Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus

Targeted animal models for preclinical assessment of cellular and gene therapies in pancreatic and liver diseases: regulatory and practical insights

Cellular and gene therapy (CGT) products have emerged as a popular approach in regenerative medicine, showing promise in treating various pancreatic and liver diseases in numerous clinical trials. Before these therapies can be tested in human clinical trials, it is essential to evaluate their safety and efficacy in relevant animal models. Such preclinical testing is often required to obtain regulatory approval for investigational new drugs. However, there is a lack of detailed guidance on selecting appropriate animal models for CGT therapies targeting specific pancreatic and liver conditions, such as pancreatitis and chronic liver diseases. In this review, the gastrointestinal committee for the International Society for Cell and Gene Therapy provides a summary of current recommendations for animal species and disease model selection, as outlined by the US Food and Drug Administration, with references to EU EMA and Japan PMDA. We discuss a range of small and large animal models, as well as humanized models, that are suitable for preclinical testing of CGT products aimed at treating pancreatic and liver diseases. For each model, we cover the associated pathophysiology, commonly used metrics for assessing disease status, the pros and limitations of the models, and the relevance of these models to human conditions. We also summarize the use and application of humanized mouse and other animal models in evaluating the safety and efficacy of CGT products. This review aims to provide comprehensive guidance for selecting appropriate animal species and models to help bridge the gap between the preclinical research and clinical trials using CGT therapies for specific pancreatic and liver diseases.

Machine learning model-based prediction of postpancreatectomy acute pancreatitis following pancreaticoduodenectomy: A retrospective cohort study

BACKGROUND

The International Study Group of Pancreatic Surgery has established the definition and grading system for postpancreatectomy acute pancreatitis (PPAP). There are no established machine learning models for predicting PPAP following pancreaticoduodenectomy (PD).

AIM

To explore the predictive model of PPAP, and test its predictive efficacy to guide the clinical work.

METHODS

Clinical data from consecutive patients who underwent PD between 2016 and 2024 were retrospectively collected. An analysis of PPAP risk factors was performed, various machine learning algorithms [logistic regression, random forest, gradient boosting decision tree, extreme gradient boosting, light gradient boosting machine, and category boosting (CatBoost)] were utilized to develop predictive models. Recursive feature elimination was employed to select several variables to achieve the optimal machine algorithm.

RESULTS

The study included 381 patients, of whom 88 (23.09%) developed PPAP. PPAP patients exhibited a significantly higher incidence of postoperative pancreatic fistula (55.68% vs 14.68%, P < 0.001), grade C postoperative pancreatic fistula (9.09% vs 1.37%, P = 0.001). The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve of 0.859 [95% confidence interval (CI): 0.814-0.905] in the training cohort and 0.822 (95%CI: 0.717-0.927) in the testing cohort. According to shapley additive explanations analysis, pancreatic texture, main pancreatic duct diameter, body mass index, estimated blood loss, and surgery time were the most important variables based on recursive feature elimination. The CatBoost algorithm based on selected variables demonstrated superior performance, with an area under the receiver operating characteristic curve of 0.837 (95%CI: 0.788-0.886) in the training cohort and 0.812 (95%CI: 0.697-0.927) in the testing cohort.

CONCLUSION

We developed the first machine learning-based predictive model for PPAP following PD. This predictive model can assist surgeons in anticipating and managing this complication proactively.

Concealed pancreatic cancer in acute pancreatitis: Early MRCP and EUS surveillance improves prognosis and identifies high-risk patients

BACKGROUND/OBJECTIVES

Acute pancreatitis (AP) may obscure small pancreatic cancers (PCs) on computed tomography during the acute phase. Surveillance with magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) may enhance early detection and improve patient outcomes. This study evaluated the impact of early MRCP/EUS surveillance on PC outcomes in AP patients and identified high-risk subgroups for early screening.

METHODS

We retrospectively analyzed 1562 AP patients treated between 2010 and 2021, categorizing them into early surveillance (MRCP/EUS within three months of AP onset; n = 760) and nonearly surveillance groups (n = 802). Key outcomes included time to PC diagnosis, surgical resection rate, tumor stage, and overall survival. Multivariate analysis was performed to identify risk factors for concealed PC in AP patients.

RESULTS

Among 27 PC cases analyzed, the early surveillance group achieved significantly earlier diagnosis, higher surgical resection rates, increased detection of early-stage PC, and improved overall survival compared with the nonearly surveillance group. Multivariate analysis revealed that subthreshold main pancreatic duct (MPD) dilation (≥2.5 mm) and moderately severe AP were significant predictors of PC.

CONCLUSIONS

Early MRCP/EUS surveillance in AP patients facilitates timely detection of occult PC and enhances patient prognosis. These findings support prioritizing early surveillance for AP patients with subthreshold MPD dilation and moderately severe disease. Further large-scale studies are warranted to validate these strategies in clinical practice.

Circulating cyclophilin A levels elevate in animal models and can predict mortality in patients with acute pancreatitis

BACKGROUND/OBJECTIVES

Cyclophilin A (CypA) is released into the blood following cellular injury and correlates with acute pancreatitis (AP) severity, however, investigations into circulating CypA in experimental AP and hypertriglyceridaemia-associated AP (HTG-AP) prevalent cohorts are lacking.

METHODS

C57Bl/6 mice received 4, 8, and 12 caerulein injections to induce escalating severity of AP models (CER-AP). Mice were sacrificed 1 h after the last injection of caerulein to assess severity of CER-AP through biochemical and histopathological analyses, and serum CypA levels were also measured. Golden Syrian hamsters fed with a high-cholesterol/high-fat diet were given 10 caerulein injections to induce experimental HTG-AP to assess severity and serum CypA. Human blood plasma samples taken within 24 h after admission from a patient cohort with a predominance of HTG-AP cases, stored in a prospectively collected AP Biobank, were assessed for plasma CypA levels and correlated with clinical data.

RESULTS

In mice, CER-AP models showed significantly increased pancreatic histopathological scores and biochemical parameters, with severity highest after 12 caerulein injections. Serum CypA levels were significantly higher in all CER-AP models compared to controls. In hamsters, CypA levels were significantly higher in HTG-AP model than controls. In AP patients, CypA levels in non-haemolytic plasma samples varied by aetiology, with the highest levels in HTG-AP, corresponding to HTG levels and AP severity. ROC analysis revealed CypA ≥9.9 ng/ml as a significant predictor of mortality (AUC = 0.865).

CONCLUSION

Circulating CypA levels are significantly increased in mouse CER-AP and hamster HTG-AP models. We have identified a novel association of raised plasma CypA levels with severity of HTG-AP and confirmed its significant prognostic ability to predict mortality in AP patients.

Outcomes of acute pancreatitis in elderly are comparable to those in adults in India: A propensity score-matched analysis

BACKGROUND AND OBJECTIVES

The ageing population is increasing in India and there is hardly any information on outcomes of acute pancreatitis (AP) in the elderly in India. Hence we studied the comprehensive clinical characteristics and outcomes of AP in elderly patients.

METHODS

This study included patients admitted with AP to a tertiary care centre from October 2018 to October 2022. Patients with the first episode of AP presenting within 14 days of disease onset were eligible for inclusion. The elderly population was defined as age ≥ 60 years. Recurrent AP, chronic pancreatitis and AP presenting after 14 days of disease onset were excluded. Propensity score matching was performed based on etiology and severity to compare elderly and non-elderly groups. Primary outcome was serious adverse outcome (SAO: in-hospital mortality or discharge in critical state). Secondary outcomes included organ failures, local complications, necrosis, mesenteric vascular thrombosis (MVT), length of hospital stay, intensive care unit (ICU) admission and infections.

RESULTS

Of 630 eligible patients, 120 were > 60 years of age. Among the elderly, 72 (60%) were males. The median age was 68 (IQR 63-74) years. The most common etiology was biliary 76 (63.3%) followed by idiopathic 25 (20.8%) and alcohol eight (6.7%). Mild AP was seen in 72 (60%), while 21 (17.5%) had moderately severe and 27 (22.5%) had severe AP. Organ failures occurred in 27.5%, necrotizing pancreatitis in 15.2%, local complications in 27.6% and MVT in 3.3%. Infections affected 28.3%. Median hospital stay was four days (IQR 1-28), with 12.5% requiring ICU admission. SAO occurred in 8.3% of elderly patients, comparable to 11.4% in the non-elderly (p = 0.334). Bedside index for severity in acute pancreatitis (BISAP) score (adjusted OR 2.7, 95% CI 1.05-6.96, p = 0.04) and Charlson comorbidity index (without age) (adjusted OR 1.94, 95% CI 1.07-3.51, p = 0.03) independently predicted SAO in the elderly.

CONCLUSION

The outcomes of AP in the elderly in India are similar to patients < 60 years. Charlson comorbidity index and BISAP score predicted serious adverse outcomes in the elderly.

Relationship Between Serum Levels of Pancreatic Exocrine Enzymes on Admission and Long-Term Clinical Outcomes in Patients with Acute Decompensated Heart Failure

Background/Objectives: Heart failure (HF) can damage organs because of poor perfusion and/or congestion. The interactions between HF and other organs have recently been studied; however, data on the interaction between HF and pancreatic exocrine function, which may affect fat and protein absorption and malnutrition, are scarce. We previously showed that the serum levels of pancreatic exocrine enzymes, as suggestive of pancreatic exocrine function, were low and associated with malnutrition or congestion in hospitalized patients with acute decompensated HF (ADHF). This study investigated the relationship between the serum levels of pancreatic exocrine enzymes and long-term outcomes in patients with ADHF. Methods: We collected serum levels of pancreatic exocrine enzymes (amylase and lipase) from patients who were admitted to the cardiac intensive care unit due to ADHF. Patients undergoing dialysis and those with neoplasms were excluded. Patients were categorized as having high or low pancreatic exocrine enzyme levels in the first quartile upon admission. The association between low serum pancreatic exocrine enzyme levels at admission and the composite of death and ADHF readmission was assessed. Results: Of the 146 patients, 37 (25.3%) and 36 (24.7%) had low amylase and lipase levels, respectively. Patients with low lipase levels showed worse cumulative event-free survival than those with high lipase levels (p < 0.001). A low lipase level was associated with worse outcomes (hazard ratio: 1.96; p = 0.012). Conclusions: These findings suggest that low serum lipase levels may be a predictor of long-term outcomes in patients with ADHF.

