Acute pancreatitis

Rapid reduction in triglyceride levels by therapeutic plasma exchange in patients with hypertriglyceridemic pancreatitis

Objective

To investigate the effect of therapeutic plasma exchange (TPE) on lowering triglyceride (TG) levels in patients with hypertriglyceridemic pancreatitis (HLAP).

Methods

The TG‐lowering in patients with HLAP was compared between the TPE group and conservative treatment group (non‐TPE). The primary outcome was TG reduction to less than 500 mg/dL within 48 hours.

Results

The primary outcome was significantly correlated with TPE (univariate analysis odds ratio [OR] 2.74; 95% confidence interval [CI] 1.30‐5.79, P = .008; multivariate analysis OR 3.03; 95% CI 1.28‐7.19, P = .012). At 24 and 48 hours, conservative treatment resulted in a 48.24% and 70.44% reduction in TG, while TPE resulted in a 70.91% and 76.39% reduction in TG, respectively. A more rapid decrease of in TGs in a short period was clearly associated with TPE (P < .001 for interaction). After 72 hours, the TGs decreased by approximately 77% in both groups, with no significant difference (P = .563). There was no difference between groups in clinical outcomes over the acute time period or over the longer term.

Conclusions

In patients with HLAP, TPE resulted in a short‐term and rapid reduction in plasma TG concentrations, with no significant advantage over non‐TPE after 72 hours.

Comparison of safety, efficacy, and long-term follow-up between “one-step” and “step-up” approaches for infected pancreatic necrosis

BACKGROUND

Although the “Step-up” strategy is the primary surgical treatment for infected pancreatic necrosis, it is not suitable for all such patients. The “One-step” strategy represents a novel treatment, but the safety, efficacy, and long-term follow-up have not yet been compared between these two approaches.

AIM

To compare the safety, efficacy, and long-term follow-up of two surgical approaches to provide a reference for infected pancreatic necrosis treatment.

METHODS

This was a retrospective analysis of infectious pancreatic necrosis patients who underwent “One-step” or “Step-up” necrosectomy at Xuan Wu Hospital, Capital Medical University, from May 2014 to December 2020. The primary outcome was the composite endpoint of severe complications or death. Patients were followed up every 6 mo after discharge until death or June 30, 2021. Statistical analysis was performed using SPSS 21.0 and GraphPad Prism 8.0, and statistical significance was set at P < 0.05.

RESULTS

One-hundred-and-fifty-eight patients were enrolled, of whom 61 patients underwent “One-step” necrosectomy and 97 patients underwent “Step-up” necrosectomy. During the long-term follow-up period, 40 patients in the “One-step” group and 63 patients in the “Step-up” group survived. The time from disease onset to hospital admission (53.69 ± 38.14 vs 32.20 ± 20.75, P < 0.001) and to initial surgical treatment was longer in the “Step-up” than in the “One-step” group (54.38 ± 10.46 vs 76.58 ± 17.03, P < 0.001). Patients who underwent “Step-up” necrosectomy had a longer hospitalization duration (65.41 ± 28.14 vs 52.76 ± 24.71, P = 0.02), and more interventions (4.26 ± 1.71 vs 3.18 ± 1.39, P < 0.001). Postoperative inflammatory indicator levels were significantly lower than preoperative levels in each group. Although the incisional hernia incidence was higher in the “One-step” group, no significant difference was found in the composite outcomes of severe complications or death, new-onset organ failure, postoperative complications, inflammatory indicators, long-term complications, quality of life, and medical costs between the groups (P > 0.05).

CONCLUSION

Compared with the “Step-up” approach, the “One-step” approach is a safe and effective treatment method with better long-term quality of life and prognosis. It also provides an alternative surgical treatment strategy for patients with infected pancreatic necrosis.

MicroRNA-361-5p Aggravates Acute Pancreatitis by Promoting Interleukin-17A Secretion via Impairment of Nuclear Factor IA-Dependent Hes1 Downregulation

This study set out to explore the potential role of microRNA-361-5p (miR-361-5p) in acute pancreatitis through regulation of interleukin-17A (IL-17A). We first identified the expression of miR-361-5p, IL-17A, nuclear factor IA (NFIA), and hes family bHLH transcription factor 1 (Hes1) in serum samples collected from patients with acute pancreatitis, caerulein-induced mice, and a Th17 cell model. The predicted binding of miR-361-5p to NFIA was confirmed in vitro. Gain- and loss-of-function assays of miR-361-5p and NFIA were employed to elucidate their effects on acute pancreatitis. miR-361-5p promoted Th17 cells to secrete IL-17A and then aggravated acute pancreatitis. miR-361-5p directly targeted NFIA by binding to its promoter region, leading to its downregulation. Overexpression of NFIA reduced Hes1 expression and rescued the promoting effect of miR-361-5p on IL-17A secretion. In summary, miR-361-5p enhances IL-17A secretion from Th17 cells and thus aggravates acute pancreatitis by targeting NFIA and upregulating Hes1.

Current epidemiological trends and in-hospital mortality of acute pancreatitis in Germany: a systematic analysis of standardized hospital discharge data between 2008 and 2017

BACKGROUND

Acute pancreatitis (AP) represents a common gastrointestinal disorder. Complicated disease courses in particular still represent a major clinical challenge and are associated with high mortality. Evaluation of existing data sets and their careful interpretation can support a rational discussion to optimize outcomes of this common gastrointestinal disease.

METHODS

We used standardized hospital discharge data provided by the Federal Statistical Office of Germany to evaluate hospital mortality and current developments of AP in Germany between 2008 and 2017.

RESULTS

In this analysis, 516,618 hospitalized AP cases were included. Main disease etiologies featured biliary (29.9%) and alcoholic (22.7%) AP. The annual frequency of AP increased from 48,858 (2008) to 52,611 (2017), mainly due to a rising incidence of biliary AP. Average hospital mortality was 2.85% and significantly improved over time. While uncomplicated AP had low hospital mortality (1.38%), the presence of organ complications was associated with a mortality of 12.34%. The necessity of mechanical ventilation dramatically increased hospital mortality to 44.06%. Hospital mortality was significantly higher in female patients (3.31%) than males (2.55%) and showed a stepwise increase with patient age. We further identified type 2 diabetes mellitus and obesity as factors associated with increased hospital mortality. Hospital mortality was lowest among patients treated at departments specializing in gastroenterology. Finally, high case volume centers (defined as >98 annual AP cases) had the lowest hospital mortality for patients with complicated courses of AP.

CONCLUSION

With over 50,000 annual hospitalization cases, AP is one of the most important inpatient treatment indications in gastroenterology in Germany. Overall, AP mortality has improved in recent years, presumably due to improved interdisciplinary treatment concepts. In this study, we identified important clinical and epidemiological risk factors for an unfavorable course, which could help to improve risk prediction and triaging, and thus the management of AP.

Machine learning predictive models for acute pancreatitis: A systematic review

INTRODUCTION

Acute pancreatitis (AP) is a common clinical pancreatic disease. Patients with different severity levels have different clinical outcomes. With the advantages of algorithms, machine learning (ML) has gradually emerged in the field of disease prediction, assisting doctors in decision-making.

METHODS

A systematic review was conducted using the PubMed, Web of Science, Scopus, and Embase databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Publication time was limited from inception to 29 May 2021. Studies that have used ML to establish predictive tools for AP were eligible for inclusion. Quality assessment of the included studies was conducted in accordance with the IJMEDI checklist.

RESULTS

In this systematic review, 24 of 2,913 articles, with a total of 8,327 patients and 47 models, were included. The studies could be divided into five categories: 10 studies (42%) reported severity prediction; 10 studies (42%), complication prediction; 3 studies (13%), mortality prediction; 2 studies (8%), recurrence prediction; and 2 studies (8%), surgery timing prediction. ML showed great accuracy in several prediction tasks. However, most of the included studies were retrospective in nature, conducted at a single centre, based on database data, and lacked external validation. According to the IJMEDI checklist and our scoring criteria, two studies were considered to be of high quality. Most studies had an obvious bias in the quality of data preparation, validation, and deployment dimensions.

