Diagnostic standards for acute pancreatitis

Accurate diagnosis of acute appendicitis in the emergency department: an artificial intelligence-based approach

The diagnosis of abdominal pain in emergency departments is challenging, and appendicitis is a common concern. Atypical symptoms often delay diagnosis. Although the Alvarado score aids in decision-making, its low specificity can lead to unnecessary surgeries. By leveraging machine learning, we aim to enhance diagnostic accuracy by predicting appendicitis and distinguishing it from other causes of abdominal pain in the emergency department. Data were collected from 534 patients who presented with acute abdominal pain. Patient characteristics, laboratory results, and causes of pain were recorded. Machine learning algorithms (support vector classifier, random forest classifier, gradient boosting classifier, and Gaussian naive Bayes) were used to predict the cause of pain. Model calibration was assessed using the Brier score. The mean age was 46.89 (20.3) years, with an almost equal sex distribution (49% male, 51% female). Cholecystitis was the most prevalent outcome (37.07%), followed by appendicitis (25.84%). The Gaussian naive Bayes model exhibited superior performance in terms of accuracy (95.03% 95% CI 90.44-97.83%), sensitivity (87.18% 95% CI 72.57-95.70%), and specificity (97.54% 95% CI 92.98-99.49%), while the random forest model showed a sensitivity of 79.49%, specificity of 96.72%, and accuracy of 92.55%. The gradient boosting algorithm achieved a sensitivity, specificity, and accuracy of 89.74%, 95.90%, and 94.41%, respectively. The support vector classifier demonstrated a sensitivity of 89.74%, specificity of 92.62%, and accuracy of 91.93%. The use of modern machine learning methods aids in the accurate diagnosis of appendicitis.

Children systemic lupus erythematosus-associated pancreatitis

OBJECTIVE

To early recognise and improve the prognosis of children systemic lupus erythematosus (cSLE)-associated pancreatitis by summarising and analysing clinical features and prognosis data from 12 cases.

METHODS

Retrospective analysis of clinical data from 12 cases of cSLE-associated pancreatitis diagnosed and treated from January 2016 to December 2021 at hospitals such as Children's Hospital of Capital Institute of Paediatrics.

RESULTS

The median SLEDAI-2K score for disease activity was 18.00 (range 12.25-21.00) in the case group and 10.00 (range 7.00-18.00) in the control group, with a statistically significant difference (P < 0.05) between the two groups. The case group had a higher proportion of abdominal pain, vomiting, abdominal distension, pleural effusion, Raynaud's phenomenon (RP), splenic infarction, and concurrent macrophage activation syndrome (MAS) than the control group, with a statistically significant difference (P < 0.05). Serum ferritin (SF), alanine transaminase (ALT), aspartate transaminase (AST), lactate dehydrogenase (LDH), amylase, and increased 24-h urine protein levels were statistically different between the two groups (P < 0.05); platelet counts (PLT) reduction was also statistically different (P < 0.05). The case group had a higher proportion of methylprednisolone pulse therapy, cyclophosphamide pulse therapy during remission induction, and therapeutic plasma exchange than the control group, with a statistically significant difference (P < 0.05) between the two.

CONCLUSION

CSLE-associated pancreatitis has a high fatality rate. The presence of RP, splenic infarction, pleural effusion, and MAS warrants attention from clinicians regarding the possibility of pancreatitis. Once pancreatitis is detected, the primary disease needs active treatment for better prognosis.

Expression level of serum miR-347a-5p in patients with acute pancreatitis and its effect on viability, apoptosis, and inflammatory factors of pancreatic acinar cells induced by cerulein

Acute pancreatitis (AP) is one of the life-threatening diseases of the digestive system. MicroRNA has been asserted to be a regulator of AP. This paper explored the miR-374a-5p expression in AP patients and investigated the efficacy of AR42J cells. In this study, 60 healthy people, 58 MAP patients and 58 SAP patients were included, and the serum miR-374a-5p levels of the subjects were detected by RT-qPCR technology. The pancreatitis cell model was structured by stimulating AR42J cells with cerulein. Next, cell viability and apoptosis were detected by CCK-8 assay and flow cytometry. ELISA was used to measure the concentration of cytokines, such as TNF-α, IL-6, and IL-1β. The data showed that miR-374a-5p was downregulated in samples from AP patients, while showing discriminative power for AP populations. Attenuated miR-374a-5p were negatively bound up with patients' Ranson score and APACHE II score. Besides, miR-374a-5p was declined in cerulein-treated AR42J cells and forced elevation of miR-374a-5p was beneficial to increase cell viability, and inhibit cell apoptosis and inflammation. The present study found that miR-374a-5p was reduced in AP serum samples, and up-regulated expression level of miR-374a-5p in cell models had a protective effect on cerulein-induced inhibition of cell function and inflammatory response.

Autoimmune pancreatitis with IgG-4 cholangiopathy in a pregnant woman: A case report

Diagnosis and management of autoimmune pancreatitis during pregnancy. Autoimmune pancreatitis is a rare and life-threatening condition with increased maternal and fetal morbidity and mortality. Autoimmune pancreatitis may result in a mass-forming lesion in the pancreas resembling pancreatic cancer; therefore, meticulous and careful investigations must be done to avoid misdiagnosing autoimmune pancreatitis as pancreatic cancer. Since autoimmune pancreatitis improves dramatically to steroid therapy, accurate diagnosis of autoimmune pancreatitis can avoid unnecessary procedures, surgeries, and pancreatic resection. A case of a pregnant lady in her third trimester was presented with abdominal pain, nausea, and vomiting. On examination, there was tenderness in both epigastric and right hypochondrium associated with elevated serum amylase, liver transaminases, alkaline phosphatase, gamma-glutamyl transpeptidase, and immunoglobulin G4. Both abdominal ultrasound and magnetic resonance cholangiopancreatography showed a pancreatic head lesion with dilation in both pancreatic duct and common bile duct. Steroid was initiated that resulted in rapid and dramatic responsiveness. Acute pancreatitis is uncommon during pregnancy, and autoimmune pancreatitis is a very rare form of acute pancreatitis; therefore, a clear and rapid assessment, diagnosis, and management plan are necessary to avoid maternal and fetal morbidity and mortality.

