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Chen Y, Tao H, Chen R, Pan Y, Wang J, Gao R, Chen J, Yang J. Biomimetic Nanoparticles Loaded with Ulinastatin for the Targeted Treatment of Acute Pancreatitis. Mol Pharm 2023; 20:4108-4119. [PMID: 37349264 DOI: 10.1021/acs.molpharmaceut.3c00238] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Ulinastatin is commonly used in the clinic to treat acute pancreatitis (AP), but its therapeutic effect was limited by the presence of the blood-pancreas barrier (BPB) and low specificity. Here, we prepared a macrophage biomimetic nanoparticle (MU) that delivered ulinastatin to address the above issues. Macrophage membrane was used as a shell for a mixture of PEG-PLGA and ulinastatin. It was found that MU showed good stability and biocompatibility in vitro and in vivo. According to in vivo fluorescence imaging, MU displayed a great inflammation targeting effect both in a subcutaneous inflammation model and in situ pancreatitis mouse model, which was ascribed to the presence of adhesion proteins. In vitro and in vivo results demonstrated that MU have a superior AP treatment effect by inhibiting pro-inflammatory factors and keeping cells viability. It was suggested the MU could provide a new strategy for targeted AP treatment.
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Affiliation(s)
- Yunlong Chen
- Department of Hepatobiliary Surgery I, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
- Research Laboratory for Biomedical Optics and Molecular Imaging, CAS Key Laboratory of Health Informatics, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Haisu Tao
- Department of Hepatobiliary Surgery I, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
- NHC Key Laboratory of Prevention and Treatment of Central Asia High Incidence Diseases, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, Xinjiang 832000, China
| | - Rui Chen
- Department of Hepatobiliary Surgery I, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
- Biliary Surgical Department of West China Hospital, Sichuan University, Chengdu, Sichuan 610064, China
| | - Yingying Pan
- Research Laboratory for Biomedical Optics and Molecular Imaging, CAS Key Laboratory of Health Informatics, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
- Department of Medical Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Junfeng Wang
- Department of Hepatobiliary Surgery I, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
| | - Rongkang Gao
- Research Laboratory for Biomedical Optics and Molecular Imaging, CAS Key Laboratory of Health Informatics, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Jingqin Chen
- Research Laboratory for Biomedical Optics and Molecular Imaging, CAS Key Laboratory of Health Informatics, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Jian Yang
- Department of Hepatobiliary Surgery I, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
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Vázquez-Frias R, Rivera-Suazo Y, Aguayo-Elorriaga AK, Alfaro-Bolaños JE, Argüello-Arévalo GA, Cadena-León JF, Chávez-Sáenz JA, Consuelo-Sánchez A, Cruz-Romero EV, Espinosa-Saavedra D, Espriu-Ramírez MX, Flores-Calderón J, González-Ortiz B, Hernández-Rosiles V, Ignorosa-Arellano KR, Jaramillo-Esparza CM, Lozano-Hernández FR, Larrosa-Haro A, Leal-Quiroga U, Macias-Flores JA, Martínez-Leo BA, Martínez-Vázquez A, Mendoza-Tavera NMJ, Pacheco-Sotelo S, Reyes-Apodaca M, Sánchez-Ramírez CA, Sifuentes-Vela CA, Sosa-Arce M, Zárate-Mondragón FE. The Asociación Mexicana de Gastroenterología consensus on the diagnosis and treatment of acute pancreatitis in children and adolescents. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:267-281. [PMID: 37336694 DOI: 10.1016/j.rgmxen.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/12/2023] [Indexed: 06/21/2023]
Abstract
Acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are conditions, whose incidence is apparently on the rise. Despite the ever-increasing evidence regarding the management of AP in children and adults, therapeutic actions that could potentially affect having a poor prognosis in those patients, especially in the pediatric population, continue to be carried out. Therefore, the Asociación Mexicana de Gastroenterología convened a group of 24 expert pediatric gastroenterologists from different institutions and areas of Mexico, as well as 2 pediatric nutritionists and 2 specialists in pediatric surgery, to discuss different aspects of the epidemiology, diagnosis, and treatment of AP and RAP in the pediatric population. The aim of this document is to present the consensus results. Different AP topics were addressed by 6 working groups, each of which reviewed the information and formulated statements considered pertinent for each module, on themes involving recommendations and points of debate, concerning diagnostic or therapeutic approaches. All the statements were presented and discussed. They were then evaluated through a Delphi process, with electronic and anonymous voting, to determine the level of agreement on the statements. A total of 29 statements were formulated, all of which reached above 75% agreement in the first round of voting.
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Affiliation(s)
- R Vázquez-Frias
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Instituto Nacional de Salud, Mexico City, Mexico.
| | - Y Rivera-Suazo
- Hospital Star Médica Infantil Privado, Mexico City, Mexico
| | - A K Aguayo-Elorriaga
- Hospital Pediátrico Coyoacán, Secretaría de Salud de la Ciudad de México, Mexico City, Mexico
| | - J E Alfaro-Bolaños
- Servicio de Gastroenterología, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | | | - J F Cadena-León
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Mexico City, Mexico
| | | | - A Consuelo-Sánchez
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Instituto Nacional de Salud, Mexico City, Mexico
| | - E V Cruz-Romero
- Servicio de Cirugía, Centro Médico Naval, Mexico City, Mexico
| | - D Espinosa-Saavedra
- Departamento de Gastroenterología, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - M X Espriu-Ramírez
- Servicio de Gastroenterología Pediátrica, Hospital General de Cancún Dr. Jesús Kumate Rodríguez, Cancún, Quintana Roo, Mexico
| | - J Flores-Calderón
- Departamento de Gastroenterología, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - B González-Ortiz
- Departamento de Gastroenterología, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - V Hernández-Rosiles
- Departamento de Gastroenterología y Nutrición, Hospital Infantil de México Federico Gómez, Instituto Nacional de Salud, Mexico City, Mexico
| | - K R Ignorosa-Arellano
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - C M Jaramillo-Esparza
- Departamento de Gastroenterología y Endoscopia Pediátrica, Hospital Ángeles Universidad, Mexico City, Mexico
| | - F R Lozano-Hernández
- Servicio de Gastroenterología Pediátrica, Centro Médico Naval, Mexico City, Mexico
| | - A Larrosa-Haro
- Instituto de Nutrición Humana, Centro Universitario de Ciencias de la Salud, Departamento de Reproducción Humana Crecimiento y Desarrollo Infantil, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - U Leal-Quiroga
- Servicio de Gastroenterología, Christus Muguerza Hospital Sur, Monterrey, Nuevo León, Mexico
| | - J A Macias-Flores
- Departamento de Gastroenterología, Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Chihuahua, Mexico
| | - B A Martínez-Leo
- Hospital Pediátrico Moctezuma, Secretaría de Salud de la Ciudad de México, Mexico City, Mexico
| | - A Martínez-Vázquez
- Departamento de Gastroenterología y Nutrición Pediátrica, Hospital para el Niño Poblano, Puebla, Puebla, Mexico
| | | | - S Pacheco-Sotelo
- Servicio de Gastroenterología y Nutrición Pediátrica, UMAE, Hospital de Pediatría, Centro Médico Nacional de Occidente, Instituto Mexicano de Seguro Social, Guadalajara, Jalisco, Mexico
| | - M Reyes-Apodaca
- Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | | | | | - M Sosa-Arce
- Departamento de Gastroenterología, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - F E Zárate-Mondragón
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, Mexico City, Mexico
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Zerem E, Kurtcehajic A, Kunosić S, Zerem Malkočević D, Zerem O. Current trends in acute pancreatitis: Diagnostic and therapeutic challenges. World J Gastroenterol 2023; 29:2747-2763. [PMID: 37274068 PMCID: PMC10237108 DOI: 10.3748/wjg.v29.i18.2747] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/07/2023] [Accepted: 04/18/2023] [Indexed: 05/11/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.
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Affiliation(s)
- Enver Zerem
- Department of Medical Sciences, The Academy of Sciences and Arts of Bosnia and Herzegovina, Sarajevo 71000, Bosnia and Herzegovina
| | - Admir Kurtcehajic
- Department of Gastroenterology and Hepatology, Plava Medical Group, Tuzla 75000, Bosnia and Herzegovina
| | - Suad Kunosić
- Department of Physics, Faculty of Natural Sciences and Mathematics, University of Tuzla, Tuzla 75000, Bosnia and Herzegovina
| | - Dina Zerem Malkočević
- Department of Internal Medicine, Cantonal Hospital “Safet Mujić“ Mostar, Mostar 88000, Bosnia and Herzegovina
| | - Omar Zerem
- Department of Internal Medicine, Cantonal Hospital “Safet Mujić“ Mostar, Mostar 88000, Bosnia and Herzegovina
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Analgesia in the Initial Management of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. World J Surg 2022; 46:878-890. [PMID: 34994837 DOI: 10.1007/s00268-021-06420-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal analgesic strategy for patients with acute pancreatitis (AP) remains unknown. OBJECTIVE The present systematic review and meta-analysis aims to compare the efficacy of different analgesic modalities trialled in AP. METHODS A systematic search of PubMed, MEDLINE, EMBASE, CENTRAL, SCOPUS and Web of Science conducted up until June 2021, identified all randomised control trials (RCTs) comparing analgesic modalities in AP. A pooled analysis was undertaken of the improvement in pain scores as reported on visual analogue scale (VAS) on day 0, day 1 and day 2. RESULTS Twelve RCTs were identified including 542 patients. Seven trial drugs were compared: opiates, non-steroidal anti-inflammatories (NSAIDs), metamizole, local anaesthetic, epidural, paracetamol, and placebo. Across all modalities, the pooled VAS scores showed global improvement from baseline to day 2. Epidural analgesia appears to provide the greatest improvement in VAS within the first 24 h but is equivalent to opiates by 48 h. Within 24 h, NSAIDs offered similar pain-relief to opiates, while placebo also showed equivalence to other modalities but then plateaued. Local anaesthetics demonstrated least overall efficacy. VAS scores for opiate and non-opiate analgesics were comparable at baseline and day 1. The identified RCTs demonstrated significant statistical and methodological heterogeneity in pain-relief reporting. CONCLUSIONS There is remarkable paucity of level 1 evidence to guide pain management in AP with small datasets per study. Epidural administration appears effective within the first 24 h of AP although infrequently used and featured in only a single RCT. NSAIDs are an effective opiate sparing alternative during the first 24 h.
