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

Efficacy of double filtration plasmapheresis in hyperlipidemia acute pancreatitis: a retrospective observational study

BACKGROUND

This study examines the role and effectiveness of double filtration plasmapheresis (DFPP) in managing hyperlipidemiclipidemic acute pancreatitis (HLAP).

METHODS

Comparative analysis was conducted between two groups: one treated with DFPP and one without. Comparative parameters included blood lipid levels, inflammatory factors, vital signs, disease severity scores, and complication rates.

RESULTS

A total of 97 HLAP patients were included in the study. Within-group analysis revealed significant pre- and post-treatment changes in total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), white blood cell count (WBC), neutrophil percentage (N%), systemic immune-inflammation index (SII), mean arterial pressure (MAP), bedside index for severity in acute pancreatitis (BISAP), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores in the DFPP group (P < 0.05). In contrast, the without DFPP group showed significant changes in TC, TG, LDL-C, WBC, N%, SII, systemic inflammation response index (SIRI), panimmune-inflammation value (PIV), respiration rate (RR), and APACHE II scores (P < 0.05). Significant differences in TC, TG, HDL-C, LDL-C, and RR were found between the DFPP and without DFPP groups (P < 0.05). The DFPP group exhibited greater reductions in TG levels and more individual variability. In terms of complications, the rate of systemic inflammatory response syndrome (SIRS) differed significantly between the groups (P < 0.05).

CONCLUSIONS

DFPP can significantly improve short-term outcomes, reduce lipid levels, and reduce the incidence of complications such as SIRS in HLAP patients compared with those not receiving DFPP treatment. The clinical utility of DFPP is considerable, and further exploration and implementation of this method are warranted.

Diagnosis and Management of Acute Pancreatitis

Acute pancreatitis is an inflammatory condition of the exocrine pancreas that is a common indication for hospital admission and has had an increasing incidence in the last few decades. The diagnosis of acute pancreatitis requires the satisfaction of two out of three criteria: (1) abdominal pain radiating to the back, (2) serum lipase or amylase levels three or more times the upper limit of the normal level, and (3) findings indicating pancreatitis obtained via a computed tomography (CT) scan or magnetic resonance imaging (MRI). The different etiologies include gallstones, autoimmune disorders, alcohol abuse, smoking, hypertriglyceridemia, obesity, drugs, and post-endoscope retrograde cholangiopancreatography (ERCP). The initial investigation includes serum amylase and lipase analysis, a lipid panel including triglycerides, analysis of immunoglobulins, a full blood count, electrolyte analysis, a hemoglobin A1c test, a complete metabolic panel, and transabdominal ultrasound. The initial therapy includes oxygen supplementation, the provision of intravenous fluids, pain control, and a nutrition regime. Early oral feeding is encouraged if tolerated; if not, liquid supplement provision or enteral tube feeding within 48 h of admission has shown better outcomes. Some complications of acute pancreatitis are necrosis, infection, insulin resistance leading to diabetes mellitus, and pancreatic exocrine insufficiency requiring enzyme supplementation. Patients need to attend regular follow-ups and abstain from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis. The mortality rate of acute pancreatitis has decreased in the past few decades because of better management skills, but the recent rise in acute pancreatitis episodes is concerning. Sustained endeavors through clinical trials are required to establish a broad variety of drugs that can be used for acute pancreatitis episodes.

Triglyceride lowering in patients with different severities of hypertriglyceridaemia-associated acute pancreatitis: secondary analysis of a multicentre, prospective cohort study

OBJECTIVE

It is controversial whether rapid lowering of triglyceride (TG) levels is associated with clinical benefits in patients with hypertriglyceridaemia-associated acute pancreatitis (HTG-AP). In particular, patients with different severity of disease may respond differently to TG-lowering therapy. In this study, we aimed to explore the association between rapid decline in serum TG levels and organ failure in patients with different severities of HTG-AP.

METHODS

This is a secondary analysis of data from a multicentre, prospective registry recruiting HTG-AP patients admitted within 72 hours from the onset of symptoms. Patients were dichotomised into either target reaching (TG≤5.65 mmol/L on study day 3) or not. The primary outcome was the presence of organ failure at day 14. The association between target-reaching and the primary outcome was modelled. Furthermore, subgroup analyses were conducted based on the disease severity of HTG-AP patients at enrolment.

RESULTS

Overall, 413 patients were included for analysis, of whom 192 (46.5%) reached the target on day 3. For the overall study cohort, there was no significant difference in presence of organ failure at day 14 between patients reaching the target or not (3.1% vs 6.8%, p=0.091). In the subgroup of HTG-AP patients with organ failure at enrolment, compared with patients with TG>5.65 mmol/L on day 3, patients who reached the target had significantly lower presence of organ failure at day 14 (7.8% vs 22%, p=0.039) and lower incidence of infected pancreatic necrosis within 60 days (3.1% vs 11.9%, p=0.049). Similar findings were seen in the subgroup with more severe HTG-AP (APACHE II ≥8 at enrolment).

CONCLUSION

More rapid decline of serum TG levels was associated with decreased presence of organ failure at day 14 in patients with more severe HTG-AP.

TRIAL REGISTRATION NUMBER

The Chinese Clinical Trial Registry, number ChiCTR2000039541.

Epidemiology of Biliary Acute Pancreatitis-A Seven-Year Experience of a Large Tertiary Center

(1) Introduction: One of the most common causes of acute pancreatitis is cholelithiasis, which is considered to be associated with female sex, older age, and recurrence. Our aim was to define a group of patients with B-AP to facilitate their diagnosis and management, while more judiciously using medical resources. (2) Materials and Methods: This retrospective, large cohort study, which was conducted by extracting data from the BUC-API registry, consisted of 1855 cases between 1 June 2015 and 1 April 2022. Each admission of the same patient was considered a separate case if it did not have signs of chronic pancreatitis. Severity and morphology were stratified according to the Revised Atlanta Classification. (3) Results: A total of 732 cases of B-AP were analyzed, with 92.5% occurring at the first attack. The median age was 65 years, with 61.9% of the patients being female. The majority (82.2%) were surgical cases, and the length of stay (LoS) was 7 days. There were 10.2% severe cases, with a mortality rate of 4%. (4) Discussion: We found positive associations between sex, age, recurrence, and morphology and biliary etiology. Compared with the general population, female sex and age over 65 years correlate better with a biliary etiology. In most scenarios, patients suffer from first attacks, with a lower probability of developing local complications. There was a tendency for biliary pancreatitis patients to be admitted to surgical wards.

The Role of Resolvin D1 in the Differential Diagnosis of Pancreatic Ductal Adenocarcinoma and Acute Pancreatitis: A Case-Control Study

Background and Objectives: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy characterized by a dense desmoplastic stroma with a poor prognosis. The aim of this study was to investigate whether resolvin (Rv) D1 could be used as a potential serum biomarker to discriminate between PDAC and acute pancreatitis (AP). Materials and Methods: In total, 67 patients were enrolled in the present study, including 21 patients with resectable PDAC, 23 patients with metastatic PDAC, 23 patients with AP, and a control group of 21 healthy individuals. RvD1 levels of PDAC patients were also analyzed through ELISA at the 6th postoperative month. Results: The mean RvD1 was 1169.24 ± 285.99 in the control group, 885.04 ± 134.25 in the AP group, 728.57 ± 140.1 in the PDAC group, and 670.09 ± 105.6 in the metastatic pancreatic cancer (PC) group. RvD1 was significantly lower in PDAC and metastatic PC groups compared to controls and patients with AP, while it was significantly lower in patients with AP compared to the control groups. Postoperative RvD1 levels of patients with PDAC were significantly higher than preoperative levels (728.57 ± 140.1 vs. 885.43 ± 275.57). In the ROC analysis, when the cut-off value for serum RvD1 level was 825 ng/L, it was found to predict PDAC from metastatic PC with 84.1% sensitivity and 81.8% specificity. Conclusions: Serum RvD1 is a new biomarker for the detection of PDAC. Serum RvD1 may provide an important diagnostic contribution in clinical practice to predict PDAC. Serum RvD1 levels were found to be predictive with high sensitivity and specificity in differentiating PDAC from metastatic PC. However, it was concluded that serum RvD1 levels cannot be used as a detection marker to differentiate PDAC from AP. RvD1 could be a representative agent of a new class of drugs to be proposed for innovative treatment of AP and PDAC. Our future study will investigate whether RvD1 can be a marker to differentiate from chronic pancreatitis.

Telling Ghost Stories Around a Bonfire-A Literature Review of Acute Bleeding Secondary to Pancreatitis

Bleeding is a rare but serious complication of pancreatitis, significantly increasing morbidity and mortality. It can arise from various sources, including erosion of blood vessels by inflammatory processes, formation of pseudoaneurysms, and gastrointestinal bleeding. Early diagnosis and timely intervention are crucial for patient survival. Imaging modalities such as computed tomography and angiography are essential for identifying the bleeding source, where endoscopy may help in detecting and treating intraluminal hemorrhage. Management strategies for patients with extraluminal bleeding may involve angioembolization or surgical intervention, depending on the severity and location of the bleeding. While advances in diagnostic and therapeutic techniques have improved outcomes, bleeding in pancreatitis remains a challenging clinical problem requiring a multidisciplinary approach. This review aims to focus its attention specifically on the bleeding complications of pancreatitis.

