度的相关性, 为其临床研究提供参考.

方法

收集解放军101医院2014-04-01/2016-04-01 AP患者, 记载临床特点, 根据病情分为轻、中、重3组, 分析AP患者DD水平、住院时间、费用、Rason评分及CT严重度指数(CT severity index, CTSI)评分.

结果

符合要求者共172例, 其中轻度急性胰腺炎(mild acute pancreatitis, MAP)组111例, 中度重症急性胰腺炎(moderately severe acute pancreatitis, MSAP)组52例, 重症急性胰腺炎(severe acute pancreatitis, SAP)组9例. DD水平在MSAP、SAP组中明显高于MAP组, 有统计学意义(P<0.01), 但MSAP组对比SAP组无明显差异; 另外住院天数及费用3组间呈递增, 有统计学差异. 将3组患者中年龄<60岁分为中青年组, 年龄≥60岁为老年组, 其中SAP、MSAP两组中老年患者明显高于中青年患者(P<0.05), SAP组中未见明显差异; 老年患者中MAP、MSAP、SAP 3组DD水平均无统计学差异. DD与住院天数、费用、CTSI分级、Ranson评分系统的相关系数分别为0.429、0.436、0.402、0.447, 呈正相关.

结论

DD在AP患者显著增高, 中、重度组尤为明显, 与住院时间、费用、评分呈正相关, 本研究表明血浆DD体对AP严重程度的早期判断有一定的意义, 但对于老年AP患者以及对MSAP和SAP患者的判断效果欠佳.

Role of intraoperative cholangiography for detecting residual stones after biliary pancreatitis: still useful? A retrospective study

Background

Intraoperative cholangiography (IOC) may detect residual stones in the common bile duct (CBD) after acute biliary pancreatitis (ABP). The aim of the present study is to analyze the utility of IOC in detecting residual stones in patients undergoing cholecystectomy for ABP and if complications are related with this procedure.

Methods

Demographic and clinical factors were assessed in patients with mild ABP who underwent IOC during laparoscopic cholecystectomy. Factors assessed included preoperative size of the CBD on ultrasonography, presence of stones in the gallbladder and the CBD, and IOC results. For the statistical analysis, χ² or Fisher’s exact tests to compare proportions and the nonparametric Mann–Whitney U test for analysis of values with abnormal distribution were used.

Results

The study included 113 patients, 82 males (72.6%) and 31 females (27.4%), of mean age 46.9 ± 14.7 years (range 18–86 years). All preoperative laboratory indicators were elevated. The group of the patients with stones in the CBD diagnosed by IOC was divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD diagnosed preoperatively with ultrasound. The laboratory tests do not demonstrate difference statistically significative between these two groups. The group of the patients without stones in the CBD diagnosed by IOC was also divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD. Also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significative difference. Most procedures were performed by specialists (64.6%), and all patients underwent IOC. IOC showed stones in 84/113 patients (74.3%). A comparison of patients with and without stones at IOC showed similar mean times from hospitalization to surgery (5.9 days [range 2–12 days] vs. 6.1 days [range 2–23 days]), from surgery until hospital discharge (2.0 days [range 0–4 days] vs. 2.2 days [range 0–11 days]), and overall length of stay (7.9 days [range 3–19 days] vs. 8.3 days [range 3–23 days]) (P > 0.001).

Conclusions

IOC is useful to diagnose residual CBD stones, without increasing complications related to the procedure itself.

Deletion Of XIAP reduces the severity of acute pancreatitis via regulation of cell death and nuclear factor-κB activity

Severe acute pancreatitis (SAP) still remains a clinical challenge, not only for its high mortality but the uncontrolled inflammatory progression from acute pancreatitis (AP) to SAP. Cell death, including apoptosis and necrosis are critical pathology of AP, since the severity of pancreatitis correlates directly with necrosis and inversely with apoptosis Therefore, regulation of cell death from necrosis to apoptosis may have practicably therapeutic value. X-linked inhibitor of apoptosis protein (XIAP) is the best characterized member of the inhibitor of apoptosis proteins (IAP) family, but its function in AP remains unclear. In the present study, we investigated the potential role of XIAP in regulation of cell death and inflammation during acute pancreatitis. The in vivo pancreatitis model was induced by the administration of cerulein with or without lipopolysaccharide (LPS) or by the administration of l-arginine in wild-type or XIAP-deficient mice, and ex vivo model was induced by the administration of cerulein+LPS in AR42J cell line following XIAP inhibition. The severity of acute pancreatitis was determined by serum amylase activity and histological grading. XIAP deletion on cell apoptosis, necrosis and inflammatory response were examined. Caspases activities, nuclear factor-κB (NF-κB) activation and receptor-interacting protein kinase1 (RIP1) degradation were assessed by western blot. Deletion of XIAP resulted in the reduction of amylase activity, decrease of NF-κB activation and less release of TNF-α and IL-6, together with increased caspases activities and RIP1 degradation, leading to enhanced apoptosis and reduced necrosis in pancreatic acinar cells and ameliorated the severity of acute pancreatitis. Our results indicate that deletion of XIAP switches cell death away from necrosis to apoptosis and decreases the inflammatory response, effectively attenuating the severity of AP/SAP. The critical role of XIAP in cell death and inflammation suggests that inhibition of XIAP represents a potential therapeutic strategy for the treatment of acute pancreatitis.

Two Mutations Induce Early-Onset Severe Chronic Pancreatitis

The SPINK1 protein is a potent antiprotease that can inactivate any intrapancreatic trypsin activity that would otherwise induce autodigestion of the pancreas. SPINK1 mutations have been recognized to be associated with chronic pancreatitis in patients without a family history of pancreatitis. We here describe the case of a 24-year-old woman referred to our service for recurrent abdominal pain and search for the cause of chronic calcifying pancreatitis, who was found to carry 2 SPINK1 mutations.

Antifibrotic Effect of Saturated Fatty Acids via Endoplasmic Reticulum Stress Response in Rat Pancreatic Stellate Cells

OBJECTIVES

We investigated the effect of saturated fatty acids on chronic pancreatitis pathogenesis by elucidating the endoplasmic reticulum (ER) stress response in pancreatic stellate cells (PSCs), which are major effector cells in pancreatic fibrosis.