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Luo L, Qiu Q, Huang F, Liu K, Lan Y, Li X, Huang Y, Cui L, Luo H. Drug repurposing against coronavirus disease 2019 (COVID-19): A review. J Pharm Anal 2021; 11:683-690. [PMID: 34513115 PMCID: PMC8416689 DOI: 10.1016/j.jpha.2021.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/16/2021] [Accepted: 09/03/2021] [Indexed: 02/07/2023] Open
Abstract
Since December 2019, severe acute respiratory syndrome coronavirus 2 has been found to be the culprit in the coronavirus disease 2019 (COVID-19), causing a global pandemic. Despite the existence of many vaccine programs, the number of confirmed cases and fatalities due to COVID-19 is still increasing. Furthermore, a number of variants have been reported. Because of the absence of approved anti-coronavirus drugs, the treatment and management of COVID-19 has become a global challenge. Under these circumstances, drug repurposing is an effective method to identify candidate drugs with a shorter cycle of clinical trials. Here, we summarize the current status of the application of drug repurposing in COVID-19, including drug repurposing based on virtual computer screening, network pharmacology, and bioactivity, which may be a beneficial COVID-19 treatment. Mechanism of SARS-CoV-2 infection and drug targets were reviewed. Drug repurposing against COVID-19 based on computer virtual screening, network pharmacology, bioactivity were summarized. The use of drug repurposing in COVID-19 was addressed.
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Affiliation(s)
- Lianxiang Luo
- The Marine Biomedical Research Institute, Guangdong Medical University, Zhanjiang, 524023, Guangdong, China.,Marine Medical Research Institute of Zhanjiang, Zhanjiang, 524023, Guangdong, China
| | - Qin Qiu
- Graduate School, Guangdong Medical University, Zhanjiang, 524023, Guangdong, China
| | - Fangfang Huang
- Graduate School, Guangdong Medical University, Zhanjiang, 524023, Guangdong, China
| | - Kaifeng Liu
- The First Clinical College, Guangdong Medical University, Zhanjiang, 524023, Guangdong, China
| | - Yongqi Lan
- The First Clinical College, Guangdong Medical University, Zhanjiang, 524023, Guangdong, China
| | - Xiaoling Li
- Animal Experiment Center, Guangdong Medical University, Zhanjiang, 524023, Guangdong, China
| | - Yuge Huang
- Department of Pediatrics, the Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524023, Guangdong, China
| | - Liao Cui
- Guangdong Key Laboratory for Research and Development of Natural Drugs, Guangdong Medical University, Zhanjiang, Guangdong, 524023, China
| | - Hui Luo
- The Marine Biomedical Research Institute, Guangdong Medical University, Zhanjiang, 524023, Guangdong, China
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Hussain A, Kaler J, Dubey AK. Emerging Pharmaceutical Treatments of Novel COVID-19: A Review. Cureus 2020; 12:e8260. [PMID: 32596078 PMCID: PMC7313429 DOI: 10.7759/cureus.8260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/24/2020] [Indexed: 12/15/2022] Open
Abstract
As a new decade began, COVID-19 quickly gained importance as it became the cause of the current global pandemic. Research has been focusing on studying the structure of SARS-CoV-2 and investigates possible pharmaceutical approaches. With the number of cases increasing every day, globally, multiple drugs are being researched as possible candidates. Although multiple drugs show promise in the treatment of COVID-19 via either inhibiting viral replication or preventing fusion of the virus to the ACE2 receptors, further investigation is still warranted and necessary before the admission of any type of pharmaceutical agent. Furthermore, several supplements have also been documented in being utilized as treatment of COVID-19. The exact mechanism and efficacy of current candidate drugs are still being explored through clinical trials. Despite the advancements in current research with emerging treatments, social distancing and engaging in preventative measures remains crucial to attempt to prevent the occurrence of more cases and deaths, worldwide. This review explores various drugs and their mechanism of action which are either currently being used in clinical trials or may be used in the future for the treatment of COVID-19.
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Affiliation(s)
- Azhar Hussain
- Healthcare Administration, Franklin University, Columbus, USA
- Medicine, Xavier University School of Medicine, Oranjestad, ABW
| | - Jasndeep Kaler
- Medicine, Xavier University School of Medicine, Oranjestad, ABW
| | - Arun Kumar Dubey
- Pharmacology, Xavier University School of Medicine, Oranjestad, ABW
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Wang J, Cheng S, Hu L, Huang T, Huang Z, Hu S. Association of asparaginase-associated pancreatitis and ULK2 gene polymorphism. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2020; 13:347-356. [PMID: 32269672 PMCID: PMC7137003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/27/2019] [Indexed: 06/11/2023]
Abstract
The purpose of the study was to analyze the clinical characteristics and the course of diagnosis and therapy of asparaginase-associated pancreatitis (AAP) in childhood, improve the ability of diagnosis and treatment, and evaluate ULK2 gene polymorphism as a predictive factor for AAP. Data of 12 patients with childhood AAP were reviewed. Sanger sequencing of ULK2 gene was performed in AAP group (n=12) and control group (n=146). The main symptoms of AAP were abdominal pain and vomiting. Generally, the levels of amylase and lipase in the serum peaked within 72 h. Abdominal ultrasonography was performed in 11 patients; seven patients exhibited findings of pancreatic enlargement. Computed tomography was performed in 9 patients. Five patients exhibited findings of pancreatic enlargement and peri-pancreatic exudation. All patients were managed by fasting at the early stage, and seven patients underwent placement of a nasojejunal tube to receive enteral nutrition. One patient underwent endoscopic retrograde cholangiopancreatography (revealing dilation of the pancreatic duct) and endoscopic retrograde pancreatic drainage. Another patient developed signs of shock and received continuous renal replacement. There were no deaths caused by AAP. Therefore, early identification of patients at risk of AAP is of great importance. In addition, repeated elevation in the levels of pancreatic enzymes is indicative of complications. Sanger sequencing analysis of ULK2 gene showed that there was a significant difference of EXON1: -493C>T and EXON1: -308C>G between the AAP group and control group (P<0.0001). Thus, ULK2 gene polymorphism may be associated with the development of AAP. However, more validation of this finding is needed.
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Affiliation(s)
- Juxiang Wang
- Department of Hematology and Oncology, The Children’s Hospital of Soochow UniversitySuzhou, China
- Department of Hematology and Oncology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical UniversityWenzhou, China
| | - Shengqin Cheng
- Department of Hematology and Oncology, The Children’s Hospital of Soochow UniversitySuzhou, China
| | - Linglong Hu
- Department of Hematology and Oncology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical UniversityWenzhou, China
| | - Tingting Huang
- Department of Hematology and Oncology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical UniversityWenzhou, China
| | - Zhen Huang
- Department of Hematology and Oncology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical UniversityWenzhou, China
| | - Shaoyan Hu
- Department of Hematology and Oncology, The Children’s Hospital of Soochow UniversitySuzhou, China
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Párniczky A, Lantos T, Tóth EM, Szakács Z, Gódi S, Hágendorn R, Illés D, Koncz B, Márta K, Mikó A, Mosztbacher D, Németh BC, Pécsi D, Szabó A, Szücs Á, Varjú P, Szentesi A, Darvasi E, Erőss B, Izbéki F, Gajdán L, Halász A, Vincze Á, Szabó I, Pár G, Bajor J, Sarlós P, Czimmer J, Hamvas J, Takács T, Szepes Z, Czakó L, Varga M, Novák J, Bod B, Szepes A, Sümegi J, Papp M, Góg C, Török I, Huang W, Xia Q, Xue P, Li W, Chen W, Shirinskaya NV, Poluektov VL, Shirinskaya AV, Hegyi PJ, Bátovský M, Rodriguez-Oballe JA, Salas IM, Lopez-Diaz J, Dominguez-Munoz JE, Molero X, Pando E, Ruiz-Rebollo ML, Burgueño-Gómez B, Chang YT, Chang MC, Sud A, Moore D, Sutton R, Gougol A, Papachristou GI, Susak YM, Tiuliukin IO, Gomes AP, Oliveira MJ, Aparício DJ, Tantau M, Kurti F, Kovacheva-Slavova M, Stecher SS, Mayerle J, Poropat G, Das K, Marino MV, Capurso G, Małecka-Panas E, Zatorski H, Gasiorowska A, Fabisiak N, Ceranowicz P, Kuśnierz-Cabala B, Carvalho JR, Fernandes SR, Chang JH, Choi EK, Han J, Bertilsson S, Jumaa H, Sandblom G, Kacar S, Baltatzis M, Varabei AV, Yeshy V, Chooklin S, Kozachenko A, Veligotsky N, Hegyi P. Antibiotic therapy in acute pancreatitis: From global overuse to evidence based recommendations. Pancreatology 2019; 19:488-499. [PMID: 31068256 DOI: 10.1016/j.pan.2019.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Unwarranted administration of antibiotics in acute pancreatitis presents a global challenge. The clinical reasoning behind the misuse is poorly understood. Our aim was to investigate current clinical practices and develop recommendations that guide clinicians in prescribing antibiotic treatment in acute pancreatitis. METHODS Four methods were used. 1) Systematic data collection was performed to summarize current evidence; 2) a retrospective questionnaire was developed to understand the current global clinical practice; 3) five years of prospectively collected data were analysed to identify the clinical parameters used by medical teams in the decision making process, and finally; 4) the UpToDate Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was applied to provide evidence based recommendations for healthcare professionals. RESULTS The systematic literature search revealed no consensus on the start of AB therapy in patients with no bacterial culture test. Retrospective data collection on 9728 patients from 22 countries indicated a wide range (31-82%) of antibiotic use frequency in AP. Analysis of 56 variables from 962 patients showed that clinicians initiate antibiotic therapy based on increased WBC and/or elevated CRP, lipase and amylase levels. The above mentioned four laboratory parameters showed no association with infection in the early phase of acute pancreatitis. Instead, procalcitonin levels proved to be a better biomarker of early infection. Patients with suspected infection because of fever had no benefit from antibiotic therapy. CONCLUSIONS The authors formulated four consensus statements to urge reduction of unjustified antibiotic treatment in acute pancreatitis and to use procalcitonin rather than WBC or CRP as biomarkers to guide decision-making.