CONCLUSION

In the prediction tasks for AP, ML has shown great potential in assisting decision-making. However, the existing studies still have some deficiencies in the process of model construction. Future studies need to optimize the deficiencies and further evaluate the comparability of the ML systems and model performance, so as to consequently develop high-quality ML-based models that can be used in clinical practice.

TNFAIP3-upregulated RIP3 exacerbates acute pancreatitis via activating NLRP3 inflammasome

Acute pancreatitis (AP) is an inflammatory disease of the pancreas. Accumulating studies have revealed the involvement of tumor necrosis factor alpha-induced protein 3 (TNFAIP3) in the progression of AP. Here, the current study was conducted to elucidate the role of TNFAIP3 and the underlying molecular mechanisms on the progression of AP. The in vivo animal model and in vitro cell model of AP were generated by retrograde injection of sodium taurocholate and stimulation of cerulein into AR42J cells, respectively. Relationships among TNFAIP3, receptor interacting protein 3 (RIP3) and nod-like receptor protein 3 (NLRP3) were predicted on bioinformatics websites and verified by co-immunoprecipitation. AR42J cells were transfected with overexpressing plasmid or shRNA to study the effects of TNFAIP3/RIP3/NLRP3 axis on cell proliferation and apoptosis, secretion of inflammatory cytokines and production of ROS. The effect of TNFAIP3/RIP3/NLRP3 axis in AP was further confirmed in vivo. High expression of TNFAIP3 was observed in AP pancreatic tissues and AP cell model. TNFAIP3 increased RIP phosphorylation through deubiquitination. RIP activated the NLRP3 inflammasome. Silencing of TNFAIP3 or RIP3T led to elevated proliferation and inhibited apoptosis in AR42J cells, accompanied by decreased inflammatory cytokine levels and ROS production. The protective role of inhibited TNFAIP3 in AP was confirmed evidenced by reduced levels of AMY, LIPA, and ROS in vivo. Collectively, overexpressed TNFAIP3 could contribute to the progression of AP by activating RIP3/NLRP3 axis, providing a potential therapeutic target for AP treatment.

Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type, rate and route

BACKGROUND

Adequate fluid resuscitation is paramount in the management of acute pancreatitis (AP). The aim of this study is to assess benefits and harms of fluid therapy protocols in patients with AP.

METHODS

MEDLINE, Embase, Science Citation Index and clinical trial registries were searched for randomised clinical trials published before May 2020, assessing types of fluids, routes and rates of administration.

RESULTS

A total 15 trials (1073 participants) were included. Age ranged from 38 to 73 years; follow-up period ranged from 0.5 to 6 months. Ringer lactate (RL) showed a reduced number of severe adverse events (SAE) when compared to normal saline (NS) (OR 0.48; 95%CI 0.29-0.81, p = 0.006); additionally, NS showed reduced SAE (RR 0.38; 95%IC 0.27-0.54, p < 0.001) and organ failure (RR 0.30; 95%CI 0.21-0.44, p < 0.001) in comparison with hydroxyethyl starch (HES). High fluid rate fluid infusion showed increased mortality (OR 2.88; 95%CI 1.41-5.88, p = 0.004), increased number of SAE (RR 1.42; 95%CI 1.04-1.93, p = 0.030) and higher incidence of sepsis (RR 2.80; 95%CI 1.51-5.19, p = 0.001) compared to moderate fluid rate infusion.

CONCLUSIONS

In patients with AP, RL should be preferred over NS and HES should not be recommended. Based on low-certainty evidence, moderate-rate fluid infusion should be preferred over high-rate infusion.

Anterior abdominal abscess - a rare manifestation of severe acute pancreatitis: A case report

BACKGROUND

Severe acute pancreatitis (SAP) is a common critical disease of the digestive system. In addition to the clinical manifestations and biochemical changes of acute pancreatitis, SAP is also accompanied by organ failure lasting more than 48 h. SAP is characterized by focal or extensive pancreatic necrosis, hemorrhage and obvious inflammation around the pancreas. The peripancreatic fat space, fascia, mesentery and adjacent organs are often involved. The common local complications include acute peripancreatic fluid collection, acute necrotic collection, pancreatic pseudocyst, walled off necrosis and infected pancreatic necrosis. After reviewing the literature, we found that in very few cases, SAP patients have complications with anterior abdominal wall abscesses.

CASE SUMMARY

We report a 66-year-old Asian male with severe acute pancreatitis who presented with intermittent abdominal pain and an increasing abdominal mass. The abscess spread from the retroperitoneum to the anterior abdominal wall and the right groin. In the described case, drainage tubes were placed in the retroperitoneal and anterior abdominal wall by percutaneous puncture. After a series of symptomatic supportive therapies, the patient was discharged from the hospital with a retroperitoneal drainage tube after the toleration of oral feeding and the improvement of nutritional status.

CONCLUSION

We believe that patients with SAP complicated with anterior abdominal abscess can be treated conservatively to avoid unnecessary exploration or operation.

The Involvement of Renal Capsule Is Associated With Acute Kidney Injury in Patients With Acute Pancreatitis

Background: Acute pancreatitis (AP) is characterized by pancreatic/peripancreatic inflammation. Involvement of renal capsule refers to peripancreatic inflammation extending beyond the Gerota fascia and disappearance of renal rim sign (+) on CT images. However, its association with acute kidney injury (AKI), an important complication of AP, was rarely studied. Aim: This study aimed to assess the relationship between the involvement of renal capsule and AKI in a cohort of patients with AP. Methods: We retrospectively screened all the patients admitted for AP from January 2018 to December 2019. The involvement of renal capsule was judged by experienced radiologists according to the CT imaging. Propensity score matching (PSM) was used to control for biases in group sizes and baseline characteristics. The primary outcome was the development of AKI during the index admission. We also categorized the pararenal inflammation with the renal rim grade (RRG) and compared the incidence of AKI among different grades. Results: Involvement of renal capsule was identified in 71 of 503 patients (14.1%). The incidence of AKI was significantly higher in these patients when compared with the matched controls (43/71, 60.6% vs. 12/71, 16.9%, p < 0.001). Moreover, mortality also differed between groups (12.7% vs. 1.4%, p = 0.017). Multivariable logistic regression showed that renal capsule involvement is an independent risk factor of AKI (odds ratio, 4.355; 95% confidence interval, 1.434, 13.230, p = 0.009). Patients with RRG grade III had a significantly higher incidence of AKI than the other two grades (60.6% for Grade III, 17.1% for Grade II, and 3.8% for Grade I, p < 0.001). Conclusion: Involvement of renal capsule is associated with higher AKI incidence and mortality.

Understanding the Effects of Metabolites on the Gut Microbiome and Severe Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory disease of the pancreas. The severity is classified as mild (MAP), moderately severe (MSAP), or severe (SAP). In patients with SAP, organ dysfunction can occur in the early stage of the disease course, accompanied by secondary infection, with a mortality rate of 36%-50%. In the late stage SAP, infection-related complications caused by pancreatic necrotic tissue and peripancreatic effusion are the main causes of death in patients. Dysbacteriosis of intestinal microflora, barrier dysfunction of intestinal mucosa, and translocation of enteric bacteria are considered to be the main causes of infection of pancreatic necrotic tissue and peripancreatic effusion. During the past few years, increasing attention has been paid to the metabolic activities of intestinal microflora in SAP, which plays an important role in the metabolic activities of the human body. This review is aimed at bringing together the most recent findings and advances regarding the gut microbial community and associated gut microbial community metabolites and illustrating the role of these metabolites in disease progression in severe acute pancreatitis. We hope that this review will provide new ideas and schemes for the treatment of SAP in the clinical settings.

