Difference in microbes contaminating pancreatic necrosis in biliary and alcoholic pancreatitis

Controversies in the management of acute pancreatitis: An update

This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Diffusion-Weighted Magnetic Resonance Imaging Is an Ideal Imaging Method to Detect Infection in Pancreatic Collections: A Brief Primer for the Gastroenterologists

Background: The development of infection in pancreatitis significantly increases the mortality rate up to 100% in the absence of any intervention. Therefore, it is extremely important to diagnose these cases at an early stage. The objectives of this study were to assess the diagnostic performance of computed tomography (CT) and diffusion-weighted MR imaging (DW-MRI) in the diagnosis of infection in pancreatic collections.

Materials and methods: Prospective observational study of abdominal collections due to pancreatitis that underwent both CT and DW-MRI from August 2018 to July 2020 were enrolled in the study. The collections were analysed for infections - air foci in CT and diffusion restriction on DW-MRI.

Results: Of the 39 patients recruited in the study, infected collections were present in 17, and 22 cases had sterile collections. On CT, air foci within the collection were present only in seven of the cases in our study (sensitivity 35%, specificity 95.4%, PPV 85.7%, NPV 65.6%). DW-MRI detected infection in all 17 cases (sensitivity 100%, specificity 72.7%, PPV 74%, NPV 100%).

Discussion: Thirteen out of 17 collections suspicious for infection on DW-MR showed microbiological growth on culture examination. We believe that this is likely due to the patient's prior antibiotic use, which might have altered the micro-environment or inflammatory cell and bacterial content of the collection.

Conclusion: DW-MRI is complementary and superior to CT in detecting infection in pancreatic collections. CT may be used to detect disease burden, extent and vascular complication.

Infected pancreatic necrosis and retroperitoneal abscess associated with Lactobacillus paracasei

Infected pancreatic necrosis is a postpancreatitis complication that is mainly caused by Enterobacteriaceae and Enterococci. Here, we have reported a very rare case of Lactobacillus paracasei bacteraemia associated with infected pancreatic necrosis and retroperitoneal abscess. In addition to the diagnosis of diabetic ketoacidosis, blood test results revealed a high inflammatory status. CT of the abdomen revealed pancreatic walled-off necrosis. Blood culture and aspiration fluid culture revealed positivity for L. paracasei, leading to the diagnosis of infected pancreatic necrosis. The abscess had spread in the retroperitoneal space later. The patient recovered after receiving antibiotic treatment and endoscopic and percutaneous drainage. L. paracasei can cause invasive infection, including infected pancreatic necrosis and retroperitoneal abscess, which requires aggressive therapy.

The microbiology of infected pancreatic necrosis

BACKGROUND

Acute pancreatitis (AP) continues to cause significant morbidity and mortality, especially when it leads to infected pancreatic necrosis (IPN). Modern treatment of IPN frequently involves prolonged courses of antibiotics in combination with minimally invasive therapies. This study aimed to update the existing evidence base by identifying the pathogens causing IPN and therefore aid future selection of empirical antibiotics.

METHODS

Clinical data, including microbiology results, of consecutive patients with IPN undergoing minimally invasive necrosectomy at our institution between January 2009 and July 2016 were retrospectively reviewed.

RESULTS

The results of 40 patients (22 males and 18 females, median age 60 years) with IPN were reviewed. The etiology of AP was gallstones, alcohol, dyslipidemia and unknown in 31, 2, 2 and 5 patients, respectively. The most frequently identified microbes in microbiology cultures were Enterococcus faecalis and faecium (22.5% and 20.0%) and Escherichia coli (20.0%). In 19 cases the cultures grew multiple organisms. The antibiotics with the least resistance amongst the microbiota were teicoplanin (5.0%), linezolid (5.6%), ertapenem (6.5%), and meropenem (7.4%).

CONCLUSION

The carbapenem antibiotics, ertapenem and meropenem provide good antimicrobial cover against the common, mainly enteral, microorganisms causing IPN. Culture and sensitivity results of acquired samples should be regularly reviewed to adjust prescribing and monitor for emergence of resistance.

Impact of etiology on course and outcomes of severe acute pancreatitis

BACKGROUND AND OBJECTIVE

Since the influence of etiological factors on the course and outcomes of acute pancreatitis (AP) is not fully understood yet, the aim of the study was to compare the outcomes of alcoholic and biliary severe acute pancreatitis (SAP).

MATERIALS AND METHODS

We investigated 81 patients with alcoholic and biliary SAP. Demographic data, etiologic factors, severity scores, intra-abdominal pressure, imaging studies, interventions, and treatment outcomes were prospectively entered into specially maintained database and subsequently analyzed.

RESULTS

No statistically significant difference was observed in the prevalence of SAP in biliary and alcoholic AP groups (P=0.429). Although, in the biliary SAP group patients were predominantly elderly women (P=0.003), the total in-hospital stay was longer in alcoholic SAP patients (P=0.021). The abdominal compartment syndrome developed more frequently (P=0.041) and necrosectomy was more frequently performed in alcoholic SAP group (not statistically significant). Although not statistically significant, a lower mortality rate among biliary SAP patients (25.0% vs. 13.5%) was observed.