Systemic Lupus Erythematosus-Related Pancreatitis in Children: Severe and Lethal Form

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease of unknown cause, characterized by multisystemic involvement. Its occurrence in children is rare, and acute pancreatitis is exceptional in this matter. Its diagnosis is clinical, biological, and radiological. Its treatment is based on corticosteroid therapy, and its progress is generally lethal. We report two cases of acute pancreatitis in the course of SLE, highlighting its life-threatening severity despite well-conducted treatment. Case 1: 14-year-old patient, admitted to the pediatric ICU for altered state of consciousness. This child, an outpatient since 2009 for chronic arthralgia, was hospitalized five days previously in the pediatric ward for suspicion of severe SLE, before presenting abdominal pain and vomiting. Hyperlipasemia was found, and an abdominal CT scan confirmed the diagnosis of acute pancreatitis. The patient was put under immunosuppressive therapy composed of high-dosage of corticosteroid and cyclophosphamide cures. She died 20 days after her hospitalization by severe lupus flare with multiorgan failure. Case 2: 14-year-old child, admitted to the Pediatric ward for prolonged fever associated with polyarthralgia (nondeforming, immovable, and additive) that had been progressing since 6 months with altered general state; his symptoms got worst 15 days before his hospitalization by having behavioral disorders and epigastralgia with vomiting. Pancreatitis was strongly suspected in the absence of improvement on symptomatic treatment and confirmed by hyperlipasemia 6 times the normal value and a swollen pancreas on the abdominal CT scan. The child was treated with Solumedrol and cyclophosphamide without improvement and then died after one month of hospitalization by a septic shock.

Ambient Ionization Mass Spectrometry Measurement of Aminotransferase Activity

A change in enzyme activity has been used as a clinical biomarker for diagnosis and is useful in evaluating patient prognosis. Current laboratory measurements of enzyme activity involve multi-step derivatization of the reaction products followed by quantitative analysis of these derivatives. This study simplified the reaction systems by using only the target enzymatic reaction and directly detecting its product. A protocol using paper spray mass spectrometry for identifying and quantifying the reaction product has been developed. Evaluation of the activity of aspartate aminotransferase (AST) was chosen as a proof-of-principle. The volume of sample needed is greatly reduced compared with the traditional method. Paper spray has a desalting effect that avoids sprayer clogging problems seen when examining serum samples by nanoESI. This very simple method does not require sample pretreatment and additional derivatization reactions, yet it gives high quality kinetic data, excellent limits of detection (60 ppb from serum), and coefficients of variation <10% in quantitation. Graphical Abstract ᅟ.

Loganin protects against pancreatitis by inhibiting NF-κB activation

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which, in its most severe form, is associated with multi-organ failure and death. Loganin, a major iridoid glycoside obtained from Corni fructus, has been shown to have anti-inflammatory and anti-shock effects. However, the effects of loganin on AP have not been determined. Pre-treatment of loganin reduced pancreatic damage and AP-associated lung injury and attenuated the severity of AP, as evidenced by (1) a reduction in several biochemical parameters (pancreatic weight to body weight ratio, myeloperoxidase activity, and level of amylase) and (2) production of pro-inflammatory cytokines such as interleukin (IL)-1β and tumor necrosis factor (TNF)-α. However, post-treatment of loganin failed to improve pancreatic damage and biochemical parameters of AP, but could inhibit the AP-induced elevation of IL-1β and TNF-α significantly. In addition, cerulein-induced activation of nuclear factor (NF)-κB was inhibited in the pancreas by administration of loganin. In conclusion, these results suggest that loganin exhibits an anti-inflammatory effect in cases of AP and its pulmonary complications through inhibition of NF-κB activation.

Pattern of acute pancreatitis in a tertiary care center in oman

OBJECTIVE

To describe the epidemiology of acute pancreatitis in a tertiary care center in Oman.

METHODS

A retrospective study evaluated all adults (>18 yrs) who presented with first attack of acute pancreatitis to SQUH from 1(st) of January 2006 to 31(st) of December 2012.

RESULTS

One hundred seventy-four patients were found. The mean age of the cohort was 44 ± 11 years. 54% (n=95) were male and 45% (n=79) were female. Majority of the cases were mild (n=131) compared to moderate (n=29) and severe (n=14). Sixty six percent (n=116) of the cases were secondary to alcohol and biliary tract diseases. Alcoholic pancreatitis occurred in 53% of the males whereas biliary pancreatitis occurred in 51% of the females. Pancreatitis recurred in 40% (n=71) of the cases, especially in alcoholic pancreatitis. 56 patients (32%) had complications, especially in the severe cases.

CONCLUSION

The data about acute pancreatitis in Oman was similar to the Western countries. Pancreatitis occurred in males more than females. Alcoholic pancreatitis was more common in males, whereas biliary pancreatitis was more common in females. Alcoholic pancreatitis re-occurred in nearly half of the cases. Severe cases were associated with more complications and recurrence.

Acute pancreatitis as the initial presentation of systematic lupus erythematosus

Systematic lupus erythematosus (SLE) is a multisystem disease, including the gastrointestinal system in about half of SLE patients. As a rare complication of SLE, acute pancreatitis presents as generalized flare-ups in most cases of patients previously diagnosed with SLE. Here we report a rare case of acute pancreatitis as the initial presentation with later diagnosis of SLE.

Use of acoustic radiation force impulse elastography to diagnose acute pancreatitis at hospital admission: comparison with sonography and computed tomography

OBJECTIVES

To compare the diagnostic success rate of acoustic radiation force impulse (ARFI) elastography with those of sonography and computed tomography (CT) for acute pancreatitis at hospital admission.

METHODS

B-mode sonography and ARFI elastography were performed on 88 patients with symptoms of acute pancreatitis and 50 healthy control participants who were admitted to our hospital between February 2013 and July 2013. Acute pancreatitis was verified in the 88 patients based on clinical and laboratory findings. Computed tomography was performed on 41 patients, and the CT results from these patients were compared with those of ARFI elastography. The appearances of the pancreases of the patients were classified into 6 groups using visual color encodings obtained with ARFI elastography. The elasticity values of pancreatic head, body, and tail regions were evaluated with Virtual Touch imaging and Virtual Touch tissue quantification (Siemens Medical Solutions, Mountain View, CA). The success rates of sonography, CT, and ARFI elastography for diagnosing acute pancreatitis at hospital admission were compared.