MGST1 Protects Pancreatic Ductal Cells from Inflammatory Damage in Acute Pancreatitis by Inhibiting Ferroptosis: Bioinformatics Analysis with Experimental Validation

Numerous animal experiments have implicated ferroptosis in the pathogenesis of acute pancreatitis (AP). Nonetheless, due to sampling constraints, the precise role of ferroptosis in the human body during AP remains elusive. Method: Peripheral blood sequencing data of patients with acute pancreatitis (GSE194331) were obtained from the Gene Expression Omnibus (GEO) database. We analyzed differentially expressed genes whose expression increased or decreased with increasing disease severity and intersected them with the ferroptosis gene set to identify ferroptosis-related driver genes for the disease. The hub genes were selected using machine learning algorithms, and a nomogram diagnosis model was constructed. Clinical samples, animal models, and an in vitro experiment were also used for validation. The investigation unveiled 22 ferroptosis-related driver genes, and we identified three hub genes, AQP3, TRIB2, and MGST1, by employing two machine learning algorithms. AQP3 and TRIB2 exhibit robust correlations with various immune cells. The disease diagnosis model constructed utilizing these three genes demonstrated high sensitivity and specificity (AUC = 0.889). In the in vitro experiments, we discovered for the first time that ferroptosis occurs in pancreatic duct cells during acute pancreatitis, and that MGST1 is significantly upregulated in duct cells, where it plays a crucial role in negatively regulating ferroptosis via the ACSL4/GPX4 axis. In addition, overexpression of MGST1 protects ductal cells from inflammatory damage. In our investigation, we explored the mechanisms of ferroptosis in immune cells and pancreatic duct cells in patients with AP. These results highlight a potential pathway for the early diagnosis and treatment of acute pancreatitis.

Atypical hemolytic uremic syndrome triggered by acute pancreatitis

The clinical manifestations of atypical hemolytic uremic syndrome （aHUS） are hemolytic anemia, thrombocytopenia, and acute kidney injury. It is one of the Thrombotic microangiopathy (TMA), with triggers for activation of the complement bypass pathway, such as infection and pregnancy, present in 70-80% of patients. Treatment for this disease requires plasma exchange or eculizumab, we encountered a patient with aHUS induced by gallstone-pancreatitis, after the initial plasma exchange, the patient's condition was improved, but the subsequent incomplete treatment eventually led to severe sequelae. In a word, early, correct and adequate treatment is critical to the prognosis of these patients.

Comprehensive management of gastrointestinal fistulas in necrotizing pancreatitis: a review of diagnostic and therapeutic approaches

INTRODUCTION

Gastrointestinal fistula (GIF) is a rare but severe complication in patients with necrotizing pancreatitis (NP), significantly prolonging disease course and increasing morbidity and mortality. Its subtle and nonspecific early symptoms often delay diagnosis and intervention. Despite its clinical significance, the low incidence of GIF in NP has resulted in limited research and a lack of consensus on optimal diagnostic and therapeutic strategies.

AREAS COVERED

This review focuses on the epidemiology, pathophysiology, diagnostic approaches, and therapeutic management of GIF in NP patients. Imaging techniques, such as contrast-enhanced computed tomography and endoscopy, have been integral to early diagnosis. Advances in interventional and surgical techniques provide new avenues for treatment, but variability in clinical practice highlights the need for standardized protocols.

EXPERT OPINION

Recent advances in diagnostic imaging have improved the detection of GIF, while innovations in interventional and surgical treatments show promise. Current research is still insufficient and varied. Future research should focus on developing diagnostic methods and treatment measures for such complications. By improving early diagnosis and offering insights into effective management strategies, it is hoped that patient outcomes can be improved.

Visceral adiposity index as a key predictor of severity in acute pancreatitis - A large-scale retrospective cohort study

BACKGROUND AND AIMS

Visceral adipose tissue has been indicated closely connected with the severity of acute pancreatitis (AP). Visceral adiposity index (VAI) is a mathematical model that consists of waist circumference, body mass index, triglyceride and high-density lipoprotein cholesterol, which has been demonstrated to be a better indicator of visceral fat than other traditional indices. This study aimed to evaluate the relationship between VAI and the severity of AP.

METHODS

A retrospective analysis was conducted on a cohort of 1174 patients diagnosed with AP. These patients were categorized into two groups based on their VAI values: the normal VAI (NVAI) group and the elevated VAI (EVAI) group.

RESULTS

The EVAI group were much younger, mainly male and had higher incidence of severe acute pancreatitis (SAP) compared with the NVAI group (p < 0.001). The EVAI group developed higher incidences of persistent respiratory failure, acute peripancreatic fluid collection (APFC) and acute necrotic collection (ANC). The VAI level and the percentage of EVAI showed an increasing trend with the severity of AP (p < 0.001). EVAI was the most independent risk factor for persistent respiratory failure (OR = 6.405, 95% CI 2.317-17.705), APFC (OR = 2.093, 95% CI 1.255-3.578) and ANC (OR = 4.910, 95% CI 1.736-13.887).

CONCLUSIONS

EVAI was strongly related to the severity of AP. It was the most independent risk factor of persistent respiratory failure, APFC and ANC.

Impact of Sepsis Onset Timing on All-Cause Mortality in Acute Pancreatitis: A Multicenter Retrospective Cohort Study

BACKGROUND

Sepsis complicates acute pancreatitis (AP), increasing mortality risk. Few studies have examined how sepsis and its onset timing affect mortality in AP. This study evaluates the association between sepsis occurrence and all-cause mortality in AP, focusing specifically on the impact of sepsis onset timing.

METHODS

This multicenter retrospective cohort study included 494 ICU-admitted AP patients from the MIMIC-IV database and 91 from our center. Patients were grouped by sepsis occurrence and onset timing. Clinical outcomes were in-hospital and 90-day all-cause mortality. Machine learning identified key variables associated with mortality. Multivariable regression analyzed the impact of sepsis and its onset timing on mortality. To reduce baseline differences, propensity score matching (PSM) based on time to sepsis was conducted. After PSM, Kaplan-Meier survival analyses incorporated data from our center for validation. Restricted cubic spline analysis examined any nonlinear relationship between sepsis onset timing and mortality.

RESULTS

Patients with sepsis had significantly higher in-hospital and 90-day mortality rates than those without sepsis (p < 0.05). Sepsis was identified as a significant risk factor for in-hospital mortality and remained significantly associated after adjusting for key variables (p < 0.05). However, sepsis onset timing did not significantly impact in-hospital or 90-day mortality. These findings were validated after PSM and with our center's data. No nonlinear relationship between sepsis onset timing and mortality was found.

CONCLUSION

Sepsis significantly increases all-cause mortality in AP patients, but the timing of its onset has limited impact. Continuous monitoring and intervention for sepsis during hospitalization are recommended to improve prognosis.

Characterization and comparison of gut microbiota in patients with acute pancreatitis by metagenomics and culturomics

Acute pancreatitis (AP) is a common gastrointestinal disorder with a high mortality rate. This study sought to identify the microbial community structure in patients with AP using metagenomics and culturomics. Compared to healthy controls, patients with AP exhibited a significant decrease in alpha diversity; a higher abundance of unclassified Enterococcus species (sp), Enterococcus faecium, and Enterococcus faecalis; and a lower abundance of Eubacterium rectale. A total of 336 isolates from 25 genera and 44 species were obtained by sample cultivation. The dominant species identified in patients with AP were Enterococcus faecium and Klebsiella grimontii, whereas those in the healthy controls were Enterococcus faecium, Escherichia coli, and Bacteroides faecis. Our research has contributed to the expanded understanding of the genome, diversity, and function of the intestinal microbiota in patients with AP and provided some reference for selecting culture medium and sample processing methods.

Pancreatic endocrine and exocrine signaling and crosstalk in physiological and pathological status

The pancreas, an organ with dual functions, regulates blood glucose levels through the endocrine system by secreting hormones such as insulin and glucagon. It also aids digestion through the exocrine system by secreting digestive enzymes. Complex interactions and signaling mechanisms between the endocrine and exocrine functions of the pancreas play a crucial role in maintaining metabolic homeostasis and overall health. Compelling evidence indicates direct and indirect crosstalk between the endocrine and exocrine parts, influencing the development of diseases affecting both. From a developmental perspective, the exocrine and endocrine parts share the same origin-the "tip-trunk" domain. In certain circumstances, pancreatic exocrine cells may transdifferentiate into endocrine-like cells, such as insulin-secreting cells. Additionally, several pancreatic diseases, including pancreatic cancer, pancreatitis, and diabetes, exhibit potential relevance to both endocrine and exocrine functions. Endocrine cells may communicate with exocrine cells directly through cytokines or indirectly by regulating the immune microenvironment. This crosstalk affects the onset and progression of these diseases. This review summarizes the history and milestones of findings related to the exocrine and endocrine pancreas, their embryonic development, phenotypic transformations, signaling roles in health and disease, the endocrine-exocrine crosstalk from the perspective of diseases, and potential therapeutic targets. Elucidating the regulatory mechanisms of pancreatic endocrine and exocrine signaling and provide novel insights for the understanding and treatment of diseases.

Early enteral nutrition with fructooligosaccharides improves prognosis in severe acute pancreatitis

Soluble dietary fiber, notably as an adjunct to early enteral nutrition (EEN), is gaining prominence in clinical therapy. This study evaluates the effect of fructooligosaccharides (FOS), a new soluble dietary fiber, on the prognosis of patients with severe acute pancreatitis (SAP). In a retrospective cohort study at the Third Xiangya Hospital of Central South University from July 2017 to July 2023, 110 SAP patients were analyzed. TPF (enteral nutritional suspension of total protein)-normal and TPF-FOS groups both received standard EEN solutions; the latter additionally received FOS. Outcomes were compared between the groups. The study included 37 patients in the TPF-FOS group and 73 patients in the TPF-normal group. Mortality was 13.50% in the TPF-FOS group and 34.20% in the TPF-normal group (P < 0.05). FOS was identified as an independent protective factor (OR: 0.826, P = 0.041). The TPF-FOS group showed lower rates of intra-abdominal infection and decreased the level of inflammation (P < 0.05). FOS potentially acts as an independent protective factor against death in SAP. Additionally, the supplementation of EEN with FOS may contribute to reducing mortality and improving the prognosis of SAP patients.

