Clinical practice guideline: management of acute pancreatitis

Systematic Review of Irreversible Electroporation Role in Management of Locally Advanced Pancreatic Cancer

BACKGROUND

Ablative techniques provide in patients with locally advanced pancreatic cancer (LAPC) symptomatic relief, survival benefit and potential downsizing. Irreversible Electroporation (IRE) represents potentially an ideal solution as no thermal tissue damage occurs. The purpose of this review is to present an overview on safety, feasibility, oncological results, survival and quality of life improvement obtained by IRE.

METHODS

A systematic search was performed in PubMed, regarding the use of IRE on PC in humans for studies published in English up to March 2019.

RESULTS

15 original studies embodying 691 patients with unresectable LAPC who underwent IRE were included. As emerged, IRE works better on tumour sizes between 3-4 cm. Oncological results are promising: median OS from diagnosis or treatment up to 27 months. Two groups investigated borderline resectable tumours treated with IRE before resection with margin attenuation, whereas IRE has proved to be effective in pain control.

CONCLUSIONS

Electroporation is bringing new hopes in LAPC management. The first aim of IRE is to offer a palliative treatment. Further efforts are needed for patient selection, as well as the use of IRE for 'margin accentuation' during surgical resection. Even if promising, IRE needs to be validated in large, randomized, prospective series.

Intensive management of severe acute pancreatitis

To investigate an optimal management bundle to improve the survival rate of severe acute pancreatitis (SAP). We constructed a treatment bundle based on our clinical investigation, literature, and empirical practice. Intensive management during the acute response stage and infection stage comprised eight main issues: etiology, diagnosis, fluid resuscitation, support of organ function, abdominal compartment syndrome (ACS), enteral nutrition, intestinal function, and antibiotics. The intensive management plan included a time-dependent plan for the eight main issues and goal-directed therapy. The plan must be started within the prescribed time (time-dependent endeavors) and must involve the right strategies, right sequence, and right ward for each individual. Effective goal-directed therapy and essential treatment measures must be performed within a specified period of time, and treatment efficacy should be regularly assessed. In 2010, intensive management was initiated in China. Intensive management has significant effects on SAP. This strategy was adopted by 36 hospitals in China, resulting in significant improvements in prognoses. Some criteria of intensive management were adopted by the International Association of Pancreatology (IAP)/American Pancreatic Association Working Group Acute Pancreatitis Guidelines in 2013. Intensive management is an important efficacy-based treatment strategy that can significantly ameliorate prognoses.

Maresin-1 Inhibits Oxidative Stress and Inflammation and Promotes Apoptosis in a Mouse Model of Caerulein-Induced Acute Pancreatitis

Background

This study aimed to investigate the effects of maresin-1 (MaR1) in a mouse model of caerulein-induced acute pancreatitis (AP).

Material/Methods

Fifty C57BL/6 mice with caerulein-induced AP were divided into the untreated control group (N=10), the untreated AP model group (N=10), the MaR1-treated (low-dose, 0.1 μg) AP model group (N=10), the MaR1-treated (middle-dose, 0.5 μg) AP model group (N=10), and the MaR1-treated (high-dose, 1 μg) AP model group (N=10). Enzyme-linked immunoassay (ELISA) measured serum levels of amylase, lipase, tumor necrosis factor-alpha (TNF-α), interleukin-1β (IL-1β), and IL-6 and mRNA was measured by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Malondialdehyde (MDA), protein carbonyls, superoxide dismutase (SOD), and the ratio of reduced glutathione/oxidized glutathione (GSH/GSSG) were measured. Histology of the pancreas included measurement of acinar cell apoptosis using the terminal-deoxynucleotidyl transferase-mediated nick end-labeling (TUNEL) assay. Western blot measured Toll-like receptor 4 (TLR4), MyD88, and phospho-NF-κB p65, and apoptosis-associated proteins Bcl-2, Bax, cleaved caspase-3, and cleaved caspase-9.

Results

Following treatment with MaR1, serum levels of amylase, lipase, TNF-α, IL-1β, and IL-6 decreased, MDA and protein carbonyl levels decreased, SOD and the GSH/GSSG ratio increased in a dose-dependent manner. In the MaR1-treated AP mice, inflammation of the pancreas and the expression of inflammatory cytokines, pancreatic acinar cell apoptosis, Bcl-2 expression, and expression of TLR4, MyD88, and p-NF-κB p65 were reduced, but Bax, cleaved caspase-3, and cleaved caspase-9 expression increased.

Conclusions

In a mouse model of caerulein-induced AP, treatment with MaR1 reduced oxidative stress and inflammation and reduced apoptosis.

Hypertriglyceridemia-Related Pancreatitis In Patients With Type 2 Diabetes: Links And Risks

Disturbances in glucose and lipid homeostasis are cardinal features of the metabolic syndrome that affect millions of people worldwide. These conditions have multi-organ impact, and while cardiovascular effects are usually the core for studies and preventive measures, other systems may also be affected, including the pancreas. Acute pancreatitis related to severe hypertriglyceridemia is an under-recognized condition that could lead to significant morbidity and mortality. Therefore, when suspected, prompt diagnosis and treatment should be initiated to cover the various aspects of this disorder. Though commonly known to be associated with excess of alcohol use, hypertriglyceridemia-related pancreatitis is particularly observed in diabetics, especially when uncontrolled. Here, we portray the possible mechanisms and clinical features that link type 2 diabetes, hypertriglyceridemia and pancreatitis, and discuss their health-related outcomes and the current and novel treatment options for this unique disease.

Reciprocal Feedback Loop of the MALAT1-MicroRNA-194-YAP1 Pathway Regulates Progression of Acute Pancreatitis

Background

Acute pancreatitis (AP) has a high mortality rate and often has serious complications. The Hippo-YAP signaling pathway is mainly involved in cell proliferation and stem cell self-renewal. Recent studies have reported that YAP1 plays a crucial role in pancreatic cancer initiation and acute and chronic pancreatitis (CP). However, the role of YAP1 in AP still needs to be clarified.

Material/Methods

To assess the role of YAP1 in the progression of AP, we established a cell model of AP in AR42J cells. AR42J, a rat pancreatic acinar cell line, was stimulated with caerulein to mimic AP-like acinar cell injury. Levels of interleukin (IL)-6 and tumor necrosis factor-α (TNF-α) were measured by ELISA to investigate the role of YAP1 in the progression of AP.

Results

The results showed that YAP1 and MALAT1 were the targets of miR-194 and were upregulated in caerulein-treated AR42J cells. Overexpression of MALAT1 or YAP1 can increase the levels of IL-6 and TNF-α secreted by AR42J cells, while miR-194 dramatically counteracts this enhancement effect.

Conclusions

Our results demonstrated a regulation loop among MATAL1, miR-194, and YAP1, which dynamically regulates the progression of AP, providing a new therapeutic target for treatment of this disease.

Hypertriglyceridaemia-associated acute pancreatitis: diagnosis and impact on severity

BACKGROUND

The level of hypertriglyceridaemia (HTG) at which the risk of acute pancreatitis (AP) increases and the impact of HTG on AP attributable to other aetiologies remains unclear.

METHODS

We compared clinical outcomes of patients admitted within 48 h of the onset of abdominal pain from a first episode of AP and admission serum triglyceride levels of either <5.65 mmol/l (<500 mg/dl) or ≥5.65 to <11.3 mmol/l (moderate HTG) or ≥11.3 mmol/l (≥1000 mg/dl, severe HTG).

RESULTS

Among a cohort of 1,233 patients with AP there were significant progressive increases in all major deleterious clinical outcomes including mortality (all P_trend < 0.05) that were directly dependent on admission triglyceride levels. Outcomes were improved by earlier presentation (<24 h compared to 24-48 h from abdominal pain onset). Patients with severe HTG and a concomitant aetiology (n = 68) had significantly more persistent organ failure, pancreatic necrosis and longer hospital stays (P < 0.05) than those with severe HTG alone (n = 206).