RESULTS

Forty-six of the 88 patients had a diagnosis of pancreatitis by B-mode sonography; pancreatitis was diagnosed in all patients by ARFI elastography; and 10 of 41 patients could not be diagnosed by CT. The sensitivity and specificity of Virtual Touch tissue quantification were 100% and 98%, respectively, when a cutoff value of 1.63 m/s was used. The control group had color scores of 1 or 2, whereas all patients with pancreatitis had color scores of 3 to 6 on color scale evaluation with Virtual Touch imaging.

CONCLUSIONS

Acoustic radiation force impulse elastography is a rapid, radiation-free, and noninvasive tool for diagnosis of acute pancreatitis at initial hospital admission, with a higher success rate for diagnosis of acute pancreatitis than the grayscale sonography and CT.

Urinary amylase/urinary creatinine ratio (uAm/uCr)--a less-invasive parameter for management of hyperamylasemia

Background

The serum level of amylase (sAm) is commonly used as a biochemical marker for diagnosis and management of pancreatic disorders. However, the use of the urine level of amylase (uAm) is limited in practice, because the diagnostic ability of uAm is inferior to that of sAm. In the present study, the possible concordance of uAm-rerated parameters with sAm was investigated, and evaluate the usefulness of uAm for management of hyperamylasemia.

Methods

From June 1995 to October 2009, 804 samples of both urine and blood were collected from 128 patients in order to measure the serum level of amylase (sAm) and the urine level of amylase (uAm) and creatinine (uCr). Concordance of parameters using uAm compared to sAm was assessed. Parameters used were uAm, amylase creatinine clearance ratio (ACCR), and the ratio of uAm to uCr (uAm/uCr).

Results

uAm/uCr had the best correlation with sAm (r = 0.779, p < 0.001) compared to uAm (r = 0.620, p < 0.001) and to ACCR (r = 0.374, p < 0.001), when sAm was over the standard level. The area under the receiver operating characteristic curve of uAm/uCr (0.884) was significantly higher than that of uAm (0.766) and of ACCR (0.666) (p < 0.001 for each). The cutoff value of uAm/uCr was 569.8, with a sensitivity of 81.0% and a specificity of 83.1%.

Conclusions

The uAm/uCr ratio correlated with sAm, and may be an alternative to sAm for prediction of hyperamylasemia. Use of urine samples results in a decreased need for blood sampling, which is especially beneficial in pediatric patients.

Long-term aspirin pretreatment in the prevention of cerulein-induced acute pancreatitis in rats

AIM: To investigate the effects of long term pretreatment with low-, medium- and high-dose aspirin (acetylsalicylic acid, ASA) on a model of acute pancreatitis (AP) induced in rats.

METHODS: Forty male Wistar rats were used. Three experimental groups, each consisting of eight animals, received low- (5 mg/kg per day), medium- (150 mg/kg per day) and high-dose (350 mg/kg per day) ASA in supplemented pellet chow for 100 d. Eight animals, serving as the AP-control group, and another eight, serving as reference value (RV) group, were fed with standard pellet chow for the same period. After pretreatment, AP was induced in the experimental animals by intraperitoneal administration of cerulein (2 × 50 μg/kg), while the RV group received saline in the same way. Twelve hours after the second injection, the animals were sacrificed. Pancreatic tissue and plasma samples were collected. One part of the collected pancreatic tissues was used for histopathological evaluation, and the remaining portion was homogenized. Cytokine levels [tumor necrosis factor, interleukin (IL)-1β, IL-6], hemogram parameters, biochemical parameters (amylase and lipase), nuclear factor-κB, aspirin triggered lipoxins and parameters related to the antioxidant system (malondialdehyde, nitric oxide, hemeoxygenase-1, catalase and superoxide dismutase) were measured.

RESULTS: Cerulein administration induced mild pancreatitis, characterized by interstitial edema (total histopathological score of 5.88 ± 0.44 vs 0.25 ± 0.16, P < 0.001). Subsequent pancreatic tissue damage resulted in an increase in amylase (2829.71 ± 772.48 vs 984.57 ± 49.22 U/L, P = 0.001) and lipase (110.14 ± 75.84 U/L vs 4.71 ± 0.78 U/L, P < 0.001) in plasma, and leucocytes (6.89 ± 0.48 vs 4.36 ± 0.23, P = 0.001) in peripheral blood. Cytokines, IL-1β (18.81 ± 2.55 pg/μg vs 6.65 ± 0.24 pg/μg, P = 0.002) and IL-6 (14.62 ± 1.98 pg/μg vs 9.09 ± 1.36 pg/μg, P = 0.04) in pancreatic tissue also increased. Aspirin pretreatment reduced the increase in the aforementioned parameters to a certain degree and partially improved the histopathological alterations caused by cerulein. No evidence of side effects related to chronic ASA administration (e.g., inflammation or bleeding) was observed in the gastrointestinal tract in macroscopic and histopathological examination.

CONCLUSION: Long term ASA pretreatment could prevent and/or ameliorate certain hematological, serological and histological alterations caused by cerulein-induced AP.

Systemic lupus erythematosus-related pancreatitis in children

We report on three patients who developed four episodes of acute pancreatitis while their systemic lupus erythematosus was active and being treated with prednisolone. In all three, gastritis was first considered and treated due to abdominal pain, vomiting, and epigastric tenderness, but their symptoms did not improve. Then pancreatic enzymes were measured, which confirmed pancreatitis. Imaging studies showed an enlarged pancreas in one case, a normal pancreas in two cases, and a focal hypodense nonenhancing parenchyma in one case. Corticosteroids were prescribed for both active SLE and SLE-related pancreatitis. Pulse methylprednisolone was prescribed in one episode, increasing oral prednisolone in one episode, and the same dose of prednisolone continued in the other two episodes. All cases recovered without complications. SLE-related pancreatitis should be considered in SLE patients when the SLE is active and a patient develops abdominal pain and vomiting.

Characteristics of patients with ketosis-prone diabetes (KPD) presenting with acute pancreatitis: implications for the natural history and etiology of a KPD subgroup

OBJECTIVE

Reports of concomitant diabetic ketoacidosis (DKA) and acute pancreatitis (AP) are lacking among emerging forms of diabetes. This longitudinal study characterized ketosis-prone diabetes (KPD) in patients presenting with concomitant AP and DKA.