Microbial dynamics of acute pancreatitis: integrating culture, sequencing, and bile impact on bacterial populations and gaseous metabolites

Background

Our study examined the composition of the intestinal microflora in a hospitalized patient with AP symptoms treated several months earlier for diverticulitis. The therapeutic intervention necessitated Hartmann's procedure, culminating in colostomy creation.

Aims

Employing a thorough microbiological analysis we attempted to demonstrate whether the microflora isolated from the peripancreatic fluid exhibited a stronger correlation with the contents of the stoma or with the rectal swab. Additionally, we sought to determine the association between later onset of AP and diverticulitis.

Methods

Following clinical materials from the patient in the initial phase of AP were collected: rectal swab, colostomy bag contents (in the publication referred to as stoma content/stool) and peripancreatic fluid. Microbiological analysis was performed, including classic culture methodology, NGS techniques, and genotyping methodologies. Furthermore, the effect of bile on the shift in the population of selected bacterial species was examined.

Results

The NGS technique confirmed greater consistency in bacteria percentage (phyla/family) between stoma content and peripancreatic fluid. In both samples, a clear dominance of the Proteobacteria phyla (over 75%) and the Enterobacteriaceae family was demonstrated. Moreover, NGS verified the presence of the Fusobacteriota phylum and Fusobacteriaceae family only in rectal swabs, which may indicate a link between this type of bacteria and the etiology of diverticulitis. We observed that Escherichia coli 33 isolated from stool exhibited active gaseous metabolite production (mainly hydrogen).

Conclusions

The abundant production of hydrogen may substantially impact enzymatic processes, inducing specific alterations in disulfide bonds and trypsin inactivation. Our investigation alludes to the conceivable active involvement of bile in effecting qualitative and quantitative modifications in the peripancreatic microbiota composition, establishing a correlation between released bile and bacterial generation of gaseous metabolites.

Predictive Value of Several Parameters for Severity of Acute Pancreatitis in a Cohort of 172 Patients

Background: The optimal management of patients with acute pancreatitis is directly related to the early detection of the mild, moderate, or severe forms of the disease, which remains a continuous challenge despite the availability of various severity scores. The aim of this study was to identify prognostic factors with the highest predictive value specific to the local patients and elaborate the score to identify the severe cases. Materials and Methods: A retrospective observational cohort study included 172 patients diagnosed with acute pancreatitis. Personal, clinical, laboratory, and imaging factors and their influence on the severity of acute pancreatitis were evaluated. Results: Etiology nonA-nonB (any etiology except unique alcoholic or biliary etiology), presence of diabetes mellitus, the pain Visual Analogue Scale (VAS), White Blood Cells (WBCs), and CRP (C-reactive protein) levels were found to be directly associated with the severity of acute pancreatitis (AP). Prediction scores were calculated to estimate disease severity using the following regression equations: Prediction Acute Pancreatitis Severity (PAPS) score I = 1.237 + 0.144 × nonA-nonB (0 = no, 1 = yes) + 0.001 × WBC1 + 0.027 × VAS0 and PAPS score II = 1.189 + 0.001 × CRP (mg/L) + 0.135 × nonA-nonB etiology (0 = no, 1 = yes) + 0.025 × VAS0 - 0.047 × CA1. The PAPS Score II demonstrated the best performance. At a cut-off value of 1.248, the score had 80% sensitivity, 80.9% specificity, a positive predictive value (PPV) of 28.6%, a negative predictive value (NPV) of 97.7%, and an accuracy of 80.8%. For a cut-off value of 221.5 mg/L, the accuracy of CRP was 81.4% for predicting severe AP. Conclusions: The PAPS score II is an easy-to-use, fast, and affordable score for determining cases of severe disease for patients diagnosed with AP.

C-reactive protein to serum calcium ratio as a novel biomarker for predicting severity in acute pancreatitis: a retrospective cross-sectional study

Background

Acute pancreatitis (AP) is a prevalent gastrointestinal emergency with a wide spectrum of clinical outcomes, varying from mild cases to severe forms. The early identification of high-risk patients is essential for improving prognosis. However, the predictive and prognostic potential of the C-reactive protein to serum calcium ratio (CCR) in AP has not been investigated. This study aims to explore the association between CCR and disease severity in patients with AP.

Methods

This retrospective cross-sectional study included 476 AP patients. The CCR was calculated from C-reactive protein and serum calcium levels within the first 24 h of admission. Multivariable logistic regression models were used to evaluate the relationship between CCR and AP severity, with restricted cubic spline analysis and receiver operating characteristic (ROC) analysis to assess dose-response and predictive performance, respectively.

Results

Of the 476 patients, 176 (37%) had mild acute pancreatitis (MAP) and 300 (63%) had moderate to severe AP. The CCR distribution had a median value of 17.5, with an interquartile range (IQR) of 3.0 to 60.2. Each unit increase in CCR was associated with a 7% increase in the risk of developing moderate to severe AP (OR: 1.07; 95% CI: 1.06-1.09). In fully adjusted models, this association remained statistically significant. The area under the curve (AUC) for CCR in predicting moderate to severe AP was 86.9%, with a sensitivity of 73.7% and specificity of 89.2%.

Conclusion

The CCR measured within the first 24 h of admission shows promise as a valuable biomarker for predicting the severity of AP. However, further multicenter prospective cohort studies are needed to confirm its clinical utility and investigate its role in improving treatment strategies and patient management.

Endoscopic papillectomy versus surgical ampullectomy for adenomas and early cancers of the papilla: a retrospective Pancreas2000/European Pancreatic Club analysis

OBJECTIVE

Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA.

DESIGN

Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-score matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10-47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher's exact or χ2 test, Mann-Whitney-U-test and log-rank test for survival.

RESULTS

Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable.

CONCLUSIONS

The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further.

Clinical risk factors for sarcopenia in acute and chronic pancreatitis

BACKGROUND

Sarcopenia is common in chronic pancreatitis (CP) and has been associated with unfavorable outcomes; however, it is not well studied in acute pancreatitis (AP).

AIMS

To evaluate risk factors for sarcopenia among individuals with AP or CP.

METHODS

A cross sectional analysis was performed among subjects with AP or CP seen in a tertiary care Pancreas Clinic. TeraRecon software was used to calculate the cross-sectional area of skeletal muscle, visceral fat, and subcutaneous fat at the level of the L3 vertebrae. Sarcopenia was classified using sex-specific skeletal muscle index. Univariate and multivariate logistic regressions were performed to assess differences between groups and associations with sarcopenia.

RESULTS

A total of 49 subjects with AP and 54 subjects with CP were included. Sarcopenia was more frequently observed in CP compared to AP (83.3% vs. 46.9%, p < 0.001). The multivariate logistic regression demonstrated CP, male sex, increased age, and decreased subcutaneous fat were independently associated with sarcopenia.

CONCLUSION

Sarcopenia is observed in both CP and AP. In addition to traditional risk factors (including male sex, older age, and decreased subcutaneous fat), CP is independently associated with sarcopenia. Further investigations are necessary to gain deeper insights into sarcopenia pathogenesis, which could inform potential intervention strategies.

Urgent Endoscopic Biliary Procedures: "Run Like the Wind"?

Emergency endoscopy is an activity that must be guaranteed 7 days a week and 24 h a day. The pathologies of endoscopic interest that require emergency intervention are mainly hemorrhages of the upper digestive tract, the removal of foreign bodies, and the ingestion of caustics. The emergency endoscopist must therefore be experienced in the management of these pathologies. Nowadays, however, we know that even some biliary tract pathologies must be managed within a variable period between 12 and 72 h, in particular acute cholangitis (Ach), acute biliary pancreatitis (ABP), biliary duct leaks (BDLs), and acute cholecystitis (AC). If, on one hand, there is little awareness among doctors about which pathologies of the biliary tract really deserve urgent treatment, on the other, the international guidelines, although not uniformly, have acquired the results of the studies and have clarified that only severe Ach should be treated within 12 h; in other cases, endoscopic treatment can be delayed up to 72 h according to the specific condition. This obviously has a significant organizational implication, as not all endoscopists have training in biliary tract endoscopy, and guaranteeing the availability of a biliary endoscopist 24/7 may be incompatible with respecting the working hours of individual professionals. This review aims to evaluate which pathologies of the biliary tract really require an endoscopic approach in emergency or urgency and the organizational consequences that this can determine. Based on the guidelines, we can conclude that a daytime availability for urgent biliary tract procedures 7 days a week should be provided for the management of severe ACh. Patients with ABP, AC unfit for surgery, and not responsive to medical therapy or BDLs can be treated over a longer period, allowing its scheduling on the first available day of the week.

β-galactosidase-activated red fluorescent probe assists in the diagnosis of pancreatitis

Acute pancreatitis (AP) is an acute inflammatory disease resulting from abnormal digestion of itself and surrounding organs by pancreatic enzymes caused by a variety of pathogenic factors. When the tissue of a biological organism is afflicted with pancreatitis and experiences swelling, bleeding, and necrotic injuries, the abnormal expression of β-galactosidase (β-Gal) activity becomes one of the main indicators for assisting in the diagnosis of pancreatitis. In this study, a highly specific red fluorescent probe designed for the detection of β-Gal activity has been developed. β-galactoside is used as the enzyme activating group, and the long-wavelength luminescent water-soluble organic molecule NBDOH is used as the luminophore to construct the fluorescent probe NBD-gal. NBD-gal is activated by abnormally overexpressed β-Gal, releasing a strong red fluorescent signal. The new fluorescent probe developed in this study is used to assist in the diagnosis of pancreatitis by detecting abnormal expression of β-Gal activity in vivo. In in vivo imaging experiments, NBD-gal can effectively differentiate between normal nude mice and pancreatitis nude mice. In addition, NBD-gal can be effectively localized in real-time to the pancreas and intestines, which are rich in β-Gal in nude mice. Therefore, NBD-gal exerts great potential in the early diagnosis, treatment, and prevention of biomedical clinical pancreatitis.