METHODS

Wistar Bonn/Kobori rats were fed either control diet or high-fat diet (HFD) for 4 weeks. Meanwhile, cultured rat PSCs were stimulated with thapsigargin, an ER stress inducer, or palmitic acid (PA). Pancreatic fibrosis, expressions of fibrosis-related and ER stress-related proteins and mRNA, cell viability, and apoptosis were examined.

RESULTS

The HFD reduced fibrosis and α-smooth muscle actin expression (ie, activated PSCs) but upregulated ER stress-related mRNA expression in the pancreas of young HFD-fed Wistar Bonn/Kobori rats. Induction of ER stress response in PSCs with thapsigargin or PA induced apoptosis, activated the protein kinase-like ER kinase (PERK) pathway, inhibited cell viability, and downregulated fibrosis-related protein and mRNA expression. The PERK inhibitor negated PA-induced ER stress response.

CONCLUSIONS

Saturated fatty acids can inhibit but may not promote the fibrogenesis of chronic pancreatitis, at least in the early stage, via an ER stress response (ie, the PERK pathway) in PSCs. Moreover, induction of an apoptotic ER stress response in PSCs might be a novel therapeutic strategy for pancreatic fibrosis.

Immunopathogenesis of pancreatitis

The conventional view of the pathogenesis of acute and chronic pancreatitis is that it is due to a genetic- or environment-based abnormality of intracellular acinar trypsinogen activation and thus to the induction of acinar cell injury that, in turn, sets in motion an intra-pancreatic inflammatory process. More recent studies, reviewed here, present strong evidence that while such trypsinogen activation is likely a necessary first step in the inflammatory cascade underlying pancreatitis, sustained pancreatic inflammation is dependent on damage-associated molecular patterns-mediated cytokine activation causing the translocation of commensal (gut) organisms into the circulation and their induction of innate immune responses in acinar cells. Quite unexpectedly, these recent studies reveal that the innate responses involve activation of responses by an innate factor, nucleotide-binding oligomerization domain 1 (NOD1), and that such NOD1 responses have a critical role in the activation/production of nuclear factor-kappa B and type I interferon. In addition, they reveal that chronic inflammation and its accompanying fibrosis are dependent on the generation of IL-33 by injured acinar cells and its downstream induction of T cells producing IL-13. These recent studies thus establish that pancreatitis is quite a unique form of inflammation and one susceptible to newer, more innovative therapy.

Different phenotypes of monocytes in patients with new-onset mild acute pancreatitis

AIM

To evaluate the numbers of different subsets of monocytes and their associations with the values of clinical measures in mild acute pancreatitis (MAP) patients.

METHODS

The study included one group of 13 healthy controls and another group of 24 patients with new-onset MAP. The numbers of different subsets of monocytes were examined in these two groups of subjects by flow cytometry. The concentrations of plasma interleukin (IL)-10 and IL-12 were determined by cytometric bead array. The acute physiology and chronic health evaluation (APACHE) II scores of individual patients were evaluated, and the levels of plasma C-reactive protein (CRP) as well as the activities of amylase and lipase were measured.

RESULTS

In comparison with that in the controls, significantly increased numbers of CD14+CD163-, CD14+CD163-MAC387+ M1 monocytes, but significantly reduced numbers of CD14+CD163+IL-10+ M2 monocytes were detected in the MAP patients (P < 0.01 or P < 0.05). Furthermore, significantly higher levels of plasma IL-10 and IL-12 were observed in the MAP patients (P < 0.01 for all). More importantly, the levels of plasma CRP were positively correlated with the numbers of CD14+CD163- (R = 0.5009, P = 0.0127) and CD14+CD163-MAC387+ (R = 0.5079, P = 0.0113) M1 monocytes and CD14+CD163+CD115+ M2 monocytes (R = 0.4565, P = 0.0249) in the patients. The APACHE II scores correlated with the numbers of CD14+CD163+CD115+ (R = 0.4581, P = 0.0244) monocytes and the levels of plasma IL-10 (R = 0.4178, P = 0.0422) in the MAP patients. However, there was no significant association among other measures tested in this population.

CONCLUSION

Increased numbers of CD14+CD163- and CD14+ CD163-MAC387+ monocytes may contribute to the pathogenesis of MAP, and increased numbers of CD14+CD163+CD115+ monocytes may be a biomarker for evaluating the severity of MAP.

Pharmacokinetics and pharmacodynamics of Da-Cheng-Qi decoction in the liver of rats with severe acute pancreatitis

AIM

To explore the pharmacokinetics and pharmacodynamics of Da-Cheng-Qi decoction (DCQD) in the liver of rats with severe acute pancreatitis (SAP) based on an herbal recipe tissue pharmacology hypothesis.

METHODS

Healthy male Sprague-Dawley rats were randomly divided into a sham operation group (SOG); a model group (MG); and low-, median- and high-dose treatment groups (LDG, MDG, and HDG, respectively). Different dosages (6, 12 and 24 g/kg for the LDG, MDG, and HDG, respectively) of DCQD were administered to the rats with SAP. The tissue concentrations of aloe-emodin, rhein, emodin, chrysophanol, honokiol, rheo chrysophanol, magnolol, hesperidin, naringenin and naringin in the liver of the treated rats were detected by high-performance liquid chromatography tandem mass spectrometry. Alanine transaminase (ALT) and aspartate transaminase (AST) in serum, inflammatory mediators in the liver and pathological scores were evaluated.

RESULTS

The major components of DCQD were detected in the liver, and their concentrations increased dose-dependently. The high dose of DCQD showed a maximal effect in ameliorating the pathological damages, decreasing the pro-inflammatory mediators tumor necrosis factor-α and interleukin (IL)-6 and increasing anti-inflammatory mediators IL-4 and IL-10 in the liver. The pathological scores in the pancreas for the MG were significantly higher than those for the SOG (P < 0.05). DCQD could reduce the pathological scores in the pancreas and liver of the rats with SAP, especially in the HDG. Compared to the SOG, the ALT and AST levels in serum were higher in the MG (P < 0.05), while there was no statistical difference in the MG and HDG.