METHODS

Multi-ethnic KPD patients (N = 755) were followed prospectively for 1 year from the time of index DKA using repeated metabolic and beta cell functional reserve measures. Baseline and longitudinal characteristics were compared between KPD patients whose index DKA was associated with (n = 54) or without (n = 701) AP.

RESULTS

The AP group had significantly higher baseline serum amylase, lipase, and triglyceride levels and significantly lower bicarbonate levels than the non-AP group. AP patients had significantly greater C-peptide area-under-the-curve with glucagon stimulation shortly after the index DKA, and higher fasting C-peptide (FCP) levels 6 to 12 months later. Using the validated "Aβ" KPD classification, 85% of AP patients had β+ status (preserved beta cell functional reserve), compared to 60% of non-AP patients (P = .04). Multivariate analysis revealed that among the β+ KPD subgroup with an identifiable precipitating factor for DKA ("provoked" DKA), patients with AP had worse long-term glycemic outcomes than patients whose DKA was associated with other factors.

CONCLUSION

Despite greater clinical severity at presentation, KPD patients with AP have better preserved beta cell function than those without AP. β+ KPD patients presenting with AP have worse long-term glycemic control than those with other causes of provoked DKA. Factors other than beta cell function negatively impact glycemic control in KPD patients presenting with AP.

Splenic infarction due to septic emboli from bacterial endocarditis: A previously unreported cause of hyperamylasaemia

We present what maybe the only case of splenic infarction causing hyperamylasaemia in a patient with bacterial endocarditis. A 49-year-old gentleman presented a 24 hour history of vomiting, abdominal pain and fever. Clinical examination showed diffuse upper abdominal tenderness, a mild tachycardia and a low grade pyrexia. Blood investigations showed a hyperamylasaemia. His failure to improve on treatment for a provisional diagnosis of alcohol induced pancreatitis lead to a CT abdomen, which showed a splenic infarct and an echo showing aortic valve vegetation's as a source of emboli. He underwent urgent aortic valve replacement with a tissue valve following which he made an uncomplicated recovery.

Dengue hemorrhagic fever complicated by pancreatitis

Acute pancreatitis is an atypical complication of dengue fever and is rarely described. We are reporting a case of dengue hemorrhagic fever complicated by acute pancreatitis in a patient with history of diabetes mellitus type 1 and end stage renal disease on hemodialysis.

Systemic-lupus-erythematosus-related acute pancreatitis: a cohort from South China

Acute pancreatitis (AP) is a rare but life-threatening complication of SLE. The current study evaluated the clinical characteristics and risk factors for the mortality of patients with SLE-related AP in a cohort of South China. Methods. Inpatient medical records of SLE-related AP were retrospectively reviewed. Results. 27 out of 4053 SLE patients were diagnosed as SLE-related AP, with an overall prevalence of 0.67%, annual incidence of 0.56‰ and mortality of 37.04%. SLE patients with AP presented with higher SLEDAI score (21.70 ± 10.32 versus 16.17 ± 7.51, P = 0.03), more organ systems involvement (5.70 ± 1.56 versus 3.96 ± 1.15, P = 0.001), and higher mortality (37.04% versus 0, P = 0.001), compared to patients without AP. Severe AP (SAP) patients had a significant higher mortality rate compared to mild AP (MAP) (75% versus 21.05%, P = 0.014). 16 SLE-related AP patients received intensive GC treatment, 75% of them exhibited favorable prognosis. Conclusion. SLE-related AP is rare but concomitant with high mortality in South Chinese people, especially in those SAP patients. Activity of SLE, multiple-organ systems involvement may attribute to the severity and mortality of AP. Appropriate glucocorticosteroid (GC) treatment leads to better prognosis in majority of SLE patients with AP.

Clinical observation on the effect of dexamethasone and Chinese herbal decoction for purgation in severe acute pancreatitis patients

OBJECTIVE

To investigate the effect of dexamethasone (Dx) combined with modified Dachengqi Decoction (DCQD), a Chinese herbal decoction for purgation, on patients with severe acute on patients with severe acute, a Chinese herbal decoction for purgation, on patients with severe acute pancreatitis (SAP) accompanied with systematic inflammatory response syndrome (SIRS).

METHODS

A total of 81 patients diagnosed as SAP were randomly assigned to a control group or treatment group according to a random number table generated from an SPSS software. The patients in the control group (38 cases) received standard treatment and Chinese herbal decoction for purgation; those in the treatment group (43 cases) received additional 1 mg/(kg·d) dexamethasone (Dx) treatment for three days based on the above treatment. The mortality rate, acute respiratory distress syndrome (ARDS), renal failure, hemorrhage, sepsis, pancreatic pseudocyst, pancreatic abscess, operability, and days of hospitalization were compared between the two groups.

RESULTS

Three patients in the control group and eight patients in the treatment group dropped out from the study with a drop-out rate of 7.8% and 18.6%, respectively, and no statistics difference was shown between the two groups (P>0.05). Dx treatment significantly reduced ARDS rate and shortened the length of hospitalization compared to those in the control group (7/35, 20.0% versus 15/35, 42.9%, P=0.0394; 32.5±13.2 days versus 40.2±17.5 days, P=0.0344). Other parameters including the mortality rate were not significant different between the two groups.

CONCLUSION

Dx combined with DCQD could decrease the risk of developing ARDS in SAP patients with SIRS and shorten their length of hospitalization.

Risk factors associated with elevated serum pancreatic amylase levels during hemodialysis

Elevated levels of serum pancreatic enzymes are frequently observed in hemodialysis (HD) patients. The complex hemodynamic, biochemical, and physiological alterations in uremia were speculated to cause excessive release of pancreatic enzymes beyond decreased renal clearance. However, hemodynamic factors are seldom explored in this aspect. We performed the study to evaluate the association between intradialytic hemodynamic change and elevated serum pancreatic amylase (SPA). Eighty-three prevalent HD patients without any clinical evidence of acute pancreatitis underwent pre-HD and post-HD blood sampling for serum pancreatic enzyme levels. Demographic, biochemical, and hematological data were collected from patient record review. Hemodialysis information including intradialytic blood pressure changes and ultrafiltration (UF) amount were collected and averaged for 1 month before the blood sampling day. Patients with elevated SPA during the HD session had greater mean systolic blood pressure and mean arterial pressure reduction, greater UF volume, greater pre-HD blood urea nitrogen and serum creatinine, higher serum phosphorus, lower pre-HD serum total CO2, and lower left ventricle ejection fraction (LVEF). Using multivariate linear and logistic regression analysis, the independent predictors of elevated SPA were determined to be mean arterial pressure reduction during HD, mean UF amount, pre-HD serum total CO2, and LVEF. Greater blood pressure reduction during HD, greater UF volume, lower pre-HD serum total CO2, and lower LVEF were significantly associated with elevated SPA during HD. This suggests that hemodynamic factors contribute to elevated serum pancreatic enzymes in HD patients.