Impact of invasive infections on clinical outcomes in acute pancreatitis: early predictive factors and implications for prophylactic anti-infective therapy

BACKGROUND

The use of antibiotic therapy in acute pancreatitis remains controversial and is currently recommended only for confirmed infections of peripancreatic necrosis. However, reliable early predictors of septic complications and unfavorable outcomes are substantially lacking.

METHODS

Patients with acute pancreatitis were retrospectively reviewed and divided into two groups: one with a septic course defined by pathogen detection [GERM(+)] and one without [GERM(-)]. After propensity score matching, both groups were compared regarding clinical outcomes. Early predictors of pathogen detection were evaluated by multivariate analysis.

RESULTS

424 patients with acute pancreatitis were included. After propensity score matching 123 GERM(-) patients were compared to 74 GERM(+) patients. GERM(+) patients demonstrated significantly worse clinical outcomes with higher rate of intensive care treatment (59.5% vs. 35.0%; p = 0.0011) and consecutive longer stay in intensive care unit (11.5 ± 25.2d vs. 3.0 ± 7.9d; p = 0.0007), longer in-hospital stay (26.8 ± 22.0d vs. 14.7 ± 15.0d; p = 0.0003) as well as worse results in the composite outcome length of in-hospital stay > 15d or death (67.6% vs. 31.7%; p < 0.0001). Prescence of ascites and elevated white blood cell count at the onset of acute pancreatitis were identified as significant predictive factors in the early disease associated with invasive infection and pathogen detection. The most frequently detected pathogens were commensals of the gastrointestinal tract, observed in 70.7% of the examined body fluids and 50.7% of the examined blood cultures.

CONCLUSIONS

Detection of pathogens is associated with unfavorable clinical outcomes in acute pancreatitis. The presence of ascites and elevated white blood cell count at onset of acute pancreatitis are significant predictive factors indicating the risk of invasive infection with relevant bacterial load. Thus, an aggressive, early anti-infective strategy against pathogens of intestinal origin should be considered in these cases and may improve patient outcomes.

Endoscopic sphincterotomy to prevent post-ERCP pancreatitis after self-expandable metal stent placement for distal malignant biliary obstruction (SPHINX): a multicentre, randomised controlled trial

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) with fully covered self-expandable metal stent (FCSEMS) placement is the preferred approach for biliary drainage in patients with suspected distal malignant biliary obstruction (MBO). However, FCSEMS placement is associated with a high risk of post-ERCP pancreatitis (PEP). Endoscopic sphincterotomy prior to FCSEMS placement may reduce PEP risk.

OBJECTIVE

To compare endoscopic sphincterotomy to no sphincterotomy prior to FCSEMS placement.

DESIGN

This multicentre, randomised, superiority trial was conducted in 17 hospitals and included patients with suspected distal MBO. Patients were randomised during ERCP to receive either endoscopic sphincterotomy (sphincterotomy group) or no sphincterotomy (control group) prior to FCSEMS placement. The primary outcome was PEP within 30 days. Secondary outcomes included procedure-related complications and 30-day mortality. An interim analysis was performed after 50% of patients (n=259) had completed follow-up.

RESULTS

Between May 2016 and June 2023, 297 patients were included in the intention-to-treat analysis, with 156 in the sphincterotomy group and 141 in the control group. After the interim analysis, the study was terminated prematurely due to futility. PEP did not differ between groups, occurring in 26 patients (17%) in the sphincterotomy group compared with 30 patients (21%) in the control group (relative risk 0.78, 95% CI 0.49 to 1.26, p=0.37). There were no significant differences in bleeding, perforation, cholangitis, cholecystitis or 30-day mortality.

CONCLUSION

This trial found that endoscopic sphincterotomy was not superior to no sphincterotomy in reducing PEP in patients with distal MBO. Therefore, there was insufficient evidence to recommend routine endoscopic sphincterotomy prior to FCEMS placement.

TRIAL REGISTRATION NUMBER

NL5130.

Irisin-mediated KEAP1 degradation alleviates oxidative stress and ameliorates pancreatitis

Oxidative stress (OS) injury is pivotal in acute pancreatitis (AP) pathogenesis, contributing to inflammatory cascades. Irisin, a ubiquitous cytokine, exhibits antioxidant properties. However, the role of irisin in AP remains inconclusive. Our study aims to elucidate irisin expression in AP patients and investigate its mechanism of action to propose a novel treatment strategy for AP. Serum irisin levels in 65 AP patients were quantified using an enzyme-linked immunosorbent assay and correlated with disease severity scores. Core genes implicated in AP-related oxidative stress were identified and screened via bioinformatics analysis. The therapeutic efficacy of irisin in AP was confirmed using a murine cerulein-induced AP model. The intrinsic mechanism of irisin's antioxidative stress action was investigated and verified in pancreatic AR42J cells (Supplementary Fig. 1). Common targets shared by irisin and AP were further validated using a molecular docking model which was constructed for virtual docking analysis. This study investigated alterations in redox status in AP and found a significant reduction in serum irisin levels, correlating inversely with AP severity. In a murine AP model, we showed that irisin triggers an antioxidative stress program via the KEAP1 gene; this process helps reestablish redox balance by decreasing the buildup of reactive oxygen species (ROS) and suppressing the secretion of inflammatory mediators within pancreatic tissues Notably, increased KEAP1 expression counteracted the antioxidative effects of irisin. Our findings unveil a novel therapeutic mechanism for AP, wherein irisin inhibits KEAP1 to alleviate OS. Increasing irisin levels in vivo presents a promising strategy for AP treatment.

Mild acute biliary pancreatitis: still a surgical disease. A post-hoc analysis of the MANCTRA-1 international study

BACKGROUND

The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) to reduce the risk of recurrence. The MANCTRA-1 project revealed a knowledge-to-action gap and higher recurrence rates in patients admitted to medical wards, attributable to fewer ELCs being performed. The project estimated a 35% to 70% probability of narrowing this gap by 2025. This study evaluates the safety of suboptimal ELC implementation and identifies risk factors for recurrent acute biliary pancreatitis (RAP) in patients not undergoing ELC after an MABP episode.

METHODS

We conducted a post-hoc analysis of the MANCTRA-1 registry, including MABP patients who did not undergo ELC during the index hospitalization, excluding those with related complications. The primary outcome was the 30-day hospital readmission rate due to RAP. We performed multivariable logistic regression to find risk factors associated with the primary outcome.

RESULTS

Between January 2019 and December 2020, 1920, MABP patients from 150 centers were included in the study. The 30-day readmission rate due to RAP was 6%. Multivariable logistic regression found the admission to a medical ward (internal medicine or gastroenterology) (OR = 1.95, p = 0.001) and a positive COVID-19 test (OR = 3.08, p = 0.029) as independent risk factors for RAP.

CONCLUSION

Our analysis offers valuable insights into the management of MABP, particularly in centers where ELC cannot be fully implemented due to logistical and clinical constraints, worsened by the COVID-19 pandemic. Regardless of the admitting ward, prompt access to surgical care is crucial in reducing the risk of early recurrence, highlighting the need to implement surgical consultation pathways within MABP care bundles.

Risk Factor Analysis and Molecular Epidemiological Investigation of Carbapenem-Resistant Enterobacteriaceae (CRE) Infection in Patients with Acute Pancreatitis

Objective

Patients with acute pancreatitis (AP) complicated by carbapenem-resistant Enterobacteriaceae (CRE) infection often have a higher mortality rate. However, little investigation on the risk factor analysis has been published for the AP complicated by CRE. Therefore, this study conducted a retrospective analysis of the clinical characteristics, risk factors, and molecular epidemiological features associated with CRE infection in patients with AP.

Methods

A total of 240 patients with AP were admitted to our hospital from 2011 to 2021 as the research objects, and were divided into a CRE group of 60 cases and a non-CRE group of 180 cases based on whether they were co-infected with CRE or not. Furthermore, both univariate analysis and multivariate analysis were used to analyze the risk factors of AP co-infection with CRE. In the CRE group, polymerase chain reaction (PCR) and agarose gel electrophoresis (AGE) were used to detect the expression of five common carbapenemase genes including bla KPC, blaIMP, blaVIM, blaNDM , and blaOXA-48 .

Results

The pathogenic bacteria in the CRE group are composed of Klebsiella pneumonia at 35.00%, Escherichia coli at 33.33%, Enterobacter cloacae at 25.00%, and Citrobacter freundii at 6.67%. Multivariate analysis showed that APACHE-II scores (OR=1.22), history of abdominal surgery (OR=81.82), and ERCP (OR=3.66) were independent risk factors for AP co-infection with CRE (P<0.05). About half (18/40) of the CRE carried carbapenemase genes. bla KPC was the major carbapenemase gene.

Conclusion

There are many risk factors for AP co-infection with CRE, which can occur in patients with high APACHE-II scores, experienced ERCP, and a history of abdominal surgery.

Clinical Outcomes in a Multicenter Cohort Involving 919 Patients With Hypertriglyceridemia-Associated Acute Pancreatitis

INTRODUCTION

Hypertriglyceridemia-associated acute pancreatitis (HTG-AP) is one of the most common etiologies of acute pancreatitis (AP) worldwide. Compared with other etiologies, patients with HTG-AP may develop more severe AP, but previous studies yielded controversial conclusion due to the lack of adequate adjustment for the confounders. Therefore, the aim of this study was to examine the possibility and risk factors of developing severe AP in HTG-AP.