CONCLUSION

DCQD could alleviate liver damage by altering the inflammatory response in rats with SAP based on the liver distribution of its components.

Acute acinar pancreatitis blocks vesicle-associated membrane protein 8 (VAMP8)-dependent secretion, resulting in intracellular trypsin accumulation

Zymogen secretory granules in pancreatic acinar cells express two vesicle-associated membrane proteins (VAMP), VAMP2 and -8, each controlling 50% of stimulated secretion. Analysis of secretion kinetics identified a first phase (0-2 min) mediated by VAMP2 and second (2-10 min) and third phases (10-30 min) mediated by VAMP8. Induction of acinar pancreatitis by supramaximal cholecystokinin (CCK-8) stimulation inhibits VAMP8-mediated mid- and late-phase but not VAMP2-mediated early-phase secretion. Elevation of cAMP during supramaximal CCK-8 mitigates third-phase secretory inhibition and acinar damage caused by the accumulation of prematurely activated trypsin. VAMP8^-/- acini are resistant to secretory inhibition by supramaximal CCK-8, and despite a 4.5-fold increase in total cellular trypsinogen levels, are fully protected from intracellular trypsin accumulation and acinar damage. VAMP8-mediated secretion is dependent on expression of the early endosomal proteins Rab5, D52, and EEA1. Supramaximal CCK-8 (60 min) caused a 60% reduction in the expression of D52 followed by Rab5 and EEA1 in isolated acini and in in vivo The loss of D52 occurred as a consequence of its entry into autophagic vacuoles and was blocked by lysosomal cathepsin B and L inhibition. Accordingly, adenoviral overexpression of Rab5 or D52 enhanced secretion in response to supramaximal CCK-8 and prevented accumulation of activated trypsin. These data support that acute inhibition of VAMP8-mediated secretion during pancreatitis triggers intracellular trypsin accumulation and loss of the early endosomal compartment. Maintaining anterograde endosomal trafficking during pancreatitis maintains VAMP8-dependent secretion, thereby preventing accumulation of activated trypsin.

CD4 + CD25 + CD127 high cells as a negative predictor of multiple organ failure in acute pancreatitis

Background

It has been suggested that severity of the immune response induced by immune cells is associated with morbidity and mortality from acute pancreatitis. The authors investigated and evaluated the relationship between distinct peripheral lymphocyte subsets at admission and clinical outcome prior to hospital discharge so as to find a predictor to the prognosis of acute pancreatitis in lymphocyte profile.

Methods

Lymphocyte subsets in admission peripheral venous blood were tested through flow cytometry on 48 patients with acute pancreatitis. Clinical data was recorded as well. The primary observational outcomes were multiple organ failure (MOF) and infection.

Results

There was a significant difference in natural killer cells between two subgroups sorted by the presence or absence of infection (25.5 ± 4.47 [95% CI 14.4, 36.6] vs 14.8 ± 7.62 [95% CI 12.5,1 7.1] p = 0.021). Patients who developed MOF had lower CD4 + CD25 + CD127^high (4.49 ± 1.5 (MOF) [95% CI 3.83, 5.16] vs 6.57 ± 2.65 (non-MOF) [95% CI 5.5, 7.64] p = 0.002) and higher CD127low/high cell counts (1.35 ± 0.66 [95% CI 1.06, 1.65] vs 0.97 ± 0.44 [95% CI 0.79, 1.15] p = 0.02). MOF patients were significantly older (55 ± 14.58 [95% CI 48.49,61.42] vs 46 ± 15.59 [95% CI 39.39,51.99] p = 0.04), and had higher Acute Physiology and Chronic Health Evaluation IIscores (7 ± 3.66 [95% CI 5.5,7.64] vs 4 ± 2.89 [95% CI 2.45,4.78] p = 0.001) and C reactive protein (100.53 ± 94.38 [95% CI 58.69,142.48] vs 50.8 ± 59.2 [95% CI 26.88,74.71] p = 0.04). In a multivariate regression model, only CD4 + CD25 + CD127^high cell was a significant predictor of non-MOF. For the detection of non-MOF, CD4 + CD25 + CD127^high cell generated a receiver operating characteristic (ROC) curve with an area under the curve of 0.74.

Conclusion

CD4 + CD25 + CD127^high cell at early phase of acute pancreatitis yields good specificity in detecting non-MOF at a suggested cutoff value 6.41%. Patients with fewer natural killer cells may be at risk in developing secondary infection.

Thrombopoietin as Early Biomarker of Disease Severity in Patients With Acute Pancreatitis

OBJECTIVES

To study the concentrations of thrombopoietin (TPO), a growth factor recently involved in the pathogenesis of experimental acute pancreatitis (AP), and its potential role as an early diagnostic and prognostic biomarker in patients with AP.

METHODS

Thrombopoietin was measured in 44 AP patients, 18 patients with nonpancreatic acute abdominal pain, and 18 healthy volunteers. Acute pancreatitis severity was classified on the basis of the 2012 International Atlanta Symposium on Acute Pancreatitis criteria.

RESULTS

Thrombopoietin levels did not differ between AP patients and control subjects, whereas these were higher in patients with moderately severe or severe AP compared with those with mild AP. Receiver operating characteristic curve analysis of TPO for severe AP diagnosis showed an area under the curve of 0.80. A cutoff value of 31.48 pg/mL showed the highest sensitivity, allowing to rule out severe AP when TPO was lower, whereas TPO higher than 98.23 pg/mL was associated with severe AP with high specificity (93.5%). Furthermore, TPO levels were greater in AP patients developing organ dysfunction or sepsis and in nonsurvivors compared with survivors.

CONCLUSIONS

Our data provide the first evidence for TPO as potential early prognostic biomarker in AP patients. High TPO levels at hospital admission may predict organ dysfunction, sepsis, and fatal outcome in AP patients.

Biliary tract external drainage protects against multiple organs injuries of severe acute pancreatitis rats via heme oxygenase-1 upregulation

OBJECTIVE

To investigate the effect of biliary tract external drainage (BTED) on severe acute pancreatitis (SAP) in rats and the relationship with heme oxygenase-1 (HO-1) pathway.