The role of acute pancreatitis in pediatric burn patients

Few publications recognize acute pancreatitis as a complication after large burns, consequently the incidence and outcome acute pancreatitis after burn in children is not well defined. The aim of this study was to determine the incidence, morbidity, and mortality relating to acute pancreatitis in a pediatric burn population and to correlate clinical diagnosis with autopsy findings to determine the incidence of unrecognized pancreatitis. Records of 2699 patients with acute burns were reviewed. Acute pancreatitis was defined as abdominal pain and/or feeding intolerance in addition to a three-fold elevation of amylase and/or lipase. One-hundred twenty-seven burned children served as the control cohort. To assess the presence of autopsy confirmed AP in pediatric burn patients, we evaluated autopsy reports of 78 children who died from burns, looking for reported evidence of pancreatic inflammation, and fat/parenchymal necrosis. Our data show that acute pancreatitis in children has a low incidence after burn. The study included 2699 patients of which 13 were suffering acute pancreatitis (13/2699 = 0.05%). Mortality is significantly higher for the acute pancreatitis group vs. the control group, p < 0.05. Autopsy reports established 11 of 78 patients with evidence of pancreatitis, resulting in an incidence of 0.17% for pancreatitis at autopsy. Although it has low incidence, acute pancreatitis is associated with increased mortality in severely burned pediatric patients, which underlines the importance of increased vigilance in the evaluation and treatment of pancreatitis in burned children.

A comparison of the consensus and clinical definitions of pancreatitis with a proposal to redefine post-endoscopic retrograde cholangiopancreatography pancreatitis

OBJECTIVES

We evaluated the correlation between the consensus and clinical definitions of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP), with the objective of updating and revising the definition of post-ERCP pancreatitis (PEP).

METHODS

Three hundred patients were subjected to serial serum amylase & lipase levels testing and abdominal computed tomography scan for abdominal pain after ERCP. Main outcome measures included the correlation between consensus and clinical definitions.

RESULTS

Using consensus criteria, 25 patients had acute pancreatitis (11 of mild and 14 of moderate severity). Forty-three patients had acute pancreatitis using the clinical definitions (18 of mild and 25 of moderate severity). At 4 hours, serum hyperamylasemia of under 1.5-fold and at 12 hours a serum hyperamylasemia of under 2-fold had a negative predictive value of 0.94 for development of PEP. Serum hyperamylasemia following ERCP had a poor positive predictive value for PEP.

CONCLUSIONS

Clinical and consensus definitions are poorly correlated; use of the latter leads to significant underrecognition of PEP. The adoption of clinical definition results in uniformity of diagnosis of pancreatitis for clinical care and research. Serum amylase levels at 4 and 12 hours after ERCP have a high negative predictive value for PEP.

Acute pancreatitis

Acute pancreatitis is a common disease most frequently caused by gallstone disease or excess alcohol ingestion. Diagnosis is usually based on characteristic symptoms, often in conjunction with elevated serum pancreatic enzymes. Imaging is not always necessary, but may be performed for many reasons, such as to confirm a diagnosis of pancreatitis, rule out other causes of abdominal pain, elucidate the cause of pancreatitis, or to evaluate for complications such as necrosis or pseudocysts. Though the majority of patients will have mild, self-limiting disease, some will develop severe disease associated with organ failure. These patients are at risk to develop complications from ongoing pancreatic inflammation such as pancreatic necrosis, fluid collections, pseudocysts, and pancreatic duct disruption. Validated scoring systems can help predict the severity of pancreatitis, and thus, guide monitoring and intervention.Treatment of acute pancreatitis involves supportive care with fluid replacement, pain control, and controlled initiation of regular food intake. Prophylactic antibiotics are not recommended in acute pancreatitis if there is no evidence of pancreatic infection. In patients who fail to improve, further evaluation is necessary to assess for complications that require intervention such as pseudocysts or pancreatic necrosis. Endoscopy, including ERCP and EUS, and/or cholecystectomy may be indicated in the appropriate clinical setting. Ultimately, the management of the patient with severe acute pancreatitis will require a multidisciplinary approach.

Acute Pancreatitis in the Postoperative Course after Esophagectomy: A Major Complication Described in 4 Patients

Background

Postoperative pancreatitis is a rare but devastating complication after esophageal surgery. It has been described in connection with abdominal surgery but the etiology in connection with esophageal surgery has never been evaluated. The present study describes 4 cases of postoperative pancreatitis, and a hypothesis about the etiology is formed.

Methods

We performed a search for patients with postoperative pancreatitis after esophagectomy using our prospective database including all patients that underwent esophageal resection at our institution between 1993 and 2008. Pancreatitis was described as abdominal pain, hyperamylasemia, signs of pancreatitis on CT scan or findings during laparotomy or autopsy.

Results

A total of 950 patients underwent esophagectomy at our institution, 4 patients developed postoperative pancreatitis (incidence 0.4%). Two out of four patients died. Discussion: Pancreatitis following esophageal surgery is a serious, potentially lethal complication. Diagnosis can be difficult as clear clinical or laboratory findings might be lacking. Peroperative manipulation of the pancreas, mobilization of the duodenum or compromized vascularization have been suggested as etiological factors; although in the described patients, none of these factors were identified as the cause of pancreatitis. In conclusion, pancreatitis following esophageal surgery is a serious but rare complication that should always be considered in patients who deteriorate postoperatively.