METHODS

Data from patients with an established diagnosis of AP were collected from January 2013 to December 2023 using a predesigned data collection form and were gathered from 5 tertiary cross-regional centers of China. HTG-AP was defined as serum triglyceride levels >500 mg/dL and excluded other etiologies. The possibility and risk factors of severe AP were assessed by multivariable logistic regressions after adjusting potential confounders. A prediction model was established and validated.

RESULTS

Between 2013 and 2023, we identified a total of 6,996 patients with AP, of whom 4,378 were included in the final analysis. Compared with other etiologies, patients with HTG-AP had a higher risk of developing severe AP (odds ratio: 1.897; 95% confidence interval: 1.380-2.608; P < 0.001) and organ failure. HTG-AP patients showed higher possibility for developing respiratory and circulation failure but renal failure compared with other etiologies. In HTG-AP patients, risk factors of severe AP included age, fasting blood glucose, white blood cell counts, and presence of pleural effusion. TG level was found not significantly associated with severity in HTG-AP patients. A prediction model incorporating these risk factors demonstrated an area under the curve (AUC) of 0.837 in the training and 0.883 in the testing set, with adequate calibration.

DISCUSSION

Using a multicenter cross-regional cohort, we demonstrated that HTG-AP had a higher risk of developing severe AP and organ failure. A risk prediction model for predicting severe AP was developed and effectively stratified patients.

Successful Treatment of Bilocular Walled-off Necrosis with Transmural Naso-cyst Continuous Irrigation

Recently, transmural naso-cyst continuous irrigation (TNCCI) has been reported as an effective and safe treatment for walled-off necrosis (WON). We herein report a case of bilocular WON that was successfully treated with TNCCI. The patient was a 60-year-old man. The patient underwent endoscopic ultrasound-guided cyst drainage of the main cavity and subcavity using a single transluminal gateway transcystic multiple drainage technique, which was ineffective. Subsequently, a lumen-apposing metal stent (LAMS) was placed in the main cavity and TNCCI was successfully performed in the subcavity. TNCCI with LAMS was effective in treating bilocular WON.

Development of an interpretable machine learning model based on CT radiomics for the prediction of post acute pancreatitis diabetes mellitus

This study sought to establish and validate an interpretable CT radiomics-based machine learning model capable of predicting post-acute pancreatitis diabetes mellitus (PPDM-A), providing clinicians with an effective predictive tool to aid patient management in a timely fashion. Clinical and imaging data from 271 patients who had undergone enhanced CT scans after first-episode acute pancreatitis from March 2017-June 2023 were retrospectively analyzed. Patients were classified into PPDM-A (n = 109) and non-PPDM-A groups (n = 162), and split into training (n = 189) and testing (n = 82) cohorts at a 7:3 ratio. 1223 radiomic features were extracted from CT images in the plain, arterial and venous phases, respectively. The radiomics model was developed based on the optimal features retained after dimensionality reduction, utilizing the extreme gradient boosting (XGBoost) algorithm. Five-fold cross-validation of the model was used to assess the performance of the model in the training and testing cohorts. The clinical performance of the model was assessed through a decision curve analysis, while insight into the predictions derived from this model was derived from Shapley additive explanations (SHAP). The final model incorporated five key radiomic features, and achieved area under the curve values in the training and testing cohorts of 0.947 (95% CI 0.915-0.979) and 0.901 (95% CI 0.838-0.964), respectively. SHAP analyses indicated that textural features were key features relevant to the prediction of PPDM-A incidence. The interpretable CT radiomics-based model developed in this study demonstrated good performance, enabling timely and effective interventions with the potential to improve patient outcomes.

Unveiling the Emerging Role of Xanthine Oxidase in Acute Pancreatitis: Beyond Reactive Oxygen Species

Acute pancreatitis (AP) is a potentially fatal acute digestive disease that is widespread globally. Although significant progress has been made in the previous decade, the study of mechanisms and therapeutic strategies is still far from being completed. Xanthine oxidase (XO) is an enzyme that catalyzes hypoxanthine and xanthine to produce urate and is accompanied by the generation of reactive oxygen species (ROS) in purine catabolism. Considerable preclinical and clinical studies have been conducted over many decades to investigate the role of XO in the pathogenesis of AP and its potential targeting therapeutic value. There is no doubt that the ROS generated by irreversibly activated XO participates in the local pancreas and multiple organ failure during AP. However, the optimal timing and doses for therapeutic interventions targeting XO in animal studies and the clinic, as well as the additional molecular mechanisms through which XO contributes to disease onset and progression, including metabolic regulation, remain to be elucidated. This review summarized the benefits and contradictions of using XO inhibitors in animal models, offered mechanisms other than ROS, and discussed the difficulties faced in clinical trials. We hope to provide a perspective on the future worthwhile basic and clinical research on XO by analyzing its chemical and biological characteristics, as well as the progress of its regulatory mechanisms in AP.

Nutritional Status and Nutritional Support in Patients with Gastrointestinal Diseases

Gastrointestinal diseases include a wide spectrum of functional and structural disorders of the alimentary system, involving hepatic, bile duct, and pancreatic diseases [...].

Characterization of Pancreatic Infections in Patients with Severe Acute Pancreatitis: A Retrospective Study from 2019 to 2023

Objective

This study investigated the distribution and changes in pancreatic infections among patients with acute pancreatitis (AP) from 2019 to 2023, while exploring the impact of multidrug-resistant bacterial infections on the prognosis of patients with poor outcomes.

Methods

This study included patients diagnosed with SAP between 2019 and 2023 and collected the demographic and clinical characteristics of all participants. Based on routine clinical microbiological culture results, the distribution and drug resistance of pathogens associated with pancreatic infections were analyzed. Multivariable logistic regression was used to evaluate the association between multidrug-resistant organism (MDRO) infection and poor prognosis.

Results

A total of 1586 pancreatic fluid specimens were analyzed and collected from 843 patients diagnosed with AP. The positive rate of the culture results was 81% (1280/1586), with the predominant pathogens identified as Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, and Acinetobacter baumannii complex. Of the 843 patients, 756 met the criteria, and the proportion of MDROs in pancreatic infections was 87.57% (662/756). Multivariate logistic regression analysis revealed that septic shock, acute kidney injury, and tracheostomy were associated with a poor prognosis, whereas ICU length of stay, infected pancreatic necrosis, and tracheostomy were associated with multidrug-resistant bacterial infections in patients with severe or critical AP.

Conclusion

The proportion of MDRO infections in patients with severe or critical AP was notably high, primarily involving multidrug-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. Septic shock, acute kidney injury, and tracheostomy have been identified as independent risk factors of poor prognosis in patients with severe or critical AP.

Ultra-early indicators of acute hypertriglyceridemic pancreatitis may influence treatment decision-making

This study aimed to explore whether ultra-early indicators can predict the severity of acute hypertriglyceridemic pancreatitis (HTGP) and guide clinical decisions. This retrospective study analyzed data from HTGP patients who were categorized into mild acute pancreatitis (MAP) and moderately severe/severe acute pancreatitis (MSAP/SAP) groups based on their final clinical outcomes. Ultra-early indicators (serum calcium, triglyceride [TG], interleukin-6 [IL-6], D-dimer, hemoglobin A1c [HbA1c], arterial lactate) were measured within 6 h of admission. Among 110 patients, 56 had MAP and 54 had MSAP/SAP. Within 6 h of admission, TG, IL-6, D-dimer, HbA1c, and arterial lactate levels were significantly higher in the MSAP/SAP group, while serum calcium was lower. Multivariable logistic regression and receiver operator characteristic curve identified IL-6, D-dimer, and serum calcium as independent risk factors and ultra-early predictors of HTGP severity. Patients with MSAP/SAP who received blood purification within 24 h had a shorter hospital stay compared to those treated later. IL-6, D-dimer, and serum calcium are promising biomarkers for early prediction of HTGP severity. Early blood purification within 24 h reduces complications and hospital stay in MSAP/SAP patients, while traditional treatments remain effective for MAP patients, potentially reducing medical costs.

Construction of a nursing management program for early fluid resuscitation in patients with acute pancreatitis: a Delphi study in China

AIM AND OBJECTIVES

To construct a set of scientific and feasible nursing management protocols for early fluid resuscitation in acute pancreatitis (AP) patients that can be used to guide clinical practice and enhance the treatment efficacy in these patients.

BACKGROUND

Fluid resuscitation is a key means of early treatment for AP patients and has become a clinical consensus. Nurses are important practitioners of fluid resuscitation, and there is a lack of specific enforceable nursing management programs.

METHODS

Through literature research, on-site research, semi-structured interviews, and other preliminary preparations of the first draft of the nursing management program for early fluid resuscitation in acute pancreatitis, the Delphi method was used to conduct two rounds of correspondence with medical and nursing experts, and then statistically analyzed.

RESULTS

Fifteen and 14 questionnaires were distributed in two rounds, respectively, and 15 and 14 questionnaires were recovered, respectively. The positive coefficient of experts was 100%, the authority coefficient was 0.970 and 0.975, respectively; the coefficient of variation coefficient was 0.05-0.21 and 0.00-0.20, respectively; the expert coordination coefficients of all levels of indices in this study are 0.166-0.335 and 0.189-0.364, respectively. The P values of the first, second, and third level indices are < 0.05 according to the test of Kendall's harmony coefficient. A total of 5 primary indicators, 11 secondary indicators, and 36 tertiary indicators were used to construct the Nursing Management Program for Early Fluid Resuscitation in Acute Pancreatitis.