METHODS

Thirty SD rats weighing 250-300 g were randomly assigned into five groups (n = 6): sham surgery (SS) group, SAP group, SAP + BTED group, SAP + zinc protoporphyrin IX (ZnPP) group, SAP + BTED + ZnPP group. The SAP model was induced via retrograde injection of 4% sodium taurocholate (1 mL/kg) into biliopancreatic duct through duodenal wall. BTED was performed by inserting a cannula into the bile duct of SAP rats. Tissue and blood samples were collected 24 h after surgery. Pathological changes in organs were scored. The level of amylase, alanine transaminase (ALT), aspartate aminotransferase (AST), diamine oxidase (DAO), lipopolysaccharide (LPS), myeloperoxidase (MPO) and ability to inhibit hydroxyl radical(·OH) in serum were measured. The expression of hemeoxygenase-1 (HO-1), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) in tissues were analyzed by RT- PCR and western-blot.

RESULTS

Organs damage in SAP rats was significantly alleviated by BTED (p < 0.05). Compared to the SAP group, the serum level of amylase, ALT, AST, DAO, MPO, and LPS were significantly lower in the SAP + BTED group, and the ability to inhibit ·OH was significantly higher (p < 0.05). The BETD treatment led to a significant reduction of TNF-α, IL-6 level and a significant increase of HO-1 level in tissues than in SAP rats (p < 0.05). ZnPP significantly inhibited all above mentioned changes.

CONCLUSIONS

BTED protected multiple organs against SAP related injuries via HO-1 upregulation.

Low-methoxyl lemon pectin attenuates inflammatory responses and improves intestinal barrier integrity in caerulein-induced experimental acute pancreatitis

SCOPE

Acute pancreatitis (AP) is a common clinical acute abdominal disease. The intestinal injury associated with AP will aggravate the condition retroactively. This study investigates whether the low-methoxyl pectin (LMP) isolated from lemon could attenuate AP and associated intestinal injury.

METHODS AND RESULTS

Experimental AP was induced in BALB/c mice by caerulien (CAE) hyperstimulation. Nutritional prophylactic group was pre-fed with 5% LMP supplemented forage 3 days before AP induction. We found that LMP supplementation attenuated the severity of AP as evidenced by reduced serum amylase and lipase levels, pancreatic edema and myeloperoxidase activity. The protective effect was also confirmed by histological examination of pancreatic damage. LMP suppressed the production of pancreatic proinflammatory cytokines including TNF-α, IL-1β, and IL-6. Moreover, LMP supplementation restored AP-associated disruption of intestinal barrier integrity as evidenced by upregulation of tight junction modulatory proteins occludin, zonula occludens (ZO)-1, antimicrobial peptides β-defensin-1 (DEFB1) and CRAMP as well as increase in SCFAs production. LMP supplemented mice with AP exhibited suppressed intestinal inflammation as shown by decreased ileal and colon cytokine production compared with CAE group.

CONCLUSION

Our results support dietary LMP supplementation as an effective nutritional intervention for AP and associated intestinal injury.

Antithrombin III and D-dimer levels as indicators of disease severity in patients with hyperlipidaemic or biliary acute pancreatitis

Objective To assess changes in anticoagulation and fibrinolytic systems between biliary and hyperlipidaemic acute pancreatitis (AP). Methods Patients with biliary or hyperlipidaemic AP were enrolled. Demographic and clinical data were collected, and antithrombin III (ATIII), protein C, protein S, and D-dimer levels were investigated. Results A total of 45 patients with biliary AP and 50 patients with hyperlipidaemic AP were included (68 with mild AP and 27 with moderately-severe AP). ATIII and protein C levels in the mild AP group were significantly higher, but prothrombin time and D-dimer were significantly lower, versus the moderately-severe AP group. ATIII and D-dimer were found to be risk factors for moderately-severe AP. ATIII could predict AP severity, particularly in patients with biliary AP. D-dimer was a sensitive and specific predictor for disease severity in patients with AP, particularly in patients with hyperlipidaemic AP. Conclusion ATIII and protein C levels decreased as severity of AP increased, particularly in cases of biliary AP. D-dimer levels increased with severity of AP, particularly in hyperlipidaemic AP. ATIII and D-dimer may be useful biomarkers for assessing AP severity in patients with biliary and hyperlipidaemic AP, respectively.

Acute pancreatitis in patients with pancreatic cancer: Timing of surgery and survival duration

Acute pancreatitis (AP) is a rare manifestation of pancreatic cancer (PC). The relationship between AP and PC remains less distinct.From January 2009 to November 2015, 47consecutive patients with PC who presented with AP were reviewed for this study. Clinical features, clinicopathologic variables, postoperative complications, and follow-up evaluations of patients were documented in detail from our database. In order to identify cutoff threshold time for surgery, receiver operating curve (ROC) was built according to patients with or without postoperative complications. Cumulative rate of survival was calculated by using the Kaplan-Meier method. The study was conducted in accordance with the principles of the Declaration of Helsinki and the guidelines of West China Hospital.This study included 35 men (74.5%) and 12 women (25.5%) (mean age: 52 years), with a median follow-up of 40 months. AP was clinically mild in 45 (95.7%) and severe in 2 (4.3%). The diagnosis of PC was delayed by 2 to 660 days (median 101 days). Thirty-nine (83.0%) cases underwent surgery. Eight (17.0%) cases performed biopsies only. Of 39 patients, radical surgery was performed in 32 (82.1%) cases and palliative in 7 (19.9%) cases. Two (8.0%) patients were needed for vascular resection and reconstruction. Postoperative complications occurred in 12 (30.8%) patients. About 24.5 days was the best cutoff point, with an area under curve (AUC) of 0.727 (P = 0.025, 95% confidence interval: 0.555-0.8999). The survival rate of patients at 1 year was 23.4%. The median survival in patients with vascular resection and reconstruction was 18 months, compared with 10 months in patients without vascular resection (P = 0.042). For the primary stage (T), Tix was identified in 3 patients, the survival of whom were 5, 28, 50 months, respectively. And 2 of them were still alive at the follow-up period.The severity of AP was mainly mild. Surgical intervention after 24.5 days may benefit for reducing postoperative complications. Patients with vascular resection and reconstruction, thus achieving tumor-free margins, had a long-time survival.