Acute pancreatitis: a historical perspective

Among the various pancreatic disorders, the pace of scientific discovery in acute pancreatitis has been particularly slow. The objective of this paper was to briefly review the history of scientific discovery of the clinical features, pathophysiology, and treatment of acute pancreatitis. A clinical description of acute pancreatitis was first presented in 1652 by the Dutch anatomist Nicholas Tulp, and despite the nearly 350 years that have passed, there continue to be many unanswered questions. In the late 19th and early 20th century, Reginald Fitz, Nicholas Senn, Eugene Opie, and others made seminal contributions that continue to influence our present understanding of acute pancreatitis. Despite remarkable progress in the past 6 decades, our ability to accurately diagnose and estimate the severity of acute pancreatitis remains limited. History provides multiple examples of empiric remedies and surgical interventions based on the prevailing theories and opinions of the scientific luminaries du jour, and indeed, after 3 centuries of inquiry, the most effective interventions for acute pancreatitis are purely supportive in nature and not specific to the pancreas. However, the perseverance of successive generations of the finest scientific minds provides hope that we will unravel the many mysteries of this enigmatic gland.

Accurate quantitation of salivary and pancreatic amylase activities in human plasma by microchip electrophoretic separation of the substrates and hydrolysates coupled with immunoinhibition

A high-performance determination system for alpha-amylase isoenzyme activities in human plasma involving microchip electrophoresis with a plastic chip was developed. The combination of microchip electrophoresis for substrate and hydrolysate separation and an immunoinhibition method for the differentiation of isoenzyme activities using antihuman salivary amylase (S-AMY) mAb allowed the highly selective determination of amylase isoenzyme (S-AMY and pancreatic amylase (P-AMY)) activities even in a complex matrix such as a crude plasma sample. We used 8-aminopyrene-1,3,6-trisulfonic acid (APTS)-labeled maltohexaose (G6) as a substrate. Amylase in a human plasma sample hydrolyzed APTS-G6 into APTS-maltotriose (G3) and G3, which was measured as the fluorescence intensity of APTS-G3 on microchip electrophoresis. A double logarithm plot revealed a linear relationship between amylase activity and fluorescence intensity in the range of 5-500 U/L of amylase activity (r2=0.9995, p<0.01), and the LOD was 4.38 U/L. Amylase activities in 13 subjects determined by the present method were compared with the results obtained by conventional methods with nitrophenylated oligosaccharides as substrates, respectively. Good correlations were observed for each method on simple linear regression analysis (both p<0.01). The reproducibilities of within-days for total amylase and P-AMY were 2.98-6.27 and 3.83-6.39%, respectively, and these between-days were 2.88-5.66 and 3.64-5.63%, respectively. This system enables us to determine amylase isoenzyme activities in human plasma with high sensitivity and accuracy, and thus will be applicable to clinical diagnosis.

Therapeutic proteasome inhibition in experimental acute pancreatitis

AIM: To establish the therapeutic potential of proteasome inhibition, we examined the therapeutic effects of MG132 (Z-Leu-Leu-Leu-aldehyde) in an experimental model of acute pancreatitis.

METHODS: Pancreatitis was induced in rats by two hourly intraperitoneal (ip) injections of cholecystokinin octapeptide (CCK; 2 × 100 μg/kg) and the proteasome inhibitor MG132 (10 mg/kg ip) was administered 30 min after the second CCK injection. Animals were sacrificed 4 h after the first injection of CCK.

RESULTS: Administering the proteasome inhibitor MG132 (at a dose of 10 mg/kg, ip) 90 min after the onset of pancreatic inflammation induced the expression of cell-protective 72 kDa heat shock protein (HSP72) and decreased DNA-binding of nuclear factor-κB (NF-κB).

Furthermore MG132 treatment resulted in milder inflammatory response and cellular damage, as revealed by improved laboratory and histological parameters of pancreatitis and associated oxidative stress.

CONCLUSION: Our findings suggest that proteasome inhibition might be beneficial not only for the prevention, but also for the therapy of acute pancreatitis.

Comparison of lipase activity in peritoneal fluid of dogs with different pathologies--a complementary diagnostic tool in acute pancreatitis?

A clinical diagnosis of acute pancreatitis is often difficult to obtain. Histopathology remains the gold standard, whereas clinical signs, diagnostic imaging and laboratory testing, even in combination, may be insufficient. In a prospective study, lipase activity in ascitic fluid of various aetiologies was determined in 44 dogs in order to investigate its performance in cases of acute pancreatitis. Data of simultaneously determined blood lipase activities were available in 27 dogs. Lipase activity was measured by a colorimetric assay. A complete peritoneal fluid analysis was performed. Dogs were divided into four groups, according to their final diagnosis: acute pancreatitis (A), abdominal trauma (B), abdominal neoplasia (C) and others (hepatic or cardiac diseases) (D). Dogs with acute pancreatitis had a significantly higher peritoneal lipase activity than those in other groups (P < or = 0.024), while no significant difference was found between the other groups (P > or = 0.734). Blood lipase activity as well as protein content and total cell count of the ascitic fluid did not show any significant difference between groups. Data show that determination of lipase activity in dogs that develop ascites may be useful in complementing the diagnosis of acute pancreatitis.

Severe hypophosphatemia associated with gallstone pancreatitis: a case report and review of the literature

Severe hypophosphatemia (<1.0 mg/dl) is a rarely reported complication of acute pancreatitis; when it does occur, it is typically attributed to alcohol abuse rather than the pancreatitis itself (1-5). In the literature, pancreatitis is not cited as a cause of hypophosphatemia (5, 6-16). Both pancreatitis and hypophosphatemia have widespread ramifications on human physiology, affecting hematologic, neural, hepatic, endocrine, respiratory, and renal systems. Given the possible synergistic consequences of pancreatitis and low serum phosphate, we emphasize the importance of recognizing hypophosphatemia as a complication of pancreatic inflammation.Herein, we report a case of acute pancreatitis unrelated to alcohol abuse associated with severe hypophosphatemia and review the pathophysiology.