Endogenous tRNA-derived small RNA (tRF3-Thr-AGT) inhibits ZBP1/NLRP3 pathway-mediated cell pyroptosis to attenuate acute pancreatitis (AP)

Endogenous transfer RNA‐derived small RNAs (tsRNAs) are newly identified RNAs that are closely associated with the pathogenesis of multiple diseases, but the involvement of tsRNAs in regulating acute pancreatitis (AP) development has not been reported. In this study, we screened out a novel tsRNA, tRF3‐Thr‐AGT, that was aberrantly downregulated in the acinar cell line AR42J treated with sodium taurocholate (STC) and the pancreatic tissues of STC‐induced AP rat models. In addition, STC treatment suppressed cell viability, induced pyroptotic cell death and cellular inflammation in AP models in vitro and in vivo. Overexpression of tRF3‐Thr‐AGT partially reversed STC‐induced detrimental effects on the AR42J cells. Next, Z‐DNA‐binding protein 1 (ZBP1) was identified as the downstream target of tRF3‐Thr‐AGT. Interestingly, upregulation of tRF3‐Thr‐AGT suppressed NOD‐like receptor protein 3 (NLRP3)‐mediated pyroptotic cell death in STC‐treated AR42J cells via degrading ZBP1. Moreover, the effects of tRF3‐Thr‐AGT overexpression on cell viability and inflammation in AR42J cells were abrogated by upregulating ZBP1 and NLRP3. Collectively, our data indicated that tRF3‐Thr‐AGT suppressed ZBP1 expressions to restrain NLRP3‐mediated pyroptotic cell death and inflammation in AP models. This study, for the first time, identified the role and potential underlying mechanisms by which tRF3‐Thr‐AGT regulated AP pathogenesis.

Hydrophobic ion-pairing assembled liposomal Rhein with efficient loading for acute pancreatitis treatment

AIM

The present study aimed to develop liposomal Rhein by employing a hydrophobic ion-pairing technique (HIP) for improved pancreatitis therapy.

METHODS

F127 modified liposomal Rhein (F127-RPC-Lip) was prepared using a two-step process consisting of complexation first, followed by a film-ultrasonic dispersion step. The drug-phospholipid interaction was characterised by FT-IR and P-XRD. Particle size and morphology were investigated using DLS and TEM, respectively. Biodistribution and therapeutic efficacy of F127-RPC-Lip were evaluated in a rat model of acute pancreatitis.

RESULTS

F127-RPC-Lip achieved efficient drug encapsulation after complexation with lipids through non-covalent interactions and had an average hydrodynamic diameter of about 141 nm. F127-RPC-Lip demonstrated slower drug release (55.90 ± 3.60%, w/w) than Rhein solution (90.27 ± 5.11%) within 24 h. Compared with Rhein, F127-RPC-Lip exhibited prolonged systemic circulation time, superior drug distribution, and attenuated injury in the pancreas of rats post-injection.

CONCLUSIONS

HIP-assembled liposomes are a promising strategy for Rhein in treating pancreatitis.

Percutaneous catheter drainage of pancreatic associated pathologies: A systematic review and meta-analysis

PURPOSE

The main goal of this systematic review was to assess the technical and clinical success, adverse events (AEs), surgery, and overall mortality proportion after percutaneous catheter drainage (PCD) of two pancreatic lesions.

METHODS

An extant search in online databases including Scopus, PubMed (Medline), Embase (Elsevier), Web of Science, Cochrane library, and Google Scholar, was conducted to recognize all studies that used PCD intervention in the management of pancreatic necrosis (PN) and pancreatic pseudocysts (PP). Random effects meta-analysis was performed, and Cochrane's Q test and I²statistic were utilized to determine heterogeneity. In addition, meta-regression was used to explore the influence of categorical variables on heterogeneity.

RESULTS

Thirty-two studies (1398 patients) including PN in 26 (1256 cases, 89.8%) studies and PP in 6 (142 cases, 10.2%) studies were identified. Technical success proportion was 100% (95% confidence interval [CI] 100%-100%, I²: 0.0%), clinical success 63% (95% CI 55%-71%, I²: 92.9%), AEs 26% (95% CI 21%-31%, I²: 78%), surgery after PCD intervention 33% (95% CI 25%-40%, I²: 92.4%), and overall mortality was 13% (95% CI 9%-17%, I²: 82.8%). The most common ADs after PCD intervention were development of fistula (106, 42.6%), hemorrhage (44, 17.7%), sepsis (40, 16.1%).

CONCLUSION

A significant clinical success proportion with low AEs, surgery, and overall mortality proportion after PCD intervention was found, although the results should be interpreted with caution due to the high heterogeneity.

Characteristics of and risk factors for biliary pathogen infection in patients with acute pancreatitis

Background

Infection in patients with acute pancreatitis, especially severe acute pancreatitis patients, is a common and important phenomenon, and the distributions and drug resistance profiles of bacteria causing biliary infection and related risk factors are dynamic. We conducted this study to explore the characteristics of and risk factors for bacterial infection in the biliary tract to understand antimicrobial susceptibility, promote the rational use of antibiotics, control multidrug-resistant bacterial infections and provide guidance for the treatment of acute pancreatitis caused by drug-resistant bacteria.

Methods

The distribution of 132 strains of biliary pathogenic bacteria in patients with acute pancreatitis from January 2016 to December 2020 were analyzed. We assessed drug resistance in the dominant Gram-negative bacteria and studied the drug resistance profiles of multidrug-resistant bacteria by classifying Enterobacteriaceae and nonfermentative bacteria. We then retrospectively analyzed the clinical data and risk factors associated with 72 strains of Gram-negative bacilli, which were divided into multidrug-resistant bacteria (50 cases) and non-multidrug-resistant bacteria (22 cases).

Results

The main bacteria were Escherichia coli, Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa. Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli had a 66.67% detection rate. Acinetobacter baumannii had more than 50.00% drug resistance to carbapenems, ESBL-producing Klebsiella pneumoniae had 100.00% drug resistance, and Pseudomonas aeruginosa had 66.67% resistance to carbapenems. Multivariate logistic regression analysis suggested that the administration of third- or fourth-generation cephalosporins was an independent risk factor for Gram-negative multidrug-resistant biliary bacterial infection in acute pancreatitis patients.

Conclusion

Drug resistance among biliary pathogens in acute pancreatitis patients remains high; therefore, rational antimicrobial drug use and control measures should be carried out considering associated risk factors to improve diagnosis and treatment quality in acute pancreatitis patients.

Glucose levels show independent and dose-dependent association with worsening acute pancreatitis outcomes: Post-hoc analysis of a prospective, international cohort of 2250 acute pancreatitis cases

BACKGROUND

Metabolic risk factors, such as obesity, hypertension, and hyperlipidemia are independent risk factors for the development of various complications in acute pancreatitis (AP). Hypertriglyceridemia dose-dependently elicits pancreatotoxicity and worsens the outcomes of AP. The role of hyperglycemia, as a toxic metabolic factor in the clinical course of AP, has not been examined yet.

METHODS

We analyzed a prospective, international cohort of 2250 AP patients, examining associations between (1) glycosylated hemoglobin (HbA1c), (2) on-admission glucose, (3) peak in-hospital glucose and clinically important outcomes (mortality, severity, complications, length of hospitalization (LOH), maximal C-reactive protein (CRP)). We conducted a binary logistic regression accounting for age, gender, etiology, diabetes, and our examined variables. Receiver Operating Characteristic Curve (ROC) was applied to detect the diagnostic accuracy of the three variables.

RESULTS

Both on-admission and peak serum glucose are independently associated with AP severity and mortality, accounting for age, gender, known diabetes and AP etiology. They show a dose-dependent association with severity (p < 0.001 in both), mortality (p < 0.001), LOH (p < 0.001), maximal CRP (p < 0.001), systemic (p < 0.001) and local complications (p < 0.001). Patients with peak glucose >7 mmol/l had a 15 times higher odds for severe AP and a five times higher odds for mortality. We found a trend of increasing HbA1c with increasing LOH (p < 0.001), severity and local complications.

CONCLUSIONS

On-admission and peak in-hospital glucose are independently and dose-dependently associated with increasing AP severity and mortality. In-hospital laboratory control of glucose and adequate treatment of hyperglycemia are crucial in the management of AP.