Construction and validation of risk prediction models for renal replacement therapy in patients with acute pancreatitis

BACKGROUND

Renal replacement therapy (RRT) plays a crucial role in managing acute pancreatitis (AP). This study aimed to develop and evaluate predictive models for determining the need for RRT among patients with AP in the intensive care unit (ICU).

METHODS

A retrospective selection of patients with AP was made from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version V2.0). The cohort was randomly divided into a training set (447 patients) and a validation set (150 patients). The least absolute shrinkage and selection operator (LASSO) regression cross-validation method was utilized to identify key features for model construction. Using these features, four machine learning (ML) algorithms were developed. The optimal model was visualized and clarified using SHapley Additive exPlanations (SHAP) and presented as a nomogram.

RESULTS

The mean age of the cohort was 59.17 years, with an average Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17.55. Acute kidney injury (AKI) was observed in 52.43% of patients with AP, and 9.05% required RRT. After feature selection, four of 41 clinical factors were ultimately chosen for use in model construction. The Lasso-Logistic Regression (Lasso-LR) model showed a high discriminative ability to predict RRT risk in patients with AP, with an area under the receiver operating characteristic (AUROC) of 0.955 (95% CI 0.924-0.987) in the training set. In the validation set, it maintained its discriminative performance, achieving an AUROC of 0.985 (95% CI 0.970-1.000). Calibration curves indicated an excellent fit in both sets (Brier scores: 0.039 and 0.032, respectively), suggesting high consistency. Decision curve analysis (DCA) highlighted the Lasso-LR model's significant clinical utility in predicting RRT likelihood in patients with AP.

CONCLUSIONS

Developed via the LASSO regression cross-validation method, the Lasso-LR model significantly excels in predicting the requirement for RRT in patients with AP, demonstrating its potential for clinical application.

Sestrin2 balances mitophagy and apoptosis through the PINK1-Parkin pathway to attenuate severe acute pancreatitis

Mitophagy serves as a mitochondrial quality control mechanism to maintain the homeostasis of mitochondria and the intracellular environment. Studies have shown that there is a close relationship between mitophagy and apoptosis. Sestrin2 (Sesn2) is a highly conserved class of stress-inducible proteins that play important roles in reducing oxidative stress damage, inflammation, and apoptosis. However, the potential mechanism of how Sesn2 regulates mitophagy and apoptosis in severe acute pancreatitis (SAP) remains unclear. In the study, RAW264.7 (macrophage cell Line) cellular inflammation model established by lipopolysaccharide (LPS) treatment as well as LPS and CAE-induced SAP mouse model (wild-type and Sen2 Knockout mouse) were used. Our study showed that LPS stimulation significantly increased the level of Sesn2 in RAW264.7 cells, Sesn2 increased mitochondrial membrane potential, decreased inflammation levels, mitochondrial superoxide levels and apoptosis, and also promoted monocyte macrophages toward the M2 anti-inflammatory phenotype, suggesting a protective effect of Sesn2 on mitochondria. Further, Sesn2 increased mitophagy and decreased apoptosis via modulating the PINK1-Parkin signaling. Meanwhile, knockout of Sesn2 exacerbated pancreatic, mitochondrial damage and inflammation in a mouse model of SAP. In addition, the protective effect of Sesn2 against SAP was shown to be associated with mitophagy conducted by the PINK1-Parkin pathway via inhibiting apoptosis. These findings reveal that Sesn2 in balancing mitochondrial autophagy and apoptosis by modulating the PINK1-Parkin signaling may present a new therapeutic strategy for the treatment of SAP.

Risk factors and a prediction model of severe asparaginase-associated pancreatitis in children

We aimed to investigate whether early clinical indicators were associated with eventual disease severity, and to develop a predictive model for severe asparaginase-associated pancreatitis (AAP). Seventy-five acute lymphoblastic leukaemia (ALL) cases with AAP admitted to Shanghai Children's Medical Center from March 2013 to August 2023 were divided into non-severe (n = 44) and severe (n = 31) groups based on Atlanta diagnostic and AAP grading criteria. We compared essential information, asparaginase(ASP) dosage form, cumulative dose, clinical characteristics and laboratory tests between the groups. Statistically significant indicators were analysed with multifactorial logistic regression to identify independent risk factors for severe AAP. Receiver operating characteristic (ROC) curves assessed the early predictive value of age, C-reactive protein (CRP) and fibrinogen (FIB) levels. In the early stages of AAP onset, significant differences in age, CRP, platelet count, red blood cell distribution width, albumin, calcium, FIB, and D-dimer levels were found between the non-severe and severe AAP groups (p < 0.05). Multifactorial logistic regression identified age (odds ratio [OR] = 1.204, p = 0.035), CRP (OR = 1.334, p = 0.003), and FIB (OR = 0.85, p = 0.008) as independent predictors of severe AAP. ROC analysis showed an area under the curves (AUC) for age was 0.681 (95% CI: 0.557-0.805), CRP was 0.766 (95% CI: 0.653-0.880), FIB was 0.735 (95% CI: 0.612-0.857). Optimal cut-off values for age, CRP, and FIB were 9.46 years, 48.5 mg/L and 1.265 g/L respectively. The combined AUC was 0.916 (95% CI: 0.845-0.986), with 0.903 sensitivity and 0.818 specificity, outperforming individual predictors (p < 0.05). Age, CRP, and FIB levels are good early predictors of severe AAP, and their combination significantly improves predictive accuracy.

Onset of pancreatic cancer before and after acute pancreatitis: A multicenter longitudinal cohort study

BACKGROUND

Pancreatic cancer (PC) is a leading cause of cancer mortality, often diagnosed at advanced stages. Acute pancreatitis (AP), particularly idiopathic cases, may serve as an early indicator of PC.

OBJECTIVE

This multicenter cohort study investigated the incidence of PC before and after an AP episode, focusing on idiopathic AP and the role of pseudocysts as potential early markers for PC development.

METHODS

We analyzed data from 2356 AP patients across 25 centers, with a median follow-up of 4.1 years (IQR: 1.6-6.8 years). Patients were categorized into 'PC before AP' and 'PC after AP' groups, and relative risk (RR) and adjusted odds ratios (OR) were calculated for idiopathic AP cases to quantify PC risk.

RESULTS

Among all cases, 69 patients (2.9 %) developed PC: 1.4 % (n = 34) before and 1.5 % (n = 35) after AP. Idiopathic AP cases had a fourfold higher risk of PC (OR = 4.46, [2.25-8.85]). Notably, pseudocysts were five times more prevalent in the PC group (14 %) compared to controls (3 %) (RR = 5.66; p < 0.01), often located at the tumor site. PC developed in 3 % of idiopathic AP cases versus 1.0 % in non-idiopathic cases. The median time to PC diagnosis post-AP was 373 days.

CONCLUSION

Idiopathic AP and pseudocyst formation significantly elevate the risk of PC, particularly within two years. These findings underscore the need for structured follow-up and early screening in idiopathic AP cases to improve PC detection and survival outcomes.

Gene Regulation of Neutrophils Mediated Liver and Lung Injury through NETosis in Acute Pancreatitis

Acute pancreatitis (AP) is one of the most common gastrointestinal emergencies, often resulting in self-digestion, edema, hemorrhage, and even necrosis of pancreatic tissue. When AP progresses to severe acute pancreatitis (SAP), it often causes multi-organ damage, leading to a high mortality rate. However, the molecular mechanisms underlying SAP-mediated organ damage remain unclear. This study aims to systematically mine SAP data from public databases and combine experimental validation to identify key molecules involved in multi-organ damage caused by SAP. Retrieve transcriptomic data of mice pancreatic tissue for AP, lung and liver tissue for SAP, and corresponding normal tissue from the Gene Expression Omnibus (GEO) database. Conduct gene differential analysis using Limma and DEseq2 methods. Perform enrichment analysis using the clusterProfiler package in R software. Score immune cells and immune status in various organs using single-sample gene set enrichment analysis (ssGSEA). Evaluate mRNA expression levels of core genes using reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. Validate serum amylase, TNF-α, IL-1β, and IL-6 levels in peripheral blood using enzyme-linked immunosorbent assay (ELISA), and detect the formation of neutrophil extracellular traps (NETs) in mice pancreatic, liver, and lung tissues using immunofluorescence. Differential analysis reveals that 46 genes exhibit expression dysregulation in mice pancreatic tissue for AP, liver and lung tissue for SAP, as well as peripheral blood in humans. Functional enrichment analysis indicates that these genes are primarily associated with neutrophil-related biological processes. ROC curve analysis indicates that 12 neutrophil-related genes have diagnostic potential for SAP. Immune infiltration analysis reveals high neutrophil infiltration in various organs affected by SAP. Single-cell sequencing analysis shows that these genes are predominantly expressed in neutrophils and macrophages. FPR1, ITGAM, and C5AR1 are identified as key genes involved in the formation of NETs and activation of neutrophils. qPCR and IHC results demonstrate upregulation of FPR1, ITGAM, and C5AR1 expression in pancreatic, liver, and lung tissues of mice with SAP. Immunofluorescence staining shows increased levels of neutrophils and NETs in SAP mice. Inhibition of NETs formation can alleviate the severity of SAP as well as the levels of inflammation in the liver and lung tissues. This study identified key genes involved in the formation of NETs, namely FPR1, ITGAM, and C5AR1, which are upregulated during multi-organ damage in SAP. Inhibition of NETs release effectively reduces the systemic inflammatory response and liver-lung damage in SAP. This research provides new therapeutic targets for the multi-organ damage associated with SAP.

Neutrophil-to-Lymphocyte Ratio Differentiates Infections from Sterile Inflammation in First Week of Acute Pancreatitis

BACKGROUND

Differentiating infections from sterile inflammation is crucial in early AP management.