CONCLUSIONS

There appears to be an association between HTG grade and the severity of AP. Severe HTG significantly increased the severity of AP, over AP attributable to other aetiologies. Moderate as well as severe HTG can be used as a criterion for the diagnosis of HTG-associated AP.

Correlation between Thiopurine S-Methyltransferase Genotype and Adverse Events in Inflammatory Bowel Disease Patients

Background and Objectives: In patients with inflammatory bowel diseases (IBD), the use of azathioprine results in adverse events at a rate of 5% to 20%. The aim of the study was to assess a possible correlation between genetic variability of the enzyme thiopurine S-methyltransferase (TPMT) and the development of toxicity to azathioprine. Materials and Methods: A retrospective, single center, blind, case-control study was conducted on 200 IBD patients, of whom 60 cases suspended azathioprine due to toxicity (leukopenia, pancreatitis, hepatitis, and nausea or vomiting), and 140 controls continued treatment with the drug without adverse events. Results: In the entire cohort, only 8 cases of heterozygous mutations of TPMT were observed, corresponding to 4% mutated haplotype rate, much lower than that reported in literature (close to 10%). No homozygous mutation was found. Regarding the TPMT allelic variants, we did not find any statistically significant difference between patients who tolerated azathioprine and those who suffered from adverse events. (OR = 0.77, 95% CI = 0.08–7.72; p = 0.82). Conclusions: According to our study, in IBD patients, the search for TPMT gene mutations before starting treatment with azathioprine is not helpful in predicting the occurrence of adverse events. Importantly, patients with allelic variants should not be denied the therapeutic option of azathioprine, as they may tolerate this drug.

Atraumatic Splenic Hemorrhage as a Rare Complication of Pancreatitis: Case Report and Literature Review

Splenic hemorrhage (hematoma and rupture) is a rare complication of pancreatitis. In this article, we present a rare case of spontaneous splenic rupture as a complication of acute pancreatitis. A literature review was also completed to describe the patient characteristics, associated pancreatitis etiology, clinical presentations, risk factors, diagnostic and treatment modalities, and outcomes.

Superoxide dismutase mimetic nanoceria restrains cerulein induced acute pancreatitis

Aim: The present study was carried out to assess the effect of nanoceria (NC) on pancreatic inflammation caused by cerulein. Methods: NC was characterized and in vitro studies were carried out in murine macrophages. The in vivo effects were tested on cerulein-induced pancreatitis. Results: In vitro treatment with NC remarkably protected macrophages from lipopolysaccharide-induced inflammation and oxidative stress as evident from the results of 2',7'-dichlorofluorescin diacetate, JC-1 and MitoSox staining. In vivo treatment with NC showed potent superoxide dismutase and catalase mimetic activity, antipancreatitis activity and improved histology. Furthermore, it reduced the expression of p65-NF-κB and acetylation of histone H3 at lysine K14, K56 and K79 residues. Conclusion: We for the first time, demonstrate that NC may be a promising candidate for the therapy of pancreatitis.

Predicting the Severity of Acute Pancreatitis With Red Cell Distribution Width at Early Admission Stage

Red cell distribution width (RDW) has been proposed as an early prognosis marker with increased mortality in variety of pathophysiological conditions. We hypothesized that elevated RDW could be used in judging the severity of acute pancreatitis (AP). We retrospectively and prospectively studied 545 and 72 AP patients, who were admitted to the Shanghai Tenth People's Hospital of Tongji University, respectively. Compared with mild acute pancreatitis, significantly higher RDW was observed in patients with moderately severe acute pancreatitis and sever acute pancreatitis (14.03 ± 1.74% vs. 13.23 ± 1.23%, P < 0.000). RDW values were also found positively correlated with the patient's blood urea nitrogen (r = 0.120, P = 0.026), creatinine (r = 0.182, P = 0.000), age (r = 0.099, P = 0.028), and bedside index of severity in acute pancreatitis scoring system (r = 0.147, P = 0.001), and were negatively correlated with the serum albumin (r = -0.244, P = 0.000). The area under the receiver-operating characteristics was as follows-RDW: 0.677 (95% confidence interval [CI], 0.619-0.735, P < 0.000); combination of RDW and albumin: 0.693 (95% CI, 0.625-0.761, P < 0.000); and the optimal cutoff value for RDW to predict whether patients with AP should be in intensive care unit (ICU) was 13.55 with a sensitivity of 54.5% and a specificity of 73.6%. In the validation study, AP with RDW ≥ 13.55% had significantly higher ICU admission ratio than those with RDW < 13.55% (44.4% vs. 9.8%, P < 0.000). In conclusion, RDW is positively associated with AP severity, and is likely a useful predictive parameter of AP severity.

Effectiveness and therapeutic value of phytochemicals in acute pancreatitis: A review

BACKGROUND

Acute pancreatitis (AP) is an inflammatory disorder of the pancreas that can lead to local and systemic complications. Repeated attacks of AP can lead to chronic pancreatitis, which markedly increases the probability of developing pancreatic cancer. Although many researchers have attempted to identify the pathogenesis involved in the initiation and aggravation of AP, the disease is still not fully understood, and effective treatment is limited to supportive therapy.

METHODS

We aim to summarize available literature focused on phytochemicals (berberine, chlorogenic acid, curcumin, emblica officinalis, ellagic acid, cinnamtannin B-1, resveratrol, piperine and lycopene) and discuss their effectiveness and therapeutic value for improving AP.

RESULTS

This study is based on pertinent papers that were retrieved by a selective search using relevant keywords in PubMed and ScienceDirect databases.

CONCLUSIONS

Many phytochemicals hold potential in improving AP symptoms and may be a valuable and effective addition to standard treatment of AP. It has already been proven that the crucial factor for reducing the severity of AP is stimulation of apoptosis along with/or inhibition of necrosis. Supplementation of phytochemicals, which target the balance between apoptosis and necrosis can be recommended in ongoing clinical studies.

Evaluation and management of acute pancreatitis

Acute pancreatitis (AP) is one of the most common gastrointestinal causes for hospi-talization in the United States. In 2015, AP accounted for approximately 390000 hospitalizations. The burden of AP is only expected to increase over time. Despite recent advances in medicine, pancreatitis continues to be associated with a substantial morbidity and mortality. The most common cause of AP is gallstones, followed closely by alcohol use. The diagnosis of pancreatitis is established with any two of three following criteria: (1) Abdominal pain consistent with that of AP; (2) Serum amylase and/or lipase greater than three times the upper limit of normal; and (3) Characteristics findings seen in cross-sectional abdominal imaging. Multiple criteria and scoring systems have been established for assessing severity of AP. The cornerstones of management include aggressive intravenous hydration, appropriate nutrition and pain management. Endoscopic retrograde cholangiopancreatography and surgery are important aspects in management of acute gallstone pancreatitis. We provide a comprehensive review of evaluation and management of AP.

The interaction between ANXA2 and lncRNA Fendrr promotes cell apoptosis in caerulein-induced acute pancreatitis

BACKGROUND

Annexin A2 (ANXA2) plays a crucial role in acute pancreatitis (AP). However, its potential mechanism remains unclear.

METHODS

In the present study, we used caerulein-treated AR42J rat pancreatic acinar cells as cell model of AP to investigate the potential functions of ANXA2 and its predicted long noncoding RNA (lncRNA) FOXF1 adjacent noncoding developmental regulatory RNA (lncRNA Fendrr). Cell apoptosis was evaluated by flow cytometry using annexinV-fluorescein isothiocyanate/propidium iodide staining. The expressions of ANAX2 and lncRNA Fendrr were detected by quantitative real-time polymerase chain reaction (qRT-PCR). Furthermore, Western blot analysis was performed to determine the protein levels of ANXA2, Bcl-2, and Bax. The association between lncRNA Fendrr and ANXA2 was disclosed by RNA pull-down, RNA immunoprecipitation, and electrophoretic mobility shift assays.