[Interventional endoscopic treatment in acute pancreatitis]

BACKGROUND

Acute pancreatitis (AP) represents a frequent gastrointestinal diseases. Approximately 80% of patients have a mild course of the disease and conservative treatment is sufficient; however, 20% of patients develop a severe AP with local and systemic complications. This article focuses on the currently recommended endoscopic management of severe AP.

OBJECTIVE

Classification of AP by the revised Atlanta classification and the occurrence of local or systemic complications. Summary of current evidence with respect to endoscopic management.

MATERIAL AND METHODS

Inspection of the current literature from specialist journals and current guidelines.

RESULTS

The AP is classified as mild, moderate or severe based on systemic (hypotension, renal failure, lung failure) and/or local complications, such as acute peripancreatic fluid collections (APFC), peripancreatic pseudocysts (PPC), acute necrotic collections (ANC) and walled-off necrosis (WON). In recent years the staged endoscopic treatment of infected ANC, WON and PPC has become established. The initial step is the endoscopic ultrasound-guided puncture and drainage with plastic or lumen-apposing metal stents. For solid components or insufficient drainage, a transgastric endoscopic necrosectomy is recommended. The treatment of severe AP requires an interdisciplinary management in specialized centers and regular re-evaluation of the therapeutic efficacy.

CONCLUSION

Interventional endoscopy has become established as the standard for treatment of severe AP.

Role of Interleukin-17 in Acute Pancreatitis

Acute pancreatitis (AP) is a leading cause of death and is commonly accompanied by systemic manifestations that are generally associated with a poor prognosis. Many cytokines contribute to pancreatic tissue damage and cause systemic injury. Interleukin-17 (IL-17) is a cytokine that may play a vital role in AP. Specifically, IL-17 has important effects on the immune response and causes interactions between different inflammatory mediators in the AP-related microenvironment. In this literature review, we will discuss the existing academic understanding of IL-17 and the impacts of IL-17 in different cells (especially in acinar cells and immune system cells) in AP pathogenesis. The clinical significance and potential mechanisms of IL-17 on AP deterioration are emphasized. The evidence suggests that inhibiting the IL-17 cytokine family could alleviate the pathogenic process of AP, and we highlight therapeutic strategies that directly or indirectly target IL-17 cytokines in acute pancreatitis.

Diabetic Bone Marrow Cell Injection Accelerated Acute Pancreatitis Progression

Acute pancreatitis (AP) is one of the leading causes of hospital admission, 20% of which could progress to the severe type with extensive acinar cell necrosis. Clinical studies have reported that diabetes is an independent risk factor of the incidence of AP and is associated with higher severity than nondiabetic subjects. However, how diabetes participates in AP progression is not well defined. To investigate this question, wild-type (wt) and diabetic db/db mice at the age of 16 weeks were used in the study. AP was induced in wt recipients by 10 injections of 50 μg/kg caerulein with a 1 h interval. One hour after the last caerulein injection, bone marrow cells (BMC) isolated from wt and db/db mice were injected intraperitoneally into the recipients (1 × 10⁷cells/recipient). The recipients with no BMC injection served as controls. Thirteen hours after BMC injection, serum lipase activity was 1.8- and 1.3-folds higher in mice that received db/db BMC, compared with those with no injection and wt BMC injection, respectively (p ≤ 0.02 for both). By H&E staining, the overall severity score was 14.7 for no cell injection and 16.6 for wt BMC injection and increased to 22.6 for db/db BMC injection (p ≤ 0.002 for both). In particular, mice with db/db BMC injection developed more acinar cell necrosis and vacuolization than the other groups (p ≤ 0.03 for both). When sections were stained with an antibody against myeloperoxidase (MPO), the density of MPO+ cells in pancreatitis was 1.9- and 1.6-folds higher than wt BMC and no BMC injection groups, separately (p ≤ 0.02 for both). Quantified by ELISA, db/db BMC produced more IL-6, GM-CSF, and IL-10 compared with wt BMC (p ≤ 0.04 for all). In conclusion, BMC of db/db mice produced more inflammatory cytokines. In response to acinar cell injury, diabetic BMC aggravated the inflammation cascade and acinar cell injury, leading to the progression of acute pancreatitis.

Nutrition in acute pancreatitis

PURPOSE OF REVIEW

This review aims to discuss recent developments in different topics regarding nutrition and acute pancreatitis (AP), including oral refeeding, nutritional therapy, and implications of gut microbiota.

RECENT FINDINGS

Obesity increases the risk for severe AP and mortality. Considering the worldwide obesity rates, this finding could have major implications in the global outcomes of patients admitted with AP. Recent research confirms that early oral feeding leads to shorter length of stay, fewer complications, and lower costs. In case of intolerance to oral feeding or severe disease, nutritional therapy should be offered within 24-72 h, whereas enteral nutrition (EN) has been shown superior to parenteral nutrition. EN can be administered through gastric or jejunal feeding, depending on digestive tolerance and the presence of ileus. Nevertheless, modalities of EN in patients undergoing endoscopic drainage of pancreatitis-related collections are still undetermined. Weight-loss after discharge occurs frequently and could reflect post-AP pancreatic exocrine failure. Finally, novel research regarding gut microbiota could open new therapeutic opportunities to prevent bacterial translocation and pancreatic necrosis' infection.

SUMMARY

Despite available evidence many questions regarding nutritional management in patients with AP remain open. Modulation of gut microbiota could play an important role in further therapeutic management.

Acute infectious pancreatitis due to Salmonella typhi : Case report and literature review

Salmonella typhi remains an endemic disease in Madagascar. Acute pancreatitis remains a rare complication of S. typhi colitis. We presented the case of a 27‐year‐old male, admitted to febrile diarrhea, vomiting, and severe abdominal pain. Blood work‐up revealed elevated plasma lipase level. Abdominal CT scan showed acute pancreatitis without necrosis. Blood and stool culture positivity for S. typhi. Patient was diagnosed as acute pancreatitis caused by S. typhi. The outcome was favorable under symptomatic medical treatment (rehydration and analgesic) combined with adapted antibiotic therapy. Acute pancreatitis is a possible complication of Salmonella infections. The presence of severe abdominal pain and febrile diarrhea should draw clinicians' attention to possible Salmonella acute pancreatitis.

The Systemic Immune-Inflammation Index May Be a Novel and Strong Marker for the Accurate Early Prediction of Acute Kidney Injury in Severe Acute Pancreatitis Patients

OBJECTIVE

This research was performed to investigate the correlation between acute kidney injury (AKI) and systemic immune-inflammation index (SII) in severe acute pancreatitis (SAP) patients.

METHODS

The study included 218 SAP patients from Chongqing Jiangjin Center Hospital during January 2016 to October 2020. The SII was defined as platelet × neutrophil/lymphocyte ratio. After univariate analysis, logistic regression analysis was used for analyzing independent risk factors of AKI in SAP patients. Receiver operating characteristic (ROC) curve was used for analyzing the prognostic value of the SII.

RESULTS

AKI occurred in 74 cases and its incidence rate was 33.9%. The median SII value of AKI patients was higher than that of patients without AKI. After multivariate analysis, SII, age, triglyceride (TG), neutrophil ratio (NEU-R), C-reactive protein (CRP), aspartate aminotransferase (AST), and serum albumin (ALB) were independent predictors of AKI. Serum ALB was an independent protective factor. The optimum threshold truncation value of SII was 2880.1*10^9/L. Compared with other inflammatory factors, SII had a better prediction efficiency.

CONCLUSION

The SII, TG, NEU-R, CRP, and ALB were significant independent predictors of AKI in SAP patients. Serum TG, NEU-R, CRP, and SII were risk factors. Serum ALB was a protective factor. The SII may be a novel, simple, and strong marker for the accurate early prediction of AKI in SAP patients.