In vitro and in vivo nuclear factor-kappaB inhibitory effects of the cell-penetrating penetratin peptide

Penetratin is a cationic cell-penetrating peptide that has been frequently used for the intracellular delivery of polar bioactive compounds. Recent studies have just revealed the major role of polyanionic membrane proteoglycans and cholesterol-enriched lipid rafts in the uptake of the peptide. Both proteoglycans and lipid-rafts influence inflammatory processes by binding a wide array of proinflammatory mediators; thus, we decided to analyze the effect of penetratin on in vitro and in vivo inflammatory responses. Our in vitro luciferase gene assays demonstrated that penetratin decreased transcriptional activity of nuclear factor-kappaB (NF-kappaB) in tumor necrosis factor (TNF)-stimulated L929 fibroblasts and lipopolysaccharide-activated RAW 264.7 macrophages. Penetratin also inhibited TNF-induced intercellular adhesion molecule-1 expression in human endothelial HMEC-1 cells. Exogenous heparan sulfate abolished the in vitro NF-kappaB inhibitory effects of the peptide. Uptake experiments showed that penetratin was internalized by all of the above-mentioned cell lines in vitro and rapidly entered the cells of the lung and pancreas in vivo. In an in vivo rat model of acute pancreatitis, a disease induced by elevated activities of stress-responsive transcription factors like NF-kappaB, pretreatment with only 2 mg/kg penetratin attenuated the severity of pancreatic inflammation by interfering with IkappaB degradation and subsequent nuclear import of NF-kappaB, inhibiting the expression of proinflammatory genes and improving the monitored laboratory and histological parameters of pancreatitis and associated oxidative stress.

Conservative management of acute pancreatitis: complications and outcome in a community-based hospital

OBJECTIVES

Acute pancreatitis remains a potentially life-threatening disease. Despite national and international consensus conferences, the management of acute pancreatitis still differs among hospitals and countries.

METHODS

This study analyzes the outcome of acute pancreatitis treated by a conservative strategy in a community-based hospital. The strategy followed a conservative interpretation of German consensus guidelines but did not determine medical decisions by a prospective protocol.

RESULTS

The analysis included 145 patients treated for acute pancreatitis in the St. Josef Hospital Oberhausen from 1998 to 2002. The etiology was alcoholic in 54.5% and biliary in 26.2% of patients (other causes, 18.6%). Only 1 patient died of septic multiorgan failure (mortality, 1/145; 0.7%). Severe complications occurred in only 22 patients, including renal failure (n = 7), ileus (n = 6), respiratory or cardiac failure (n = 7), need for surgery (n = 4), and sepsis (n = 11). Further complications included pneumonia, delirium, choledocholithiasis/cholecystitis, diabetes mellitus, convulsions, gastric/duodenal ulcers, and pericardial effusion. Of the 145 patients, 75 subjects had at least 1 complication. Fine-needle puncture, mechanical ventilation, hemoperfusion, and hemodialysis were rarely necessary. Computed tomography (CT) was performed in only 69 of 145 patients (47.6%) and showed pancreatic necrosis in 27 of the 69 patients. Maximal C-reactive protein during the first 72 hours and CT findings proved useful in predicting the outcome in univariate analyses. By logistic regression, however, complication rates were associated with Ranson score, but not with CT findings, C-reactive protein, sex, age, etiology, or serum enzymes.

CONCLUSIONS

A conservative management of acute pancreatitis in a community-based hospital results in a low rate of complications, mortality, and costs. Clinical assessment (eg, by Ranson score) is sufficient to predict the severity of pancreatitis in most patients. In this cohort, none of the patients were transferred to a specialized center over a 5-year period. Thus, almost all patients with acute pancreatitis can adequately and cost-effectively be cared for in community-based hospitals when following conservative guidelines.

The proteasome inhibitor MG132 protects against acute pancreatitis

The cell-permeant MG132 tripeptide (Z-Leu-Leu-Leu-aldehyde) is a peptide aldehyde proteasome inhibitor that also inhibits other proteases, including calpains and cathepsins. By blocking the proteasome, this tripeptide has been shown to induce the expression of cell-protective heat shock proteins (HSPs) in vitro. Effects of MG132 were studied in an in vivo model of acute pancreatitis. Pancreatitis was induced in male Wistar rats by injecting 2 x 100 microug/kg cholecystokinin octapeptide intraperitoneally (ip) at an interval of 1 h. Pretreating the animals with 10 mg/kg MG132 ip before the induction of pancreatitis significantly inhibited IkappaB degradation and subsequent activation of nuclear factor-kappaB (NF-kappaB). MG132 also increased HSP72 expression. Induction of HSP72 and inhibition of NF-kappaB improved parameters of acute pancreatitis. Thus MG132 significantly decreased serum amylase, pancreatic weight/body weight ratio, pancreatic myeloperoxidase activity, proinflammatory cytokine concentrations, and the expression of pancreatitis-associated protein. Parameters of oxidative stress (GSH, MDA, SOD, etc.) were improved in both the serum and the pancreas. Histopathological examinations revealed that pancreatic specimens of animals pretreated with the peptide demonstrated milder edema, cellular damage, and inflammatory activity. Our findings show that simultaneous inhibition of calpains, cathepsins, and the proteasome with MG132 prevents the onset of acute pancreatitis.

Ascites in the puerperium: a missed diagnosis of acute postpartum pancreatitis

INTRODUCTION

Acute pancreatitis in pregnancy is often associated with severe morbidity. It is usually an antepartum problem occurring in late pregnancy. It rarely occurs in the postpartum period and when it does diagnosis can be difficult.

CASE REPORT

We report a case of 'unexplained' ascites following ventouse delivery, diagnosed 6 weeks later as acute pancreatitis.

CONCLUSION

Although it is rare, acute pancreatitis must be considered when evaluating patients presenting with abdominal pain and/or ascites in the postpartum period. Serum amylase may not always be elevated and early recourse to CT scan will facilitate diagnosis and allow for appropriate management.

Acute pancreatitis as an initial symptom of systemic lupus erythematosus: A case report and review of the literature

Acute pancreatitis as an initial symptom of systemic lupus erythematosus (SLE) is rare. We present a report of a 46-year-old female patient who had fever, abdominal pain and vomiting, elevated pancreatic enzyme levels, hypocalcemia, hypoxemia, and various other laboratory abnormalities. She was first diagnosed with acute severe pancreatitis and then with SLE after further investigations. After a 2-mo treatment with somatostatin, the patient recovered.

Serum elastase in the diagnosis of acute pancreatitis: a prospective study

BACKGROUND

The aim of the present study was to evaluate the usefulness of the elastase 1 (E1) enzyme-linked immunosorbent assay (ELISA) in the diagnosis of acute pancreatitis. This is the first Australian evaluation of the E1 ELISA.

METHODS

Three groups of patients were prospectively assessed: control patients, patients with acute pancreatitis, and patients with acute non-pancreatitic abdominal pain. Serum was collected on all patients on admission and the sensitivity, specificity and diagnostic accuracy of serum elastase, amylase and lipase was determined.