RESULTS

ANXA2 was elevated in caerulein-induced AP model and promoted apoptosis of AR42J cells. LncRNA Fendrr was also upregulated in AP cell model and directly bound ANXA2 protein. Further studies indicated that the interaction between ANXA2 and lncRNA Fendrr contributed to the apoptosis of AR42J cells in AP cell model.

CONCLUSION

Our study demonstrated that ANXA2 promoted AP progression via interacting with lncRNA Fendrr in vitro, which will provide a novel insight into the therapeutic target for AP.

American Association for the Surgery of Trauma emergency general surgery guidelines gap analysis

BACKGROUND

Emergency general surgery (EGS) has been rapidly adopted as one of the major components of acute care surgery. Although heterogenous, the most common disease states that comprise EGS often have published guidelines containing recommendations for their diagnosis and management. Not all diseases included within EGS however have published guidelines and existing guidelines may have important gaps in their recommendations. We present a thorough assessment of the existing guidelines for the most common EGS diseases and highlight gaps that will require additional literature review or new research to fill.

METHODS

Literature searches for existing comprehensive guidelines were performed. These guidelines were summarized based on level of supporting evidence and further subcategorized based on American Association for the Surgery of Trauma (AAST) grade of disease. Using these summaries, gaps in the exiting recommendations were then generated and refined through review by at least two authors.

RESULTS

The initial gap analysis focused on diverticulitis, acute pancreatitis, small bowel obstruction and acute cholecystitis. Despite extensive research into each of these disease processes, critical questions regarding diagnosis and management remain to be answered. Gaps were the result of either low quality research or a complete lack of research. The use of the AAST grade of disease established a framework for evaluating these guidelines and grouping the recommendations.

CONCLUSIONS

Despite extensive prior research, EGS diseases have multiple areas where additional research would likely result in improved patient care. Consensus on the most important areas for additional research can be obtained through analysis of gaps in existing guidelines. This gap analysis has the potential to inform efforts around developing a research agenda for EGS.

American Association for the Surgery of Trauma emergency general surgery guideline summaries 2018: acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction

In April 2017, the American Association for the Surgery of Trauma (AAST) asked the AAST Patient Assessment Committee to undertake a gap analysis for published clinical practice guidelines in emergency general surgery (EGS). Committee members performed literature searches to catalogue published guidelines for common EGS diseases and also to identify gaps in the literature where guidelines could be created. For five of the most common EGS conditions, acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction, we found multiple well-referenced guidelines published by leading professional organizations. We have summarized guideline recommendations for each of these disease states stratified by the AAST EGS anatomic severity score based on these published consensus guidelines. These summaries could be used to help inform evidence-based clinical decision-making, but are intended to be flexible and updatable in real time as further research emerges. Comprehensive guidelines were available for all of the diseases queried and identified gaps most commonly represented areas lacking a solid evidence base. These are therefore areas where further research is needed.

Successful Management of a Child With Drug-induced Necrotizing Pancreatitis During Acute Lymphoblastic Leukemia Therapy: A Case Report

Acute pancreatitis in children acute lymphoblastic leukemia is commonly caused by drugs, for example, L-Asparaginase, pegapargase, steroids. The incidence of this complication is estimated at 6.7% to 18%. Although the majority of drug-induced acute pancreatitis cases are mild, severe cases can rarely occur. This work presents a case of successful management of a child with drug-induced necrotizing pancreatitis during acute lymphoblastic leukemia therapy. This case illustrates that comprehensive care and immediate intensive treatment can rescue patient despite poor prognosis. Administration of octreotide may serve a role in limiting the severity of the disease.

The consensus of integrative diagnosis and treatment of acute pancreatitis-2017

Acute pancreatitis (AP) is one of the most common acute abdominal diseases. The digestive disease committee, Chinese Association of Integrative Medicine, released Integrated traditional Chinese and Western medicine for diagnosis and treatment of acute pancreatitis in 2010.¹ Since then, further studies and great progress have been made by domestic and foreign counterparts from the perspective of both Chinese and Western medicine in AP, including the classification, fluid resuscitation, organ function maintenance, surgery intervention, enteral nutrition (EN), and syndrome differentiation and treatment. It is necessary to update the consensus on diagnosis and treatment of integrated Chinese and Western medicine to meet clinical needs. Therefore, the 2012 Revision of the Atlanta Classification Standard (RAC) by the International AP Consensus,² the 2013 the Management of Acute Pancreatitis by the American College of Gastroenterology,^{3, 4} the 2014 Guidelines for diagnosis and treatment of the acute pancreatitis guide (2014) by the Chinese medical association branch,⁵ the 2014 Guidelines on Integrative Medicine for Severe Acute Pancreatitis by the General Surgery Committee of the Chinese Society of Integrated Traditional Chinese and Western Medicine,⁶ and Traditional Chinese Medicine Consensus on the Diagnosis and Treatment for Acute Pancreatitis by the Spleen and Stomach committee of China Association of Traditional Chinese Medicine^{7, 8} were taken into account for the revision of the consensus published in 2010. The digestive specialists in Chinese and Western medicine had a discussion on traditional Chinese medicine (TCM) types, syndrome differentiation, the main points of integrative medicine, and so on. According to the Delphi method, Consensus of Integrative Diagnosis and Treatment of Acute Pancreatitis (the 2017 revision) has been passed after three rounds votes. (The voting options are as follows: (a) totally agree; (b) agree, but with some reservations; (c) agree, but with larger reservations; (d) disagree, but reserved; and (e) absolutely disagree. If more than two out of three choose (a), or over 85% choose (a) + (b), the consensus will be passed.) The final validation was carried out by the core expert group in Taizhou, Jiangsu on June 9, 2017. The full text is as follows.

Bone marrow-derived mesenchymal stromal cells ameliorate severe acute pancreatitis in rats via hemeoxygenase-1-mediated anti-oxidant and anti-inflammatory effects

BACKGROUND AND AIMS

It has been previously verified that mesenchymal stromal cells (MSCs) have a good therapeutic effect on severe acute pancreatitis (SAP) and the potential for regeneration of damaged pancreatic tissue, but the exact molecular mechanism remains unclear. In this study, we demonstrated the therapeutic effect of bone morrow MSCs (BMSCs) on SAP, probably by targeting heme oxygenase-1 (HO-1).

METHODS

Six hours after SAP induction, either phosphate-buffered saline (PBS) or BMSCs were transfused into the caudal vein of rats, zinc protoporphyrin (ZnPP) was administered intraperitoneally. Pancreatic pathological scoring, serum levels of amylase and inflammatory factors, as well as levels of reactive oxygen species (ROS), malondialdehyde (MDA) and myeloperoxidase (MPO), superoxide dismutase (SOD) and catalase (CAT) activity in the pancreas were evaluated.

RESULTS

Our data showed that BMSCs significantly reduce inflammation and oxidative stress, reduce apoptosis and promote angiogenesis of damaged pancreas. Moreover, BMSCs increased the level of HO-1 in the serum and pancreatic tissue in rats with SAP. In addition, the protective effect of BMSCs was partially neutralized by the HO-1 activity inhibitor ZnPP, suggesting a key role of HO-1 in the therapeutic effect of BMSCs on SAP.

CONCLUSIONS

BMSCs ameliorated SAP, probably by inducing expression of HO-1, which can exert anti-inflammatory and anti-oxidant effects, reduce apoptosis and promote angiogenesis.

Severe Acute Pancreatitis - How Conservative Can We Be?

Background

Acute pancreatitis still is a disease with overall high mortality. Continuously improved understanding of the pathophysiology, however, led to changes in treatment algorithms within the last decades, thus resulting in decreased mortality. This knowledge of acute pancreatitis enabled a new classification system introduced by an international expert panel. This classification system is helpful in initiating treatment strategies which are adapted to the course of acute pancreatitis. Especially the role of surgery experienced a paradigm shift towards a more conservative approach.