CONCLUSIONS

The constructed nursing management plan for early fluid resuscitation in acute pancreatitis patients puts forward clear requirements and standards for nursing care in the early stage of AP treatment. This plan is scientific, represent good clinical practice, are feasible for nurses to follow, and construct a standardized protocol for the management of early fluid resuscitation in patients with acute pancreatitis.

Plozasiran for Managing Persistent Chylomicronemia and Pancreatitis Risk

BACKGROUND

Persistent chylomicronemia is a genetic recessive disorder that is classically caused by familial chylomicronemia syndrome (FCS), but it also has multifactorial causes. The disorder is associated with the risk of recurrent acute pancreatitis. Plozasiran is a small interfering RNA that reduces hepatic production of apolipoprotein C-III and circulating triglycerides.

METHODS

In a phase 3 trial, we randomly assigned 75 patients with persistent chylomicronemia (with or without a genetic diagnosis) to receive subcutaneous plozasiran (25 mg or 50 mg) or placebo every 3 months for 12 months. The primary end point was the median percent change from baseline in the fasting triglyceride level at 10 months. Key secondary end points were the percent change in the fasting triglyceride level from baseline to the mean of values at 10 months and 12 months, changes in the fasting apolipoprotein C-III level from baseline to 10 months and 12 months, and the incidence of acute pancreatitis.

RESULTS

At baseline, the median triglyceride level was 2044 mg per deciliter. At 10 months, the median change from baseline in the fasting triglyceride level (the primary end point) was -80% in the 25-mg plozasiran group, -78% in the 50-mg plozasiran group, and -17% in the placebo group (P<0.001). The key secondary end points showed better results in the plozasiran groups than in the placebo group, including the incidence of acute pancreatitis (odds ratio, 0.17; 95% confidence interval, 0.03 to 0.94; P = 0.03). The risk of adverse events was similar across groups; the most common adverse events were abdominal pain, nasopharyngitis, headache, and nausea. Severe and serious adverse events were less common with plozasiran than with placebo. Hyperglycemia with plozasiran occurred in some patients with prediabetes or diabetes at baseline.

CONCLUSIONS

Patients with persistent chylomicronemia who received plozasiran had significantly lower triglyceride levels and a lower incidence of pancreatitis than those who received placebo. (Funded by Arrowhead Pharmaceuticals; PALISADE ClinicalTrials.gov number, NCT05089084.).

Integrating CT-based radiomics and clinical features to better predict the prognosis of acute pancreatitis

OBJECTIVES

To develop and validate the performance of CT-based radiomics models for predicting the prognosis of acute pancreatitis.

METHODS

All 344 patients (51 ± 15 years, 171 men) in a first episode of acute pancreatitis (AP) were retrospectively enrolled and randomly divided into training (n = 206), validation (n = 69), and test (n = 69) sets with the ratio of 6:2:2. The patients were dichotomized into good and poor prognosis subgroups based on follow-up CT and clinical data. The radiomics features were extracted from contrast-enhanced CT. Logistic regression analysis was applied to analyze clinical-radiological features for developing clinical and radiomics-derived models. The predictive performance of each model was evaluated using the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA).

RESULTS

Eight pancreatic and six peripancreatic radiomics features were identified after reduction and selection. In the training set, the AUCs of clinical, pancreatic, peripancreatic, radiomics, and combined models were 0.859, 0.800, 0.823, 0.852, and 0.899, respectively. In the validation set, the AUCs were 0.848, 0.720, 0.746, 0.773, and 0.877, respectively. The combined model exhibited the highest AUC among radiomics-based models (pancreatic, peripancreatic, and radiomics models) in both the training (0.899) and validation (0.877) sets (all p < 0.05). Further, the AUC of the combined model was 0.735 in the test set. The calibration curve and DCA indicated the combined model had favorable predictive performance.

CONCLUSIONS

CT-based radiomics incorporating clinical features was superior to other models in predicting AP prognosis, which may offer additional information for AP patients at higher risk of developing poor prognosis.

CRITICAL RELEVANCE STATEMENT

Integrating CT radiomics-based analysis of pancreatic and peripancreatic features with clinical risk factors enhances the assessment of AP prognosis, allowing for optimal clinical decision-making in individuals at risk of severe AP.

KEY POINTS

Radiomics analysis provides help to accurately assess acute pancreatitis (AP). CT radiomics-based models are superior to the clinical model in the prediction of AP prognosis. A CT radiomics-based nomogram integrated with clinical features allows a more comprehensive assessment of AP prognosis.

Efficacy analysis of pancreatic duct stenting in treating severe acute pancreatitis: a retrospective study

BACKGROUND

This study aims to evaluate the clinical efficacy of pancreatic duct stenting in the treatment of SAP, providing reference for clinical diagnosis and treatment.

METHODS

A retrospective analysis was conducted on clinical data from patients with SAP admitted to the General Hospital of Ningxia Medical University from June 1, 2019 to December 31, 2022. A total of 51 patients were included (33 males, 18 females). Patients were divided into two groups based on treatment: the control group (n = 28) receiving conventional treatment and the stent group (n = 23) undergoing pancreatic duct stenting in addition to conventional treatment. Data collected and analyzed include demographic information, rates of late local complications, late surgical interventions, new-onset OF, infected pancreatic necrosis and new-onset systemic complications. Specific outcomes measured were incidences of new-onset respiratory, renal and circulatory failure, single and multiple OF, sepsis, ACS, abdominal hypertension, and pancreatogenic encephalopathy, as well as use of ≥ 3 types of antibiotics, time of antibiotic use, time of analgesic administration, oral refeeding, length of hospital stay, ICU care, and length of ICU stay. These indicators were used to assess the therapeutic efficacy of pancreatic duct stenting.

RESULTS

All 23 patients in the stent group successfully underwent stenting. The incidence of new-onset OF and new-onset systemic complications was significantly lower in the stent group compared to the control group (χ2 = 4.96, 6.65, P < 0.05). However, no significant differences were observed between the groups regarding late local complications, infected pancreatic necrosis, and late surgical intervention (χ2 = 0.22, 0.002, 0.024, P > 0.05). Notably, two patients in the control group required additional procedures due to inadequate drainage, with one undergoing endoscopic debridement and the other, laparotomy. Mortality rates were 3 (10.7%) in the control group and 4 (17.4%) in the stent group, with no statistically significant difference (P > 0.05). Furthermore, significant differences were noted in new-onset respiratory failure, single OF, sepsis, abdominal hypertension, time of analgesic administration, oral refeeding, length of enzyme inhibitor use, and hospitalization expenses (χ2 = 3.94, 4.37, 5.79, 4.79; Z = - 2.008, - 4.176, - 4.165, - 2.309; P < 0.05). No significant differences were found in new-onset renal, circulatory, multiple OF, ACS, pancreatogenic encephalopathy, use of ≥ 3 types of antibiotics, time of antibiotic use, length of hospital stay, ICU care, and length of ICU stay (P > 0.05).

CONCLUSIONS

Pancreatic duct stenting effectively reduces the incidence of new-onset systemic complications and OF in SAP, preventing further deterioration. Pancreatic duct stenting can alleviate symptoms, shorten oral refeeding, and promote patient recovery.

TRIAL REGISTRATION

This study was recorded as a single-center, retrospective case-control study (ChiCTR1900025833).

Profile of intestinal fungal microbiota in acute pancreatitis patients and healthy individuals

OBJECTIVE

The gut is involved in the development of acute pancreatitis (AP). Increased focus is being given to the role of gut microbiota in the pathogenesis of AP. Nevertheless, there is currently no available evidence regarding the composition of fungal microorganisms in the intestines of patients with AP.

METHODS

In this study, we sequenced ITS rRNA gene amplicons and examined the intestinal fungal microbiota in feces from 11 AP patients (the test group) and 15 healthy people (the control group). Additionally, we examined the relationship between fungus and clinical and biochemical markers.

RESULTS

Results showed a decline in alpha diversity in AP patients. The overall fungal microbiota in the test group was significantly different from that of the control group (P < 0.05). In both groups, the fecal fungal microbiota was dominated by Ascomycota and Basidiomycota phyla. At the genus level, the abundance of Candida was significantly higher in the test group and the abundances of Penicillium, Auricularia, unclassified Eurotiomycetes, Epicoccum and Vishniacozyma were significantly lower. Furthermore, AP patients had a significant decrease in the GMHI score and a significant increase in the MDI index. The co-abundance networks of gut fungus in AP patients showed more interactions and mostly positive correlations than in the control group. There was a strong positive link between Aspergillus and WBC counts, while There was a strong link between unclassified Rozellomycota and IL-6.

CONCLUSION

Our study provides the first empirical evidence that AP patients have different fecal fungal microbiota, which raises the possibility that mycobiota contribute to the etiology and progression of AP.

Lysine acetylation and its role in the pathophysiology of acute pancreatitis

Acute pancreatitis (AP) represents a severe inflammatory condition of the exocrine pancreas, precipitating systemic organ dysfunction and potential failure. The global prevalence of acute pancreatitis is on an ascending trajectory. The condition carries a significant mortality rate during acute episodes. This underscores the imperative to elucidate the etiopathogenic pathways of acute pancreatitis, enhance comprehension of the disease's intricacies, and identify precise molecular targets coupled with efficacious therapeutic interventions. The pathobiology of acute pancreatitis encompasses not only the ectopic activation of trypsinogen but also extends to disturbances in calcium homeostasis, mitochondrial impairment, autophagic disruption, and endoplasmic reticulum stress responses. Notably, the realm of epigenetic regulation has garnered extensive attention and rigorous investigation in acute pancreatitis research over recent years. One of these modifications, lysine acetylation, is a reversible post-translational modification of proteins that affects enzyme activity, DNA binding, and protein stability by changing the charge on lysine residues and altering protein structure. Numerous studies have revealed the importance of acetylation modification in acute pancreatitis, and that it is a favorable target for the design of new drugs for this disease. This review centers on lysine acetylation, examining the strides made in acute pancreatitis research with a focus on the contributory role of acetylomic alterations in the pathophysiological landscape of acute pancreatitis, thereby aiming to delineate novel therapeutic targets and advance the development of more efficacious treatment modalities.