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Affiliation(s)
- Andrea Párniczky
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Heim Pál National Insititute of Pediatrics, Budapest, Hungary
| | - Tamás Lantos
- Department of Medical Physics and Informatics, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Eszter Margit Tóth
- Pándy Kálmán Hospital of Békés County, Gyula, Hungary; First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Szilárd Gódi
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Roland Hágendorn
- Intesive Care Unit, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dóra Illés
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Balázs Koncz
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Translational Medicine, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dóra Mosztbacher
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Balázs Csaba Németh
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary; Hungarian Academy of Sciences-University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Anikó Szabó
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Ákos Szücs
- First Department of Surgery, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Varjú
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Erika Darvasi
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Ferenc Izbéki
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - László Gajdán
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Adrienn Halász
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Imre Szabó
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gabriella Pár
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Judit Bajor
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - József Czimmer
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | - Tamás Takács
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - László Czakó
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | | | - János Novák
- Pándy Kálmán Hospital of Békés County, Gyula, Hungary
| | | | | | - János Sümegi
- Borsod-Abaúj-Zemplén County Hospital and University Teaching Hospital, Miskolc, Hungary
| | - Mária Papp
- Department of Internal Medicine, Division of Gastroenterology, University of Debrecen, Debrecen, Hungary
| | - Csaba Góg
- Healthcare Center of County Csongrád, Makó, Hungary
| | - Imola Török
- County Emergency Clinical Hospital of Targu Mures Hospital, University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Targu Mures, Romania
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Ping Xue
- Department of Integrated Traditional Chinese and Western Medicine, Shangjin Hospital, West China Medical School of Sichuan University, Chengdu, China
| | - Weiqin Li
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weiwei Chen
- Department of Gastroenterology, Subei People's Hospital of Jiangsu Province, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Natalia V Shirinskaya
- Omsk State Medical Information-Analytical Centre, Omsk State Clinical Emergency Hospital #2, Omsk, Russia
| | | | - Anna V Shirinskaya
- Department of Surgery and Urology, Omsk State Medical University, Omsk, Russia
| | - Péter Jenő Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Departement of Gastroenterology Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Marian Bátovský
- Departement of Gastroenterology Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Juan Armando Rodriguez-Oballe
- Department of Gastroenterology, University Hospital Santa María - University Hospital Arnau de Vilanova, Lerida, Spain
| | - Isabel Miguel Salas
- Department of Gastroenterology, University Hospital Santa María - University Hospital Arnau de Vilanova, Lerida, Spain
| | - Javier Lopez-Diaz
- Department of Gastroenterology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - J Enrique Dominguez-Munoz
- Department of Gastroenterology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Xavier Molero
- Exocrine Pancreas Research Unit, Hospital Universitari Vall d'Hebron - Institut de Recerca, Autonomous University of Barcelona, CIBEREHD, Barcelona, Spain
| | - Elizabeth Pando
- Department of Hepato-pancreato-biliary and Transplat Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Beatriz Burgueño-Gómez
- Digestive Diseases Department Clinical University Hospital of Valladolid, Valladolid, Spain
| | - Yu-Ting Chang
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Chu Chang
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ajay Sud
- Liverpool Pancreatitis Research Group, University of Liverpool and the Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Danielle Moore
- Liverpool Pancreatitis Research Group, University of Liverpool and the Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, University of Liverpool and the Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Amir Gougol
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - António Pedro Gomes
- Department of Surgery, Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal
| | | | - David João Aparício
- Department of Surgery, Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal
| | - Marcel Tantau
- Iuliu Hatieganu" University of Medicine and Pharmacy, Department of Internal Medicine, 3rd Medical Clinic and "Prof. Dr. Octavian Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Floreta Kurti
- Department of Gastroenterology and Hepatology, University Hospital Center "Mother Theresa", Tirana, Albania
| | - Mila Kovacheva-Slavova
- University Hospital "Tsaritsa Ioanna - ISUL", Departement of Gastroenterology, Sofia, Bulgaria
| | | | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Germany
| | - Goran Poropat
- Department of Gastroenterology, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Croatia
| | - Kshaunish Das
- Division of Gastroenterology, School of Digestive and Liver Diseases, IPGME &R, Kolkata, India
| | - Marco Vito Marino
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Ewa Małecka-Panas
- Department of Digestive Tract Diseases, Medical University of Lodz, Poland
| | - Hubert Zatorski
- Department of Digestive Tract Diseases, Medical University of Lodz, Poland
| | | | - Natalia Fabisiak
- Department of Gastroenterology Medical University of Lodz, Poland
| | - Piotr Ceranowicz
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Beata Kuśnierz-Cabala
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Joana Rita Carvalho
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Center, Hospital Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Samuel Raimundo Fernandes
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Center, Hospital Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Jae Hyuck Chang
- Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Kwang Choi
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, South Korea
| | - Jimin Han
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, South Korea
| | - Sara Bertilsson
- Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Health Sciences, Lund University, Lund, Sweden
| | - Hanaz Jumaa
- Eskilstuna Hospital, Mälarsjukhuset, Eskilstuna, Sweden
| | - Gabriel Sandblom
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Sabite Kacar
- Department of Gastroenterology Türkiye Yüksek İhtisas Hospital, Ankara, Turkey
| | - Minas Baltatzis
- Manchester Royal Infirmary Hospital, Manchester, United Kingdom
| | | | - Vizhynis Yeshy
- Department of Surgery, Belarusian Medical Academy Postgraduate Education, Minsk, Belarus
| | | | - Andriy Kozachenko
- Kharkiv Emergency Hospital, Medical Faculty of V. N. Karazin Kharkiv National University, Kharkiv, Ukraine
| | - Nikolay Veligotsky
- Department Thoraco-abdominal Surgery Kharkov Medical Academy Postgraduate Education, Kharkov, Ukraine
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary; Division of Translational Medicine, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences-University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary.
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9
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Abstract
Nearly all patients with acute pancreatitis (AP) experience some degree of abdominal pain that is severe enough to prompt medical evaluation and necessitate analgesia. Effective analgesia is a priority in caring for such patients. Despite its importance, strategies for pain management in AP have been poorly studied, particularly in the field of pediatrics. Presently, no published data examine the management of pain because of AP in children at the time of initial presentation. Management approaches are often extrapolated from adult practice and based on anecdotal experience in the absence of objective data. The aim of our study was to examine the initial provision of analgesia to children who presented to a pediatric emergency department with AP.
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10
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Mourad MM, Evans R, Kalidindi V, Navaratnam R, Dvorkin L, Bramhall SR. Prophylactic antibiotics in acute pancreatitis: endless debate. Ann R Coll Surg Engl 2017; 99:107-112. [PMID: 27917667 PMCID: PMC5392851 DOI: 10.1308/rcsann.2016.0355] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2016] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality. MATERIALS AND METHODS A non-systematic review of current evidence, meta-analyses and randomized controlled trials was conducted to assess the role of prophylactic antibiotics in acute pancreatitis and whether it might improve morbidity and mortality in pancreatitis. RESULTS Mixed evidence was found to support and refute the role of prophylactic antibiotics in acute pancreatitis. Most studies have failed to demonstrate much benefit from its routine use. Data from our unit suggested little benefit of their routine use, and showed that the mortality of those treated with antibiotics was significantly higher compared with those not treated with antibiotics (9% vs 0%, respectively, P = 0.043). In addition, the antibiotic group had significantly higher morbidity (36% vs 5%, respectively, P = 0.002). CONCLUSIONS Antibiotics should be used in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome or pancreatic and extra-pancreatic infection. Despite the many other factors that should be considered, prompt antibiotic therapy is recommended once inflammatory markers are raised, to prevent secondary pancreatic infection. Unfortunately, there remain many unanswered questions regarding the indications for antibiotic administration and the patients who benefit from antibiotic treatment in acute pancreatitis.
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Affiliation(s)
- M M Mourad
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
| | - Rpt Evans
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
| | - V Kalidindi
- North Middlesex University Hospital NHS Trust , London , UK
| | - R Navaratnam
- North Middlesex University Hospital NHS Trust , London , UK
| | - L Dvorkin
- North Middlesex University Hospital NHS Trust , London , UK
| | - S R Bramhall
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
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11
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Mourad MM, Evans R, Kalidindi V, Navaratnam R, Dvorkin L, Bramhall SR. Prophylactic antibiotics in acute pancreatitis: endless debate. Ann R Coll Surg Engl 2016. [PMID: 27917667 DOI: 10.1308/rcsann.2016.0355.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality. MATERIALS AND METHODS A non-systematic review of current evidence, meta-analyses and randomized controlled trials was conducted to assess the role of prophylactic antibiotics in acute pancreatitis and whether it might improve morbidity and mortality in pancreatitis. RESULTS Mixed evidence was found to support and refute the role of prophylactic antibiotics in acute pancreatitis. Most studies have failed to demonstrate much benefit from its routine use. Data from our unit suggested little benefit of their routine use, and showed that the mortality of those treated with antibiotics was significantly higher compared with those not treated with antibiotics (9% vs 0%, respectively, P = 0.043). In addition, the antibiotic group had significantly higher morbidity (36% vs 5%, respectively, P = 0.002). CONCLUSIONS Antibiotics should be used in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome or pancreatic and extra-pancreatic infection. Despite the many other factors that should be considered, prompt antibiotic therapy is recommended once inflammatory markers are raised, to prevent secondary pancreatic infection. Unfortunately, there remain many unanswered questions regarding the indications for antibiotic administration and the patients who benefit from antibiotic treatment in acute pancreatitis.
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Affiliation(s)
- M M Mourad
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
| | - Rpt Evans
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
| | - V Kalidindi
- North Middlesex University Hospital NHS Trust , London , UK
| | - R Navaratnam
- North Middlesex University Hospital NHS Trust , London , UK
| | - L Dvorkin
- North Middlesex University Hospital NHS Trust , London , UK
| | - S R Bramhall
- Hereford County Hospital, Wye Valley NHS Trust , Hereford , UK
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12
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Scarpignato C, Gatta L, Zullo A, Blandizzi C. Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression. BMC Med 2016; 14:179. [PMID: 27825371 PMCID: PMC5101793 DOI: 10.1186/s12916-016-0718-z] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/14/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications. METHODS The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence. RESULTS Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile. CONCLUSIONS Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .
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Affiliation(s)
- Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy.
| | - Luigi Gatta
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy
- Gastroenterology & Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Angelo Zullo
- Division of Gastroenterology & Digestive Endoscopy, Nuovo Regina Elena Hospital, Rome, Italy
| | - Corrado Blandizzi
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
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Ishiwatari H, Urata T, Yasuda I, Matsusaki S, Hisai H, Kawakami H, Ono M, Iwashita T, Doi S, Kawakubo K, Hayashi T, Sonoda T, Sakamoto N, Kato J. No Benefit of Oral Diclofenac on Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Dig Dis Sci 2016; 61:3292-3301. [PMID: 27447477 DOI: 10.1007/s10620-016-4251-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/09/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is a serious complication. Rectal diclofenac (100 mg) has been shown to reduce the incidence of pancreatitis; however, this dosage form is unavailable in several countries. AIMS We aimed to investigate the preventive effect of oral diclofenac on pancreatitis after ERCP in a multicenter, randomized, prospective, placebo-controlled, double-blind trial. METHODS Patients undergoing a first ERCP in seven high-volume centers between July 2012 and August 2014 were considered eligible. Participants were administered oral diclofenac (50 mg) or placebo before and after ERCP. The primary endpoint was the incidence of pancreatitis. A subgroup analysis was performed for patients at high or low risk of pancreatitis. Secondary endpoints were pancreatic enzyme levels (amylase and lipase). RESULTS We initially enrolled 430 patients (216 in the diclofenac and 214 in the placebo group), and 23 were excluded after randomization. The overall incidence of pancreatitis was 9.8 % (20/205) and 9.4 % (19/202) in the diclofenac and placebo groups, respectively (p = 0.90). The incidence of pancreatitis was 20.3 % (13/64) and 21.3 % (13/61) in patients at high risk of pancreatitis (p = 0.78) and 5.0 % (7/141) and 4.3 % (6/141) in patients at low risk of pancreatitis in the diclofenac and placebo groups (p = 0.94), respectively. There were no significant differences in serum amylase and lipase levels between the two groups before and 24 h after ERCP. CONCLUSIONS Oral administration of diclofenac before and after ERCP showed no benefit in the prevention of pancreatitis. CLINICAL TRIALS REGISTRY NO UMIN000008109.
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Affiliation(s)
- Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Takahiro Urata
- Department of Gastroenterology, Japanese Red Cross Kumamoto Hospital, 1-1-2, Nagamineminami, Higashiku, Kumamoto, 861-8520, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 3-8-3, Mizonokuchi, Takatsuku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Shimpei Matsusaki
- Department of Gastroenterology, Suzuka General Hospital, 53-1275, Uyamanohana, Yasuzukacho, Suzuka, Mie, 513-8630, Japan
| | - Hiroyuki Hisai
- Department of Gastroenterology, Japanese Red Cross Date Hospital, 81, Suenagacho, Date, Hokkaido, 052-8511, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Center for Digestive Disease, University of Miyazaki, 5200 Kihara, Kiyotake-cho, Miyazaki City, Miyazaki, 889-1692, Japan
| | - Michihiro Ono
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1, Yanagito, Gifu, Gifu, 501-1194, Japan
| | - Shinpei Doi
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, 3-8-3, Mizonokuchi, Takatsuku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, West 5, North 14, Kitaku, Sapporo, Hokkaido, 060-8648, Japan
| | - Tsuyoshi Hayashi
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Tomoko Sonoda
- Department of Public Health, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, West 5, North 14, Kitaku, Sapporo, Hokkaido, 060-8648, Japan
| | - Junji Kato
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
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14
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Isayama H, Nakai Y, Rerknimitr R, Khor C, Lau J, Wang HP, Seo DW, Ratanachu-Ek T, Lakhtakia S, Ang TL, Ryozawa S, Hayashi T, Kawakami H, Yamamoto N, Iwashita T, Itokawa F, Kuwatani M, Kitano M, Hanada K, Kogure H, Hamada T, Ponnudurai R, Moon JH, Itoi T, Yasuda I, Irisawa A, Maetani I. Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment. J Gastroenterol Hepatol 2016; 31:1546-54. [PMID: 27044023 DOI: 10.1111/jgh.13394] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/03/2016] [Accepted: 03/22/2016] [Indexed: 12/12/2022]
Abstract
Walled-off necrosis (WON) is a relatively new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christopher Khor
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore, Singapore
| | - James Lau
- Department of Surgery, Endoscopic Center, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hsiu-Po Wang
- Endoscopic Division, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Dong Wan Seo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tsuyoshi Hayashi
- Department of Gastroenterology, Hokkaido Cancer Center, Sapporo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Natusyo Yamamoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Fumihide Itokawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Sapporo, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-sayama, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon/Seoul, Korea
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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15
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Isaji S, Takada T, Mayumi T, Yoshida M, Wada K, Yokoe M, Itoi T, Gabata T. Revised Japanese guidelines for the management of acute pancreatitis 2015: revised concepts and updated points. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 22:433-45. [PMID: 25904407 DOI: 10.1002/jhbp.260] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 04/10/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Taking together the recent dramatic changes of the revised Atlanta classification and evidence newly obtained such as the role of step-up approach for necrotizing pancreatitis, the revision committee of the Japanese (JPN) Guidelines 2015 was prompted to perform an extensive revision of the guidelines. METHODS The JPN Guidelines 2015 was compared to the former edition 2010, and revision concepts and major revision points were reviewed. We compared the JPN 2015 with the other two guidelines, International Association of Pancreatology (IAP)/American Pancreas Association (APA) 2013 and American College of Gastroenterology (ACG) 2013, in order to clarify the distinct points. RESULTS The meta-analysis team conducted a new meta-analysis of four subjects that have been associated with conflicting results. It is apparent that the revised guidelines have been created more systematically and more objectively. As of antibiotics prophylaxis, its use in early phase (within 72 h of onset) for severe acute pancreatitis is recommended in JPN 2015 according to the results of original meta-analysis, whereas the other two guidelines do not recommend its routine use. An approach and management of local complications in necrotizing pancreatitis including infected necrosis are almost similar in the three guidelines. JPN 2015 alone emphasizes the implementation of the pancreatitis bundles that specify the management and treatment within the first 48 h after the onset of severe acute pancreatitis. CONCLUSION The JPN Guidelines 2015 prove to be the highest quality in terms of systematic literature review conducting original analyses by the meta-analysis team, determining the grading of recommendations and providing pancreatitis bundles.
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Affiliation(s)
- Shuji Isaji
- Hepatobiliary Pancreatic & Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshihiro Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Masamichi Yokoe
- General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Toshifumi Gabata
- Department of Radiology, School of Medical Science, Kanazawa University, Kanazawa, Japan
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16
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Stefanović M, Jazbec J, Lindgren F, Bulajić M, Löhr M. Acute pancreatitis as a complication of childhood cancer treatment. Cancer Med 2016; 5:827-36. [PMID: 26872431 PMCID: PMC4864812 DOI: 10.1002/cam4.649] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/04/2015] [Accepted: 12/29/2015] [Indexed: 12/12/2022] Open
Abstract
Acute pancreatitis (AP) is now well recognized as a possible complication of childhood cancer treatment, interrupting the chemotherapy regimen, and requiring prolonged hospitalization, possibly with intensive care and surgical intervention, thereby compromising the effect of chemotherapy and the remission of the underlying malignant disease. This review summarizes the current literature and presents the various etiological factors for AP during chemotherapy as well as modern trends in the diagnosis and therapy of AP in children.
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Affiliation(s)
- Milica Stefanović
- Division of Pediatrics, Unit of Hemato-oncology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Janez Jazbec
- Division of Pediatrics, Unit of Hemato-oncology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Fredrik Lindgren
- Department of Pediatric, Karolinska University Hospital, Stockholm, Sweden
| | - Milutin Bulajić
- Department of Gastroenterology, University Hospital Center "Santa Maria della Misericordia", Udine, Italy.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Matthias Löhr
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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17
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Baltatzis M, Jegatheeswaran S, O'Reilly DA, Siriwardena AK. Antibiotic use in acute pancreatitis: Global overview of compliance with international guidelines. Pancreatology 2016; 16:189-93. [PMID: 26804006 DOI: 10.1016/j.pan.2015.12.179] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/22/2015] [Accepted: 12/25/2015] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Practice guidelines for the management of acute pancreatitis make recommendations in relation to antibiotic prophylaxis and treatment in acute pancreatitis. However, it is difficult to ascertain whether this information translates into clinical practice. The aim of this study is to obtain a global overview assessing reports from across the world of the use of antibiotic use in acute pancreatitis. METHODS A computerised literature search was performed from January 1992 to September 2015. Studies were either national physician surveys or national database reports on antibiotic prophylaxis in acute pancreatitis. Using these criteria, 10 studies were identified which comprise the final study population. RESULTS Eight studies report on the questionnaire responses of 2397 physicians. The range of response rate was 38-96%. A separate study reported on outcome of a national insurance database outcomes in 7193 patients. The lowest incidence of use of antibiotic prophylaxis was 41% and the highest 88%. CONCLUSION This study provides a unique global perspective on antibiotic use in acute pancreatitis and indicates that the use of antibiotics, both as prophylaxis and as treatment in this disease is widespread.
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Affiliation(s)
- Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK; The University of Manchester, UK
| | - Santhalingam Jegatheeswaran
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK; The University of Manchester, UK
| | - Derek A O'Reilly
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK; The University of Manchester, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK; The University of Manchester, UK.
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18
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Stewart JM, Tarantal AF, Hawthorne WJ, Salvaris EJ, O'Connell PJ, Nottle MB, d'Apice AJF, Cowan PJ, Kearns-Jonker M. Clonidine inhibits anti-non-Gal IgM xenoantibody elicited in multiple pig-to-primate models. Xenotransplantation 2015; 22:413-26. [PMID: 26490547 DOI: 10.1111/xen.12199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 08/25/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Survival of vascularized xenografts is dependent on pre-emptive inhibition of the xenoantibody response against galactosyltransferase knockout (GTKO) porcine organs. Our analysis in multiple GTKO pig-to-primate models of xenotransplantation has demonstrated that the anti-non-gal-α-1,3-gal (anti-non-Gal) xenoantibody response displays limited structural diversity. This allowed our group to identify an experimental compound which selectively inhibited induced anti-non-Gal IgM xenoantibodies. However, because this compound had an unknown safety profile, we extended this line of research to include screening small molecules with known safety profiles allowing rapid advancement to large animal models. METHODS The NIH clinical collections of small molecules were screened by ELISA for their ability to inhibit xenoantibody binding to GTKO pig endothelial cells. Serum collected from non-immunosuppressed rhesus monkeys at day 14 post-injection with GTKO pig endothelial cells was utilized as a source of elicited xenoantibody for initial screening. Virtual small molecule screening based on xenoantibody structure was used to assess the likelihood that the identified small molecules bound xenoantibody directly. As a proxy for selectivity, ELISAs against tetanus toxoid and the natural antigens laminin, thyroglobulin, and single-stranded DNA (ssDNA) were utilized to assess the ability of the identified reagents to inhibit additional antibody responses. The identified inhibitory small molecules were further tested for their ability to inhibit xenoantibody elicited in multiple settings, including rhesus monkeys pre-treated with an anti-non-Gal selective anti-idiotypic antibody, non-immunosuppressed rhesus monkeys immunized with wild-type fetal pig isletlike cell clusters, and non-immunosuppressed baboons transplanted with GTKO multiple transgenic pig kidneys. RESULTS Four clinically relevant small molecules inhibited anti-non-Gal IgM binding to GTKO pig endothelial cells in vitro. Three of these drugs displayed a limited region of structural similarity suggesting they may inhibit xenoantibody by a similar mechanism. One of these, the anti-hypertensive agent clonidine, displayed only minimal inhibition of antibodies elicited by vaccination against tetanus toxoid or pre-existing natural antibodies against laminin, thyroglobulin, or ssDNA. Furthermore, clonidine inhibited elicited anti-non-Gal IgM from all animals that demonstrated a xenoantibody response in each experimental setting. CONCLUSIONS Clinically relevant small molecule drugs with known safety profiles can inhibit xenoantibody elicited against non-Gal antigens in diverse experimental xenotransplantation settings. These molecules are ready to be tested in large animal models. However, it will first be necessary to optimize the timing and dosing required to inhibit xenoantibodies in vivo.