Methods

A specific literature search regarding the treatment of acute pancreatitis was performed in the PubMed database, and the results of key studies were compared. Results of these studies are discussed in the context of the most recent international classification system.

Results and Conclusion

Based upon the available data, we can summarize that conservative treatment of acute pancreatitis with pancreatic necrosis is a valid treatment option for selected cases and is associated with reduced mortality compared to more aggressive therapy. However, patients with acute pancreatitis should be treated in experienced centers.

Incidence and epidemiological features of acute pancreatitis among adult inhabitants in Qatar

BACKGROUND/AIMS

Acute pancreatitis (AP) is one of the most common gastrointestinal causes of hospital admission in Qatar. The aim of the present study was to investigate the epidemiological features and demographic characteristics of patients with AP and to estimate the annual incidence rates of this disease among adult inhabitants in Qatar.

MATERIALS AND METHODS

This retrospective study was conducted using the data collected by reviewing records of patients with AP admitted to the medical and surgical wards of Hamad GeneralHospital and Alkhor Hospital, Qatar from January 2007 to December 2012. Diagnosis of AP was based on abdominal pain suggestive of AP, serum lipase and/or amylase at least three times the upper limit of normal, and/or characteristic findings of AP on abdominal ultrasound or computed tomography.

RESULTS

A total of 382 AP events were reported in 334 patients. There were 250 (75%) males and 84 (25%) females. The mean age (±SD) of the patients was 56.8±18.7 years. Gallstone disease (40.6%) was the highest cause of AP, followed by alcohol consumption (28.5%) and idiopathic AP (20.7%). The mean annual incidence rate of AP was 5 per 100,000 adult inhabitants in Qatar from January 2007 to December 2012. The incidence rate among men was higher than that among women. Mortality rate was low (0.3%), and there were complications in 112 (29.3%) patients.

CONCLUSION

The annual incidence rate of AP is relatively low in Qatar and tends to behave similar to many European countries in etiology, which can be explained by population structure. Gallstone and alcohol consumption are the main causes, and idiopathic AP is responsible for more cases than expected.

Thrombin activatable fibrinolysis inhibitor as an indicator of the severity of acute pancreatitis

BACKGROUND/AIMS

Thrombin Activatable Fibrinolysis Inhibitor (TAFI), in addition to suppressing fibrinolysis, can be involved as a natural anti-inflammatory molecule in the inflammatory process in acute pancreatitis (AP). The goal of this study was to discover the significance of early determination of the values of TAFI in the assessment of the severity of AP.

MATERIALS AND METHODS

The prospective study included 92 patients with AP. In accordance with the revised Atlanta classification, we divided all patients into 3 groups (I-mild AP, II- moderate AP and III-severe AP). All patients were further classified into group A (mild AP) and group B (moderate and severe AP) with the aim of separating the patients with complicated and potentially bad prognosis. Biochemical markers, inflammatory biomarkers, coagulation parameters and TAFI were analyzed in all patients.

RESULTS

The level of TAFI were significantly higher among the patients with the complicated form (group B) of AP (p=0.002). The analysis of the ROC curve in regard to the inflammatory biomarkers (fibronectin and CRP) has shown that TAFI possesses the best discriminatory ability for complicated forms of AP (AUC=0.724, p=0.013), with the sensitivity of 83.30% and the specificity of 56.00%.

CONCLUSION

The level of TAFI in plasma is higher in patients with moderate or severe AP. Determining the level of TAFI as a single parameter has a greater significance in the early estimation of the severity of AP than inflammatory biomarkers that we have analyzed.

The effect of serum triglyceride concentration on the outcome of acute pancreatitis: systematic review and meta-analysis

Elevated serum triglyceride concentration (seTG, >1.7 mM or >150 mg/dL) or in other words hypertriglyceridemia (HTG) is common in the populations of developed countries. This condition is accompanied by an increased risk for various diseases, such as acute pancreatitis (AP). It has been proposed that HTG could also worsen the course of AP. Therefore, in this meta-analysis, we aimed to compare the effects of various seTGs on the severity, mortality, local and systemic complications of AP, and on intensive care unit admission. 16 eligible studies, including 11,965 patients were retrieved from PubMed and Embase. The results showed that HTG significantly elevated the odds ratio (OR = 1.72) for severe AP when compared to patients with normal seTG (<1.7 mM). Furthermore, a significantly higher occurrence of pancreatic necrosis, persistent organ failure and renal failure was observed in groups with HTG. The rates of complications and mortality for AP were significantly increased in patients with seTG >5.6 mM or >11.3 mM versus <5.6 mM or <11.3 mM, respectively. We conclude that the presence of HTG worsens the course and outcome of AP, but we found no significant difference in AP severity based on the extent of HTG.

Early Predictors of Abdominal Hemorrhage Among Critically Ill Patients With Pancreatitis: A Prospective Cohort Study

OBJECTIVE

To establish incidence, risk factors, and prognostic implications of abdominal hemorrhage (AH) among critically ill patients with acute pancreatitis (AP).

METHODS

Prospective cohort study in 46 intensive care units aimed at describing the characteristics of critically ill patients with AP (Epidemiología de la Pancreatitis Aguda en Medicina Intensiva Study). Adult patients with AP and at least 1 organ failure were included. The presence of AH was established either by using computed tomography, magnetic resonance imaging, or by direct visualization during surgery. Statistical analyses were carried out using multivariate logistic regression.

RESULTS

Three hundred seventy-four patients were studied. Most were men (62.6%), with a mean (standard deviation) age of 60.4 (15.6) years. Most episodes (56.4%) of AP were severe, and 28.9% died during their hospital stay. Thirty-eight patients (10.2%; 95% confidence interval, 7.3%-13.7%) developed AH. The odds of presenting AH was influenced by age, the underlying cause of pancreatitis, and the presence of shock or respiratory failure on admission.

CONCLUSIONS

Abdominal hemorrhages were common among critically ill patients with pancreatitis. These early predictors may be of use in detecting patients at risk of developing them.

Impact of continuous regional arterial infusion in the treatment of acute necrotizing pancreatitis: analysis of a national administrative database

BACKGROUND

Although continuous regional arterial infusion (CRAI) of protease inhibitors and broad antibiotics has been suggested as one of the therapeutic option for patients with acute necrotic pancreatitis (ANP), the effectiveness has not been well-corroborated in clinical studies.

METHODS

We conducted a retrospective cohort study using a Japanese national administrative database. Severe acute pancreatitis patients with a poorly enhanced pancreas region (i.e., definitive or clinically suspected ANP) were identified and dichotomized according to whether CRAI was performed. We compared the outcomes of in-hospital mortality, surgical interventions, hospital-free days, and healthcare costs between groups adjusted by the well-validated case-mix adjustment model using a multivariate mixed-effect regression analysis and a propensity score matching analysis.

RESULTS

Of 243,312 acute pancreatitis patients, 702 eligible patients were identified, of these 339 patients underwent CRAI. The case-mix adjustment model established had good predictability for in-hospital mortality with an area under the receiver operating characteristics curve of 0.87. CRAI was significantly associated with reduced in-hospital mortality [14.5% in the CRAI group vs. 18.2% in the non-CRAI group, adjusted odds ratio (95% confidence interval; CI) = 0.60 (0.36-0.97)]. Significant associations were not observed for the frequency of surgical interventions and mean hospital-free days; however, significantly higher healthcare costs were observed in the CRAI group. Results of the propensity score matching analysis did not alter these results.

CONCLUSIONS

Analysis of a nationwide large-scale database suggested that CRAI was significantly associated with reduced in-hospital mortality for patients with ANP. Further randomized controlled trials are warranted.