Genetic Susceptibility in Acute Pancreatitis: Genotyping of GSTM1, GSTT1, GSTP1, CASP7, CASP8, CASP9, CASP10, LTA, TNFRSF1B, and TP53 Gene Variants

OBJECTIVES

Genetic testing could play a critical role in diagnosis and prognosis of acute pancreatitis (AP) and guide effective therapeutic interventions. We hypothesized that genetic polymorphisms in apoptosis and oxidative stress genes could determine incidence or severity in AP.

METHODS

We conducted a hospital-based case-control study in a white Portuguese population (133 AP patients and 232 age- and sex-matched healthy controls) to evaluate the role of 15 gene polymorphisms (2 deletions and 13 single nucleotide polymorphisms [SNPs]) in oxidative stress (GSTM1, GSTT1, GSTP1) and apoptosis genes (CASP7, CASP8, CASP9, CASP10, LTA, TNFRSF1B, TP53) in AP. Criteria for AP were abdominal pain, hyperamylasemia, and contrast-enhanced computed tomography.

RESULTS

The presence of GSTM1 is associated with increased susceptibility for AP, and the GSTP1 Val105Ile SNP is associated with an increased risk for AP in men. CASP9 Phe136Leu/Phe136Phe SNPs (heterozygotes) increases the risk for mild AP (odds ratio, 3.616; 95% confidence interval, 1.151-11.364; P < 0.05), whereas the homozygotic genotype of CASP9 Ala28Val decreases risk for mild AP (odds ratio, 0.296; 95% confidence interval, 0.091-0.963; P < 0.05).

CONCLUSIONS

Our results suggest that variations in GSTM1, GSTP1, and CASP9 may influence risk for AP.

Nucleotide-binding oligomerization domain 1 and gastrointestinal disorders

Nucleotide-binding oligomerization domain 1 (NOD1) is an intracellular sensor that detects small peptides derived from the cell wall component of intestinal microflora. NOD1 is expressed in both non-hematopoietic cells such as epithelial cells and hematopoietic cells such as antigen-presenting cells. Detection of its ligand by NOD1 leads to innate immune responses through activation of nuclear factor kappa B and type I interferon as well as induction of autophagy. Innate immune responses through NOD1 activation play an indispensable role both in host defense against microbial infection and in the development of gastrointestinal disorders. Of particular importance, NOD1-mediated innate immune responses are associated with mucosal host defenses against Helicobacter pylori (H. pylori) infection of the stomach and with the development of pancreatitis. In this review, we discuss the molecular mechanisms by which NOD1 activation leads to the development of H. pylori-related gastric diseases and pancreatitis.

Network Pharmacological Screening of Herbal Monomers that Regulate Apoptosis-Associated Genes in Acute Pancreatitis

OBJECTIVES

In this study, we screened for differentially expressed genes in acute pancreatitis and the herbal monomers that regulate these genes.

METHODS

Gene expression profile data were downloaded from the Gene Expression Omnibus database (GSE3644). We used the Human Protein Reference Database to determine the protein-protein interaction network and CFinder software (Department of Biological Physics of Eötvös University, Budapest, Hungary) to identify several functional modules. Then, we used Database for Annotation, Visualization and Integrated Discovery software (Frederick, Md) to perform a gene ontology-biological process functional enrichment analysis. Based on a database of herbal monomers and a literature search, we constructed a gene-herbal monomer regulatory network using Cytoscape software (San Diego, Calif), and we analyzed the relationships between apoptosis, genes, and herbal monomers.

RESULTS

A total of 1745 differentially expressed genes were identified. Nine modules were identified, and the main function of module 3 was closely related to apoptosis. Within module 3, we selected 13 genes that were closely related to apoptosis for further analysis. In the gene-herbal monomer regulatory network, 18 herbal monomers that regulate multiple target genes were selected as the focus of this study.

CONCLUSIONS

These herbal monomers regulate multiple target genes to induce apoptosis and may potentially be used as new drugs for acute pancreatitis treatment in the future.

Expression pattern of HMGB1 and its association with autophagy in acute necrotizing pancreatitis

High-motility group box protein 1 (HMGB1) has an important role in autophagy; however, its exact role in acute necrotizing pancreatitis (ANP) remains unknown. The present study aimed to investigate the expression pattern of HMGB1 in ANP, and to determine its association with autophagy. Sprague Dawley rats (weight, 350±30 g, n=48) were randomly divided into control (n=12) and experimental (n=36) groups. Experimental rats were retrogradely injected with 5% sodium taurocholate into the biliopancreatic duct to induce ANP. Control rats received an equal amount of saline. Serum amylase levels were used to determine whether the model had been successfully generated. Autophagosomes in pancreatic acinar cells were observed under electron microscopy. The expression levels of HMGB1 and Beclin 1 were detected in pancreatic tissues by western blotting, quantitative polymerase chain reaction and immunohistochemistry. HMGB1 levels were also determined in the serum and in isolated nuclei. The results demonstrated that autophagy was detected at 3 h post-ANP induction; however, HMGB1 expression remained unaltered during the early stage (0–6 h; P>0.05). HMGB1 expression was significantly increased at 12 h, and was still increasing at 24 h (P<0.05). Notably, HMGB1 was increased in the nuclei compared with in the cytoplasm at 3–6 h. Furthermore, serum HMGB1 levels began to increase at 3 h, and reached the highest levels at 24 h in the ANP group. In conclusion, in an ANP model, HMGB1 was initially increased in the nuclei to initiate autophagy. Subsequently, it moved into the cytoplasm, where it interacted with Beclin 1 to enhance autophagy, and HMGB1 was released into the blood, leading to the deterioration of ANP.

Hydrogen-Rich Saline Attenuates Acute Hepatic Injury in Acute Necrotizing Pancreatitis by Inhibiting Inflammation and Apoptosis, Involving JNK and p38 Mitogen-Activated Protein Kinase-dependent Reactive Oxygen Species

OBJECTIVES

The objective of this study was to study the role of hydrogen-rich saline (HRS) on acute hepatic injury (AHI) in acute necrotizing pancreatitis (ANP).