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Affiliation(s)
- John M Stewart
- Department of Human Anatomy, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Alice F Tarantal
- Departments of Pediatrics and Cell Biology and Human Anatomy, and California National Primate Research Center, University of California, Davis, CA, USA
| | - Wayne J Hawthorne
- Centre for Transplant and Renal Research, Westmead Millennium Institute, Westmead, NSW, Australia.,National Pancreas Transplant Unit, University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Evelyn J Salvaris
- Immunology Research Centre, St. Vincent's Hospital Melbourne, Melbourne, Vic., Australia
| | - Philip J O'Connell
- Centre for Transplant and Renal Research, Westmead Millennium Institute, Westmead, NSW, Australia.,National Pancreas Transplant Unit, University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Mark B Nottle
- Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, SA, Australia
| | - Anthony J F d'Apice
- Immunology Research Centre, St. Vincent's Hospital Melbourne, Melbourne, Vic., Australia.,Department of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Peter J Cowan
- Immunology Research Centre, St. Vincent's Hospital Melbourne, Melbourne, Vic., Australia.,Department of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Mary Kearns-Jonker
- Department of Human Anatomy, Loma Linda University School of Medicine, Loma Linda, CA, USA
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19
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Eguchi T, Tsuji Y, Yamashita H, Fukuchi T, Kanamori A, Matsumoto K, Hasegawa T, Koizumi A, Kitada R, Tsujimae M, Iwatsubo T, Koyama S, Ubukata S, Fujita M, Okada A. Efficacy of recombinant human soluble thrombomodulin in preventing walled-off necrosis in severe acute pancreatitis patients. Pancreatology 2015; 15:485-490. [PMID: 26320826 DOI: 10.1016/j.pan.2015.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 06/04/2015] [Accepted: 08/12/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the efficacy of recombinant human soluble thrombomodulin (rTM) in preventing the development of walled-off necrosis (WON) in severe acute pancreatitis (SAP) patients. METHODS We retrospectively analyzed 54 SAP patients divided into two groups: SAP patients treated by rTM (rTM group, 24 patients) and not treated by rTM (control group, 30 patients). rTM was administered to patients with disseminated intravascular coagulation (DIC). Initially, on the admission day, we recorded patient severity and pancreatic necrosis/ischemia positive or negative. Then we investigated development of WON using 4 weeks later CT/MRI. Finally we compared the proportions of patients developing WON in the rTM group and the control group. RESULTS On the admission day, the condition of patients treated by rTM was significantly worse than patients in the control group; rTM group vs. CONTROL 71.8 ± 13.9 vs. 59.8 ± 15.3 years for age, 10.7 ± 3.5 vs. 8.0 ± 4.4 for Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and 3.3 ± 1.8 vs. 2.2 ± 1.8 for sequential organ failure assessment (SOFA) score (p < 0.05). We found no significant differences on the admission day in rate of pancreatic necrosis/ischemia between patients treated by rTM and controls (58.3% vs. 63.3%, p = 0.71). Nevertheless, the proportion of patients developing WON was significantly lower among those administered rTM than in those not administered rTM {29.2% (7/24 patients) vs. 56.7% (17/30 patients), p < 0.05}. CONCLUSION Treatment of SAP patients treated by rTM may prevent progression from pancreatic necrosis/ischemia to WON.
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Affiliation(s)
- Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Yoshihisa Tsuji
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kawaramachi 54, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Hiroshi Yamashita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takumi Fukuchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Atsushi Kanamori
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Kei Matsumoto
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takashi Hasegawa
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akio Koizumi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Ryuki Kitada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Masahiro Tsujimae
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Taro Iwatsubo
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Shintaro Koyama
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Satoshi Ubukata
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Mikio Fujita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akihiko Okada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan.
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20
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Kolotushkin IA, Balnykov SI, Shubin LB. [Estimation of the role of octreotide in treatment of severe pancreatic necrosis]. Khirurgiia (Mosk) 2015:21-25. [PMID: 26271418 DOI: 10.17116/hirurgia2015621-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It was analyzed the results of treatment of 204 patients with severe course of destructive pancreatitis (severity of organs' dysfunction was 9 and more scores according to APACHE-II scale upon admission to the hospital). Logistic regression and Cox regression were used along with univariant statistical analysis, what permitted to estimate overall effect of octreotide and other potential predictors including severity of condition and medical factors on the mortality rate and extension of necrosis in patients with pancreatic necrosis. It was established that the use of octreotide in case of severe pancreatic necrosis significantly decreases mortality and extension of necrosis.
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Affiliation(s)
- I A Kolotushkin
- Chair of Surgery, Institute of Postgraduate Education, Yaroslavl State Medical Academy, Yaroslavl, Russia
| | - S I Balnykov
- Chair of Surgery, Institute of Postgraduate Education, Yaroslavl State Medical Academy, Yaroslavl, Russia
| | - L B Shubin
- Chair of Surgery, Institute of Postgraduate Education, Yaroslavl State Medical Academy, Yaroslavl, Russia
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21
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Pezzilli R, Zerbi A, Campra D, Capurso G, Golfieri R, Arcidiacono PG, Billi P, Butturini G, Calculli L, Cannizzaro R, Carrara S, Crippa S, De Gaudio R, De Rai P, Frulloni L, Mazza E, Mutignani M, Pagano N, Rabitti P, Balzano G. Consensus guidelines on severe acute pancreatitis. Dig Liver Dis 2015; 47:532-43. [PMID: 25921277 DOI: 10.1016/j.dld.2015.03.022] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/17/2015] [Accepted: 03/24/2015] [Indexed: 02/07/2023]
Abstract
This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.
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22
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Li J, Zhang J, Fu Y, Sun X, Gong T, Jiang J, Zhang Z. Dual pancreas- and lung-targeting therapy for local and systemic complications of acute pancreatitis mediated by a phenolic propanediamine moiety. J Control Release 2015; 212:19-29. [PMID: 26071629 DOI: 10.1016/j.jconrel.2015.06.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 06/04/2015] [Accepted: 06/09/2015] [Indexed: 12/29/2022]
Abstract
To inhibit both the local and systemic complications with acute pancreatitis, an effective therapy requires a drug delivery system that can efficiently overcome the blood-pancreas barrier while achieving lung-specific accumulation. Here, we report the first dual pancreas- and lung-targeting therapeutic strategy mediated by a phenolic propanediamine moiety for the treatment of acute pancreatitis. Using the proposed dual-targeting ligand, an anti-inflammatory compound Rhein has been tailored to preferentially accumulate in the pancreas and lungs with rapid distribution kinetics, excellent tissue-penetrating properties and minimum toxicity. Accordingly, the drug-ligand conjugate remarkably downregulated the proinflammatory cytokines in the target organs thus effectively inhibiting local pancreatic and systemic inflammation in rats. The dual-specific targeting therapeutic strategy may help pave the way for targeted drug delivery to treat complicated inflammatory diseases.
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Affiliation(s)
- Jianbo Li
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, Sichuan University, No. 17, Section 3, Southern Renmin Road, Chengdu 610041, People's Republic of China
| | - Jinjie Zhang
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, Sichuan University, No. 17, Section 3, Southern Renmin Road, Chengdu 610041, People's Republic of China
| | - Yao Fu
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, Sichuan University, No. 17, Section 3, Southern Renmin Road, Chengdu 610041, People's Republic of China
| | - Xun Sun
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, Sichuan University, No. 17, Section 3, Southern Renmin Road, Chengdu 610041, People's Republic of China
| | - Tao Gong
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, Sichuan University, No. 17, Section 3, Southern Renmin Road, Chengdu 610041, People's Republic of China
| | - Jinghui Jiang
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, Sichuan University, No. 17, Section 3, Southern Renmin Road, Chengdu 610041, People's Republic of China
| | - Zhirong Zhang
- Key Laboratory of Drug Targeting and Drug Delivery Systems, Ministry of Education, Sichuan University, No. 17, Section 3, Southern Renmin Road, Chengdu 610041, People's Republic of China.
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23
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Yokoe M, Takada T, Mayumi T, Yoshida M, Isaji S, Wada K, Itoi T, Sata N, Gabata T, Igarashi H, Kataoka K, Hirota M, Kadoya M, Kitamura N, Kimura Y, Kiriyama S, Shirai K, Hattori T, Takeda K, Takeyama Y, Hirota M, Sekimoto M, Shikata S, Arata S, Hirata K. Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:405-32. [PMID: 25973947 DOI: 10.1002/jhbp.259] [Citation(s) in RCA: 267] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines. METHODS A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines. RESULTS Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles. CONCLUSIONS The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.