Low and high pancreatic amylase is associated with pancreatic cancer and chronic pancreatitis

Incidences of pancreatic cancer and acute and chronic pancreatitis are rising globally, and often no curative treatment is available at the time of diagnosis. We tested the hypothesis that low and high plasma concentrations of pancreatic amylase are associated with increased risk of pancreatic cancer, acute pancreatitis, and chronic pancreatitis in the general population. We included 101,765 individuals (55% women) aged 20-100 years from the Copenhagen General Population Study with baseline measurements of plasma pancreatic amylase. After recruitment in 2004-2015 during a median 9 years of follow-up (range 0-15), we collected information about diagnoses of pancreatic cancer, acute pancreatitis, and chronic pancreatitis from the national Danish Patient Registry, the national Danish Cancer Registry, and the national Danish Causes of Death Registry. The median age was 58 years (interquartile range: 48-67) and the median plasma pancreatic amylase 32 U/L (26-40). During follow-up, 442 individuals were diagnosed with pancreatic cancer, 282 with chronic pancreatitis, and 401 with acute pancreatitis. Compared to individuals with pancreatic amylase levels in the 41st-60th percentiles, those with extreme low (1st-2.5th percentiles) and extreme high (97.5th-100th percentiles) pancreatic amylase had hazard ratios of 2.4 (95% confidence interval; 1.6-3.6) and 2.2 (1.4-3.7) for pancreatic cancer, of 1.8 (1.1-3.3) and 3.2 (1.8-5.6) for chronic pancreatitis, and of 1.1 (0.6-1.8) and 1.5 (0.8-2.7) for acute pancreatitis, respectively. In apparently healthy individuals from the general population, extreme low and extreme high plasma pancreatic amylase were associated with 2-threefold higher risk of both pancreatic cancer and chronic pancreatitis.

Salidroside alleviates taurolithocholic acid 3-sulfate-induced AR42J cell injury

OBJECTIVES

To investigate the protective effects of Salidroside (Sal) on AP cell model induced by taurolithocholic acid 3-sulfate (TLC-S) as well as its underlying mechanism.

METHODS

AR42J cells were divided into normal group (N group), AP cell model group (Mod group), Sal treated alone group (S+N group) and Sal treated AP cell model group (S+Mod group). The cell viability was examined by CCK-8 assay. Secretion of lipase and trypsin by AR42J cells, quantified using commercial assay kits, was used as the markers of TLC-S-induced pancreatitis. The levels of TNF-α, IL-1β, IL-8, IL-6 and IL-10 in the cell supernatant were measured by ELISA. The effect of Sal on molecules in the NF-κB signaling pathway and autophagy was investigated by qRT-PCR and western blot.

RESULTS

The decreased cell viability in Mod group was increased by Sal (P < 0.01). The upheaved activities of lipase and trypsin in AP cell model were declined by Sal (P < 0.01). The levels of TNF-α, IL-1β, IL-8 and IL-6 in the cell supernatant, Beclin-1 and LC3-Ⅱ mRNA and protein, p-p65/p65 protein, which were increased in AP cell model, were decreased by Sal; and IL-10 in the cell supernatant, LAMP2 mRNA and protein, p-IκBα/IκBα protein which was declined in AP cell model, was increased by Sal (P < 0.05 or 0.01). There were no significant differences in all indexes between the N and S+N groups (P > 0.05).

CONCLUSIONS

Sal alleviated AR42J cells injury induced by TLC-S, inhibited the inflammatory responses and modulated the autophagy, mainly through inhibiting the NF-κB signaling pathway.

The global, regional, and national burden of acute pancreatitis in 204 countries and territories, 1990-2019

BACKGROUND

Acute pancreatitis is a common and potentially lethal gastrointestinal disease, but literatures for the disease burden are scarce for many countries. Understanding the current burden of acute pancreatitis and the different trends across various countries is essential for formulating effective preventive intervenes. We aimed to report the incidence, mortality, and disability-adjusted life-years (DALYs) caused by acute pancreatitis in 204 countries and territories between 1990 and 2019.

METHODS

Estimates from the Global Burden of Disease Study 2019 (GBD 2019) were used to analyze the epidemiology of acute pancreatitis at the global, regional, and national levels. We also reported the correlation between development status and acute pancreatitis' age-standardized DALY rates, and calculated DALYs attributable to alcohol etiology that had evidence of causation with acute pancreatitis. All of the estimates were shown as counts and age-standardized rates per 100,000 person-years.

RESULTS

There were 2,814,972.3 (95% UI 2,414,361.3-3,293,591.8) incident cases of acute pancreatitis occurred in 2019 globally; 1,273,955.2 (1,098,304.6-1,478,594.1) in women and 1,541,017.1 (1,307,264.4-1,814,454.3) in men. The global age-standardized incidence rate declined from 37.9/100,000 to 34.8/100,000 during 1990-2019, an annual decrease of 8.4% (5.9-10.4%). In 2019, there were 115,053.2 (104,304.4-128,173.4) deaths and 3,641,105.7 (3,282,952.5-4,026,948.1) DALYs due to acute pancreatitis. The global age-standardized mortality rate decreased by 17.2% (6.6-27.1%) annually from 1.7/100,000 in 1990 to 1.4/100,000 in 2019; over the same period, the age-standardized DALY rate declined by 17.6% (7.8-27.0%) annually. There were substantial differences in the incidence, mortality and DALYs across regions. Alcohol etiology attributed to a sizable fraction of acute pancreatitis-related deaths, especially in the high and high-middle SDI regions.

CONCLUSION

Substantial variation existed in the burden of acute pancreatitis worldwide, and the overall burden remains high with aging population. Geographically targeted considerations are needed to tailor future intervenes to relieve the burden of acute pancreatitis in specific countries, especially for Eastern Europe.

Escin Sodium Improves the Prognosis of Acute Pancreatitis via Promoting Cell Apoptosis by Suppression of the ERK/STAT3 Signaling Pathway

Acute pancreatitis (AP), an inflammatory disorder of the pancreas, can cause systemic inflammatory responses. Escin Sodium (ES), a natural mixture of triterpene saponins extracted from the dry ripe fruit of Fructus Aesculi or horse chestnut crude, has been demonstrated to have antiedematous, anti-inflammatory, and antiexudative effects. We here aim to investigate the effects of ES pretreatment on AP in vivo and in vitro and explore its potential molecular mechanism. In the present study, we demonstrated that ES pretreatment could apparently decrease amylase and lipase, downregulate inflammatory cytokines, and attenuate pancreatic damage. Additionally, the increased expression of apoptotic-related proteins and the results of flow cytometry demonstrated the effects of ES on promoting apoptosis in acinar cells. Moreover, ES could enhance mitochondrial membrane potential (MMP, ΔΨm) and reactive oxygen species (ROS) level and reduce intracellular calcium concentration, which are closely related to mitochondrial-mediated death. The effect of ES pretreatment on acinar cell apoptosis was furtherly confirmed by the regulatory pathway of the ERK/STAT3 axis. These results suggest that ES attenuates the severity of AP by enhancing cell apoptosis via suppressing the ERK/STAT3 signaling pathway. These findings provide evidence for ES which is treated as a novel and potent therapeutic for the treatment of AP.

Fluid resuscitation via colon alleviates systemic inflammation in rats with early-stage severe acute pancreatitis

Fluid resuscitation via colon (FRVC) is a complementary therapeutic procedure for early-stage cases of severe acute pancreatitis (SAP). The expression of intestinal dendritic cell-specific intercellular adhesion molecule 3-grabbing nonintegrin (DC-SIGN) regulates systemic inflammation. This study aimed to investigate the effect of FRVC on the expression of DC-SIGN in the colon tissue of SAP rats and its effect on the early response of systemic inflammatory and multiple organ injury. SAP was induced in rats via retrograde injection of sodium taurocholate into the biliopancreatic duct. DC-SIGN expression of appeared in the proximal and distal colon. Histological characteristics and inflammatory cytokines were examined to compare the effect of FRVC and intravenous fluid resuscitation (IVFR). The results showed that DC-SIGN expression in the proximal colon increased in a time-dependent manner in the early-stage of SAP rats. FRVC inhibited DC-SIGN expression in the proximal colon. Both FRVC and IVFR alleviated histological injuries of the pancreas and colon. However, FRVC had an advantage over IVFR in alleviating lung injury and reducing serum TNF-α, IL-6 and LPS. These results suggest that FRVC treatment might help suppress systemic inflammation and prevent subsequent organ failure in early-stage SAP rats likely through inhibiting DC-SIGN expression in the proximal colon.