RESULTS

Twenty-nine patients with 30 episodes of pancreatitis, 38 patients with acute non-pancreatitic abdominal pain and 121 control patients were studied. For all patient episodes E1 ELISA at a cut-off of 3.5 ng/mL had a sensitivity of 80%, specificity of 96% and an efficiency of 94% in the diagnosis of acute pancreatitis. For episodes more than 48 h after onset of symptoms, sensitivity was 100%, specificity was 96% and diagnostic efficiency was 96%. This performance was equivalent to amylase but inferior to lipase.

CONCLUSION

Of the biochemical markers for pancreatitis currently available, lipase is the most useful. The relatively inferior sensitivity and problematic reference range for the ELISA E1, together with its limitations in measuring total elastase, currently prevent its widespread use.

Plasmapheresis in the management of acute severe hyperlipidemic pancreatitis: report of 5 cases

BACKGROUND/AIM

Hyperlipidemic pancreatitis is an acute and potentially life-threatening complication of hypertriglyceridemia that can be provoked when triglyceride levels (TGL) exceed 11.3 mmol/l (1,000 mg/dl). Except for standard symptomatic treatment, plasmapheresis has been performed to rapidly reduce TGL and chylomicron levels in the blood. In 5 patients with hyperlipidemic pancreatitis, treatment with plasmapheresis was evaluated.

METHODS

Five male patients who suffered from acute pancreatitis with severe primary hyperlipidemia were studied. In addition to the standard treatment, they were treated with plasmapheresis.

RESULTS

Plasma exchange lowered the lipid level and TGLs in all cases. It also improved abdominal pain, the clinical state of the patients, and signs and symptoms of the disease. Complications of treatment were not encountered, none of the patients died and only 1 patient underwent surgery. Follow-up of the patients lasted 4-28 months, and recurrence of pancreatitis was not noted.

CONCLUSION

Our study showed that plasmapheresis was successfully applied in patients with hyperlipidemic pancreatitis, especially to improve the acute phase of the disease.

Comparison of sensitivity and specificity of serum poly-C avid ribonuclease activity and C-reactive protein concentration in detection of mild and severe acute pancreatitis

The aim of this study was to compare diagnostic performance of C-reactive protein (CRP) and poly-C avid ribonuclease (P-RNase) levels in the prediction of a severe clinical course of acute pancreatitis (AP). The study included 36 patients with mild and 20 with severe AP. CRP concentration was measured by an immunonephelometric method and P-RNase activity by the rate of polycytidylate hydrolysis at pH 7.8. At the time of admission, both P-RNase and CRP levels were significantly increased in all patients when compared to healthy subjects (29.2 vs. 18.7 U/l and 91.1 vs. 2.89 mg/l; p < 0.001). Up to days 3 and 4 a further increase in P-RNase was observed. On the other hand, the increase in CRP continued only through days 2 and 3 (p < 0.001). Severe acute pancreatitis (SAP) and mild acute pancreatitis (MAP) differed significantly with respect to P-RNase levels on all days studied; whereas CRP levels differed significantly on days 2-5 but did not differ at admission. Receiver operating characteristic (ROC) curve function analysis yielded the best sensitivity of SAP detection for P-RNase, equaling 72.2%, at the cut-off point value 65.3 U/l on day 3 after admission. The sensitivity of CRP for detection of SAP was 85.0% at 125.7 mg/l on the 2nd day after admission. Both parameters studied were significantly associated with the severity of the AP clinical course; however, on days 1 and 2 post-admission, P-RNase was more specific for detection of SAP than CRP (94.4% vs. 77.1% on the 1st day and 94.4% vs. 55.5% on the 2nd day). In conclusion, P-RNase has shown an excellent performance for early differentiation of acute necrotizing pancreatitis.

Pancreatitis induced by pegylated interferon alfa-2b in a patient affected by chronic hepatitis C

A middle-aged man was admitted to the ED because of nausea and vomiting, abdominal distention and fainting. A blood analysis revealed high levels of serum amylase and lipase, confirming a diagnosis of acute pancreatitis. The history showed that the patient had self-administered a single dose of pegylated interferon alfa-2b and ribavirin daily for 7 days for chronic hepatitis C. The medications were stopped and his condition gradually improved. In agreement with the literature and the Naranjo algorythm result, pegylated interferon alfa-2b is associated with acute pancreatitis. Identification of a few signs and symptoms is the first 'signal' in preventing a serious drug-induced adverse event.

Magnetic resonance imaging in patients with pancreatitis: evaluation of signal intensity and enhancement changes

PURPOSE

To evaluate the utility of unenhanced and enhanced T1-weighted fat-suppressed (T1-FS) magnetic resonance imaging (MRI) in detecting pancreatitis.

MATERIALS AND METHODS

1.5-T MRI was performed in 25 patients with acute and 23 patients with chronic pancreatitis and in 20 control subjects without known pancreatic disease. T1-FS spin-echo and contrast-enhanced arterial-predominant (DYN1) and portal-predominant (DYN2) fast multiplanar spoiled gradient-echo (FMPSPGR) sequences were evaluated. These three sets of images were evaluated both subjectively for decreased or heterogeneous signal intensity (rating scale, 0-3) and objectively (region of interest (ROI)) in the head, body, and tail of the pancreas, in each patient.

RESULTS

Good correlation between subjective assessment and objective data was demonstrated. The T1-FS sequence showed an abnormality with greater frequency (T1-FS > DYN1, 81/144 scores; T1-FS = DYN1, 63/144 scores; T1-FS < DYN1, 0/144 scores) and magnitude (average subjective score, 2.48 vs. 1.74; P < 0.0003) than that of the contrast-enhanced FMPSPGR (decreased or heterogeneous enhancement). The overall sensitivity and specificity of MRI was 92% and 50%, respectively. On the basis of signal intensity and enhancement, MRI was not able to differentiate acute from chronic pancreatitis.

CONCLUSION

MRI was highly sensitive for disease detection, particularly using the T1-FS sequence, but using the sequences described, was not able to differentiate acute from chronic pancreatitis.

Acute and chronic pancreatitis

Acute pancreatitis has multiple causes, an unpredictable course, and myriad complications. The diagnosis relies on a combination of history, physical examination, serologic markers, and radiologic findings. The mainstay of therapy includes aggressive hydration, maintenance of NPO, and adequate analgesia with narcotics. Antibiotic and nutritional support with total parenteral nutrition should be used when appropriate.