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Affiliation(s)
- Masamichi Yokoe
- General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, KitaKyushu, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic & Transplant Surgery Mie University Graduate School of Medicine, Mie, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University, School of Medical Science, Kanazawa, Japan
| | - Hisato Igarashi
- Clinical Education Center, Kyushu University Hospital, Fukuoka, Japan
| | - Keisho Kataoka
- Otsu Municipal Hospital, Shiga.,Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiko Hirota
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Masumi Kadoya
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Takayuki Hattori
- Department of Radiology, Tokyo Metropolitan Health and Medical Treatment Corporation, Ohkubo Hospital, Tokyo, Japan
| | - Kazunori Takeda
- Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miho Sekimoto
- The University of Tokyo Graduate School of Public Policy, Health Policy Unit, Tokyo
| | - Satoru Shikata
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Shinju Arata
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Koichi Hirata
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
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24
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Boadas J, Balsells J, Busquets J, Codina-B A, Darnell A, Garcia-Borobia F, Ginés À, Gornals J, Gruartmoner G, Ilzarbe L, Merino X, Oms L, Puig I, Puig-Diví V, Vaquero E, Vida F, Molero X. Valoración y tratamiento de la pancreatitis aguda. Documento de posicionamiento de la Societat Catalana de Digestologia, Societat Catalana de Cirurgia y Societat Catalana de Pàncrees. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:82-96. [DOI: 10.1016/j.gastrohep.2014.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/07/2014] [Accepted: 09/10/2014] [Indexed: 12/12/2022]
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25
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Orlov YP, Ershov AV, Lukach VN, Govorova NV, Degovtsov EN, Glushchenko AV. [Correction of endotoxemia in patients with pancreatic necrosis]. Khirurgiia (Mosk) 2015:36-42. [PMID: 26978466 DOI: 10.17116/hirurgia20151036-42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
AIM To study the results of deferoxamine (Deferal) administration in intensive therapy program of 63 patients with severe acute pancreatitis to decrease effect of oxidative stress and endotoxemia. MATERIAL AND METHODS In deferoxamine group (31 patients) there were decrease of serum iron's level and inhibition of free radical oxidation that led to early relief of endotoxemia, reducing periods of organs' dysfunction. It was not observed in comparison group (32 patients). RESULTS Deferoxamine decrease risk of pancreatic necrosis and pancreatogenic sepsis. It allows reducing ICU- and hospital-stay and number of extended surgical procedures.
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Affiliation(s)
- Yu P Orlov
- Omsk State Medical Academy, Omsk, Russia
| | - A V Ershov
- Omsk State Medical Academy, Omsk, Russia
| | - V N Lukach
- Omsk State Medical Academy, Omsk, Russia
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Zerem E. Treatment of severe acute pancreatitis and its complications. World J Gastroenterol 2014; 20:13879-13892. [PMID: 25320523 PMCID: PMC4194569 DOI: 10.3748/wjg.v20.i38.13879] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/08/2014] [Accepted: 06/05/2014] [Indexed: 02/06/2023] Open
Abstract
Severe acute pancreatitis (SAP), which is the most serious type of this disorder, is associated with high morbidity and mortality. SAP runs a biphasic course. During the first 1-2 wk, a pro-inflammatory response results in systemic inflammatory response syndrome (SIRS). If the SIRS is severe, it can lead to early multisystem organ failure (MOF). After the first 1-2 wk, a transition from a pro-inflammatory response to an anti-inflammatory response occurs; during this transition, the patient is at risk for intestinal flora translocation and the development of secondary infection of the necrotic tissue, which can result in sepsis and late MOF. Many recommendations have been made regarding SAP management and its complications. However, despite the reduction in overall mortality in the last decade, SAP is still associated with high mortality. In the majority of cases, sterile necrosis should be managed conservatively, whereas in infected necrotizing pancreatitis, the infected non-vital solid tissue should be removed to control the sepsis. Intervention should be delayed for as long as possible to allow better demarcation and liquefaction of the necrosis. Currently, the step-up approach (delay, drain, and debride) may be considered as the reference standard intervention for this disorder.
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Asari S, Matsumoto I, Ajiki T, Shinzeki M, Goto T, Fukumoto T, Ku Y. Perioperative management for pancreatoduodenectomy following severe acute pancreatitis in patients with periampullary cancer: our experience with six consecutive cases. Surg Today 2014; 45:181-8. [PMID: 24799280 DOI: 10.1007/s00595-014-0900-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 03/06/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE We rarely have an opportunity to perform pancreatoduodenectomy (PD) following the onset of severe acute pancreatitis (SAP) for patients with periampullary cancer. The perioperative risks and optimal timing of subsequent PD have, therefore, remained unclear. METHODS Between January 2006 and December 2012, we performed PD in six patients with SAP. We reviewed these six cases, and compared the perioperative risks of morbidity and mortality with those of 81 concurrent PD patients matched for primary cancer without preoperative SAP. RESULTS The six patients were classified as having SAP based on the Japanese criteria developed in 2008. The SAP in five patients was caused by ERCP procedures. The median interval from SAP onset to the operation was 111 days. The rate of Grade B/C postoperative pancreatic fistula formation in the SAP patients was significantly higher than that of the 81 control patients (83 vs. 26 %, P < 0.001). In addition, the median postoperative hospital stay was significantly longer in the six SAP patients relative to that of the control patients (40 vs. 30 days, P < 0.001). CONCLUSIONS An interval of at least 3 months after surgery may be needed to decrease the inflammation of the peripancreas region after SAP. Therefore, unnecessary and low-yield ERCP procedures should be avoided in these patients.
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Affiliation(s)
- Sadaki Asari
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan,
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Gou S, Yang Z, Liu T, Wu H, Wang C. Use of probiotics in the treatment of severe acute pancreatitis: a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R57. [PMID: 24684832 PMCID: PMC4056604 DOI: 10.1186/cc13809] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/04/2014] [Indexed: 02/07/2023]
Abstract
Introduction Necrotic tissue infection can worsen the prognosis of severe acute pancreatitis (SAP), and probiotics have been shown to be beneficial in reducing the infection rate in animal experiments and primary clinical trials. However, the results of multicenter randomized clinical trials have been contradictory. Our aim in this study was to systematically review and quantitatively analyze all randomized controlled trials with regard to important outcomes in patients with predicted SAP who received probiotics. Methods A systematic literature search of the PubMed, Embase and Cochrane Library databases was conducted using specific search terms. Eligible studies were randomized controlled trials that compared the effects of probiotic with placebo treatment in patients with predicted SAP. Mean difference (MD), risk ratio (RR) and 95% confidence interval (95% CI) were calculated using the Mantel-Haenszel fixed- and random-effects models. A meta-analysis on the use of probiotics in the treatment of critically ill patients was also performed to serve as a reference. Results In this study, 6 trials comprising an aggregate total of 536 patients were analyzed. Significant heterogeneities were observed in the type, dose, treatment duration and clinical effects of probiotics in these trials. Systematic analysis showed that probiotics did not significantly affect the pancreatic infection rate (RR = 1.19, 95% CI = 0.74 to 1.93; P = 0.47), total infections (RR = 1.09, 95% CI = 0.80 to 1.48; P = 0.57), operation rate (RR = 1.42, 95% CI = 0.43 to 3.47; P = 0.71), length of hospital stay (MD = 2.45, 95% CI = −2.71 to 7.60; P = 0.35) or mortality (RR = 0.72, 95% CI = 0.42 to 1.45; P = 0.25). Conclusions Probiotics showed neither beneficial nor adverse effects on the clinical outcomes of patients with predicted SAP. However, significant heterogeneity was noted between the trials reviewed with regard to the type, dose and treatment duration of probiotics, which may have contributed to the heterogeneity of the clinical outcomes. The current data are not sufficient to draw a conclusion regarding the effects of probiotics on patients with predicted SAP. Carefully designed clinical trials are needed to validate the effects of particular probiotics given at specific dosages and for specific treatment durations.
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Petejova N, Martinek A. Acute kidney injury following acute pancreatitis: A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 157:105-13. [PMID: 23774848 DOI: 10.5507/bp.2013.048] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 06/07/2013] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED BACKROUND. Acute kidney injury (AKI) is a common serious complication of severe acute pancreatitis (SAP) and an important marker of morbidity and mortality in critically ill septic patients. AKI due to severe acute pancreatitis can be the result of hypoxemia, release of pancreatic amylase from the injured pancreas with impairment of renal microcirculation, decrease in renal perfusion pressure due to abdominal compartment syndrome, intraabdominal hypertension or hypovolemia. Endotoxins and reactive oxygen species (ROS) also play an important role in the pathophysiology of SAP and AKI. Knowledge of the pathophysiology and diagnosis of AKI following SAP might improve the therapeutic outcome of critically ill patients. METHODS AND RESULTS An overview of the pathophysiology, diagnosis and potential treatment options based on a literature search of clinical human and experimental studies from 1987 to 2013. CONCLUSIONS Early recognition of AKI and SAP in order to prevent severe complication like septic shock, intraabdominal hypertension or abdominal compartment syndrome leading to multiple organ dysfunction syndrome is a crucial tool of therapeutic measures in intensive care.
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Affiliation(s)
- Nadezda Petejova
- Department of Internal Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Czech Republic.
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Wu BU, Banks PA. Clinical management of patients with acute pancreatitis. Gastroenterology 2013; 144:1272-81. [PMID: 23622137 DOI: 10.1053/j.gastro.2013.01.075] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Revised: 12/31/2012] [Accepted: 01/07/2013] [Indexed: 12/14/2022]
Abstract
Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. As rates of hospitalization for acute pancreatitis continue to increase, so does demand for effective management. We review approaches to best manage patients with acute pancreatitis, covering diagnosis, risk and prognostic factors, treatment, and complications, considering recommendations from current practice guidelines.
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Affiliation(s)
- Bechien U Wu
- Center for Pancreatic Care, Southern California Permanente Medical Group, Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA.
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Abstract
OBJECTIVES This study aimed to explore the period between onset of pain and hospital-admission (pain-to-admission time) in patients with acute pancreatitis (AP), to investigate the prognostic value and associated factors of this time, and to ascertain the knowledge about the pancreas in these patients. METHODS An analysis of a prospective multicenter study was done, which included 188 patients with AP. RESULTS Median pain-to-admission time was 27 hours (interquartile range, 6.0-72.0). Median pain-to-admission time was significantly shorter in intensive care unit (ICU) patients (10 hours) compared to non-ICU patients (36 hours) (P = 0.045). Short pain-to-admission time was associated with high pain level. Median pain level (0, no pain; 10, maximal pain) was 8.0 (interquartile range, 7.0-10.0). Older age correlated with lower pain level (r = -0.26; P = 0.002). Multiple logistic regression analysis including the admission values for serum lipase and C-reactive protein and the corresponding interactions to the pain-to-admission time showed substantial discriminative ability regarding ICU admission (concordance index, 0.706; P = 0.006). 86% (112/130) knew that they have a pancreas, 72% (81/112) of these patients knew that AP exists, and 56% (45/81) recognized that AP is potentially fatal. CONCLUSIONS Knowledge about AP in hospitalized AP patients is poor. Serum lipase and C-reactive protein in dependency of the pain-to-admission time might be a suitable predictor for severity of AP.