Pancreatitis

Acute pancreatitis is an inflammation of the glandular parenchyma of the retroperitoneal organ that leads to injury with or without subsequent destruction of the pancreatic acini. This inflammatory process can either result in a self-limited disease or involve life-threatening multiorgan complications. Chronic pancreatitis consists of endocrine and exocrine gland dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the pancreatic acini with permanent structural damage. Recurrent attacks of acute pancreatitis can result in chronic pancreatitis; acute and chronic pancreatitis are different diseases with separate morphologic patterns. Acute pancreatitis has an increasing incidence but a decreasing mortality.

Safety and efficacy of total parenteral nutrition versus total enteral nutrition for patients with severe acute pancreatitis: a meta-analysis

Objective

This study was performed to systematically compare the safety and efficacy of total enteral nutrition (TEN) and total parenteral nutrition (TPN) for patients with severe acute pancreatitis (SAP).

Methods

The PubMed database was searched up to January 2017, and nine studies were retrieved. These studies were selected according to specific eligibility criteria. The methodological quality of each trial was assessed, and the study design, interventions, participant characteristics, and final results were then analyzed by Review Manager 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).

Results

Nine relevant randomized controlled trials involving 500 patients (244 patients in the TEN group and 256 patients in the TPN group) were included in the meta-analysis. Pooled analysis showed a significantly lower mortality rate in the TEN than TPN group [odds ratio (OR), 0.31; 95% confidence interval (CI), 0.18–0.54]. The duration of hospitalization was significantly shorter in the TEN than TPN group (mean difference, −0.59; 95% CI, −2.56–1.38). Compared with TPN, TEN had a lower risk of pancreatic infection and related complications (OR, 0.41; 95% CI, 0.22–0.77), organ failure (OR, 0.17; 95% CI, 0.06–0.52), and surgical intervention (OR, 0.17; 95% CI, 0.05–0.62).

Conclusions

This meta-analysis indicates that TEN is safer and more effective than TPN for patients with SAP. When both TEN and TPN have a role in the management of SAP, TEN is the preferred option.

Pathophysiology and nursing management of acute pancreatitis

Acute pancreatitis is a potentially life-threatening condition primarily associated with gallstones or prolonged and excessive alcohol intake. Although the initial triggers of the condition can vary, the resulting pathophysiology is broadly similar irrespective of the cause. This article explores the pathophysiology of the main causes of acute pancreatitis, and discusses nursing management of the condition in the acute setting and the long-term issues to consider. It also outlines the conservative management of the condition, which includes pain management, provision of fluids and nutritional care. In the management of acute pancreatitis, nursing care can often overlap with medical management, especially as the condition deteriorates. Therefore, it is important that nurses develop comprehensive knowledge of the management of acute pancreatitis.

Comparative effectiveness of elemental formula in the early enteral nutrition management of acute pancreatitis: a retrospective cohort study

Background

Although enteral nutrition has become one of the standard therapies for patients with acute pancreatitis, the optimal formulae for enteral nutrition have been under debate. Elemental formula is assumed to be suitable in the treatment of patients with acute pancreatitis because it has less stimulating effects for exocrine secretions of the pancreas, simultaneously maintaining gut immunity; however, clinical studies corroborating this assumption have been scarce.

Methods

We conducted a retrospective cohort study using a Japanese national administrative database between 2010 and 2015. Patients with acute pancreatitis who received enteral feeding within 3 days of admission were identified and divided into two groups according to whether elemental formula was administered. We assessed the impact of elemental formula for the outcomes (primary, in-hospital mortality; secondary, development of sepsis, hospital-free days at 90 days, and total health-care costs) using a multivariate mixed-effect regression analysis and propensity score matching analysis adjusted by a well-validated case-mix adjustment model. Analysis for the subpopulation of patients with severe acute pancreatitis was also performed.

Results

Of 243,312 patients with acute pancreatitis, 948 patients were identified and classified into the elemental formula group (N = 382) and the control group (N = 566). No significant differences were observed for in-hospital mortality [10.2% in the elemental formula group vs. 11.0% in the control group; adjusted adds ratio (95% confidence interval; CI) = 0.94 (0.53–1.67)], sepsis development [5.0 vs. 7.1%; adjusted adds ratio (95% CI) = 0.66 (0.34–1.28)], mean hospital-free days [54 days vs. 51 days; adjusted difference (95% CI) = 2 days (− 2 to 5)], and mean total health-care costs [$29,360 vs. $34,214; adjusted difference (95% CI) = − $4250 (− 8643 to 141)]. Similar results were also observed in patients with severe acute pancreatitis.

Conclusions

The results of our retrospective cohort study using a large-scale national database did not demonstrate the benefit of elemental formula compared to semi-elemental and polymeric formulae in patients with acute pancreatitis. Further assessment of alternative nutritional strategy is expected.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0414-6) contains supplementary material, which is available to authorized users.

Endoscopic Retrograde Cholangiopancreatography Decreases All-Cause and Pancreatitis Readmissions in Patients With Acute Gallstone Pancreatitis Who Do Not Undergo Cholecystectomy: A Nationwide 5-Year Analysis

OBJECTIVES

Cholecystectomy is the definitive management of gallstone pancreatitis (GSP). The benefit of endoscopic retrograde cholangiopancreatography (ERCP) in patients who do not undergo cholecystectomy remains unclear. This study aims to evaluate the effect of ERCP on all-cause and pancreatitis readmissions in GSP.

METHODS

Adult hospitalizations for GSP in the 2010-2014 National Readmissions Database were divided into the following 3 groups: (1) no cholecystectomy nor ERCP, (2) no cholecystectomy with ERCP, and (3) cholecystectomy group. A multivariable Cox model was used to compare the 60-day readmission rates controlling for significant confounders.

RESULTS

There were 153,480 GSP admissions, 29.2% did not undergo cholecystectomy or ERCP, 12.0 % underwent ERCP only, and 58.8% had cholecystectomy. In the no cholecystectomy group, ERCP was associated with lower all-cause readmissions (adjusted hazard ratio, 0.80; 95% confidence interval, 0.76-0.83; P < 0.0001) and pancreatitis readmissions rate (adjusted hazard ratio, 0.51; 95% confidence interval, 0.47-0.55; P < 0.0001) compared with no ERCP. The protective effect of ERCP remained significant in severe pancreatitis. Cholecystectomy had the strongest protective effect against readmissions.

CONCLUSIONS

In this large, nationally representative sample, ERCP was associated with reduced readmissions in patients with GSP who did not undergo cholecystectomy. Although cholecystectomy remains the most important intervention to prevent readmissions, these results support performing ERCP in patients unfit for surgery.

Mechanisms and Management of Acute Pancreatitis

Acute pancreatitis represents a disorder characterized by acute necroinflammatory changes of the pancreas and is histologically characterized by acinar cell destruction. Diagnosed clinically with the Revised Atlanta Criteria, and with alcohol and cholelithiasis/choledocholithiasis as the two most prominent antecedents, acute pancreatitis ranks first amongst gastrointestinal diagnoses requiring admission and 21st amongst all diagnoses requiring hospitalization with estimated costs approximating 2.6 billion dollars annually. Complications arising from acute pancreatitis follow a progression from pancreatic/peripancreatic fluid collections to pseudocysts and from pancreatic/peripancreatic necrosis to walled-off necrosis that typically occur over the course of a 4-week interval. Treatment relies heavily on fluid resuscitation and nutrition with advanced endoscopic techniques and cholecystectomy utilized in the setting of gallstone pancreatitis. When necessity dictates a drainage procedure (persistent abdominal pain, gastric or duodenal outlet obstruction, biliary obstruction, and infection), an endoscopic ultrasound with advanced endoscopic techniques and technology rather than surgical intervention is increasingly being utilized to manage symptomatic pseudocysts and walled-off pancreatic necrosis by performing a cystogastrostomy.