Decreased circulating retinol binding protein is an independent risk factor for local complications of acute pancreatitis

BACKGROUND

Acute pancreatitis is a common acute abdomen in China. There is a decrease of serum retinol-binding protein (RBP) in some patients, but its clinical significance is not clear.

AIM

To explore the relationship between serum RBP and the severity and complications of AP.

METHODS

The clinical data of AP patients admitted to Jinling Hospital in 2018 within 7 days of onset were analyzed retrospectively. The enrolled patients were divided into either a normal RBP (NRBP) group or a low RBP (LRBP) group according to the serum RBP level. The baseline characteristics, severity, and prognosis of disease were compared between the two groups. Logistic regression analysis was used to explore the independent risk factors for local complications. Receiver operating characteristic (ROC) curve was drawn to evaluate the performance of serum RBP in predicting complications.

RESULTS

A total of 176 patients were enrolled, including 41 in the NRBP group and 135 in the LRBP group. The severity of AP in the LRBP group was significantly more severe than that of the NRBP group (MAP: 15.6% vs 39.0%, MSAP: 53.3% vs 29.3%, SAP: 31.1% vs 31.7%; P < 0.05). The incidence of acute necrotic collection was 70.4% in the LRBP group, significantly higher than that (52.1%) of the NRBP group (P < 0.05). The serum level of RBP in patients with local complications was significantly lower than that in patients without (24.00 (15.00, 27.50) mg/L vs 12.00 (9.00, 22.00) mg/L, P < 0.05). The AUC of serum RBP for predicting local complications was 0.708 (95%CI: 0.615-0.801) and the cut-off value was 15.5 mg/L with a sensitivity 60.4% and specificity 75.7%. The decrease of serum RBP was an independent risk factor for local complications (OR = 5.306, P = 0.003, 95%CI: 1.771-15.896).

CONCLUSION

The level of serum RBP in the acute phase could predict the occurrence of local complications of AP, but has no significant correlation with systemic inflammatory response and remote organ failure.

[Recurrent pancreatitis in a 43-year-old patient with high-output stoma]

Hypercalcemia is a rare cause of pancreatitis. A thorough differential diagnosis is essential to distinguish causes for hypercalcemia. We here report a patient with a high-output stoma that was completely immobilized after surgery. This led to a hypercalcemia that repetitively resulted in acute pancreatitis. This etiology of a pancreatitis has not been described yet.

Massive post-traumatic neglicted diaphragmatic hernia revealed by necrotizing pancreatitis, A case report according scare guidelines

•

Atypical chest presentation of acute pancreatitis consisting of a post-traumatic of less than 10 cases reported in the literature.

•

We describe a very exceptional complication of diaphragmatic rupture.

•

We propose to take into consideration diaphragmatic involvement in any patient suffering from abdominal trauma.

Blood glucose-related indicators are associated with in-hospital mortality in critically ill patients with acute pancreatitis

Acute pancreatitis (AP) results in potentially harmful blood glucose fluctuations, affecting patient prognosis. This study aimed to explore the relationship between blood glucose-related indicators and in-hospital mortality in critically ill patients with AP. We extracted data on AP patients from the Multiparameter Intelligent Monitoring in Intensive Care III database. Initial glucose (Glucose_initial), maximum glucose (Glucose_max), minimum glucose (Glucose_min), mean glucose (Glucose_mean), and glucose variability (glucose standard deviation [Glucose_SD] and glucose coefficient of variation [Glucose_CV]) were selected as blood glucose-related indicators. Logistic regression models and the Lowess smoothing curves were used to display the association between significant blood glucose-related indicators and in-hospital mortality. Survivors and non-survivors showed significant differences in Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV (P < 0.05). Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV were risk factors for in-hospital mortality in AP patients (OR > 1; P < 0.05). According to the Lowess smoothing curve, the overall trends of blood glucose-related indicators showed a non-linear correlation with in-hospital mortality. Glucose_max, Glucose_mean, Glucose_SD, and Glucose_CV were associated with in-hospital mortality in critically ill patients with AP.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to develope medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy appointed a Task Force to develop medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies. (Gut Liver 2021;15:-693)

Current status of treatments of pancreatic and peripancreatic collections of acute pancreatitis

Pancreatic and peripancreatic collections are the main local complications of acute pancreatitis with a high incidence. In the early phase, most acute pancreatic and peripancreatic collections can resolve spontaneously with supportive treatment. However, in some cases, they will develop into pancreatic pseudocyst (PPC) or walled-off necrosis (WON). When causing symptoms or coinfection, both PPC and WON may require invasive intervention. Compared to PPC, which can be effectively treated by endoscopic ultrasound-guided transmural drainage with plastic stents, the treatment of WON is more complicated and challenging, particularly in the presence of infected necrosis. In the past few decades, with the development of minimally invasive interventional technology especially the progression of endoscopic techniques, the standard treatments of those severe complications have undergone tremendous changes. Currently, based on the robust evidence from randomized controlled trials, the step-up minimally invasive approaches have become the standard treatments for WON. However, the pancreatic fistulae during the surgical step-up treatment and the stent-related complications during the endoscopic step-up treatment should not be neglected. In this review article, we will mainly discuss the indications of PPC and WON, the timing for intervention, and minimally invasive treatment, especially endoscopic treatment. We also introduced our preliminary experience in endoscopic gastric fenestration, which may be a promising innovative method for the treatment of WON.

Order Set Use and Education Association With Pediatric Acute Pancreatitis Outcomes

BACKGROUND

The management of acute pancreatitis (AP) in children was historically derived from adult practice recommendations. Pediatric-specific recommendations for treatment of AP were recently developed by North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, but their impact on clinical outcomes has yet to be evaluated. We developed an AP order set on the basis of these recommendations to assess impact on clinical outcomes.

METHODS

Patients admitted to a single center with 3 children's hospitals in 2017 and 2018 for isolated AP were included in a retrospective review. Patient demographic data, order set use, treatment variables (eg, fluid type, rate, type and timing of diet initiation, and narcotic use), and outcome variables (eg, length of stay [LOS], PICU admission, and 30-day readmission) were collected. Mixed-effects modeling was used to estimate the impact of order set use on clinical outcomes.

RESULTS

There were 159 pancreatitis encounters and 137 unique patients who met inclusion criteria. In 2018, when using the log transform of LOS in a linear mixed-effects model for clustering by hospital, there was a 10% decrease in mean LOS, but this failed to reach statistical significance (P = .30). Among the 107 encounters who received at least 1 dose of narcotic, there were significantly fewer doses prescribed after implementation of the order set: mean (SD) of5.22 (2.86) vs 3.59 (2.47) (P < .001). Thirty-day readmission (P = .25) and PICU admission rates (P = .31) were not different between years.

CONCLUSIONS

The implementation of a pancreatitis order set is associated with a significant decrease in narcotic use in pediatric patients with AP without increasing readmission rates or PICU admissions.