METHODS

Rats were used for this study and an ANP model was induced by injecting 5% sodium taurocholate into the biliary-pancreatic duct. Experiments were performed in 3 groups: sham, ANP, and ANP + HRS (HRS). Animals were killed at 3, 12, and 24 hours after operation, and then blood and tissue samples were harvested. Various physiological, histological, and cellular and molecular parameters were analyzed.

RESULTS

Analyses of serum, lipase, alanine transaminase, and aspartate aminotransferase indicated that ANP-induced AHI model was established successfully and HRS attenuated hepatic dysfunction. Hepatic superoxide dismutase and malondialdehyde levels showed HRS against oxidative stress. Cellular and molecular analyses including p-p38, p-JNK, p-ERK, and caspase-3, caspase-9, NF-κB, and TNF-α in hepatic tissues revealed that HRS attenuated ANP-induced AHI by inhibiting apoptosis and phosphorylation of JNK and p38, as well as NF-κB activation.

CONCLUSIONS

Hydrogen-rich saline plays a protective role in ANP-induced AHI through inhibiting inflammation and apoptosis, involving JNK and p38 MAPK-dependent reactive oxygen species.

Accuracy of contrast-enhanced ultrasound compared with conventional ultrasound in acute pancreatitis: Diagnosis and complication monitoring

Contrast-enhanced ultrasound (CEUS) has been used for diagnosing acute pancreatitis (AP), particularly severe acute pancreatitis (SAP). However, the diagnostic difference between CEUS and conventional ultrasonography (CUS) for AP and SAP has not been reported. The aim of the present study was to investigate the diagnostic accuracy of CUS and CEUS for AP. A total of 196 patients clinically diagnosed with AP were selected. All patients underwent CUS, CEUS and contrast-enhanced computed tomography (CECT) within 72 h. CECT was considered the gold standard. Pancreatic size, peripancreatic fluid collection (PPFC) and splenic vessel complications were the variables observed by CUS and CEUS. The differences in the variables among the three methods were analyzed using the χ² test and statistical analysis software. Significant differences in pancreatic size, PPFC and splenic vessel complications in AP were observed between CEUS and CUS (P<0.05). χ² test results indicated that CEUS significantly differed from CUS in terms of having a higher diagnostic accuracy for AP and SAP (P<0.05). The results indicate that CEUS is a reliable method for the diagnosis and monitoring of AP and SAP, and may be substituted for CECT.

Carbon monoxide-bound hemoglobin vesicles ameliorate multiorgan injuries induced by severe acute pancreatitis in mice by their anti-inflammatory and antioxidant properties

Carbon monoxide (CO) has attracted attention as a possible therapeutic agent for affecting anti-inflammatory and antioxidant activities. Previously, CO-bound hemoglobin vesicle (CO-HbV) was developed as a nanotechnology-based CO donor, and its safety profile and therapeutic potential as a clinically applicable carrier of CO were examined in vitro and in vivo. In the present study, the therapeutic efficacy of CO-HbV against severe acute pancreatitis was examined with secondary distal organ-injured model mice that were fed with a choline-deficient ethionine-supplemented diet. A CO-HbV treatment significantly reduced the mortality of the acute pancreatitis model mice compared to saline and HbV. Biochemical and histological evaluations clearly showed that CO-HbV suppressed acute pancreatitis by inhibiting the production of systemic proinflammatory cytokines, neutrophil infiltration, and oxidative injuries in pancreatic tissue. Interestingly, CO-HbV also diminished the subsequent damage to distal organs including liver, kidneys, and lungs. This could be due to the suppression of neutrophil infiltration into tissues and the subsequently enhanced oxidative injuries. In contrast, O₂-bound HbV, the inactive form of CO-HbV, was ineffective against both pancreatitis and distal organ injuries, confirming that CO was directly responsible for the protective effects of CO-HbV in acute pancreatitis. These findings suggest that CO-HbV has anti-inflammatory and antioxidant characteristics of CO and consequently exerts a superior protective effect against acute pancreatitis-induced multiorgan damage.

Yin-Chen-Hao Tang Attenuates Severe Acute Pancreatitis in Rat: An Experimental Verification of In silico Network Target Prediction

Yin-Chen-Hao Tang (YCHT) is a classical Chinese medicine compound that has a long history of clinical use in China for the treatment of inflammatory diseases. However, the efficacy and mechanisms of YCHT for the treatment of severe acute pancreatitis (SAP) are not known. The current study investigated the pharmacological properties of YCHT against SAP and its underlying mechanisms. A computational prediction of potential targets of YCHT was initially established based on a network pharmacology simulation. The model suggested that YCHT attenuated SAP progress by apoptosis inducement, anti-inflammation, anti-oxidation and blood lipid regulation. These effects were validated in SAP rats. YCHT administration produced the following results: (1) significantly inhibited the secretion of pancreatic enzymes and protected pancreatic tissue; (2) obviously increased the number of in situ terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL)-positive cells and induced apoptosis; (3) markedly inhibited neutrophil infiltration to the impaired pancreas and reduced the inflammatory reaction; (4) notably enhanced the activities of antioxidant enzymes and decreased the nitric oxide synthase levels; (5) significantly reduced the levels of triglycerides, total cholesterol and low-density lipoprotein and increased high-density lipoprotein; and (6) significantly up-regulated peroxisome proliferator-activated receptor-γ (PPARγ) and down-regulated nuclear factor-kappa B (NF-κB). In summary, these results demonstrated that YCHT attenuated SAP progress by inducing apoptosis, repressing inflammation, alleviating oxidative stress and regulating lipid metabolism partially via regulation of the NF-κB/PPARγ signal pathway.

MDCT of acute pancreatitis: Intraindividual comparison of single-phase versus dual-phase MDCT for initial assessment of acute pancreatitis using different CT scoring systems

OBJECTIVES

The purpose of the retrospective study was to evaluate the additional value of dual-phase multidetector computed tomography (MDCT) protocols over a single-phase protocol on initial MDCT in patients with acute pancreatitis using three CT-based pancreatitis severity scores with regard to radiation dose.