AIM

This study aimed to assess the capability of Neutrophil-to-Lymphocyte Ratio (NLR) and procalcitonin to differentiate between sterile inflammation and infections in the first week of AP and to analyze the source, microbiological profile, and impact of infections in AP.

METHODS

Consecutive patients presenting within 5 days of symptom onset were included. Microbiological profiles and serious adverse events (SAEs: in-hospital mortality or discharge in critical state) were analyzed. Blood count obtained at fever onset was used for calculating the NLR. The ability of NLR and procalcitonin to differentiate infections from sterile inflammation in the first week was assessed.

RESULTS

Of 505 AP patients, 150 developed fevers. 48 (32%) had sterile inflammation, while 102 (68%) had infections. Most patients (n = 98, 65.3%) developed fever during the first week of illness (sterile inflammation (n = 43) and infections (n = 55)). NLR demonstrated good accuracy in differentiating infections from sterile inflammation in the first week (AUROC 0.70, p = 0.001), outperforming procalcitonin (AUROC 0.54, p = 0.58). Within infections (n = 102), 44 (43.1%) had infected pancreatic necrosis, 68 (66.7%) had extra-pancreatic infections, and 10 (9.8%) had both. Lower respiratory tract infection was the most common extra-pancreatic infection. Of 54 patients with culture-positive infections, 36 (66.7%) had grown multidrug-resistant (MDR) organisms. Fungal isolates were identified in 5 patients. Patients with infections had higher SAE incidence (21.6% vs. 4.2%, p = 0.007) than those with inflammation. The SAE incidence was higher with MDR infections than those without MDR (37.5% vs. 9.3%, p < 0.01).

CONCLUSIONS

Infections in AP occur early in the course of illness. NLR could serve as a reliable biomarker to distinguish infections from sterile inflammation in the early course of AP, aiding timely management. Patients with MDR infections have higher serious adverse outcomes.

YKL-40 as a risk stratification marker in acute pancreatitis: A prospective study

BACKGROUND/OBJECTIVES

Increased systemic concentrations of YKL-40 are seen in various inflammatory conditions. We explored the relationship between the serum YKL-40 concentrations and subsequent disease severity in patients with acute pancreatitis (AP).

METHODS

Consecutive adults with AP were prospectively enrolled, and classified as having mild, moderate or severe disease. On admission and 48 h later, C-reactive protein (CRP), YKL-40, interleukin-6 and 8 (IL-6, IL-8), and tumor necrosis factor alpha (TNF-α) concentrations were measured. Patients were also classified as those with low (<50 ng/mL, in the range seen in 30 age and sex-matched non-AP subjects), high (≥190 ng/mL, seen in most of the other inflammatory conditions), and intermediate YKL-40 (50-189 ng/mL).

RESULTS

Incidence of mild, moderate and severe AP among the 150 enrolled patients was 80 (53.3 %), 59 (39.3 %), and 11 (7.4 %), respectively. Both on admission and 48 h later, high YKL-40 (vs. intermediate or low) was strongly associated with higher odds of a more severe AP, independently of the concurrent IL-8 and TNF-α concentrations (OR around 3.5-4.0, or higher). On admission, the association was independent also of the concurrent CRP, whereas the association between the later concentrations and the outcome was conditional on CRP - uncertain at low, strong at high CRP. The high YKL-40 - outcome association at both time-points was conditional on concurrent IL-6: uncertain if IL-6 was low, strong if IL-6 was high.

CONCLUSIONS

Serum YKL-40 is a plausible candidate for further evaluation as an early biochemical indicator of subsequent AP severity, particularly if considered jointly with CRP and/or IL-6.

Diagnostic performance of pancreatic fluid aspiration through metagenomic next-generation sequencing for suspected infected pancreatic necrosis

AIMS

This study aimed to evaluate the diagnostic performance of metagenomic next-generation sequencing (mNGS) with pancreatic fluid aspiration for the detection of infected pancreatic necrosis (IPN).

METHODS

This retrospective observational study included 66 patients with suspected IPN. The participants simultaneously underwent pancreatic fluid aspiration mNGS, and microbial and blood culture. We compared the diagnostic performance of mNGS with that of culture in the detection of pathogens associated with IPN.

RESULTS

Of the 66 patients, 45 (68.2 %) were confirmed to have IPN. Pancreatic fluid aspiration mNGS yielded positive results in 32 of these patients (71.1 %), significantly outperforming microbial culture results (25 patients, 55.6 %; P = 0.039); however, both methods exhibited similar specificity (95.2% vs. 100 %). The results of pancreatic fluid aspiration mNGS and microbial culture matched in 73.3 % (33/45) of patients with IPN. The turnaround time for the mNGS results was significantly shorter than that for the microbial culture method (P < 0.001). In addition, survival analysis demonstrated that a positive mNGS result was not associated with increased mortality (hazard ratio, 0.652; 95 % confidence interval 0.157-2.699, P = 0.555).

CONCLUSIONS

Our study highlights the potential of mNGS for diagnosing IPN, with implications for improving patient care by facilitating early and accurate diagnosis, guiding appropriate interventions, and possibly improving patient outcomes.

Diagnostic accuracy of interleukin-6 as a biomarker for early prediction of severe acute pancreatitis: A systematic review and meta-analysis

Background

Acute pancreatitis (AP) is an inflammatory disease of the pancreas with varying severity. The mortality rate varies from 20% to 40% among severe acute pancreatitis (SAP). Interleukin-6 (IL-6) is a pro- and anti-inflammatory cytokine that involves various infections, inflammations, and systemic disorders. Injury to acinar cells leads to necrosis, releasing proinflammatory cytokines, including IL-6, which peaks earlier. The lack of extensive data regarding the association of IL-6 with AP influences us to do this meta-analysis for early detection and treatment of AP to prevent multiorgan failure.

Methods

We searched the PubMed, Cochrane Library, and Google Scholar databases for relevant articles published from inception to June 2024. We examined the positive and negative likelihood ratios, diagnostic odds ratios, and pooled sensitivity and specificity. We used the QUADAS-2 tool to evaluate the risk of bias.

Results

This meta-analysis included 13 studies involving 1386 patients with AP, of which 343 had SAP and 1043 had mild and moderately severe AP. The positive and negative likelihood ratios were 3.5 (95% CI 2.6 to 4.5) and 0.25 (95% CI 0.16 to 0.40). The diagnostic odds ratio of IL-6 to diagnose SAP is 14 (95% CI: 7 to 27), and the summary receiver operating characteristic curve is 0.85 (95% CI: 0.82-0.88).

Conclusion

Based on the results of this meta-analysis, serum IL-6 is a promising biomarker for diagnosing SAP in the early stage. However, a larger-scale study involving a more extensive population is necessary due to the considerable variation between the studies.

Percutaneous Interventions and Necrosectomy in the Management of Peripancreatic Collections

Acute pancreatitis (AP) is a severe inflammatory condition of the pancreas with significant morbidity and mortality, particularly in its necrotizing form. This review explores the management of peripancreatic collections and in particular necrotizing pancreatitis, focusing on the evolution from traditional open surgical methods to contemporary minimally invasive image-guided techniques. AP can lead to various local complications, including pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Imaging plays a crucial role in diagnosing complications of AP, while treatment approaches have shifted toward a step-up strategy involving percutaneous, endoscopic, and minimally invasive methods. Percutaneous necrosectomy, combining mechanical and chemical debridement, has shown promising results. Mechanical necrosectomy uses devices like baskets and retrieval nets, while chemical necrosectomy adds agents like hydrogen peroxide and streptokinase. Current evidence suggests that the step-up approach, starting with percutaneous drainage or necrosectomy and escalating to endoscopic or surgical interventions, if necessary, improves patient outcomes. The review underscores the need for a multidisciplinary approach in managing complicated AP and highlights ongoing advancements in minimally invasive techniques.

Risk Factors for Acute Pancreatitis Following Intragastric Balloon Insertion: A 7-Year Retrospective Cohort Study

BACKGROUND

Acute pancreatitis (AP) is a rare but serious complication of intragastric balloon (IGB) therapy. Despite the popularity of IGBs for weight loss, the incidence and risk factors of AP post-IGB insertion are not well understood. This study aimed to identify potential predictors and risk factors of AP in IGB patients.

METHODS

A retrospective time-to-event study was conducted over 7 years, encompassing patients who received IGBs between January 2017 and 2024. Cox regression analyses were performed to identify risk factors. The incidence of AP was evaluated as a secondary outcome. Patients were categorized into the AP and non-AP groups at a 1:3 ratio. The Revised Atlanta Classification was used to diagnose AP.

RESULTS

Among 450 patients with IGB, 25 developed AP, yielding an incidence of 5.56%. The Orbera balloon was associated with a lower AP risk (HR 0.29, 95% CI: 0.09-0.96; P = 0.042). The median time to AP onset was 40 days. Higher preprocedural BMI and age > 30 years showed a trend toward reduced AP risk, though not statistically significant.

CONCLUSIONS

AP following IGB insertion is uncommon but may be underreported, with substantial variability in onset time. The Orbera balloon demonstrated a protective effect, highlighting the role of balloon type in AP risk. These findings underscore the importance of balloon selection and the need for further prospective studies to confirm these results and optimize AP risk management in IGB patients.

Pancreatic Cystic Lesions in Children: A Comprehensive Scoping Review

OBJECTIVE

Pediatric pancreatic cystic lesions (PPCLs) are uncommon and differ from adult pancreatic cystic lesions. Literature is limited on the etiologies, evaluation, and management of PPCL. A multidisciplinary working group formed to provide a comprehensive description of PPCL and recommend best available evidence-based evaluation and management.

MATERIALS AND METHODS

The PPCL working group performed a scoping review by 2 methods: 1) a targeted literature review to describe PPCL and 2) a systematic literature review for management recommendations for PPCL. The systematic review was completed using a 2-stage sifting approach: title and abstract screening followed by a full text review.