Phytoceuticals in Acute Pancreatitis: Targeting the Balance between Apoptosis and Necrosis

Despite recent advances in understanding the complex pathogenesis of pancreatitis, the management of the disease remains suboptimal. The use of phytoceuticals (plant-derived pleiotropic multitarget molecules) represents a new research trend in pancreatology. The purpose of this review is to discuss the phytoceuticals with pancreatoprotective potential in acute pancreatitis and whose efficacy is based, at least in part, on their capacity to modulate the acinar cell death. The phytochemicals selected, belonging to such diverse classes as polyphenols, flavonoids, lignans, anthraquinones, sesquiterpene lactones, nitriles, and alkaloids, target the balance between apoptosis and necrosis. Activation of apoptosis via various mechanisms (e.g., inhibition of X-linked inhibitor of apoptosis proteins by embelin, upregulation of FasL gene expression by resveratrol) and/or inhibition of necrosis seem to represent the essential key for decreasing the severity of the disease. Apart from targeting the apoptosis/necrosis balance, the phytochemicals displayed other specific protective activities: inhibition of inflammasome (e.g., rutin), suppression of neutrophil infiltration (e.g., ligustrazine, resveratrol), and antioxidant activity. Even though many of the selected phytoceuticals represent a promising therapeutic alternative, there is a shortage of human evidence, and further studies are required to provide solid basis to justify their use in the treatment of pancreatitis.

Role of Ulinastatin, a trypsin inhibitor, in severe acute pancreatitis in critical care setting: A retrospective analysis

PURPOSE

To evaluate the clinical utility of Ulinastatin, a multifunctional serine protease inhibitor, in the management of severe acute pancreatitis.

MATERIALS AND METHODS

We conducted a retrospective analysis of the archived data of adult patients diagnosed with acute pancreatitis and admitted to surgical intensive care unit with one or more end organ dysfunction. The patients were divided into two groups depending on whether they did or did not receive ulinastatin. Outcome variables namely in-hospital mortality, development of new-onset organ dysfunction, resolution of existing organ dysfunction by Day 5 and length of hospital stay were compared.

RESULTS

Forty-eight patients, 25 who received Ulinastatin (Ulinastatin group) and 23 who did not (Control group) were analyzed. The in-hospital mortality was significantly lower in the Ulinastatin group (16% vs 69.6%; p = 0.0003). Significantly smaller proportion of patients (24% vs 73.9%; p = 0.0005) developed new-onset organ dysfunction in the ulinastatin group by day 5. Resolution of existing organ dysfunctions by day 5 was more frequent in the ulinastatin group. Duration of hospital stay was similar in the two groups.

CONCLUSION

Ulinastatin treatment was associated with improved outcomes in patients with severe acute pancreatitis.

Fatal and non-fatal inflammatory injuries induced by different concentrations of L-arginine in Kunming rats

To establish animal models of fatal and non-fatal pancreatitis, we randomly divided 55 Kunming rats into three groups: Group A received three intraperitoneal injections of 8% L-arginine (L-arg); Group B received three intraperitoneal injections of 10% L-arg; and Group C (the control group) received three intraperitoneal injections of saline. After the third injection, biochemical indices and pathological changes in the pancreas and lungs were evaluated. In Group A, the rats experienced peak inflammatory edema at 48 h after the injections and exhibited the highest pathological score, but the biochemical indices showed no phase-related changes. In Group B, the rats exhibited significantly increased biochemical indices at 12 h after injection and experienced peak inflammatory edema at 24 h; the pathological score was also the highest, significantly different from the observations for Groups A and C ( P < 0.05), and the mortality rate was 64% over 72 h. Thus, it was inferred that L-arg could be used to establish pancreatitis models and that different concentrations lead to different lesions.

Role of Inflammasomes in the Development of Gastrointestinal Diseases

Many diseases of the gastrointestinal tract have been attributed to chronic inflammation, and a few have identified the role of inflammasomes in their pathogenesis. Inflammasomes are a group of protein complexes comprising of several intracellular proteins that link the sensing of microbial products and metabolic stress to the proteolytic activation of the proinflammatory cytokines. Recent studies have implicated activation of several families of NOD-like receptors (NLRs) which are major components of inflammasomes in the development and exacerbation of many diseases of human systems. In this chapter, we discuss the role of inflammasomes in some of the most prevalent diseases of the gastrointestinal tract and highlight potential targets for treatment.

Incidence and Predictors of Readmissions in Acute Pancreatitis: A Nationwide Analysis

OBJECTIVES

Acute pancreatitis (AP) is a common cause for hospitalization, and readmission is common, with variable associated risk factors for readmission. Here, we assessed the incidence and risk factors for readmission in AP in a large national database.

METHODS

We analyzed data from the National Readmission Database during the year 2013. Index admissions with a primary discharge diagnosis of AP using the International Classification of Diseases, Ninth Revision, Clinical Modification were identified from January to November to identify 30-day readmission rates. Demographic, hospital, and clinical diagnoses were included in multivariate regression analysis to identify readmission risk factors.

RESULTS

We identified 243,816 index AP discharges with 39,623 (16.2%) readmitted within 30 days. The most common reason for readmission was recurrent AP (41.5%). Increased odds of all-cause readmission were associated with younger age, nonhome discharge, increasing Charlson Comorbidity Index, and increased length of stay. Cholecystectomy during index admission was associated with reduced all-cause and recurrent AP readmissions (odds ratios of 0.5, and 0.35, respectively).

CONCLUSIONS

Readmission for AP is common, most often due to recurrent AP. Multiple factors, including cholecystectomy, during index admission, are associated with significantly reduced odds of all-cause and recurrent AP readmissions.

Elevated Serum miR-7, miR-9, miR-122, and miR-141 Are Noninvasive Biomarkers of Acute Pancreatitis

Background

It has been reported that several microRNAs (miRNAs), such as miR-141, miR-9, and miR-122, are involved in the regulation of pancreatitis-related proteins or that their levels change in acute pancreatitis (AP) animal models. However, the serum levels, as well as the clinical diagnostic and prognostic values, of these miRNAs in AP patients remain unclear. Furthermore, as a pancreas- (islet) enriched miRNA, miR-7 was reported to be downregulated in AP patients, which requires further verification.

Methods

The levels of miR-7, miR-9, miR-122, and miR-141 were examined and compared using qRT-PCR among 80 severe AP patients, 80 mild AP patients, and 74 healthy controls.

Results

The serum levels of these four miRNAs were increased markedly in the AP patients compared with the controls, and these levels decreased significantly after effective therapy. Particularly, the level of miR-7 was higher in severe AP patients than in mild AP patients. ROC curve analysis demonstrated that four miRNAs could be used as potential biomarkers for AP. Moreover, these miRNAs showed strong positive correlations with CRP, which may be associated with inflammation.

Conclusions

The serum miR-7, miR-9, miR-122, and miR-141 levels were increased in AP patients. These 4 miRNAs may represent diagnostic and prognostic biomarkers for AP.

Gastrointestinal tract involvement in acute pancreatitis: initial findings and follow-up by magnetic resonance imaging

Background

To study the initial and follow up patterns of gastrointestinal tract involvement in acute pancreatitis (AP) using magnetic resonance imaging (MRI).

Methods

A total of 209 patients with AP undergoing abdominal MRI on 1.5 T MRI were compared to 100 control patients selected from our daily clinical caseload who underwent MRI over the same recruitment period and had no other disease which can cause abnormality of gastrointestinal tract. Initial and follow up MRI examinations of gastrointestinal tract abnormalities were noted for AP patients. The severity of AP was graded by the MRSI and APACHE II. Spearman correlation of gastrointestinal tract involvement with MRSI and APACHE II was analyzed.