METHODS

In this retrospective, IRB approved study MDCT was performed in 102 consecutive patients (73 males; 55years, IQR48-64) with acute pancreatitis. Inclusion criteria were CT findings of interstitial edematous pancreatitis (IP) or necrotizing pancreatitis (NP) and a contrast-enhanced dual-phase (arterial phase and portal-venous phase) abdominal CT performed at ≥72h after onset of symptoms. The severity of pancreatic and extrapancreatic changes was independently assessed by 2 observers using 3 validated CT-based scoring systems (CTSI, mCTSI, EPIC). All scores were applied to arterial phase and portal venous phase scans and compared to score results of portal venous phase scans, assessed ≥14days after initial evaluation. For effective dose estimation, volume CT dose index (CTDIvol) and dose length product (DLP) were recorded in all examinations.

RESULTS

In neither of the CT severity scores a significant difference was observed after application of a dual-phase protocol compared with a single-phase protocol (IP: CTSI: 2.7 vs. 2.5, p=0.25; mCTSI: 4.0 vs. 4.0, p=0.10; EPIC: 2.0 vs. 2.0, p=0.41; NP: CTSI: 8.0 vs. 7.0, p=0.64; mCTSI: 8.0 vs. 8.0, p=0.10; EPIC: 3.0 vs. 3.0, p=0.06). The application of a single-phase CT protocol was associated with a median effective dose reduction of 36% (mean dose reduction 31%) compared to a dual-phase CT scan.

CONCLUSIONS

An initial dual-phase abdominal CT after ≥72h after onset of symptoms of acute pancreatitis was not superior to a single-phase protocol for evaluation of the severity of pancreatic and extrapancreatic changes. However, the effective radiation dose may be reduced by 36% using a single-phase protocol.

Ameliorating effect of antioxidants and pregabalin combination in pain recurrence after ductal clearance in chronic pancreatitis: Results of a randomized, double blind, placebo-controlled trial

BACKGROUND AND AIM

The aim of this study was to evaluate the effect of antioxidant-pregabalin combination on pain recurrence in patients with chronic calcific pancreatitis.

METHODS

In this randomized, double-blind, placebo-controlled trial, chronic calcific pancreatitis patients with pain recurrence following pancreatic ductal clearance of stones received either antioxidant-pregabalin combination or matching placebo for 2 months followed by open-label antioxidants for the next 4 months in both groups. Compliance, daily pain, and adverse events were recorded weekly and at the end of study by a coordinator blinded to treatment status. Primary outcome was pain improvement (visual analog scale and Izbicki score); secondary outcomes were as follows: complete pain resolution, painful days, and adverse events. Number needed-to-treat was calculated.

RESULTS

We randomized 42 and 45 patients (mean age 29.3 years) to treatment and placebo arms, respectively. Baseline characteristics, including pain scores, were similar for both groups. No patients received high-potency narcotic. At 2 months, a significant improvement in the treatment arm was observed in percent reduction of visual analog scale (-50 [-80.0; -32.1] vs -29.5 [-64.5; 0]; P = 0.01), Izbicki score (14.5 [0; 21.3] vs 30.0 [11.8; 41.3]; P = 0.001), complete pain resolution (20 [47.6%] vs 12 [26.7%]; P = 0.04), and number of painful days (10.0 [2.0; 16.0] vs 18.0 [7.0; 34.0]; P = 0.01). Needed-to-treat was 4.8. Pain reduction persisted at 6 months in the original treatment group (20.0 [15.0; 28.0] vs 36.0 [20.0; 50.0]; P = 0.006). A total of 33 patients in the treatment arm experienced mild to moderate self-limiting nausea/vomiting and drowsiness, respectively and did not require any change in study protocol.

CONCLUSION

Antioxidant-pregabalin combination results in significant relief in pain recurrence after ductal clearance in narcotic naïve patients with chronic calcific pancreatitis.

Legumain is activated in macrophages during pancreatitis

Pancreatitis is an inflammatory disease of the pancreas characterized by dysregulated activity of digestive enzymes, necrosis, immune infiltration, and pain. Repeated incidence of pancreatitis is an important risk factor for pancreatic cancer. Legumain, a lysosomal cysteine protease, has been linked to inflammatory diseases such as atherosclerosis, stroke, and cancer. Until now, legumain activation has not been studied during pancreatitis. We used a fluorescently quenched activity-based probe to assess legumain activation during caerulein-induced pancreatitis in mice. We detected activated legumain by ex vivo imaging, confocal microscopy, and gel electrophoresis. Compared with healthy controls, legumain activity in the pancreas of caerulein-treated mice was increased in a time-dependent manner. Legumain was localized to CD68(+) macrophages and was not active in pancreatic acinar cells. Using a small-molecule inhibitor of legumain, we found that this protease is not essential for the initiation of pancreatitis. However, it may serve as a biomarker of disease, since patients with chronic pancreatitis show strongly increased legumain expression in macrophages. Moreover, the occurrence of legumain-expressing macrophages in regions of acinar-to-ductal metaplasia suggests that this protease may influence reprogramming events that lead to inflammation-induced pancreatic cancer.

Nucleotide-binding oligomerization domain 1 acts in concert with the cholecystokinin receptor agonist, cerulein, to induce IL-33-dependent chronic pancreatitis

Nucleotide-binding oligomerization domain 1 (NOD1) fulfills important host-defense functions via its responses to a variety of gut pathogens. Recently, however, we showed that in acute pancreatitis caused by administration of cholecystokinin receptor (CCKR) agonist (cerulein) NOD1 also has a role in inflammation via its responses to gut commensal organisms. In the present study, we explored the long-term outcome of such NOD1 responsiveness in a new model of chronic pancreatitis induced by repeated administration of low doses of cerulein in combination with NOD1 ligand. We found that the development of chronic pancreatitis in this model requires intact NOD1 and type I IFN signaling and that such signaling mediates a macrophage-mediated inflammatory response that supports interleukin (IL)-33 production by acinar cells. The IL-33, in turn, has a necessary role in the induction of IL-13 and TGF-β1, factors causing the fibrotic reaction characteristic of chronic pancreatitis. Interestingly, the Th2 effects of IL-33 were attenuated by the concomitant type I IFN response since the inflammation was marked by clear increases in IFN-γ and TNF-α production but only marginal increases in IL-4 production. These studies establish chronic pancreatitis as an IL-33-dependent inflammation resulting from synergistic interactions between the NOD1 and CCKR signaling pathways.