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Maraví Poma E, Zubia Olascoaga F, Petrov M, Navarro Soto S, Laplaza Santos C, Morales Alava F, Darnell Martin A, Gorraiz López B, Bolado Concejo F, Casi Villarroya M, Aizcorbe Garralda M, Albeniz Arbizu E, Sánchez-Izquierdo Riera J, Tirapu León J, Bordejé Laguna L, López Camps V, Marcos Neira P, Regidor Sanz E, Jiménez Mendioroz F. SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. Med Intensiva 2013; 37:163-79. [PMID: 23541063 DOI: 10.1016/j.medin.2013.01.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/17/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU. PARTICIPANTS Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations. CONCLUSIONS Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management.
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Effect and cost of treatment for acute pancreatitis with or without gabexate mesylate: a propensity score analysis using a nationwide administrative database. Pancreas 2013; 42:260-4. [PMID: 23000890 DOI: 10.1097/mpa.0b013e31826495a0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Despite a lack of evidence, gabexate mesylate (GM) is routinely used for the treatment of acute pancreatitis (AP) in some countries. The present study examined the effect and cost of GM for AP treatment using the Japanese Diagnosis Procedure Combination database. METHODS We performed a propensity score analysis to compare inhospital mortality, length of stay (LOS), and total costs between patients with AP treated with GM and those without GM in 2010. RESULTS We identified 2483 patients treated with GM and 890 patients without GM. Overall, 77% of the patients treated with GM were nonsevere AP cases. The propensity-matched 707 pairs showed no significant difference between GM users and nonusers in inhospital mortality or median length of stay in nonsevere AP (1.0% vs 1.2%, P = 0.789; 10 vs 10 days, P = 0.160) and severe AP (8.4% vs 5.0%, P = 0.438; 12 vs 14 days, P = 0.487) cases. Total costs were significantly different between the GM users and the nonusers in nonsevere AP cases (US$4982 vs US$4373, P < 0.001), but not in severe AP cases ($6605 vs $6490, P = 0.764). CONCLUSIONS Using GM for nonsevere AP cannot be justified because of higher costs without significant effects. Gabexate mesylate use is also not justifiable for severe AP because it does not reduce mortality or length of stay.
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Parenteral analgesics for pain relief in acute pancreatitis: a systematic review. Pancreatology 2013; 13:201-6. [PMID: 23719588 DOI: 10.1016/j.pan.2013.02.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 02/14/2013] [Accepted: 02/14/2013] [Indexed: 12/11/2022]
Abstract
AIM To assess the efficiency and safety of parenteral analgesics for pain relief in acute pancreatitis. MATERIALS AND METHODS We carried out an electronic search of PubMed, Cochrane Library, EMBASE, WEIPU, CNKI and CBM and a manual search for eligible studies. The methodological quality of included trials and quality of evidence were examined by the Cochrane Collaboration's tool for assessing risk of bias and GRADE, respectively. The data were mainly analyzed descriptively and some were pooled by Review manager 5. RESULTS Eight randomized controlled trials with a total of 356 patients were finally included in this systematic review. Compared with procaine, pentazocine led to lower pain severity: day 1, Mean Difference (MD), 95%CI: 40.0 [35.3, 44.7]; day 2, MD, 95%CI: 24.00 [20.88, 27.12]; day 3, MD, 95%CI: 5.00 [2.17, 7.83], and it decreased the requirement for additional analgesics, Relative Risk, 95%CI: 2.23 [1.63, 3.05]. The combination of fentanyl, atropine, droperidol and lidocaine rendered lower pain score: day 1, MD, 95%CI: -5.46 [-6.95, -3.97]; day 2, MD, 95%CI: -5.78 [-7.39, -4.17]. Patients treated with metamizole tended to had lower pain than those treated with morphine, MD, 95%CI: -2.60 [-2.95, -2.25]. Nausea, emesis and vomiting were the common adverse events reported and there was almost no significant difference between different agents on safety. CONCLUSIONS The systemic review showed that the randomized controlled trials comparing different analgesics were of low quality and did not favor clearly any particular analgesic for pain relief in acute pancreatitis.
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Pupelis G, Plaudis H, Zeiza K, Drozdova N, Mukans M, Kazaka I. Early continuous veno-venous haemofiltration in the management of severe acute pancreatitis complicated with intra-abdominal hypertension: retrospective review of 10 years' experience. Ann Intensive Care 2012; 2 Suppl 1:S21. [PMID: 23281603 PMCID: PMC3527156 DOI: 10.1186/2110-5820-2-s1-s21] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Conservative treatment of patients with severe acute pancreatitis (SAP) may be associated with development of intra-abdominal hypertension (IAH), deterioration of visceral perfusion and increased risk of multiple organ dysfunction. Fluid balance is essential for maintenance of adequate organ perfusion and control of the third space. Timely application of continuous veno-venous haemofiltration (CVVH) may help in balancing fluid replacement and removal of cytokines from the blood and tissue compartments. The aim of the present study was to determine whether CVVH can be recommended as a constituent of conservative treatment in patients with SAP who suffer IAH. Methods A retrospective analysis of 10 years' experience with low-flow CVVH application in patients with SAP who develop IAH was. In all patients, measurement of the intra-abdominal pressure (IAP) was done indirectly through the urinary bladder. Sequential organ failure assessment (SOFA) score was calculated for severity assessment, and necrotizing forms were verified by contrast-enhanced computed tomography. Dynamics of IAP were analysed in parallel with signs of systemic inflammation, dynamics of C-reactive protein and cumulative fluid balance. All variables, complication rate and outcomes were analysed in the whole group and in patients with IAH (CVVH and no-CVVH groups). Results From the total of 130 patients, 75 were treated with application of CVVH and 55 without CVVH. Late hospitalization was associated with application of CVVH. Infection was observed in 28.5% of cases regardless of the type of treatment received, with a similar necessity for surgical intervention. IAH was observed in 68.5% of patients, and they had significantly higher SOFA scores compared to patients with normal IAP. CVVH treatment resulted in negative cumulative fluid balance starting from day 5 in patients with IAH, whereas without this treatment, fluid balance remained increasingly positive after a week. Finally, application of CVVH resulted in a lower infection rate and shorter hospital stay, 26.7% vs. 37.9%, and a median of 32 (interquartile range (IQR) = 60 to 12) days vs. 24 (IQR = 34 to 4) days, p = 0.05, comparing CVVH vs. no-CVVH group. Mortality rate reached 11.7% in the CVVH group and 13.8% in the no-CVVH group. Conclusions Early application of CVVH facilitates negative fluid balance and reduction of IAH in patients with SAP; it is not associated with increased infection or mortality rate and may reduce hospital stay.
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Affiliation(s)
- Guntars Pupelis
- Department of General and Emergency Surgery, Riga East Clinical University Hospital 'Gailezers', Hipokrata str, 2, Riga, 1038, Latvia.
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Ikawa K, Kondo N, Nakashima A, Yoshizawa K, Morikawa N, Ikeda K, Murakami Y, Ohge H, Sueda T. Penetration of meropenem into human pancreatic juice. ACTA ACUST UNITED AC 2012; 45:404-6. [PMID: 23176150 DOI: 10.3109/00365548.2012.738936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study examined the penetration of meropenem into pancreatic juice in patients who had undergone hepato-biliary-pancreatic surgery. The patients received a 0.5-h infusion of 500 mg meropenem. The observed maximum concentration (mean ± standard deviation, n = 5) was 39.1 ± 11.2 μg/ml at 0.5 h in plasma and 2.12 ± 0.73 μg/ml at 1.10 ± 0.14 h in pancreatic juice. The pancreatic juice/plasma ratio was 0.06 ± 0.02. The area under the drug concentration-time curve was 73.0 ± 37.5 μg•h/ml in plasma and 4.24 ± 2.77 μg•h/ml in pancreatic juice. The pancreatic juice/plasma ratio was 0.06 ± 0.01. The mean drug-exposure times above 0.125 μg/ml and 0.25 μg/ml (the minimum inhibitory concentrations (MIC) for common pathogens) in pancreatic juice were 99.4% and 87.3%, respectively, for 500 mg meropenem 3 times daily. This commonly used regimen for pancreatitis achieved the drug-exposure time target (40% of the time above the MIC) at the action site, despite the low penetrability of meropenem.
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Affiliation(s)
- Kazuro Ikawa
- Department of Clinical Pharmacotherapy, Hiroshima University, Hiroshima, Japan.
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Landy C, Plancade D, Millot I, Gagnon N, Nadaud J, Favier JC. Another use of the ultrasound-guided transversus abdominis plane block in the ED. Am J Emerg Med 2012; 30:626-7. [DOI: 10.1016/j.ajem.2011.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 12/09/2011] [Indexed: 11/16/2022] Open
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Mirtallo JM, Forbes A, McClave SA, Jensen GL, Waitzberg DL, Davies AR. International consensus guidelines for nutrition therapy in pancreatitis. JPEN J Parenter Enteral Nutr 2012; 36:284-91. [PMID: 22457421 DOI: 10.1177/0148607112440823] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Guidelines for nutrition support in pancreatitis have been inconsistently adapted to clinical practice. The International Consensus Guideline Committee (ICGC) established a pancreatitis task force to review published guidelines for pancreatitis in nutrition support. A PubMed search using the terms pancreatitis, acute pancreatitis, chronic pancreatitis, nutrition support, parenteral nutrition, enteral nutrition, and guidelines was conducted for the period from January 1999 to May 2011. Eleven guidelines were identified for review. The ICGC used the following process to develop unified guideline statements: summarize the strength of evidence (grading) of the guidelines; establish level of evidence for ICGC statements as high, intermediate, and low; assign published guideline levels of evidence; and define an ICGC grading system. International Pancreatitis Guideline Grades were established as follows: platinum-high level of evidence and consistent agreement among the guidelines; gold-acceptable level of evidence and no conflicting statements in guidelines; and silver-single existing guideline statement with no conflict in other guidelines. Eighteen ICGC statements were derived from the 11 published pancreatitis guidelines. Uniform agreement from widely disparate groups (United States, Europe, Japan, and China) resulted in 4 platinum-level guideline statements for nutrition in pancreatitis: nutrition support therapy (NST) is generally not needed for mild to moderate disease, NST is needed for severe disease, enteral nutrition (EN) is preferred over parenteral nutrition (PN), and use PN when EN is contraindicated or not feasible. This methodology provides a template for future ICGC nutrition guideline development.