Advances in the clinical application of machine learning in acute pancreatitis: a review

Traditional disease prediction models and scoring systems for acute pancreatitis (AP) are often inadequate in providing concise, reliable, and effective predictions regarding disease progression and prognosis. As a novel interdisciplinary field within artificial intelligence (AI), machine learning (ML) is increasingly being applied to various aspects of AP, including severity assessment, complications, recurrence rates, organ dysfunction, and the timing of surgical intervention. This review focuses on recent advancements in the application of ML models in the context of AP.

Application of EUS or MRCP prior to ERCP in patients with suspected choledocholithiasis in clinical practice

Background and study aims Patients with symptomatic cholelithiasis can be stratified according to the 2019 European Society for Gastrointestinal Endoscopy (ESGE) guideline into low-, intermediate- and high-likelihood groups for presence of choledocholithiasis. For the intermediate group, endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is recommended to assess whether an endoscopic retrograde cholangiopancreatography (ERCP) is necessary prior to cholecystectomy. The aim of the study was to investigate adherence to the guideline for diagnostic and treatment strategy for cholelithiasis in daily clinical practice. Patients and methods A multicenter, retrospective cross-sectional observational study of the diagnostic pathway of patients with suspicion of choledocholithiasis was conducted between 2019 and 2021. Patients were stratified according to the ESGE guideline "Endoscopic management of common bile duct stones". Results A total of 305 patients were included in the analysis and stratified into low- (17%), intermediate- (40%) and high- (43%) likelihood of choledocholithiasis. In these three categories, 182 patients (60%) underwent ERCP. Adherence to the ESGE guideline recommendation was 59.7% overall and was the highest in the intermediate-likelihood group (83.6%), compared with 45.1% in the low- and 43.2% in the high-likelihood group, respectively ( P < 0.001). In the high-likelihood group, 49% underwent additional imaging. In 195 patients who underwent additional imaging, 55 ERCPs (28.2%) could be avoided. Conclusions This study shows that stratification according to the ESGE guideline is useful to reduce the number of unnecessary additional imaging procedures and ERCPs in patients with a suspicion of choledocholithiasis. It seems worthwhile to perform EUS prior to ERCP in the same session.

Prediction Models of Severity in Acute Biliary Pancreatitis

Background: Acute pancreatitis is a common condition with a variable prognosis. While the overall mortality rate of acute pancreatitis is relatively low, ranging between 3 and 5% in most cases, severe forms can result in significantly higher morbidity and mortality. Therefore, early risk assessment is crucial for optimizing management and treatment. The aim of the present study wasto compare simple prognostic markers and identify the best predictors of severity in patients with acute pancreatitis. Material and Methods: A retrospective analysis was carried outon 108 patients admitted in our center during one year with acute biliary pancreatitis. Acute pancreatitis severity was stratified based on the revised Atlanta criteria. Results: 108 subjects (mean age of 60.1 ± 18.6, 65.7% females) diagnosed with acute biliary pancreatitis were included. Based on the Atlanta criteria, 59.3% (64/108) of the subjects were classified as having mild acute biliary pancreatitis, 35.2% (38/108) as having a moderate-severe pancreatitis, and 5.5% (6/108) were classified as having severe acute pancreatitis. In univariate analysis, the following parameterswere associatedwith at least a moderate-severe form of acute pancreatitis: Balthazar score, fasting blood glucose (mg/dL), modified CTSI score, CRP values at 48 h, BISAP score at admission, CTSI score, Ranson score, duration of hospitalization (days), and the presence of leukocytosis (×1000/µL) (all p < 0.05).BISAP score at admission (AUC-0.91), CRP levels at 48 h (AUC-0.92), mCTSI (AUC-0.94), and CTSI score (AUC-0.93) had the highest area under the curve (AUC) for predicting the severity of acute pancreatitis. In multivariate analysis, the model including the following independent parameters was predictive for the severity of acute pancreatitis: CTSI score (p < 0.0001), BISAP score (p = 0.0082), and CRP levels at 48 h (p = 0.0091), respectively. The model showed a slightly higher AUC compared to the independent predictors (AUC-0.96). Conclusions: The use of a multiparametric prediction model can increase the accuracy of predicting severity in patients with acute biliary pancreatitis.

Effect and safety of sivelestat on acute severe pancreatitis with systemic inflammatory response syndrome: a retrospective study

The study was to explore the efficacy and safety of sivelestat (SV) in the treatment of severe acute pancreatitis (SAP) with systemic inflammatory response syndrome (SIRS). A total of 102 SAP patients diagnosed and treated in the Emergency Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University from January 2021 to August 2024 were selected. The changes of disease outcome, hospital stays and mortality were compared between the two groups. A total of 102 patients were recruited to control group (n = 56) or SV group (n = 46) according to whether SV was applied or not. There was no significant difference in baseline data at admission between the two groups. After 1 week of treatment, all the indexes in both groups improved. The duration of ventilator use (p = 0.0400) and ICU stays (p  = 0.0495) in SV group was shorter than that in control group, but there was no significant difference in mortality between the two groups. Although SV did not reduce the mortality of patients with SAP, it reduced the length of ventilator use and ICU stay.

Controversies in endoscopic ultrasonography-guided management of walled-off necrosis

Walled-off necrosis (WON) develops as local complications after acute necrotizing pancreatitis. Although less invasive interventions such as endoscopic ultrasonography (EUS)-guided drainage and endoscopic necrosectomy are selected over surgical interventions, delayed and step-up interventions are still preferred to avoid procedure-related adverse events. However, there is a controversy about the appropriate timing of drainage and subsequent necrosectomy. The advent of large-caliber lumen-apposing metal stents has also brought about potential advantages of proactive interventions, which still needs investigation in future trials. When step-up interventions of necrosectomy and additional drainage are necessary, a structured or protocoled approach for WON has been reported to improve safety and effectiveness of endoscopic and/or percutaneous treatment, but has not been standardized yet. Finally, long-term outcomes such as recurrence of WON, pancreatic endocrine, and exocrine function are increasingly investigated in association with disconnected pancreatic duct syndrome. In this review we discuss current evidence and controversy on EUS-guided management of WON.

Comparative study of gut microbiota and metabolite variations between severe and mild acute pancreatitis patients at different stages

Acute pancreatitis (AP) is influenced by interactions between gut microbiota and metabolic products, though the mechanisms remain unclear. This study investigates variations in gut microbiota and metabolites between severe (SAP) and mild acute pancreatitis (MAP) patients to assess their impact on disease progression. Using a cross-sectional cohort design, gut microbiota and metabolite profiles were compared in SAP and MAP patients over two weeks post-diagnosis. 16S rRNA gene sequencing and metabolomic analyses, including KEGG pathway assessments and Spearman correlation, were employed, along with Mendelian Randomization (MR) to assess the influence of specific microbiota on AP. Results showed that SAP patients had significantly reduced gut microbiota diversity, which further declined in the second week. This was marked by increases in pathogenic bacteria like Stenotrophomonas and Enterobacter and decreases in beneficial bacteria such as Blautia. Key changes included a rise in Proteobacteria and a decline in Ruminococcaceae, Enterococcus, and Faecalicatena. Metabolic shifts included lipid metabolite upregulation and antioxidant downregulation. Correlation analysis linked Stenotrophomonas to short-chain fatty acid and amino acid metabolism, highlighting its role in disease progression. MR analysis confirmed negative causal relationships between Enterococcus B, Faecalicatena torques, and AP, suggesting protective effects. Variations in Blautia species indicated differing influences on AP. This study underscores the critical role of gut microbiota and metabolites in AP progression and suggests the need for further research to confirm these findings and explore targeted therapeutic interventions.

Severe Acute Pancreatitis Complicated by Multiple Intra-Abdominal Hemorrhages

Introduction

Intra-abdominal hemorrhage is a rare yet life-threatening complication of acute pancreatitis (AP), with a higher prevalence in cases of severe acute pancreatitis (SAP). This condition is primarily caused by vessel wall erosion and rupture of pseudoaneurysms (PSAs). However, SAP cases involving multiple sequential arterial hemorrhages are extremely rare. This condition is primarily brought on by the process of vessel wall degeneration and the development of PSAs. Nonetheless, SAP necessitating multiple episodes of arterial bleeding is very uncommon.

Case Presentation

Here is the case history of a 31-year-old man already being treated for SAP. His condition was then complicated by massive, frequent intra-abdominal bleeding. The patient initially presented to the hospital with SAP. He was transferred to the intensive care unit for proper management. Massive intra-abdominal bleeds occurred on the 31st, 45th, and 60th days during hospitalization. The maximum blood loss was 1,500 mL. In each of the instances, digital subtraction angiography (DSA) embolization was carried out after the bleeding source had been verified. In order to manage SAP, continuous percutaneous drainage and staged pancreatic necrosectomy were undertaken for 6 months. No recurrence of intra-abdominal hemorrhage was detected. Infection of the abdominal cavity was properly controlled. The patient left the hospital in good condition.