Spautin-1 Ameliorates Acute Pancreatitis via Inhibiting Impaired Autophagy and Alleviating Calcium Overload

Acute pancreatitis is characterized by zymogen pre-activation. Severe inflammation caused by zymogen activation can eventually lead to multiple organ dysfunctions, which contributes to the high mortality rate of severe acute pancreatitis. However, there is no specific treatment available for acute pancreatitis therapy. Here, we show that spautin-1, which effectively inhibits autophagy flux, ameliorated the pathogenesis of acute pancreatitis induced by cerulein or L-Arginine. CaMKII phosphorylation due to cytosolic calcium oeverload was revealed in this paper. It was also demonstrated that autophagic protein aggregates degradation blockade accompanying with impaired autophagy correlated positively to intra acinar cells digestive aymogen activation sitimulated by cerulein or L-Arginine. The role of spautin-1 in ameliorating acute pancreatitis was shown here to be associated with impaired autophagy inhibition and Ca²⁺ overload alleviation. We provided a promising therapy for acute pancreatitis here through targeting both impaired autophagy and increased cytosolic calcium.

Management of acute pancreatitis in Japan: Analysis of nationwide epidemiological survey

Acute pancreatitis (AP) is an acute inflammatory disease of the exocrine pancreas. In Japan, nationwide epidemiological surveys have been conducted every 4 to 5 years by the Research Committee of Intractable Pancreatic Diseases, under the support of the Ministry of Health, Labour, and Welfare of Japan. We reviewed the results of the nationwide surveys focusing on the severity assessment and changes in the therapeutic strategy for walled-off necrosis. The severity assessment system currently used in Japan consists of 9 prognostic factors and the imaging grade on contrast-enhanced computed tomography. By univariate analysis, all of the 9 prognostic factors were associated with AP-related death. A multivariate analysis identified 4 out of the 9 prognostic factors (base excess or shock, renal failure, systemic inflammatory response syndrome criteria, and age) that were associated with AP-related death. Receiver-operating characteristics curve analysis showed that the area under the curve was 0.82 for these 4 prognostic factors and 0.84 for the 9 prognostic factors, suggesting the comparable utility of these 4 factors in the severity assessment. We also examined the temporal changes in treatment strategy for walled-off necrosis in Japan according to the 2003, 2007, and 2011 surveys. Step-up approaches and less-invasive endoscopic therapies were uncommon in 2003 and 2007, but became popular in 2011. Mortality has been decreasing in patients who require intervention for walled-off necrosis. In conclusion, the nationwide survey revealed the comparable utility of 4 prognostic factors in the severity assessment and the increased use of less-invasive, step-up approaches with improved clinical outcomes in the management of walled-off necrosis.

Role of phosphoinositide-3 kinase signaling pathways in pathogenesis of acute pancreatitis

Acute pancreatitis (AP) as a common acute disease poses a great threat to people's health. According to statistics, about one-fifth of cases develop acute respiratory distress syndrome and multiple organ dysfunction, which result in high mortality. The early understanding of the pathogenesis of this disease is limited to an inflammatory response resulting in autodigestion, edema, hemorrhage and necrosis of pancreatic tissue after the abnormal activation of trypsin. In recent years, researchers have focused their research on the role of immune inflammatory response in the pathogenesis of AP. Here we discuss the relationship between the immune inflammation and PI3K signaling pathways in AP.

Serum Metabonomics of Mild Acute Pancreatitis

BACKGROUND

Mild acute pancreatitis (MAP) is a common acute abdominal disease, and exhibits rising incidence in recent decades. As an important component of systemic biology, metabonomics is a new discipline developed following genomics and proteomics. In this study, the objective was to analyze the serum metabonomics of patients with MAP, aiming to screen metabolic markers with potential diagnostic values.

METHODS

An analysis platform with ultra performance liquid chromatography-high-resolution mass spectrometry was used to screen the difference metabolites related to MAP diagnosis and disease course monitoring.

RESULTS

A total of 432 endogenous metabolites were screened out from 122 serum samples, and 49 difference metabolites were verified, among which 12 difference metabolites were identified by nonparametric test. After material identification, eight metabolites exhibited reliable results, and their levels in MAP serum were higher than those in healthy serum. Four metabolites exhibited gradual downward trend with treatment process going on, and the differences were statistically significant (P < 0.05).

CONCLUSION

Metabonomic analysis has revealed eight metabolites with potential diagnostic values toward MAP, among which four metabolites can be used to monitor the disease course.

Thoracic epidural analgesia: a new approach for the treatment of acute pancreatitis?

This review article analyzes, through a nonsystematic approach, the pathophysiology of acute pancreatitis (AP) with a focus on the effects of thoracic epidural analgesia (TEA) on the disease. The benefit-risk balance is also discussed. AP has an overall mortality of 1 %, increasing to 30 % in its severe form. The systemic inflammation induces a strong activation of the sympathetic system, with a decrease in the blood flow supply to the gastrointestinal system that can lead to the development of pancreatic necrosis. The current treatment for severe AP is symptomatic and tries to correct the systemic inflammatory response syndrome or the multiorgan dysfunction. Besides the removal of gallstones in biliary pancreatitis, no satisfactory causal treatment exists. TEA is widely used, mainly for its analgesic effect. TEA also induces a targeted sympathectomy in the anesthetized region, which results in splanchnic vasodilatation and an improvement in local microcirculation. Increasing evidence shows benefits of TEA in animal AP: improved splanchnic and pancreatic perfusion, improved pancreatic microcirculation, reduced liver damage, and significantly reduced mortality. Until now, only few clinical studies have been performed on the use of TEA during AP with few available data regarding the effect of TEA on the splanchnic perfusion. Increasing evidence suggests that TEA is a safe procedure and could appear as a new treatment approach for human AP, based on the significant benefits observed in animal studies and safety of use for human. Further clinical studies are required to confirm the clinical benefits observed in animal studies.