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Affiliation(s)
- Jay M Mirtallo
- Ohio State University, College of Pharmacy, Columbus, Ohio, USA.
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Abstract
Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.
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Abstract
Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.
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Is continuous regional arterial infusion of antiproteases now a standard of care in the treatment of acute pancreatitis? Pancreas 2011; 40:1141. [PMID: 21926550 DOI: 10.1097/mpa.0b013e3182311ecb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Nafamostat mesilate for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a prospective, randomized, double-blind, controlled trial. Pancreas 2011; 40:181-6. [PMID: 21206331 DOI: 10.1097/mpa.0b013e3181f94d46] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Pancreatitis is the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). Efforts have been made to identify pharmacologic agents capable of reducing its incidence and severity. The aim of this trial was to determine whether prophylactic nafamostat mesilate, a synthetic protease inhibitor, would reduce the frequency and severity of post-ERCP pancreatitis. METHODS A total of 286 patients were randomized to receive either intravenous nafamostat mesilate or placebo 60 minutes before ERCP and for 6 hours after ERCP. A database was prospectively collected by a defined protocol. Standardized criteria were used to diagnose and grade the severity of pancreatitis. RESULTS The groups were similar with regard to patient demographics and to patient and procedure risk factors for pancreatitis. The overall incidence of pancreatitis was 5.9%. It occurred in 4 (2.8%) of 143 patients in the nafamostat group and in 13 (9.1%) of 143 patients in the control group (P = 0.03). Pancreatitis was graded mild in 2.1% and moderate in 0.7% of the nafamostat group and mild in 7.0% and moderate in 2.1% of the control group. There was no significant difference between the groups in the severity of pancreatitis. CONCLUSIONS Prophylactic intravenous nafamostat mesilate reduces the frequency of post-ERCP pancreatitis.
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Loveday BPT, Rossaak JI, Mittal A, Phillips A, Windsor JA. Survey of trends in minimally invasive intervention for necrotizing pancreatitis. ANZ J Surg 2011; 81:56-64. [DOI: 10.1111/j.1445-2197.2010.05265.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Pezzilli R, Zerbi A, Di Carlo V, Bassi C, Delle Fave GF. Practical guidelines for acute pancreatitis. Pancreatology 2010; 10:523-35. [PMID: 20975316 DOI: 10.1159/000314602] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The following is a summary of the official guidelines of the Italian Association for the Study of the Pancreas regarding the medical, endoscopic and surgical management of acute pancreatitis. STATEMENTS Clinical features together with elevation of the plasma concentrations of pancreatic enzymes are the cornerstones of diagnosis (recommendation A). Contrast-enhanced computed tomography (CT) provides good evidence for the presence of pancreatitis (recommendation C) and it should be carried out 48-72 h after the onset of symptoms in patients with predicted severe pancreatitis. Severity assessment is essential for the selection of the proper initial treatment in the management of acute pancreatitis (recommendation A) and should be done using the APACHE II score, serum C-reactive protein and CT assessment (recommendation C). The etiology of acute pancreatitis should be able to be determined in at least 80% of cases (recommendation B). An adequate volume of intravenous fluid should be administered promptly to correct the volume deficit and maintain basal fluid requirements (recommendation A); analgesia is crucial for the correct treatment of the disease (recommendation A). Enteral feeding is indicated in severe necrotizing pancreatitis and it is better than total parenteral nutrition (recommendation A). The use of prophylactic broad-spectrum antibiotics reduces infection rates in CT-proven necrotizing pancreatitis (recommendation A). Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention, including surgery and radiological drainage (recommendation B). CONCLUSIONS The participants agreed to revise the guidelines every 3 years in order to re-evaluate each question on the management of acute pancreatitis patients according to the most recent literature.
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Affiliation(s)
- R Pezzilli
- Department of Digestive Diseases and Internal Medicine, Sant’Orsola-Malpighi Hospital, Via Massarenti 9, IT–40138 Bologna, Italy.
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Abstract
OBJECTIVES Studies evaluating hemoconcentration as a marker of necrosis in acute pancreatitis have reached different conclusions. The aim of this study was to determine the impact of transfer status on the accuracy of hemoconcentration for the prediction of pancreatic necrosis. METHODS We prospectively enrolled 339 patients in an observational cohort study from June 2005 to December 2007. Univariate and multivariate logistic regression analyses were used to evaluate the impact of transfer status on the relationship between hemoconcentration and necrosis. Accuracy for prediction of necrosis was measured by the area under the receiver operating characteristic curve. RESULTS Hemoconcentration was associated with increased risk of necrosis only among transferred patients (odds ratio [95% confidence limits], 3.6 [1.2, 10.8]). The area under the receiver operating characteristic curve for admission hematocrit for prediction of necrosis was 0.78 among the transferred patients versus 0.55 among those with primary admissions (chi2, P < 0.0001). Transferred patients had greater initial severity (median bedside index of severity in acute pancreatitis, 2 vs 1; P < 0.0001), were more likely to have hemoconcentration (44% vs 18%; chi2, P < 0.0001), and experienced increased necrosis (37.5% vs 3.6%; chi2, P < 0.0001) compared with primary admissions. After adjusting for sex, disease severity, fluid resuscitation, and transfer status, hemoconcentration was not associated with necrosis (Wald chi2, P = 0.14). CONCLUSIONS Transfer status is a confounder in the relationship between hemoconcentration and pancreatic necrosis.
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Loveday BPT, Srinivasa S, Vather R, Mittal A, Petrov MS, Phillips ARJ, Windsor JA. High quantity and variable quality of guidelines for acute pancreatitis: a systematic review. Am J Gastroenterol 2010; 105:1466-76. [PMID: 20606652 DOI: 10.1038/ajg.2010.137] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Several clinical guidelines exist for acute pancreatitis, with varying recommendations. The aim of this study was to determine the quality of guidelines for acute pancreatitis. METHODS A literature search identified relevant guidelines, which were then reviewed to determine their document format and scope and the presence of endorsement by a professional body. The quality of guidelines was determined using the validated Grilli, Shaneyfelt, and AGREE instruments. RESULTS Twenty-one of the 30 guidelines analyzed were endorsed by professional bodies. Median quality scores were as follows: Grilli, 2; Shaneyfelt, 13; and AGREE, 50. Guideline quality did not improve over time. Guidelines endorsed by a professional body had higher scores than those without official endorsement. Guidelines with tables, a recommendations summary, evidence grading, and audit goals had significantly higher scores than guidelines lacking those features. CONCLUSIONS The many clinical guidelines for acute pancreatitis range widely in quality. Guidelines developed by professional bodies, and those with tables, a recommendations summary, evidence grading, and audit goals, are of higher quality. Further research is required to determine whether guideline quality alters clinical outcomes.
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Affiliation(s)
- Benjamin P T Loveday
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
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Faisst M, Wellner UF, Utzolino S, Hopt UT, Keck T. Elevated blood urea nitrogen is an independent risk factor of prolonged intensive care unit stay due to acute necrotizing pancreatitis. J Crit Care 2010; 25:105-11. [DOI: 10.1016/j.jcrc.2009.02.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 02/01/2009] [Accepted: 02/12/2009] [Indexed: 12/14/2022]
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Kotán R, Pósán J, Sápy P, Damjanovich L, Szentkereszty Z. Analysis of clinical course of severe acute biliary and non biliary pancreatitis: a comparative study. Orv Hetil 2010; 151:265-8. [DOI: 10.1556/oh.2010.28760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Az akut pancreatitis viszonylag gyakran előforduló betegség. Évenként 5 és 80 közötti új megbetegedés esik 100 000 lakosra, és ez a szám az utóbbi években növekedést mutat a különböző tanulmányok szerint. A két fő etiológiai faktor az alkohol és az epekövesség. Az alkoholos eredetű hasnyálmirigy-gyulladás a férfiak körében, a biliaris pancreatitis a nők körében gyakoribb.
Célkitűzés:
a szerzők súlyos akut pancreatitis miatt kezelt betegek adatait elemezik, arra keresve a választ, hogy milyen eltérő sajátságokkal rendelkezik a biliaris és a más etiológiájú pancreatitis.
Betegek és módszer:
a szerzők 139, súlyos akut pancreatitisben szenvedő beteget kezeltek, akiket etiológiai szempontból két csoportra osztottak: az epeköves (A csoport) és a nem epeköves (B csoport) talajon kialakult súlyos hasnyálmirigy-gyulladásban szenvedők csoportjára. Összehasonlították a két csoport nem és kor szerinti sajátosságait, a mortalitási és a morbiditási adatokat, a műtétek és az ápolási napok számát. A statisztikai analízishez a χ
2
-tesztet alkalmazták.
Eredmények:
a szövődmények az epés (A) csoportban súlyosabbak voltak, mint a nem epés (B) csoportban. A halálozás az A csoportban 17,8%-nak, a B csoportban 13,8%-nak bizonyult, míg az átlagos 15,1% volt. A mortalitás a nők körében az A csoportban szignifikánsan magasabb volt.
Következtetések:
a súlyos epés akut pancreatitisben szenvedő nőbetegek esetében súlyosabb lefolyással, magasabb halálozási aránnyal kell számolnunk. A szerzők az idős, egyéb betegségekkel terhelt epeköves nőknél még a szövődmények jelentkezése előtt elektív cholecystectomiát javasolnak.
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Affiliation(s)
- Róbert Kotán
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Nagyerdei krt. 98. 4028
| | - János Pósán
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Nagyerdei krt. 98. 4028
| | - Péter Sápy
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Nagyerdei krt. 98. 4028
| | - László Damjanovich
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Nagyerdei krt. 98. 4028
| | - Zsolt Szentkereszty
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Általános Orvostudományi Kar Sebészeti Intézet Debrecen Nagyerdei krt. 98. 4028
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[Acute pancreatitis and bradycardia]. ACTA ACUST UNITED AC 2010; 29:159-61. [PMID: 20074894 DOI: 10.1016/j.annfar.2009.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 10/01/2009] [Indexed: 11/24/2022]
Abstract
Acute pancreatitis is frequently associated with electrocardiographic abnormalities, including arrhythmias and repolarization. We briefly describe a male patient with a severe acute pancreatitis who presented several bradycardias during his hospitalization in our intensive care unit. The aim of this case report is to underline the probability of severe arrhythmias during acute pancreatitis, which can increase morbidity of this pathology. Despite many publications or reports, causes of increased EKG abnormalities during severe pancreatitis remained unclear and are probably multifactorial. To prevent accidents or complications, patients with severe acute pancreatitis should have a continuous EKG monitoring.
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