RESULTS

One hundred thirty-one studies were included in the systematic review and an additional 20 were included in the targeted search to complete a comprehensive list of PPCL. Five neoplastic PPCL and 10 nonneoplastic PPCL were identified, and prevalence of different cystic lesions differs widely in adults and children. Recommendations on evaluation and management of PPCL are presented based on best available evidence.

CONCLUSIONS

We present a comprehensive review and evidence-based management recommendations with management algorithms for pediatric pancreatic cystic lesions. Given the rarity of many of these entities, this review also highlights many aspects of PPCL, which are not adequately described in the current literature.

Systematic Review of Volume and Methodological Quality of Randomized Trials in Acute Pancreatitis

BACKGROUND

This systematic review assessed the volume and methodological quality of randomized controlled trials (RCTs) in relation to management of acute pancreatitis (AP).

MATERIALS AND METHODS

The PubMed, MEDLINE, and CENTRAL databases were systematically searched for RCTs published across 3 time periods: <1996 (P1), 1996-2008 (P2), and >2008 (P3). RCT quality was assessed using the Cochrane Risk of Bias (RoB) 2 tool and sample size recalculation, and for spin (interpretation of nonstatistically significant results as relevant, making the study appear to be positive).

RESULTS

Overall, 263 RCTs with 23,232 patients with AP were included. The average number of RCTs per year increased from 1.4, 6.0, to 10.6 in P1, P2, and P3, respectively. The RoB assessment showed low, some, and high concerns in overall RoB in 21%, 56%, and 24% of all RCTs. Selective reporting bias improved over time. Sample size calculation reporting significantly increased through the 3 time periods (17%, 38%, and 47%; P < 0.001). Spin was identified in 68 RCTs (26% of all RCTs).

CONCLUSION

The quantity and quality of published RCTs relating AP management has increased over time, however significant shortcomings of methodological quality persist. Significant improvements in the conduct and reporting of randomized trials in AP are required to improve the evidence base in this field.

Significant projected savings with expansion of an emergency department observation protocol for mild acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) significantly contributes to healthcare costs, but not all patients require hospitalization. A novel, validated Emergency Department (ED) pathway for mild AP (MAP) at our tertiary care center reduced hospitalizations and resource utilization, without affecting outcomes.

METHODS

A decision-analytic model was constructed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist and methodologic recommendations by the Second Panel on Cost-Effectiveness in Health and Medicine to predict healthcare costs based on whether an ED discharge protocol for MAP was utilized.

RESULTS

Average savings for one MAP discharged from the ED were $1720.5 compared to the standard of care hospitalization. Assuming that 67.7 % of cases are mild and that there are 288,820 hospitalizations for AP annually, the ED discharge pathway would result in $98.6 million direct healthcare savings.

CONCLUSIONS

Implementation of an evidence-based, protocoled ED pathway for MAP could result in over $100 million in direct healthcare savings.

Six-fold increased risk of acute pancreatitis in alcohol-related liver disease compared to matched comparators: A population-based cohort study

BACKGROUND AND AIMS

Patients with alcohol-related liver disease (ALD) might be at increased risk of acute pancreatitis (AP), but large-scale data are lacking.

METHODS

Population-based cohort study using data from the Swedish National Patient Register on 37,062 patients with ALD from 1969 to 2020. Patients were matched to ≤10 general population comparators (n = 352,931). We used logistic regression to estimate the risk of acute or chronic pancreatitis prior to ALD diagnosis and Cox regression to estimate rates for hospitalization for AP after ALD diagnosis.

RESULTS

Median age at ALD diagnosis was 59 years; 72% were men, and 67% had cirrhosis at baseline. Overall, 7% had experienced pancreatitis before ALD diagnosis, resulting in 9-fold higher odds of pancreatitis compared to comparators. The 10-year cumulative incidence of hospitalization for AP was 2.7% (95%CI = 2.5-2.8) in ALD and 0.6% (95%CI = 0.58-0.63) in comparators, yielding an adjusted HR of 6.3 (95%CI = 5.8-6.9). Younger age, male sex, and diagnoses of alcohol use disorders and chronic obstructive pulmonary disease were independent risk factors for developing AP in ALD. Continued drinking after baseline was associated with a higher risk of AP (adjusted hazard ratio [aHR] 2.6, 95%CI = 2.29-2.85).

CONCLUSIONS

ALD is associated with 9-fold higher odds of prevalent pancreatitis compared to the general population. The hospitalization rate for AP following ALD diagnosis is 6-fold higher. About 10% of patients with ALD have or develop AP, suggesting that assessing history of pancreatitis and its sequelae might be relevant for patients with ALD.

Visceral adipose tissue area predicts major adverse kidney events in patients with acute necrotizing pancreatitis

BACKGROUND

Given the previously reported harmful effects of abdominal fat burden on kidney function, we aim to investigate the relationship between major adverse kidney events within 30 days (MAKE30) and abdominal obesity in acute necrotizing pancreatitis (ANP) patients and explore the underlying risk factors.

METHODS

A retrospective cohort study of all patients admitted within 72 h after the first episode of ANP to a tertiary center between June 2015 and June 2019 was conducted. Automatic image analysis software was used to calculate the area of subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT) and skeletal muscle from computed tomography scans at the umbilical level. The potential risk factors of MAKE30 were analyzed by logistic regression.

RESULTS

A total of 208 eligible ANP patients were enrolled, with an incidence of 23% for MAKE30. VAT area was more closely associated with the development of MAKE30, with an area under the ROC curve of 0.69 (cutoff value 200 cm2, 63.8% sensitivity and 66.7% specificity). Multivariate logistic regression analysis demonstrated that VAT area [OR 1.01 (1.01-1.02); p < 0.001] was an independent risk factor in predicting MAKE30. Patients with a VAT area > 200 cm2 had more requirements of renal replacement therapy (32% vs. 12%, P < 0.001), and a significantly higher incidence of other poor clinical outcomes (all p < 0.05).

CONCLUSION

Early assessment of the VAT area may help identify ANP patients at high risk of MAKE30, suggesting that it could be a potential indicator for adverse kidney events.

Artesunate protects against a mouse model of cerulein and lipopolysaccharide‑induced acute pancreatitis by inhibiting TLR4‑dependent autophagy

Severe acute pancreatitis (SAP) is a severe clinical condition associated with high rates of morbidity and mortality. Multiple organ dysfunction syndrome that follows systemic inflammatory response syndrome is the leading cause of SAP‑related death. Since the inflammatory mechanism of SAP remains unclear, there is currently a lack of effective drugs available for its treatment. Therefore, it is important to study effective therapeutic drugs and their molecular mechanisms based on studying the inflammatory mechanism of SAP. In the present study, in vivo, a mouse model of AP induced by cerulein (CR) combined with lipopolysaccharide (LPS) was established to clarify the therapeutic effect of artesunate (AS) in AP mice by observing the gross morphological changes of the pancreas and surrounding tissues, calculating the pancreatic coefficient, and observing the histopathology of the pancreas. The serum amylase activity in AP mice was detected by iodine colorimetry and the superoxide dismutase activity in the pancreas was detected by WST‑1 assay. The levels of proinflammatory cytokines in the serum, the supernatant of pancreatic tissue homogenates and the peritoneal lavage fluid were detected by ELISA assay. The total number of peritoneal macrophages was assessed using the cellular automatic counter, and the expression of proteins related to autophagy, and the TLR4 pathway was detected by immunohistochemistry and western blotting. In vitro, the effect of trypsin (TP) combined with LPS was observed by detecting the release of proinflammatory cytokine levels from macrophages by ELISA assay, and detecting the expression of proteins related to autophagy and the TLR4 pathway by immunofluorescence and western blotting. The present study revealed that AS reduced pancreatic histopathological damage, decreased pancreatic TP and serum amylase activities, increased superoxide dismutase activity, and inhibited pro‑inflammatory cytokine levels in a mouse model of AP induced by cerulein combined with lipopolysaccharide. In vitro, TP combined with LPS was found to synergistically induce pro‑inflammatory cytokine release from mouse macrophages and RAW264.7 cells, while AS could inhibit cytokine release. Furthermore, CR combined with LPS synergistically increased amylase activity in acinar cells, whereas AS decreased amylase activity. Autophagy serves an important role in the release of pro‑inflammatory cytokines. In the present study, it was revealed that the autophagy inhibitor LY294002 suppressed the release of pro‑inflammatory cytokines from macrophages treated with TP combined with LPS, and pro‑inflammatory cytokine release was not further reduced by AS combined with LY294002. Furthermore, AS not only inhibited the expression of important molecules in the Toll‑like receptor 4 (TLR4) signaling pathway, but also inhibited autophagy proteins and reduced the number of autolysosomes in mice with AP and in macrophages. In conclusion, these results suggested that AS may protect against AP in mice via inhibition of TLR4‑dependent autophagy; therefore, AS may be considered a potential therapeutic agent against SAP.

A systematic review of the relationship between gut microbiota and prevalence of pancreatic diseases

Acute pancreatitis (AP) represents one of the most common gastrointestinal (GI) diseases; it can manifest in varying degrees of severity, sometimes leading to a life-threatening condition for the patient. Pancreatic ductal adenocarcinoma (PDAC), due to its high malignancy and uncertain prognosis, is widely regarded as one of the most fatal diseases. The increasing prevalence of AP and PDAC represents a major burden on public health and the healthcare system worldwide. The aim of this systematic review was to discuss the current state of knowledge regarding the relationship between the gut microbiota and the incidence, prognosis, diagnosis and treatment of AP and PDAC. To identify studies that analyzed the relationship between the gut microbiota and the occurrence/development of pancreatic diseases or PDAC, the online databases PubMed, Scopus and Google Scholar were searched between November 2023 and January 2024. Finally, 14 publications met the inclusion criteria (1. were conducted exclusively in humans and/or animals; 2. original, published in English in peer-reviewed journals after 2019; 3. described the relationship between gut microbiota and the occurrence of AP or PDAC). The collected studies indicated significant changes in the gut microbiota of patients with AP and PDAC. Moreover, they highlighted the presence of a relationship between the gut microbiota and the occurrence, course, treatment efficiency and prognosis of the disease in question. Further research is needed to understand precisely the relationship between the gut microbiota and the occurrence of pancreatic diseases and whether it may be a starting point for the development of modern forms of therapy based on the use of prebiotics and/or diet to restore the normal composition of the intestinal bacteria.