Astaxanthin Inhibits Interleukin-6 Expression in Cerulein/Resistin-Stimulated Pancreatic Acinar Cells

Acute pancreatitis is a common clinical condition with increasing the proinflammatory mediators, including interleukin-6 (IL-6). Obesity is a negative prognostic factor in acute pancreatitis. Obese patients with acute pancreatitis have a higher systemic inflammatory response rate. Levels of serum resistin, an adipocytokine secreted by fat tissues, increase with obesity. Cerulein, a cholecystokinin analog, induces calcium (Ca²⁺) overload, oxidative stress, and IL-6 expression in pancreatic acinar cells, which are hallmarks of acute pancreatitis. A recent study showed that resistin aggravates the expression of inflammatory cytokines in cerulein-stimulated pancreatic acinar cells. We aimed to investigate whether resistin amplifies cerulein-induced IL-6 expression and whether astaxanthin (ASX), an antioxidant carotenoid with anti-inflammatory properties, inhibits ceruelin/resistin-induced IL-6 expression in pancreatic acinar AR42J cells. We found that resistin enhanced intracellular Ca²⁺ levels, NADPH oxidase activity, intracellular reactive oxygen species (ROS) production, NF-κB activity, and IL-6 expression in cerulein-stimulated AR42J cells, which were inhibited by ASX in a dose-dependent manner. The calcium chelator BAPTA-AM inhibited cerulein/resistin-induced NADPH oxidase activation and ROS production. Antioxidant N-acetyl cysteine (NAC) and ML171, a specific NADPH oxidase 1 inhibitor, suppressed cerulein/resistin-induced ROS production, NF-κB activation, and IL-6 expression. In conclusion, ASX inhibits IL-6 expression, by reducing Ca²⁺ overload, NADPH oxidase-mediated ROS production, and NF-κB activity in cerulein/resistin-stimulated pancreatic acinar cells. Consumption of ASX-rich foods could be beneficial for preventing or delaying the incidence of obesity-associated acute pancreatitis.

Predictors of Mortality and Drug Resistance Among Carbapenem-Resistant Enterobacteriaceae-Infected Pancreatic Necrosis Patients

Introduction

Carbapenem-resistant Enterobacteriaceae (CRE) has emerged as a global threat to hospitalization patients. Infected pancreatic necrosis (IPN) leads to high risks of CRE infections with increasing mortality. Our study aims to determine the predictors related to 90-day overall mortality of CRE IPN.

Methods

We retrospectively reviewed the drug resistance rates and clinical characteristics of CRE IPN patients from January 1, 2016, to January 1, 2021. Independent predictors of mortality were identified via univariate and multivariate analyses.

Results

During the 5-year period, 75 IPN patients suffered from 135 episodes of CRE infections with mortality up to 50.7%. CRE strains were highly resistant (> 50%) to nine of ten common antibiotics, except tigecycline (18%). The most common pathogen was carbapenem-resistant Klebsiella pneumoniae (84 of 135). Lung was the main site of extrapancreatic infections, followed by bloodstream and biliary tract. The independent predictors of mortality were Sequential Organ Failure Assessment (SOFA) score > 2 (hazard ratio 3.746, 95% confidence interval 1.209–11.609, P = 0.022) and procalcitonin > 6 ng/l (hazard ratio 2.428, 95% confidence interval 1.204–4.895, P = 0.013).

Conclusion

CRE is widespread as a global challenge with a high mortality rate among IPN patients due to limited therapeutic options. Carbapenem-resistant K. pneumoniae is the leading category of CRE which requires more attention in clinical practice. High SOFA score and procalcitonin level represent two independent predictors of mortality in CRE IPN patients. Greater efforts are needed toward timely therapeutic intervention for CRE IPN.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00489-5.

Leukocyte cell population data from the blood cell analyzer as a predictive marker for severity of acute pancreatitis

BACKGROUND

The prediction for severe acute pancreatitis (SAP) is the key to give timely targeted treatment. Leukocyte cell population data (CPD) have been widely applied in early prediction and diagnosis of many diseases, but their predictive ability for SAP remains unexplored. We aim to testify whether CPD could be an indicator of AP severity in the early stage of the disease.

METHODS

The prospective observational study was conducted in the emergency department ward of a territory hospital in Shanghai. The enrolled AP patients should meet 2012 Atlanta guideline.

RESULTS

Totally, 103 AP patients and 62 healthy controls were enrolled and patients were classified into mild AP (n = 30), moderate SAP (n = 42), and SAP (n = 31). Forty-two CPD parameters were examined in first 3 days of admission. Four CPD parameters were highest in SAP on admission and were constantly different among 3 groups during first 3 days of hospital stay. Eighteen CPD parameters were found correlated with the occurrence of SAP. Stepwise multivariate logistic regression analysis identified a scoring system of 4 parameters (SD_LALS_NE, MN_LALS_LY, SD_LMALS_MO, and SD_AL2_MO) with a sensitivity of 96.8%, specificity of 65.3%, and AUC of 0.87 for diagnostic accuracy on early identification of SAP. AUC of this scoring system was comparable with MCTSI, SOFA, APACHE II, MMS, BISAP, or biomarkers as CRP, PCT, and WBC in prediction of SAP and ICU transfer or death.

CONCLUSIONS

Several leukocyte CPD parameters have been identified different among MAP, MSAP, and SAP. They might be ultimately incorporated into a predictive system marker for severity of AP.

A narrative review of a type of pancreatitis worthy of attention: acute pancreatitis associated with pancreatic tumors-current problems and future thinking

OBJECTIVE

Our purpose is to explain the onset, diagnosis, and treatment of pancreatic tumor-associated pancreatitis (PTP), and inform clinicians about the management of PTP. It is hoped that clinicians can gain some experience and inspiration from this review, so that patients can obtain better treatment results.

BACKGROUND

Acute pancreatitis (AP) is an inflammatory disease, and pancreatic tumors are one of the causes of pancreatitis. When pancreatic tumors and pancreatitis exist at the same time, and there is a "connection" between them, this type of pancreatitis is referred to as PTP. The manifestations of PTP can be as follows: (I) AP is the first symptom of pancreatic tumors; (II) pancreatitis is found in patients after pancreatic tumor diagnosis or during pancreatic tumor surgery. Because pancreatic tumors are not one of the most common causes of pancreatitis, PTP has not attracted the attention of researchers and clinicians, and there is no consistent and clear understanding of the diagnosis and treatment of PTP.

METHODS

From the online database PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Web of Science (https://webofknowledge.com/), we use specific retrieval strategies to retrieve relevant articles, and we review and discuss them.

CONCLUSIONS

What we need to realize is that PTP is different from ordinary AP. It has its own characteristics in terms of diagnosis and treatment, which requires the attention of clinicians. More importantly, future research should design the best diagnosis and treatment algorithms for PTP.

The impact of fluid resuscitation via colon on patients with severe acute pancreatitis

Severe acute pancreatitis (SAP) is a life-threatening disease. Fluid Resuscitation Via Colon (FRVC) may be a complementary therapy for early controlled fluid resuscitation. But its clinical application has not been reported. This study aims to explore the impact of FRVC on SAP. All SAP patients with the first onset within 72 h admitted to the hospital were included from January 2014 to December 2018 through electronic databases of Ruijin hospital and were divided into FRVC group (n = 103) and non-FRVC group (n = 78). The clinical differences before and after the therapy between the two groups were analyzed. Of the 181 patients included in the analysis, the FRVC group received more fluid volume and reached the endpoint of blood volume expansion ahead of the non-FRVC group. After the early fluid resuscitation, the inflammation indicators in the FRVC group were lower. The rate of mechanical ventilation and the incidence of hypernatremia also decreased significantly. Using pure water for FRVC was more helpful to reduce hypernatremia. However, Kaplan–Meier 90-day survival between the two groups showed no difference. These results suggest that the combination of FRVC might benefit SAP patients in the early stage of fluid resuscitation, but there is no difference between the prognosis of SAP patients and that of conventional fluid resuscitation. Further prospective study is needed to evaluate the effect of FRVC on SAP patients.