Results

In 209 patients with AP, 63% of the AP patients on their initial MRI exams and 5% of control subjects had at least one gastrointestinal tract abnormality (P<0.05). In the control group, thirty-seven patients were normal on MRI, 24 patients with renal cysts, eighteen patients with liver cysts, eleven patients with liver hemangiomas, and ten patients with splenomegaly. The abnormalities of gastrointestinal tract observed in AP patients included thickened stomach wall (20%), thickened duodenum wall (27%), thickened ascending colon wall (11%), thickened transverse colon wall (15%), and thickened descending colon wall (26%), among others. Gastrointestinal tract abnormalities were correlated with the MRSI score (r=0.46, P<0.05) and APACHE II score (r=0.19, P<0.05). Among 62 patients who had follow up examinations, 26% of patients had gastrointestinal tract abnormality, which was significantly lower than that in the initial exams (P<0.05). Resolution of gastrointestinal tract abnormal MRI findings coincided with symptom alleviation in AP patients.

Conclusions

Gastrointestinal tract abnormalities on MRI are common in AP and they are positively correlated with the severity of AP. It may add value for determining the severity of AP.

Derivation and validation of the prediabetes self-assessment screening score after acute pancreatitis (PERSEUS)

BACKGROUND AND AIM

Approximately 40% of patients develop abnormal glucose metabolism after a single episode of acute pancreatitis. This study aimed to develop and validate a prediabetes self-assessment screening score for patients after acute pancreatitis.

METHODS

Data from non-overlapping training (n=82) and validation (n=80) cohorts were analysed. Univariate logistic and linear regression identified variables associated with prediabetes after acute pancreatitis. Multivariate logistic regression developed the score, ranging from 0 to 215. The area under the receiver-operating characteristic curve (AUROC), Hosmer-Lemeshow χ² statistic, and calibration plots were used to assess model discrimination and calibration. The developed score was validated using data from the validation cohort.

RESULTS

The score had an AUROC of 0.88 (95% CI, 0.80-0.97) and Hosmer-Lemeshow χ² statistic of 5.75 (p=0.676). Patients with a score of ≥75 had a 94.1% probability of having prediabetes, and were 29 times more likely to have prediabetes than those with a score of <75. The AUROC in the validation cohort was 0.81 (95% CI, 0.70-0.92) and the Hosmer-Lemeshow χ² statistic was 5.50 (p=0.599). Model calibration of the score showed good calibration in both cohorts.

CONCLUSION

The developed and validated score, called PERSEUS, is the first instrument to identify individuals who are at high risk of developing abnormal glucose metabolism following an episode of acute pancreatitis.

The optimal timing of enteral nutrition and its effect on the prognosis of acute pancreatitis: A propensity score matched cohort study

BACKGROUND

Early enteral nutrition (EN) can improve the prognosis of acute pancreatitis (AP), but the optimal initiation time is unknown. In this study, the optimal time of early EN was analyzed to disclose the application of early EN in AP.

METHODS

Data of 104 patients with AP were prospectively collected. With secondary infection (infected pancreatic necrosis and extrapancreatic infection) as the primary outcome variable, receiver operating characteristic (ROC) curve was used to calculate the optimal cut-off time of early EN. Propensity score matching was used to adjust for covariates. Secondary outcomes include acute gastrointestinal injury (AGI) grades, serum albumin level, and EN-related complications.

RESULTS

The ROC curve analysis showed that the third day after hospital admission was the best cut-off time of early EN (with the area under the curve of 0.744). After PS matching, the proportion of secondary infection in the early EN group was significantly lower than the late EN group (8.6% vs. 36.5%, P < 0.05). Regression analysis showed that early EN was a protective factor against secondary infection (OR 0.161, 95%CI 0.036-0.718, P < 0.05). The AGI grades and serum albumin levels were better improved in the early EN group (AGI F = 4.468, P < 0.05; serum albumin F = 3.794, P < 0.05).The proportion of EN-related abdominal distension in the early EN group was significantly lower (8.8% vs. 38.5%, P < 0.05).

CONCLUSIONS

Early EN initiated within three days could reduce the risk of secondary infection and improve the nutritional status of patients with acute pancreatitis, with a better tolerance.

血清钙离子对急性胰腺炎持续性器官功能衰竭的预测价值

目的

探讨血清钙离子(serum calcium Ca²⁺)在急性胰腺炎(acute pancreatitis, AP)持续性器官功能衰竭(persistent organ failure, POF)中的临床意义.

方法

选取2012-01/2016-12温州市龙湾区第一人民医院及温州医科大学附属第二医院进行治疗的AP患者165例, 收集患者在症状发作72 h内的临床资料及实验室数据, 分为AP非持续性器官功能衰竭(non persistent organ failure, NO-POF)127例和POF 38例两组, 多因素Logistic回归分析用于评价血清Ca²⁺的预测能力, 采用工作特征曲线(receiver operator characteristic curve, ROC)分析计算血清Ca²⁺的截断值.

结果

经急性胰腺炎NO-POF 127例和POF 38例临床资料及实验室数据比较, 血清Ca²⁺ POF组明显低于NO-POF组, 差异有统计学意义(P<0.001); 多因素Logistic回归分析, 血清Ca²⁺是急性胰腺炎POF的独立危险因素(OR = 0.30, 95%CI: 0.12-0.76); ROC分析结果显示: 血清Ca²⁺预测急性胰腺炎POF的曲线下面积为0.764(95%CI: 0.27-0.58, P<0.001), 其最佳预测截点1.84 mmol/L, 预测POF的敏感性为75.4%, 特异性为72.5%.

结论

入院患者血清Ca²⁺与急性胰腺炎POF独立相关, 可作为一个潜在的预后因素.

集束化护理在重症急性胰腺患者胃肠功能恢复中的应用

重症急性胰腺炎(severe acute pancreatitis, SAP)是临床中常见的发病率高、并发症多、死亡率较高的疾病, 其死亡的主要原因是并发了不同程度的多器官功能障碍综合征(multiple organ dysfunction syndrome, MODS), 全身炎症反应综合征(systemic inflammatory response syndrome, SIRS)是导致MODS的重要基础, 而胃肠功能障碍又是激发SIRS的源头. 因此, 胃肠功能障碍在该病的发生发展过程中起重要作用, 早期胃肠功能恢复有助于疾病的恢复和并发症的预防. 集束化护理的运用, 可以使每一位患者在有限的时间内, 得到最有效的治疗, 这是集束化护理最突出的特点. 文章就集束化护理在SAP患者的胃肠功能恢复中的应用进行简要综述, 为临床工作提供循证参考.

Early discharge in Mild Acute Pancreatitis. Is it possible? Observational prospective study in a tertiary-level hospital

BACKGROUND AND AIMS

In acute pancreatitis (AP), first 24 h are crucial as this is the period in which the greatest amount of patients presents an organ failure. This suggests patients with Mild AP (MAP) could be early identified and discharged. This is an observational prospective trial with the aim to demonstrate the safety of early discharge in Mild Acute Pancreatitis (MAP).

METHODS

Observational prospective study in a third level single centre. Consecutive patients with AP from March 2012 to March 2014 were collected.

INCLUSION CRITERIA

MAP, tolerance to oral intake, control of pain, C Reactive Protein <150 mg/dL and blood ureic nitrogen < 5 mg/dL in two samples.

EXCLUSION CRITERIA

pregnant, lack of family support, active comorbidities, temperature and serum bilirubin elevation. Patients with MAP, who met the inclusion criteria, were discharged within the first 48 h. Readmissions within first week and first 30 days were recorded. Adverse effects related to readmissions were also collected.

RESULTS

Three hundred and seventeen episodes were collected of whom 250 patients were diagnosed with MAP. From these, 105 were early discharged. Early discharged patients presented a 30-day readmission rate of 15.2% (16 patients out of 105) corresponding to the readmission rates in Acute Pancreatitis published to date. Any patient presented adverse effects related to readmissions.