Conclusion

Spontaneous bleeding in the abdominal cavity is a severe and life-threatening complication of SAP. This is often caused by vessel wall erosion. In such cases, DSA plays a crucial role in diagnosis and management. Besides precisely locating the bleeding source, one can perform a much-needed embolization immediately. Consequently, the disease is under total control, and the patient is much more likely to survive.

Development and validation of a machine learning-based, point-of-care risk calculator for post-ERCP pancreatitis and prophylaxis selection

BACKGROUND AND AIMS

A robust model of post-ERCP pancreatitis (PEP) risk is not currently available. We aimed to develop a machine learning-based tool for PEP risk prediction to aid in clinical decision making related to periprocedural prophylaxis selection and postprocedural monitoring.

METHODS

Feature selection, model training, and validation were performed using patient-level data from 12 randomized controlled trials. A gradient-boosted machine (GBM) model was trained to estimate PEP risk, and the performance of the resulting model was evaluated using the area under the receiver operating curve (AUC) with 5-fold cross-validation. A web-based clinical decision-making tool was created, and a prospective pilot study was performed using data from ERCPs performed at the Johns Hopkins Hospital over a 1-month period.

RESULTS

A total of 7389 patients were included in the GBM with an 8.6% rate of PEP. The model was trained on 20 PEP risk factors and 5 prophylactic interventions (rectal nonsteroidal anti-inflammatory drugs [NSAIDs], aggressive hydration, combined rectal NSAIDs and aggressive hydration, pancreatic duct stenting, and combined rectal NSAIDs and pancreatic duct stenting). The resulting GBM model had an AUC of 0.70 (65% specificity, 65% sensitivity, 95% negative predictive value, and 15% positive predictive value). A total of 135 patients were included in the prospective pilot study, resulting in an AUC of 0.74.

CONCLUSIONS

This study demonstrates the feasibility and utility of a novel machine learning-based PEP risk estimation tool with high negative predictive value to aid in prophylaxis selection and identify patients at low risk who may not require extended postprocedure monitoring.

Endovascular Management of Noncirrhotic Acute Portomesenteric Venous Thrombosis

Acute portomesenteric venous thrombosis (PVT) is a rare but potentially life-threatening condition in individuals without cirrhosis. Initial management typically involves anticoagulation therapy, but the optimal approach to interventional treatment remains a topic of ongoing research. This article explores both traditional and emerging endovascular techniques, providing an overview of the existing evidence supporting their use. Additionally, it delves into the significance of acute PVT in the context of contemporary pathologies, notably coronavirus disease 2019 infection, vaccine-induced immune thrombotic thrombocytopenia, and liver transplantation.

Treatment of severe hypertriglyceridemia through therapeutic plasma exchange in patients with acute pancreatitis or at risk of developing it

INTRODUCTION AND OBJECTIVES

TPE drastically reduces serum triglyceride (sTG), but its role in the treatment of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) or at risk of developing it, is not well established. The objectives were to assess the effectiveness and safety of TPE in the treatment of severe HTG (sHTG), as well as to evaluate the severity of HTG-AP treated with TPE.

MATERIALS AND METHODS

Observational-retrospective-single-center study, in which a descriptive analysis of sHTG treated with TPE was conducted, with the aim of treating HTG-AP or preventing its recurrence. TPE was performed if sTG≥ 1000 mg/dL after 24 hours of admission.

RESULTS

42 TPE were performed to treat 35 sHTG in 23 patients: 29 HTG-AP, and 6 sHTG with previous HTG-AP. Among the patients, 37% (13/55) were women, with 37 ± 14 years-old, 74.3% had normal BMI (25/35), 34% (12/35) were drinking > 40 g/alcohol/day and 54% (19/35) were diabetics. TPE significantly reduced the baseline sTG (4425 ± 2782 mg/dL vs. 709 ± 353 mg/dL, p < 0.001) in a single session, achieving a mean percentage reduction of 79 ± 13%; 20% (7/35) of sHTG cases required two TPE sessions to reduce sTG to < 1000 mg/dL. Adverse effects were reported in 4/42 TPE sessions (9,5%). sHTG-AP was observed in 3% of cases (1/29), and there were no deaths. sTG at 24 hours of admission showed no relation with the severity of APs.

CONCLUSION

The treatment of sHTG with TPE, with the aim of treating HTG-AP or preventing its recurrence, reduces sTG quickly and safety.

Beyond the revised atlanta classification: a comprehensive review of the imaging assessment of acute pancreatitis and its complications

While the Revised Atlanta Classification outlines the primary complications of acute pancreatitis, it is crucial to recognize additional factors that contribute to morbidity and mortality associated with acute pancreatitis. In this review, we discuss the imaging-based classification and staging of acute pancreatitis as described by the Revised Atlanta Classification, but also provide a comprehensive understanding of the pancreatic anatomy and its relation to surrounding structures, which is essential for imaging-based assessment of both acute pancreatitis and its complications. We further extend the discussion beyond common complications such as pseudocysts and walled-off necrosis to include lesser-known but significant complications such as peripancreatic infection, disconnected ductal disconnection syndrome, thrombosis, hemorrhage, and gastrointestinal complications. Additionally, illustrative examples are presented to highlight relevant points pertaining to real-life imaging assessment of acute pancreatitis and its complications.

Efficacy and Safety of Endoscopic Ultrasound (EUS)-Guided Lumen-Apposing Metal Stents (LAMS) as a Primary Treatment for Walled-Off Pancreatic Necrosis

Pancreatic necrosis, a severe complication of acute pancreatitis, is associated with significant morbidity and mortality. The use of lumen-apposing metal stents (LAMS) as a primary treatment offers a less invasive approach that may improve patient outcomes. This study evaluates the efficacy and safety of endoscopic ultrasound (EUS)-guided LAMS for treating walled-off pancreatic necrosis. In this retrospective cohort study, 95 patients treated with EUS-guided LAMS between March 2020 and October 2023 were included. Data were collected on the technical success of stent placement, clinical improvement, and management of symptomatic patients. Patients with other primary interventions, preexisting chronic pancreatitis, or incomplete clinical data were excluded. The technical success rate for LAMS placement was 100%, with a clinical success rate of 92.63%. Seven patients (7.37%) did not respond to LAMS treatment: five underwent video-assisted retroperitoneal drainage, and two had percutaneous drainage. Stent occlusion occurred in seven patients within the first week, managed through saline irrigation or direct endoscopic necrosectomy. No procedure-related complications were reported. The use of LAMS significantly reduced hospital stays and eliminated the need for additional surgeries in most cases. These findings suggest that LAMS is a highly effective and safe primary treatment for pancreatic necrosis, with high success rates and no related complications. The study's strengths include a large sample size and comprehensive follow-up, although its retrospective, single-center design may limit generalizability. These results support the use of LAMS as a primary treatment option for pancreatic necrosis, with future research needed to refine patient selection and explore long-term outcomes.

Updates on therapeutic endoscopic ultrasound

PURPOSE OF REVIEW

Multiple endoscopic ultrasound (EUS) guided therapeutic interventions have been developed for the management of benign and malignant pancreaticobiliary and gastrointestinal luminal pathology. Recent high-quality evidence is increasingly validating these interventions and positioning them within evidence-based therapeutic algorithms.

RECENT FINDINGS

Here we review therapeutic EUS-guided interventions including pancreatic fluid collection drainage, gastroenterostomy, biliary drainage, pancreatic duct drainage and gallbladder drainage. The most up-to-date high-quality evidence supporting these interventions is presented including comparative data with other conventional treatment options. Newer emerging interventions such as tumor ablation are also reviewed. Current controversies and future avenues for research are discussed. The key role of EUS-guided interventions in managing pancreaticobiliary pathology in patients with a surgically altered anatomy is highlighted.

SUMMARY

Multiple EUS therapeutic interventions have evolved from experimental or rescue options to now well established first- and second-line interventions over other endoscopic, percutaneous and surgical alternatives with the support of high-quality data. Further research is needed to better optimize patient selection and guide long term postintervention follow-up.

Developing a predictive model for septic shock risk in acute pancreatitis patients using interpretable machine learning algorithms

Background

Septic shock is a severe complication of acute pancreatitis (AP), often associated with poor prognosis. This study aims to analyze the clinical characteristics of patients with acute pancreatitis and develop an interpretable early prediction model for septic shock in these patients using machine learning (ML). The model is intended to assist emergency physicians in resource allocation and medical decision making.

Methods

Data were collected from the MIMIC-IV 3.0 database. The dataset was divided into a training set and a test set in a 7:3 ratio. Feature selection was performed using LASSO (Least Absolute Shrinkage and Selection Operator) regression. Subsequently, 10 ML models were developed: Random Forest, Logistic Regression, Gradient Boosting Machine, Neural Network, Extreme Gradient Boosting (XGBoost), K-Nearest Neighbor, Adaptive Boosting, Light Gradient Boosting Machine, Category Boosting, and Support Vector Machine. To enhance and optimize model interpretability, Shapley Additive Explanations (SHAP) were employed.

Results

A total of 1032 patients with AP were included in this study, from which 31 variables were selected for model development. By comparing the area under the receiver operating characteristic curve and decision curve analysis results between the training and test sets, the XGBoost model demonstrated a significant advantage over other models. SHAP analysis revealed that white blood cell count, total bilirubin (bilirubin total), and bicarbonate (HCO3 -) levels were the three most critical risk factors for the development of septic shock in patients with AP.