Propofol, Triglycerides, and Acute Pancreatitis: A Multicenter Epidemiologic Analysis

Rationale: Propofol is one of the first-line sedative-hypnotic agents for critically ill adults requiring mechanical ventilation. Although propofol can elevate triglyceride levels, and the latter is a risk factor for pancreatitis, the association between propofol and acute pancreatitis is unclear. Objectives: We sought to determine the clinical impact and potential associations between propofol infusion, hypertriglyceridemia, and acute pancreatitis. Methods: This is an observational multicenter study of adults (⩾18 yr old) who were admitted to an intensive care unit, who required mechanical ventilation and received continuous propofol infusion for at least 24 hours. The primary outcomes were the frequency of hypertriglyceridemia (>400 mg/dl) and acute pancreatitis. Further analyses were done to determine the clinical impact of elevated triglyceride levels (i.e., sedation changes) and risk factors for pancreatitis development. Results: Of 11,828 patients included, 33.2% (n = 3,922) had triglyceride levels measured, of whom 21.7% (n = 851) had hypertriglyceridemia at 4.5 days (SD = 6.8) after propofol initiation. Of those still requiring sedation, 70.4% (n = 576/818) received alternative sedatives after developing hypertriglyceridemia. Pancreatitis occurred in 1.2% of patients (n = 47/3,922) and was more frequent in those with hypertriglyceridemia (3.2%, 27/851; vs. 0.7%, 20/3,071; P < 0.001). After adjustment for potential confounding variables, each 100 mg/dl increase in triglyceride levels was associated with an 11% increase in risk of pancreatitis. Propofol dose was not associated with pancreatitis development. Conclusions: Acute pancreatitis is uncommon in patients receiving propofol infusion, and it occurs over a wide range of triglyceride levels, indicating a multifactorial pathophysiology. Hypertriglyceridemia frequently prompts the use of alternative sedatives. Further study is needed to determine how to best monitor and treat hypertriglyceridemia in critically ill patients receiving propofol infusion.

Markers of Collagen Formation and Degradation in Serum and Pancreatic Fluid Collections in Patients With Acute and Chronic Pancreatitis

OBJECTIVES

Current knowledge on the fibro-inflammatory process underlying chronic pancreatitis originates from animal studies or human studies based on circulating biomarkers. To provide new insight into the underlying fibro-inflammatory processes, we simultaneously assessed fibrosis biomarkers in pancreatic fluid collections and the systemic circulation.

MATERIALS AND METHODS

This prospective observational cross-sectional study included patients with acute and chronic pancreatitis undergoing drainage of pancreatic fluid collections, as well as 20 healthy controls (only serum levels). PRO-C3, PRO-C11 and PRO-C19 (markers of collagen formation), and C3M and C4M (markers of collagen degradation) were evaluated for both compartments (serum and fluid collection).

RESULTS

Forty-three patients were included: 26 with walled-off necrosis and 17 with pseudocyst. Serum levels of all 5 fibrosis biomarkers were elevated in patients as compared to controls (all P < 0.001). PRO-C3 levels were significantly higher in pancreatic fluid vs serum (280.6 vs 20.8 ng/mL, P < 0.001). In contrast, levels of C3M (20.5 vs 13.1 ng/mL, P = 0.003), PRO-C19 (64.9 vs 14.3 nM, P < 0.001), and C4M (55.6 vs 20.4 ng/mL, P < 0.001) were significantly higher in serum vs pancreatic fluid.

CONCLUSIONS

The high serum levels in patients suggest increased overall fibrotic activity in pancreatitis patients as compared to healthy controls. PRO-C3 elicited higher levels in the pancreatic fluid, indicating localized fibrotic activity.

Outcomes of percutaneous endoscopic versus endoscopic transmural necrosectomy for necrotizing pancreatitis: A propensity score-matched study

BACKGROUND

Few published studies exist that compare the outcomes of different endoscopic necrosectomy methods for necrotizing pancreatitis (NP). We compared the safety and efficacy of percutaneous versus transmural endoscopic necrosectomy for NP patients.

METHODS

In this retrospective cohort study, we analyzed adult NP patients who underwent either percutaneous endoscopic necrosectomy (PEN) or endoscopic transmural necrosectomy (ETN), and compared safety and efficacy between the two groups. Propensity score-matched analysis and multivariable logistic regression analysis were conducted.

RESULTS

A total of 280 patients were enrolled, among which 142 underwent PEN and 138 underwent ETN. There were differences in baseline characteristics between the two groups, including body mass index, C-reactive protein, systemic inflammatory response syndrome score. The incidences of sepsis, respiratory failure, and intensive care unit stay were higher among patients who underwent PEN than those who underwent ETN (all P < 0.01). Ninety-one pairs were matched with comparable baseline characteristics and severity. The incidence of postoperative complications, open surgery, clinical success, radiological success, collection recurrence, and reintervention were not significantly different between the ETN group and PEN group (all P > 0.05). Multivariate analysis also showed that the approaches (PEN vs ETN) was not associated with postoperative complications or mortality.

CONCLUSIONS

In real world setting, sicker patients tend to be more effectively managed through PEN compared to ETN. PEN demonstrates comparable efficacy and safety to ETN in the treatment of NP patients.

Three-tiered critical care management of acute pancreatitis

INTRODUCTION AND AIMS

Acute pancreatitis (AP) can rapidly progress from a stable condition to multiple organ failure with high mortality. We aimed to describe the characteristics of AP patients requiring admission to a critical care facility and to identify predictors of disease progression.

METHODS

We conducted a post-hoc analysis using prospectively collected data from AP patients admitted to the high dependency unit (HDU) and intensive care unit (ICU) at the University of Pécs, Hungary, from 2016 to 2019. Patients were categorized according to critical care needs and severity. Daily records of organ function, organ support and laboratory parameters were kept. Descriptive analysis and predictive models were developed to forecast the need for escalated critical care and mortality.

RESULTS

Analysis of 92 cases (65 % male, mean age 63 (range 19-92) years) revealed a median critical care stay of 8 days (range 1-69) and a mortality rate of 47 %. Naive Bayes prediction models using admission C-reactive protein (CRP) and amylase levels achieved 75 % accuracy in predicting mortality and a 65 % probability of requiring HDU and/or ICU admission. CRP levels increased significantly (47 vs 62 mg/l, p: 0.015) from 48 to 24 h before critical care admission, contrasting with controls, resulting in significantly higher CRP levels in critical care patients (62 vs 32 mg/l, p: 0.007) 24 h before admission.

CONCLUSION

Our findings suggest that on-admission CRP and amylase cannot reliably predict progression of AP. However, elevated and increasing levels of CRP and amylase may indicate the need for early HDU admission to enable closer monitoring.

Outcomes of Acute Pancreatitis in Patients With and Without Liver Cirrhosis: A Retrospective Analysis

Background Acute pancreatitis (AP) is a common cause of hospitalization in the United States. Our study aimed to investigate the impact of liver cirrhosis (LC) on the outcomes of AP in adult patients hospitalized with AP. Methods We performed a retrospective study of adult patients with AP utilizing the Nationwide Inpatient Sample (NIS) database from 2020 to 2022. We compared AP outcomes in patients with and without LC. The primary outcome was all-cause inpatient mortality. Secondary outcomes were the length of stay (LOS), healthcare cost utilization adjusted to 2022, the incidence of acute renal failure (ARF), sepsis, shock, venous thromboembolism (VTE), and the need for intensive care unit (ICU) admission. Statistical analyses were performed using STATA, version 16.1 (StataCorp., College Station, Texas, USA). A multivariate logistic regression analysis was conducted to assess if gender was an independent predictor for these outcomes and to adjust for any confounders. Results From 2020 to 2022, 738,139 adult patients underwent AP admissions. Among the patients, 723,959 had AP without LC, and 14,180 had AP with LC. The mean age for patients with and without LC was the same, 50.9 years. Patients without LC had a higher prevalence of cerebrovascular accident (CVA) and obesity. Patients with LC had a higher prevalence of congestive heart failure (CHF), diabetes mellitus type 2 (DM2), diabetes mellitus type 1 (DM1), chronic kidney disease (CKD), and smoking/tobacco use. We found that AP patients with LC had a significantly higher likelihood of in-hospital mortality (aOR: 1.74, 95% CI: 1.22-2.42, P < 0.01), longer LOS (+ 0.46 days, 95% CI: 0.26-0.67, P < 0.01), higher healthcare utilization cost (+ $4163, 95% CI: $1530.9-$6796.0, P < 0.01), shock (aOR: 1.87, 95% CI: 1.42-2.46, P < 0.01), ARF (aOR: 1.44, 95% CI: 1.30-1.59, P < 0.01), ICU admission (aOR: 1.67, 95% CI: 1.38-1.91, P < 0.01), and acute VTE (aOR: 1.65, 95% CI: 1.30-2.11, P < 0.01).  Conclusions We found that patients with AP who concomitantly had LC had significantly poor clinical outcomes, including higher mortality, ARF, shock, ICU admission, VTE, LOS, and total hospitalization charges as compared to AP patients who did not have LC. Our study highlights that cirrhotic patients with AP have poor inpatient hospital outcomes and need aggressive treatment to prevent morbidity and mortality.

A systematic review of machine learning-based prognostic models for acute pancreatitis: Towards improving methods and reporting quality

BACKGROUND

An accurate prognostic tool is essential to aid clinical decision-making (e.g., patient triage) and to advance personalized medicine. However, such a prognostic tool is lacking for acute pancreatitis (AP). Increasingly machine learning (ML) techniques are being used to develop high-performing prognostic models in AP. However, methodologic and reporting quality has received little attention. High-quality reporting and study methodology are critical for model validity, reproducibility, and clinical implementation. In collaboration with content experts in ML methodology, we performed a systematic review critically appraising the quality of methodology and reporting of recently published ML AP prognostic models.