Necroptosis protects against exacerbation of acute pancreatitis

The sensing of various extrinsic stimuli triggers the receptor-interacting protein kinase-3 (RIPK3)-mediated signaling pathway, which leads to mixed-lineage kinase-like (MLKL) phosphorylation followed by necroptosis. Although necroptosis is a form of cell death and is involved in inflammatory conditions, the roles of necroptosis in acute pancreatitis (AP) remain unclear. In the current study, we administered caerulein to Ripk3- or Mlkl-deficient mice (Ripk3^−/− or Mlkl^−/− mice, respectively) and assessed the roles of necroptosis in AP. We found that Ripk3^−/− mice had significantly more severe pancreatic edema and inflammation associated with macrophage and neutrophil infiltration than control mice. Consistently, Mlkl^−/− mice were more susceptible to caerulein-induced AP, which occurred in a time- and dose-dependent manner, than control mice. Mlkl^−/− mice exhibit weight loss, edematous pancreatitis, necrotizing pancreatitis, and acinar cell dedifferentiation in response to tissue damage. Genetic deletion of Mlkl resulted in downregulation of the antiapoptotic genes Bclxl and Cflar in association with increases in the numbers of apoptotic cells, as detected by TUNEL assay. These findings suggest that RIPK3 and MLKL-mediated necroptosis exerts protective effects in AP and caution against the use of necroptosis inhibitors for AP treatment.

Advances in research of early use of prophylactic antibiotics in severe acute pancreatitis

Severe acute pancreatitis (SAP) is a common critical digestive system disease with high mortality, which can lead to multiple organ failure. SAP is often accompanied by massive necrosis of the pancreas, which is prone to secondary infection. Infected pancreatic necrosis is associated with an increased mortality of SAP. Whether early prophylactic use of antibiotics in the treatment of SAP can reduce the incidence of secondary infection is still controversial. This paper reviews the research progress of prophylactic use of antibiotics in the treatment of secondary infection of SAP in recent years.

Increased risk of acute pancreatitis in persons with spinal cord injury: a population-based, propensity score-matched longitudinal follow-up study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the risk of acute pancreatitis (AP) in persons with spinal cord injury (SCI) based on a nationally representative sample.

SETTING

A retrospective cohort study using Taiwan's National Health Insurance Research Database.

METHODS

Drawing on Taiwan's Longitudinal Health Insurance Database 2005, the researchers created an SCI group consisting of 2280 persons with SCI aged 20-74 years. Propensity-score matching was then used to generate a non-SCI group of 9120 participants with similar baseline characteristics to the SCI group. These two groups' respective cumulative incidence of AP was compared, and the effect of SCI on AP risk was then assessed using stratified Cox proportional-hazards regression.

RESULTS

For the SCI and non-SCI groups, the respective incidence rates of AP were 1.34 per 1000 person-years (95% confidence interval [CI], 0.83-2.05) and 0.79 per 1000 person-years (95% CI, 0.61-1.01). Compared with the non-SCI group, the hazard ratio of AP for the SCI group was 1.96 (95% CI 1.19-3.25, p = 0.0088); and the SCI group's cumulative incidence of AP was significantly higher than that of the non-SCI group (p = 0.0227).

CONCLUSION

This population-based longitudinal follow-up study indicates that there is an increased long-term risk of AP in persons with SCI.

Pancreatitis after endoscopic retrograde cholangiopancreatography: A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a feared and potentially fatal complication that can be as high as up to 30% in high-risk patients. Pre-examination measures, during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events. Several studies have debated on the subject, however, numerous topics remain controversial, such as the effectiveness of prophylactic medications and the amylase dosage time. This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.

Variations in Gut Microbiome are Associated with Prognosis of Hypertriglyceridemia-Associated Acute Pancreatitis

Hypertriglyceridemia-associated acute pancreatitis (HTGAP) is linked with increased severity and morbidity. Intestinal flora plays an important role in the progression of acute pancreatitis (AP). However, pathogenetic association between gut microbiota and HTGAP remains unknown. In this study, we enrolled 30 HTGAP patients and 30 patients with AP that is evoked by other causes. The V3–V4 regions of 16S rRNA sequences of the gut microbiota were analyzed. Clinical characteristics, microbial diversity, taxonomic profile, microbiome composition, microbiological phenotype, and functional pathways were compared between the two groups. Our results showed that the HTGAP group had a higher proportion of severe AP (46.7% vs. 20.0%), organ failure (56.7% vs. 30.0%), and a longer hospital stay (18.0 days vs. 6.5 days). HTGAP group also had poorer microbial diversity, higher abundances of Escherichia/Shigella and Enterococcus, but lower abundances of Dorea longicatena, Blautia wexlerae, and Bacteroides ovatus as compared with non-HTGAP group. Correlation analysis revealed that gut bacterial taxonomic and functional changes were linked with local and systemic complications, ICU admission, and mortality. This study revealed that alterations of gut microbiota were associated with disease severity and poor prognosis in HTGAP patients, indicating a potential pathophysiological link between gut microbiota and hypertriglyceridemia related acute pancreatitis.

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

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

Hypertriglyceridemia is often under recognized as an aetiologic risk factor for acute pancreatitis: A population-based cohort study

BACKGROUND

Severe hypertriglyceridemia (HTG) is a well-known risk factor for acute pancreatitis, but updated population-based estimates on incidence of HTG-associated pancreatitis are lacking.

METHODS

We identified all individuals with severe HTG (triglyceride level >10 mmol/L [886 mg/dL]) in a population-based sample from 2008 to 2019 and linked these with Danish nationwide health-registers to identify patients with acute pancreatitis. Pancreatitis cases were subsequently confirmed by a detailed medical chart review. Crude and standardized incidence rates were estimated and studied in relation to age, gender and time-period. In addition, aetiological classification designated during index hospitalization, severity and follow-up of individuals with HTG-associated pancreatitis were studied.

RESULTS

Among 2146 individuals with severe HTG during the observation period, 75 were diagnosed with acute pancreatitis (3.5%). The mean incidence rate of HTG-associated pancreatitis was 1.4 (95% CI, 1.1-1.7) per 100,000 person years for the total population, for women it was 0.7 (95% CI, 0.5-1.1) and for men 2.0 (95% CI, 1.5-2.6) per 100,000 person-years. The mean incidence rate increased from 0.7 to 1.7 per 100,000 person-years from 2008 to 2019 (p_trend = 0.01). The highest incidence rate of HTG-associated pancreatitis was observed for men in the age group 50-59 years. An elevated triglyceride level was recognized as aetiological risk factor in 35% of patients during index hospitalization.

CONCLUSIONS

Only a fraction of patients with severe HTG are hospitalized for acute pancreatitis, but the incidence is increasing. In more than half of patients elevated triglycerides is not recognized as a risk factor for acute pancreatitis during index hospitalization.

Lycopene Inhibits Oxidative Stress-Mediated Inflammatory Responses in Ethanol/Palmitoleic Acid-Stimulated Pancreatic Acinar AR42J Cells

High alcohol intake results in the accumulation of non-oxidative ethanol metabolites such as fatty acid ethyl esters (FAEEs) in the pancreas. High FAEE concentrations mediate pancreatic acinar cell injury and are associated with alcoholic pancreatitis. Treatment with ethanol and the fatty acid palmitoleic acid (EtOH/POA) increased the levels of palmitoleic acid ethyl ester and induced zymogen activation and cytokine expression in pancreatic acinar cells. EtOH/POA induces nicotinamide adenine dinucleotide phosphate (NADPH) oxidase-mediated reactive oxygen species (ROS) production and pancreatic acinar cell injury. Lycopene, a bright-red carotenoid, is a potent antioxidant due to its high number of conjugated double bands. This study aimed to investigate whether lycopene inhibits the EtOH/POA-induced increase in ROS production, zymogen activation, and expression of the inflammatory cytokine IL-6 in EtOH/POA-stimulated pancreatic acinar AR42J cells. EtOH/POA increased the ROS levels, NADPH oxidase and NF-κB activities, zymogen activation, IL-6 expression, and mitochondrial dysfunction, which were inhibited by lycopene. The antioxidant N-acetylcysteine and NADPH oxidase 1 inhibitor ML171 suppressed the EtOH/POA-induced increases in ROS production, NF-κB activation, zymogen activation, and IL-6 expression. Therefore, lycopene inhibits EtOH/POA-induced mitochondrial dysfunction, zymogen activation, and IL-6 expression by suppressing NADPH oxidase-mediated ROS production in pancreatic acinar cells.

[Acute Pancreatitis]

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