Conclusion

ML approaches exhibited promising performance in predicting septic shock in patients with AP. These models may aid in guiding treatment decisions for patients with AP in the emergency department.

B Lymphocyte-A Prognostic Indicator in Post-Acute Pancreatitis Diabetes Mellitus

OBJECTIVE

To determine the value of lymphocyte subsets and granulocyte/monocyte surface markers in predicting the risk of post-acute pancreatitis diabetes (PPDM-A).

METHODS

This study included 308 in patients with acute pancreatitis (AP). The markers of granulocytes and monocytes and lymphocyte subsets were detected by flow cytometry, and the fluorescence intensity, absolute count and percentage were obtained. Based on the occurrence of diabetes after AP, patients were divided into two groups: PPDM-A and PPNG-A (post-acute pancreatitis with normal glucose). Correlations between granulocyte and monocyte surface markers and lymphocyte subsets were analyzed. Binary logistic regression was used to analyze the potential influencing factors of PPDM-A.

METHODS

Compared with patients with PPNG-A, patients with PPDM-A tend to be younger (p < 0.001) and have a higher proportion of fatty liver, recurrent pancreatitis, and hyperlipidemic pancreatitis. The results of linear regression showed that B% was negatively correlated with MFI of HLA-DR on monocytes (R2 = 0.145, p < 0.001), B% was positively correlated with CD10-NEUT% (R2 = 0.291, p < 0.001), and MFI of HLA-DR on monocytes was negatively correlated with CD10-NEUT% (R2 = 0.457, p < 0.001). Multivariate logistic regression analysis revealed that age, serous effusion, fatty liver, recurrent pancreatitis, and B% were independent risk factors for the occurrence of PPDM-A.

CONCLUSION

Our study has first confirmed the correlation between PPDM-A and lymphocyte subsets and CD10-NEUT%. Furthermore we indicated that age, fatty liver, serous effusion, recurrent AP, and B% were independent risk factors for PPDM-A. The mechanism of granulocyte and monocyte surface markers and B lymphocytes on PPDM-A is worthy of study. This would help clarify the pathogenesis of PPDM-A at the cellular level and potentially provide new strategies for immunotherapy and even disease prevention.

Association Between High-Density Lipoprotein Cholesterol and Length of Hospital Stay in Acute Pancreatitis: A Retrospective Cohort Study

Background

Acute pancreatitis (AP) is a complex inflammatory disorder with varying degrees of severity, impacting patient recovery and healthcare resource utilization. The length of hospital stay (LOS) is a pivotal indicator of recovery, and identifying factors influencing LOS can offer insights into AP management. High-density lipoprotein cholesterol (HDL-C), known for its cardioprotective properties, has been posited to influence AP outcomes; however, its relationship with LOS remains unclear.

Objective

This study aimed to investigate the potential correlation between HDL-C levels and LOS in patients with AP, considering the effects of demographic factors, comorbidities, and other clinical parameters.

Methods

A retrospective cohort study was conducted. Data collection adhered to the STROBE guidelines, and baseline clinical and laboratory variables were analyzed. Statistical analysis comprised univariate and multivariate regression models, Generalized Additive Models (GAM), and stratified linear regression models to assess the relationship between HDL-C and LOS, while accounting for confounding factors.

Results

After adjusting for key confounders, including age, sex, BMI, WBC, HB, PLT, CRP, ALT, AMY, TB, GLU, LDL-C, SCR, BUN, ALB, Ca2+, and the presence of comorbidities such as hypertension, gallstones, diabetes mellitus, liver dysfunction, renal insufficiency, smoking and alcohol consumption, the study revealed a nonlinear relationship between HDL-C levels and LOS, with an inflection point at 1.5 mmol/L. Below this threshold, HDL-C was significantly and inversely correlated with LOS, whereas above this threshold, HDL-C was positively correlated with LOS. Subgroup analyses emphasized that in non-diabetic, non-alcoholic and non-hyperlipidemic pancreatitis patients, there is a negative correlation between HDL-C levels and LOS.

Conclusion

HDL-C exhibits a U-shaped relationship with LOS in patients with AP, suggesting that both low and high levels of HDL-C may influence hospital stay duration. These findings underscore the importance of considering HDL-C levels in the clinical management of AP. Especially in patients who are non-diabetic, non-hyperlipidemic, and non-alcoholic, the management of HDL-C may significantly reduce hospital stay.

Efficiency of laparoscopic retroperitoneal pancreatic necrosectomy for treating infected pancreatic necrosis with duodenal fistula: a single-center retrospective cohort study

BACKGROUND

Open surgical debridement was the main treatment option for infected pancreatic necrosis (IPN). However, it was associated with significant trauma, leading to a higher mortality rate. With the development of minimally invasive surgery, the step-up treatment principle centered around minimally invasive intervention, significantly reducing the incidence of complications and mortality rates among IPN patients. However, few studies have reported the efficacy of laparoscopic retroperitoneal pancreatic necrosectomy (LRPN), a new minimally invasive debridement technique, in IPN patients with duodenal fistula (DF)-a severe complication of IPN. Therefore, we analyzed the effectiveness and safety of LRPN for treating IPN with DF and discussed the impact of DF on patient prognosis.

METHODS

We retrospectively examined patients diagnosed with IPN between 2018 and 2023. The patients were divided into two groups based on the presence or absence of DF. Clinical characteristics, treatment strategies, clinical outcomes, and follow-up information were analyzed. A 1:1 propensity score-matching (PSM) method was used to assess differences in outcome indicators more accurately.

RESULTS

A total of 197 patients were examined. After PSM, no significant differences were observed between the two groups in in-hospital mortality rate, incidence of single organ failure, rate of postoperative severe complications (Clavien-Dindo Classification ≥ 3), and intensive care unit stay (P > 0.05). However, the incidence of multiorgan failure, gastrointestinal bleeding, number of percutaneous catheter drainage (PCD) procedures, surgery cases, hospital stay, and hospitalization costs were higher in the DF group (P < 0.05). Of these patients, 71.6% (n = 141) were treated with PCD + LRPN, with a conversion rate of 6.38% to open surgery. A higher proportion of patients in the non-DF group showed improved clinical outcomes solely with PCD (22.6% vs. 2.4%, P < 0.05), whereas a higher proportion of patients in the DF group underwent PCD + LRPN (88.1% vs. 67.1%, P < 0.05). Both groups showed a significant reduction in the Sequential Organ Failure Assessment score 72 h postoperatively.

CONCLUSIONS

For patients with IPN and DF, the LRPN-centered step-up strategy was safe and effective. DF prolongs hospital stay and increases hospitalization costs for patients.

Mitochondrial dysfunction in pancreatic acinar cells: mechanisms and therapeutic strategies in acute pancreatitis

Acute pancreatitis (AP) is an inflammatory disease of the pancreas and a complex process involving multiple factors, with mitochondrial damage playing a crucial role. Mitochondrial dysfunction is now considered a key driver in the development of AP. This dysfunction often presents as increased oxidative stress, altered membrane potential and permeability, and mitochondrial DNA damage and mutations. Under stress conditions, mitochondrial dynamics and mitochondrial ROS production increase, leading to decreased mitochondrial membrane potential, imbalanced calcium homeostasis, and activation of the mitochondrial permeability transition pore. The release of mitochondrial DNA (mtDNA), recognized as damage-associated molecular patterns, can activate the cGAS-STING1 and NF-κB pathway and induce pro-inflammatory factor expression. Additionally, mtDNA can activate inflammasomes, leading to interleukin release and subsequent tissue damage and inflammation. This review summarizes the relationship between mitochondria and AP and explores mitochondrial protective strategies in the diagnosis and treatment of this disease. Future research on the treatment of acute pancreatitis can benefit from exploring promising avenues such as antioxidants, mitochondrial inhibitors, and new therapies that target mitochondrial dysfunction.

Topical application of Glauber's salt accelerates the absorption of abdominal fluid after pancreatectomy

BACKGROUND

Abdominal fluid collection (AFC) is one of the most common complications after pancreatic surgery, yet there are few recommendations on how to manage it. Most cases of AFC only require observation, while others may require more invasive techniques. Unfortunately, there are no drugs that effectively promote the absorption of AFCs. The aim of this study was to evaluate the potential efficacy of Glauber's salt solution for promoting the absorption of AFCs after pancreatectomy.

METHODS

This study included 196 patients who underwent pancreatomy and had AFCs on at least 2 cross-sectional follow-up CT images between 2020 and 2022. AFCs were defined as effusion with a diameter ≥ 3 cm and located around the pancreatic resection margin. We retrospectively investigated the relationship between Glauber's salt concentration and clinical variables.

RESULTS

The rate of clinically significant pancreatic fistula (grades B + C) was significantly higher in the control group (62.8% vs. 40.7%, P = 0.014). The median maximum diameter of the AFC was smaller, and the median time for the AFC to decrease to 30 mm in diameter was shorter in the Glauber's salt group than in the control group (41.9 mm vs. 53.5 mm, P = 0.008; 35.5 d vs. 100 d, P < 0.001). According to the multivariate analysis, percutaneous drainage and the application of Glauber's salt were found to be independent risk factors for AFCs decreasing to less than 30 mm in diameter (HR = 2.338, 95% CI = 1.524-3.585, P < 0.001; HR = 1.853, 95% CI = 1.327-2.589, P < 0.001). Additionally, patients with a maximum postoperative temperature exceeding 38.5 °C exhibited enhanced AFC absorption (hazard ratio (HR) = 1.850, 95% CI = 1.268-2.701; P = 0.001).