CONCLUSIONS

We defined a trend toward decreased incidence of infected necrosis in larger volume (≥30%) pancreatic necrosis, absence of abdominal compartment syndrome, lower rate of necrosectomies, shorter in-hospital stay, and an insignificantly reduced mortality rate in biliary SAP patients, indicating more favorable course of biliary SAP.

Effects of probiotic supplementation on markers of acute pancreatitis in rats

BACKGROUND

Intestinal barrier disruption followed by bacterial translocation seems to play a role in secondary pancreatic infection in acute pancreatitis. The use of probiotics as a possible adjuvant strategy in the treatment of acute pancreatitis needs to be investigated.

OBJECTIVE

The aim of this study was to determine the effects of dietary supplementation with a prophylactically administered multispecies probiotic mixture on the markers of acute pancreatitis and on the occurrence of bacterial translocation.

METHODS

Thirty adult male Wistar rats were randomly assigned to 1 of 3 groups of 10 rats each: (1) the PS group, in which the rats were given probiotic supplementation prior to induction of acute pancreatitis; (2) the WP group, in which the rats underwent surgery to induce acute pancreatitis without prior probiotic supplementation; and (3) the control group, in which the rats underwent sham surgery. For 14 days before surgery, animals in the PS group received a single daily dose containing ~1.2 × 10(9) colony-forming units of a probiotic mixture administered intragastrically as a bolus. On day 15, the animals underwent surgery to induce acute pancreatitis (PS and WP groups) or simulated surgery (control group). Blood samples were collected to determine leukocyte count, amylase and lipase activities, and glucose and calcium concentrations immediately before and 6 and 12 hours after the beginning of the procedure. Samples of pancreas, spleen, liver, and mesenteric lymph nodes were harvested for microbiologic and histopathologic analysis after the last blood sample collection. The pathologist examining the histopathology was blinded to treatment assignment.

RESULTS

The mean leukocyte count was significantly increased in the PS group compared with the WP group (P = 0.018), whereas the serum amylase and lipase activities and the serum glucose and calcium concentrations were not significantly different between the 2 groups. Comparing the risk for tissue colonization in the PS group with that of the WP group, the odds ratio (OR) for pancreas was 2.91 (95% CI, 0.13-67.10); liver, 66.55 (95% CI, 1.89-2282.66); spleen, 88.58 (95% CI, 3.04-2583.08); and mesenteric lymph nodes, 1.23 (95% CI, 0.06-25.48). When the risks for histopathologic changes were compared between the 2 groups, the OR for acinar necrosis was 1.73 (95% CI, 0.21-12.17); steatonecrosis, 12.08 (95% CI, 1.26-115.54); hemorrhage, 1.38 (95% CI, 0.21-9.53); and leukocyte infiltration, 5.91 (95% CI, 0.64-54.89).

CONCLUSION

Probiotic supplementation before the induction of acute pancreatitis was associated with a greater degree of bacterial translocation and pancreatic tissue damage in this animal model.

Interventions for necrotizing pancreatitis: an overview of current approaches

The management of necrotizing pancreatitis has undergone a paradigm shift toward minimally invasive techniques for necrosectomy, obviating the need for open necrosectomy in most cases. There is increasing evidence that minimally invasive approaches including a step-up approach that incorporates percutaneous catheter or endoscopic transluminal drainage, followed by video-assisted retroperitoneal or endoscopic debridement are associated with improved outcomes over traditional open necrosectomy for patients with infected necrosis. A recent international multidisciplinary consensus conference emphasized the superiority of minimally invasive approaches over standard surgical approaches. The success of these techniques depends on concerted efforts of a multidisciplinary team of interventional endoscopists, radiologists, intensivists and surgeons dedicated to the management of severe acute pancreatitis and its complications. This review provides an overview of minimally invasive techniques for management of necrotizing pancreatitis, including indications, timing, advantages and disadvantages.

Intra-abdominal fungal infections complicating acute pancreatitis: a review

Intra-abdominal infections of pancreatic or peripancreatic necrotic tissue complicate the clinical course of severe acute pancreatitis (SAP) and are associated with significant morbidity. Fungal infection of necrotic pancreatic tissue is increasingly being reported. The incidence of intra-abdominal pancreatic fungal infection (PFI) varies from 5% to 68.5%. Candida albicans is the most frequently isolated fungus in patients with necrotizing pancreatitis. Prolonged use of prophylactic antibiotics, prolonged placement of chronic indwelling devices, and minimally invasive or surgical interventions for pancreatic fluid collections further increase the risk of PFI. Computed tomography- or ultrasound-guided fine-needle aspiration of pancreatic necrosis is a safe, reliable method for establishing pancreatic infection. Amphotericin B appears to be the most effective antifungal treatment. Drainage and debridement of infected necrosis are also critical for eradication of fungi from the poorly perfused pancreatic or peripancreatic tissues where the antifungal agents may not reach to achieve therapeutic levels. Fungal infection adversely affects the outcome of patients with SAP and is associated with increased morbidity, although the mortality rate is not increased specifically because of PFI. Although antifungal prophylaxis has been suggested for patients on broad-spectrum antibiotics, no randomized controlled trials have yet studied its efficacy in preventing PFI.