CONCLUSION

Early discharge in accurately selected patients with MAP is feasible, safe and efficient and leads to a decrease in median stay with the ensuing savings per process and with no increase in readmissions or inmorbi-mortality.

Analysis of factors influencing survival in patients with severe acute pancreatitis

OBJECTIVE

Acute pancreatitis (AP) ranges from a mild and self-limiting disease to a fulminant illness with significant morbidity and mortality. Severe acute pancreatitis (SAP) is defined as persistent organ failure lasting for 48 h. We aimed to determine the factors that predict survival and mortality in patients with SAP.

METHODS

We reviewed a consecutive series of patients who were admitted with acute pancreatitis between January 2003 and January 2013. A total of 1213 cases involving 660 patients were evaluated, and 68 cases with SAP were selected for the study. Patients were graded based on the Computer Tomography Severity Index (CTSI), the bedside index for severity (BISAP), and Ranson's criteria.

RESULTS

The frequency of SAP was 5.6% (68/1213 cases). Among these patients, 17 died due to pancreatitis-induced causes. We compared several factors between the survivor (n = 51) and non-survivor (n = 17) groups. On multivariate analysis, there were significant differences in the incidence of diabetes mellitus (p = .04), Ranson score (p = .03), bacteremia (p = .05) and body mass index (BMI) (p = .02) between the survivor and non-survivor groups.

CONCLUSIONS

Bacteremia, high Ranson score, DM, and lower BMI were closely associated with mortality in patients with SAP. When patients with SAP show evidence of bacteremia or diabetes, aggressive treatment is necessary. For the prediction of disease mortality, the Ranson score might be a useful tool in SAP.

Epidural analgesia in critically ill patients with acute pancreatitis: the multicentre randomised controlled EPIPAN study protocol

BACKGROUND

Acute pancreatitis (AP) is associated with high morbidity and mortality in its most severe forms. Most patients with severe AP require intubation and invasive mechanical ventilation, frequently for more than 7 days, which is associated with the worst outcome. Recent increasing evidence from preclinical and clinical studies support the beneficial effects of epidural analgesia (EA) in AP, such as increased gut barrier function and splanchnic, pancreatic and renal perfusion, decreased liver damage and inflammatory response, and reduced mortality. Because recent studies suggest that EA might be a safe procedure in the critically ill, we sought to determine whether EA reduced AP-associated respiratory failure and other major clinical outcomes in patients with AP.

METHODS AND ANALYSIS

The Epidural Analgesia for Pancreatitis (EPIPAN) trial is an investigator-initiated, prospective, multicentre, randomised controlled two-arm trial with assessor-blinded outcome assessment. The EPIPAN trial will randomise 148 patients with AP requiring admission to an intensive care unit (ICU) to receive EA (with patient-controlled epidural administration of ropivacaine and sufentanil) combined with standard care based on current recommendations on the treatment of AP (interventional group), or standard care alone (reference group). The primary outcome is the number of ventilator-free days at day 30. Secondary outcomes include main complications of AP (eg, organ failure and mortality, among others), levels of biological markers of systemic inflammation, epithelial lung injury, renal failure, and healthcare-associated costs.

ETHICS AND DISSEMINATION

The study was approved by the appropriate ethics committee (CPP Sud-Est VI). Informed consent is required. If the combined application of EA and standard care proves superior to standard care alone in patients with AP in the ICU, the use of EA may become standard practice in experienced centres, thereby decreasing potential complications related to AP and its burden in critically ill patients. The results will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02126332.

Pancreatitis Induced by Cocaine

Pancreatitis is one of the commonest diseases of the gastrointestinal tract, characterized by epigastric pain of moderate to severe intensity, which radiates to the back, elevation of pancreatic lipase and amylase enzymes, and changes in pancreatic parenchyma in imaging methods. The most common etiologies vary, generally the most frequent being biliary lithiasis and alcohol, followed by hypertriglyceridemia. Among the less frequent causes is drug-induced pancreatitis. We report a case of acute pancreatitis caused by cocaine, rarely described in literature.

Clusterin and Pycr1 alterations associate with strain and model differences in susceptibility to experimental pancreatitis

Acute pancreatitis has several underlying etiologies, and results in consequences ranging from mild to complex multi-organ failure. The wide range of pathology suggests a genetic predisposition for progression. We compared the susceptibility to acute pancreatitis in BALB/c and FVB/N mice, coupled with proteomic analysis, in order to identify potential protein associations with pancreatitis progression.

METHODS

Pancreatitis was induced in BALB/c and FVB/N mice by administration of cerulein or feeding a choline-deficient, ethionine-supplemented (CDE) diet. Histology and changes in serum amylase were examined. Proteome profiling in cerulein-treated mice was performed using 2-dimensional differential in gel electrophoresis (2D-DIGE) followed by mass spectrometry analysis and biochemical validation.

RESULTS

Male and female FVB/N mice manifested more severe cerulein-induced pancreatitis as compared with BALB/c mice, but both strains were similarly susceptible to CDE-induced pancreatitis. Few of the 2D-DIGE alterations were validated by immunoblotting. Clusterin was markedly up-regulated after cerulein-induced pancreatitis in FVB/N but less-so in BALB/c mice. Pyrroline-5-carboxylate reductase (Pycr1), an enzyme involved in proline biosynthesis, had higher basal levels in FVB/N male and female mouse pancreata compared with BALB/c pancreata, and was relatively more resistant to degradation in FVB/N pancreata. However, serum and pancreas tissue proline levels were similar in the two strains.

CONCLUSION

FVB/N is more susceptible than BALB/c mice to cerulein-induced but not CDE-induced pancreatitis. Most of the 2D-DIGE alterations in the two strains likely relate to posttranslational modifications rather than protein level differences. Clusterin levels increase dramatically in association with pancreatitis severity, while Pycr1 is higher in FVB/N versus BALB/c pancreata basally and after induction of pancreatitis. Changes in proline metabolism may represent a novel potential genetic modifier in the context of pancreatitis.

PEG-asparaginase in BFM-90 regimen improves outcomes in adults with newly diagnosed lymphoblastic lymphoma

OBJECTIVE

Although L-asparaginase (L-ASP) is a standard treatment for lymphoblastic lymphoma (LBL), hypersensitivity reactions by some patients limit its application. Polyethylene glycol-conjugated asparaginase (PEG-ASP) has a lower immunogenicity and is a standard treatment in all pediatric acute lymphoblastic leukemia (ALL). In this study, we investigated the efficacy and toxicity of PEG-ASP instead of L-ASP as used in the BFM-90 regimen (PEG-ASP-BFM-90) for adult LBL.

METHODS

Between June 2012 and July 2015, we treated 30 adult patients with newly diagnosed LBL, using PEG-ASP-BFM-90 in a prospective, multicenter and single-arm clinical study at 5 participating institutions in China.

RESULTS

All the 30 patients, including 19 males and 11 females with a median age of 30 (range: 18-62) years, completed 128 times of the PEG-ASP, with the median of 4 (range: 2-6) times. Patients did not receive radiotherapy at this time. The overall response rate was 86.7% (26/30), with 50.0% (15/30) complete response and 36.7% (11/30) partial response. The 3-year overall survival was 46.0% [95% confidence interval (95% CI), 28.2%-64.8%], and the 3-year progression-free survival was 43.0% (95% CI, 25.7%-62.0%). Major adverse events were myelosuppression, reduced fibrinogen, liver dysfunction and digestive tract toxicities. No allergic reaction and no treatment-related mortality or severe complications were recorded.

CONCLUSIONS

Our clinical data and observed outcomes indicate that 1 dose of PEG-ASP can replace multiple doses of native L-ASP in BFM-90, with predominantly grade 3-4 neutropenia for adult LBL, and no therapy-related deaths. The effect is similar to previous reports of PEG-ASP-containing regimens for adult ALL. Major advantages include less serious allergic reactions, 2-3 weeks of action duration, and convenience for patients and physicians.