CONCLUSIONS

Topical application of Glauber's salt solution after pancreatic surgery can promote the absorption of AFCs.

Conjugated bile acids alleviate acute pancreatitis through inhibition of TGR5 and NLRP3 mediated inflammation

INTRODUCTION

Severe acute pancreatitis (SAP) is a crucial gastrointestinal disease characterized by systemic inflammatory responses and persistent multiple organ failure. The role of bile acids (BAs) in diverse inflammatory diseases is increasingly recognized as crucial, but the underlying role of BA conjugation remains elusive.

OBJECTIVES

Our study aim to investigate the potential role of conjugated bile acids in SAP and reveal the molecular mechanisms underlying its regulatory effects. We hypothesized that taurochenodeoxycholic acid (TCDCA) and glycochenodeoxycholic acid (GCDCA) could protect SAP through inhibiting the activation of NLRP3 inflammasomes via the TGR5 pathway in macrophages.

METHODS

To test our hypothesis, we used BA-CoA: amino acid N-acyltransferase knockout (Baat-/-) mice and established SAP mouse models using caerulein- and sodium taurocholate- induced. We utilized a range of methods, including pathology sections, qRT-PCR, immunofluorescence, Western blotting, and ELISA, to identify the mechanisms of regulation.

RESULTS

BA-CoA: Amino acid N-acyltransferase knockout (Baat-/-) mice significantly exacerbated pancreatitis by increasing pancreatic and systemic inflammatory responses and pancreatic damage in SAP mouse models. Moreover, the serum TCDCA levels in Baat-/- mice were lower than those in wild-type (WT) mice with or without SAP, and GCDCA and TCDCA showed stronger anti-inflammatory effects than chenodeoxycholic acid (CDCA) in vitro. TCDCA treatment alleviated SAP in a Takeda G protein-coupled receptor 5 and NOD-like receptor family, pyrin domain containing 3-dependent manner in vivo. Reinforcing our conclusions from the mouse study, clinical SAP patients exhibited decreased serum content of conjugated BAs, especially GCDCA, which was inversely correlated with the severity of systemic inflammatory responses.

CONCLUSION

Conjugated bile acids significantly inhibit NLRP3 inflammasome activation by activating TGR5 pathway, thereby alleviating pancreatic immunopathology. The results provide new insights into the variability of clinical outcomes and paves the way for developing more effective therapeutic interventions for AP.

Epidemiology of chronic and acute pancreatitis in India (EPICAP-India): protocol for a multicentre study

INTRODUCTION

Acute and chronic pancreatitis (CP) are inflammatory conditions of the pancreas that cause local and systemic complications. The epidemiology of these conditions are not well-known in India.

METHODS AND ANALYSIS

We describe the protocol and procedures of a multicentre study for delineating the epidemiology of pancreatitis in India. We plan to cover 110 000 people across 10 geographically distributed sites in 10 states of India to estimate the burden and risk factors of CP. Trained investigators will make house visits and screen for abdominal pain requiring hospitalisation or pre-diagnosed CP. The screened positive participants will be reviewed by a gastroenterologist to confirm the diagnosis of CP based on radiological imaging. For each case, four controls will be selected and data on risk factors for CP (tobacco, alcohol, family history, metabolic causes) and blood for genetic markers will be collected. Information on the cost of treatment and quality of life will be collected from patients with CP. For estimating incidence of acute pancreatitis (AP), hospital-based sentinel surveillance will be conducted in 10 districts across these 10 states. All hospitals in the district will be contacted to provide a line list of admissions due to acute abdomen including AP for 2 years. The spread of acute abdomen cases will be used to define the catchment area and estimate the denominator population. The line-listed cases with AP living in the catchment area will form the numerator to calculate the incidence. The study will provide critical information for planning pancreatitis-related services in the country.

ETHICS AND DISSEMINATION

The institutional ethics committee (IECs) at all the participating sites have given their approval for the study. All the participants whose data will be collected will be included after written informed consent. The results may be presented at national or international conferences and will be reported in peer-reviewed publications.

Pancreatic pseudocyst after acute pancreatitis in children

Acute pancreatitis in children is a rare condition; however, the incidence of this acute condition has been increasing over the past few decades. In most cases, acute pancreatitis does not cause severe complications in children, but in some cases, it can be complicated by fluid accumulation, fistulas and vascular pathologies, but the most common complication remains the formation of pseudocysts. This article describes the clinical case of a 11-year-old girl from Lithuania, which effectively illustrates a rare condition in children-acute pancreatitis and its developed complication-the formation of a pancreatic pseudocyst. The article discusses the frequency of acute pancreatitis and its complication, pancreatic pseudocyst in children, and the clinical expression of the disease and methods of diagnostics and treatment.

Different trend of muscle wasting extracted from computed tomography in patients with severe acute pancreatitis

PURPOSE

The trend of muscle wasting in patients with acute severe and moderately severe pancreatitis (AP) remains unclear. This retrospective study aimed to investigate the trend of skeletal muscle area (SMA) changes and its impact on patients with severe and moderately severe AP.

METHODS

Patients diagnosed with AP who had repeated CT scans after intensive care unit (ICU) admission were included. The patients were categorized into moderately severe AP or severe AP groups. The generalized additive mixed model (GAMM) was used to analyze the SMA trajectories.

RESULTS

A total of 126 patients were included. The patients in the severe AP group had more rapid muscle wasting during the first 3 weeks following ICU admission. The SMA decreased by 1.1 cm2 (95% CI: 1.3 to 0.8) per day in the severe AP group, while the SMA decreased by 0.5 cm2 (95% CI: 0.6 to 0.4) in the moderately severe AP group in the GAMM model. A larger change in the SMA during the first 10 days after admission was significantly associated with prolonged length of hospital stay (LOS) (β = - 0.205, P = 0.036).

CONCLUSIONS

Patients with severe AP experienced more muscle wasting during the first 3 weeks after ICU admission. A larger reduction in the SMA was associated with prolonged LOS.

CLINICAL IMPLICATIONS

Different patterns of muscle wasting were present during the first 3 weeks after ICU admission in moderately severe and severe AP patients. Accordingly, different nutrition and rehabilitation strategies might be employed depending upon the severity of AP.

Machine learning predictive model for aspiration risk in early enteral nutrition patients with severe acute pancreatitis

Background

The aim of this study was to build and validate a risk prediction model for aspiration in severe acute pancreatitis patients receiving early enteral nutrition (EN) by identifying risk factors for aspiration in these patients.

Methods

The risk factors for aspiration were analyzed to build a prediction model based on the data collected from 339 patients receiving enteral nutrition. Subsequently, we used six machine learning algorithms and the model was validated by the area under the curve.

Results

In this study, the collected data were divided into two groups: a training cohort and a validation cohort. The results showed that 28.31 % (77) of patients had aspiration and 71.69 % (195) of patients had non-aspiration in training cohort. Moreover, age, consciousness, mechanical ventilation, aspiration history, nutritional risk and number of comorbidities were included as predictive factors for aspiration in patients receiving EN. The XGBoost model is the best of all machine learning models, with an AUROC of 0.992 and an F1 value of 0.902. The specificity and accuracy of XGBoost are higher than those of traditional logistic regression.

Conclusion

In accordance with the predictive factors, XGBoost model, characterized by excellent discrimination and high accuracy, can be used to clinically identify severe acute pancreatitis patients with a high risk of enteral nutrition aspiration.

Relevance to clinical practice

This study contributed to the development of a predictive model for early enteral nutrition aspiration in severe acute pancreatitis patients during hospitalization that can be shared with medical staff and patients in the future.

No patient or public contribution

This is a retrospective cohort study, and no patient or public contribution was required to design or undertake this research.

Bone marrow mesenchymal stem cell-derived exosomal miR-181a-5p promotes M2 macrophage polarization to alleviate acute pancreatitis through ZEB2-mediated RACK1 ubiquitination

As a common digestive disease, acute pancreatitis (AP) often threatens the life of patients. Bone marrow mesenchymal stem cells (BMSCs) derived exosomes have exhibited some benefits for AP. However, the mechanism remains unclear and deserves to be further investigated. The characteristics of BMSCs-exosomes (BMSCs-Exos) were identified. The abundance of genes and proteins was evaluated using quantitative real-time PCR (RT-qPCR), western blot, enzyme-linked immunosorbent assay (ELISA) and IF assay. Cell apoptosis and CD206-positive cells were measured by flow cytometry. The interactions among miR-181a-5p, Zinc finger E-box binding homeobox 2 (ZEB2) and Receptor for Activated C Kinase 1 (RACK1) were verified using dual luciferase reporter assay, RNA immunoprecipitation (RIP), coimmunoprecipitation (Co-IP). BMSCs-Exos effectively improved AP injury through restraining AR42J cell apoptosis and promoting M2 macrophage polarization, which was realized due to BMSCs-Exos harboring an abundance of miR-181a-5p. Further experiments validated miR-181a-5p silenced ZEB2 and ZEB2 reduced RACK1 expression through mediating RACK1 ubiquitination. ZEB2 knockdown decreased AR42J cell apoptosis and induced M2 macrophage polarization to alleviate AP injury, whereas RACK1 downregulation abolished these phenomena. BMSCs-Exos harboring miR-181a-5p suppressed AR42J cell apoptosis and promoted M2 macrophage polarization to delay AP progression through ZEB2-mediated RACK1 ubiquitination.