METHODS/FINDINGS

Using a validated search strategy, we identified ML AP studies from the databases MEDLINE and EMBASE published between January 2021 and December 2023. We also searched pre-print servers medRxiv, bioRxiv, and arXiv for pre-prints registered between January 2021 and December 2023. Eligibility criteria included all retrospective or prospective studies that developed or validated new or existing ML models in patients with AP that predicted an outcome following an episode of AP. Meta-analysis was considered if there was homogeneity in the study design and in the type of outcome predicted. For risk of bias (ROB) assessment, we used the Prediction Model Risk of Bias Assessment Tool. Quality of reporting was assessed using the Transparent Reporting of a Multivariable Prediction Model of Individual Prognosis or Diagnosis-Artificial Intelligence (TRIPOD+AI) statement that defines standards for 27 items that should be reported in publications using ML prognostic models. The search strategy identified 6,480 publications of which 30 met the eligibility criteria. Studies originated from China (22), the United States (4), and other (4). All 30 studies developed a new ML model and none sought to validate an existing ML model, producing a total of 39 new ML models. AP severity (23/39) or mortality (6/39) were the most common outcomes predicted. The mean area under the curve for all models and endpoints was 0.91 (SD 0.08). The ROB was high for at least one domain in all 39 models, particularly for the analysis domain (37/39 models). Steps were not taken to minimize over-optimistic model performance in 27/39 models. Due to heterogeneity in the study design and in how the outcomes were defined and determined, meta-analysis was not performed. Studies reported on only 15/27 items from TRIPOD+AI standards, with only 7/30 justifying sample size and 13/30 assessing data quality. Other reporting deficiencies included omissions regarding human-AI interaction (28/30), handling low-quality or incomplete data in practice (27/30), sharing analytical codes (25/30), study protocols (25/30), and reporting source data (19/30).

CONCLUSIONS

There are significant deficiencies in the methodology and reporting of recently published ML based prognostic models in AP patients. These undermine the validity, reproducibility, and implementation of these prognostic models despite their promise of superior predictive accuracy.

REGISTRATION

Research Registry (reviewregistry1727).

Liver and pancreatic fat fractions as predictors of disease severity in acute pancreatitis: an MRI IDEAL-IQ study

PURPOSE

Metabolic dysfunction-associated steatotic liver disease (MASLD) and non-alcoholic fatty pancreatic disease (NAFPD) are metabolic diseases with rising incidence. Fatty infiltration may lead to dysfunction of the liver and pancreatic tissues. This study aims to quantify liver and pancreatic fat fractions and examine their correlation with disease severity in acute pancreatitis patients.

METHODS

The severity of acute pancreatitis was assessed using the revised Atlanta classification (RAC), computed tomography severity index (CTSI), and modified CTSI (mCTSI). Proton density fat fraction (PDFF) levels of the liver and pancreas were measured via IDEAL MRI. Patients were categorized into biliary and non-biliary pancreatitis groups. Correlations between PDFF levels and the RAC, CTSI, and mCTSI scores were analyzed.

RESULTS

A total of 127 patients were included, with MASLD present in 40.9% and NAFPD in 30%. Liver PDFF values were significantly higher in non-biliary pancreatitis (p = 0.040). Patients with MASLD exhibited higher CTSI and mCTSI scores (p = 0.009, p = 0.033, respectively). No significant differences were observed in severity scales between patients with and without NAFPD. Liver PDFF was positively correlated with CTSI and mCTSI scores in biliary pancreatitis. ROC analysis identified a liver PDFF > 3.9% (p = 0.002) and pancreatic corpus PDFF > 12.1% (0.028) as diagnostic markers for severe pancreatitis. In addition, a liver PDFF < 4.5% (p = 0.042) was an indicator for biliary pancreatitis.

CONCLUSION

MASLD is associated with increased severity in acute pancreatitis. IDEAL MRI-derived PDFF levels of the liver and pancreas show potential in predicting severe acute pancreatitis and distinguishing between biliary and non-biliary etiologies.

The Importance of Resolvin D1, LXA4, and LTB4 in Patients with Acute Pancreatitis Due to Gallstones

Background and Objectives: Acute pancreatitis (AP) is an inflammatory disease where there is autodigestion of the pancreas by prematurely activated enzymes which may lead to a systemic inflammatory response. The aim of our study was to investigate the levels of circulating serum leukotriene B4 (LTB4), lipoxin A4 (LXA4), and resolvin D1 (RvD1) in pancreatitis due to gallstones in the etiologic investigation of AP. Materials and Methods: A total of 147 patients with AP (n: 49), AC (n: 49), and combined AP + AC (n: 49) will be included in the study. Healthy volunteers (n: 49) will be included as the control group. Results: RvD1 levels were significantly lower in patient groups compared to controls, while LXA4 levels were lower in patients with combined AP + AC (145.24 ng/L) compared to both controls (312.36 ng/L) and other patient groups. LTB4 levels were elevated in all patient groups compared to controls (335.56 ng/L vs. 65.56 ng/L) and were highest in combined AP + AC. Significant correlations were identified: RvD1 showed a negative correlation with LTB4 (r =-0.676; p < 0.001) and a positive correlation with LXA4 (r = 0.563, p < 0.001). ROC analysis demonstrated high diagnostic accuracy, with LXA4 and LTB4 achieving perfect differentiation (AUC: 1.0) between control and combined AP + AC cases. Conclusions: Our study showed that serum RvD1 and LXA4 levels have powerful anti-inflammatory properties in accordance with the literature. LTB4 may represent new, effective indicators to predict the severity of AP and the presence of necrosis in patients with AP. Despite its low sensitivity and specificity, RvD1 could be used as a complementary marker to the current scoring systems for the initial assessment of AP prognosis. These findings provide a new mechanistic understanding of how RvD1 attenuates inflammation to facilitate resolution, which could help develop novel therapeutic strategies for diseases caused by unresolved inflammation. It is easily obtainable and can provide additional prognostic information to clinicians.

Mesalazine-Induced Acute Pancreatitis in Inflammatory Bowel Disease Patients: A Systematic Review

Objective

Mesalazine is a widely used medication for treating mild to moderate inflammatory bowel disease (IBD). First identified as a potential cause of acute pancreatitis (AP) in 1989, the link between mesalazine and AP has primarily been established through case reports and a limited number of retrospective studies. This study aims to explore the characteristics of mesalazine-induced AP.

Methods

The databases of CNKI, Wanfang Data, VIP, PubMed and Web of Science were searched (up to March, 2024), and the case reports of mesalazine-related AP in IBD patients were collected and descriptively analyzed.

Results

Thirty-four reports were included, describing 42 patients (22 males, 16 females, 4 unspecified) with mesalazine-related AP. The onset of pancreatitis occurred a median of 14 days (range 1-730 days) after starting mesalazine. Common symptoms included abdominal pain (100%), vomiting (38.1%), fever (21.4%), and nausea (21.4%). Most patients had elevated serum amylase and lipase levels, with some showing raised C-reactive protein and erythrocyte sedimentation rate. Imaging tests, such as computed tomography and B-scan ultrasonography, revealed edematous infiltration and inflammation. Discontinuation of mesalazine led to symptom resolution in all patients, with 93.3% improving within a week. Alternative treatments or switching to other forms of 5-aminosalicylic acid may be considered for ongoing management. Rechallenge with mesalazine led to recurrence of AP in 21 cases, with a shorter median time to symptom onset.

Conclusion

Mesalazine-induced AP is a rare but significant adverse reaction, not related to drug dosage, and can occur at any point during treatment, typically within two weeks. The reaction can recur upon rechallenge. Discontinuation of mesalazine and symptomatic treatment typically resolves the condition.

FGF21 and APOA1 mRNA-based therapies for the treatment of experimental acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) presents a significant clinical challenge with limited therapeutic options. The complex etiology and pathophysiology of AP emphasize the need for innovative treatments. This study explores mRNA-based therapies delivering fibroblast growth factor 21 (FGF21) and apolipoprotein A1 (APOA1), alone and in combination, for treating experimental AP.

METHODS

Liver-targeted lipid nanoparticles (LNP)-mRNA formulations encoding FGF21, APOA1, and a chimeric APOA1-FGF21, were first tested for protein expression and bioavailability in vitro and in mice fed a high-fat diet. Efficacy studies were performed in the caerulein-induced AP (Cer-AP) model, and a new AP model combining ethanol feeding with ethanol binge plus palmitoleic acid administration, the EtOH/POA-AP model. A single dose of the APOA1, FGF21, and APOA1-FGF21 LNP-mRNAs formulations was administered in both models. Serum levels of pancreatic lipase (LIPC), amylase (AMYL), and aspartate aminotransferase (AST), along with pancreatic tissue analyses using two histopathological scores were performed to evaluate treatment effects.

RESULTS

In vitro studies demonstrated the translation and secretion of APOA1, FGF21, and APOA1-FGF21 proteins encoded by the LNP-mRNAs. In vivo, LNP-mRNA administration increased serum levels of the respective proteins in metabolically impaired (i.e. high fat diet-fed) mice. In the Cer-AP model, serum markers of pancreatic injury were similarly reduced when mice were treated with APOA1, FGF21, and APOA1-FGF21 LNP-mRNA, and this effect was also observed in the histopathological analyses. The EtOH/POA-AP model was more aggressive than the Cer-AP model. FGF21 and APOA1-FGF21 LNP-mRNAs were protective according to LIPC and AMYL serum levels, while APOA1 LNP-mRNA had little effect. On the other hand, histological improvements were more evident in mice receiving APOA1 LNP-mRNA. In the EtOH/POA-AP model, FGF21 and APOA1-FGF21 LNP-mRNAs reduced serum AST levels, indicating hepatoprotective activity.

DISCUSSION

This proof-of-concept study demonstrates the potential of mRNA-based therapies delivering FGF21 and APOA1 in experimental AP. While individual treatments effectively reduced pancreatic injury, the APOA1-FGF21 fusion molecule did not exhibit superior activity. Liver-targeted LNP-mRNA administration may offer a promising approach for treating AP, leveraging endogenous production pathways for therapeutic proteins. Further research is warranted to elucidate the mechanisms underlying their therapeutic efficacy and optimize treatment regimens for clinical translation.