New diagnostic criteria of acute pancreatitis

Identification of early prognostic biomarkers in Severe Fever with Thrombocytopenia Syndrome using machine learning algorithms

OBJECTIVE

We aimed at identifying acute phase biomarkers in Severe Fever with Thrombocytopenia Syndrome (SFTS), and to establish a model to predict mortality outcomes.

METHODS

A retrospective analysis was conducted on multicenter clinical data. Group-based trajectory modeling (GBTM) was utilized to demonstrate the overall trend of laboratory indicators and their correlation with mortality. Six different machine learning algorithms were employed to develop prognostic models based on the clinical features during the acute phase, which were reduced using Lasso regression.

RESULTS

Seven indicators (ALT, AST, BUN, LDH, a-HBDH, DD, and PLT) at 7-10 days post-onset and their change slopes were found to be crucial during disease progression. These, along with other clinical features, were reduced to 8 variables using Lasso regression for model construction. The random forest model demonstrated the best performance in both internal validation (AUC: 0.961) and external validation (AUC: 0.948). Decision Curve Analysis indicated a good balance between model benefits and risks.

CONCLUSIONS

a-HBDH and its change slope along with central nervous symptom manifestations within 7-10 days after onset accurately predicted mortality in SFTS. Various algorithms provided a comprehensive overview of disease progression and constructed more stable and efficient models.

Association between red cell distribution width to albumin ratio and all-cause mortality in patients with acute pancreatitis admitted to the intensive care unit: a retrospective study based on the MIMIC-IV database

Background

Red blood cell volume distribution width (RDW) and albumin (Alb) have been proved to be predictors of mortality in various diseases, such as acute pancreatitis (AP). However, until now the relationship between RDW to Alb ratio (RAR) and mortality in AP has not been fully elucidated. Therefore, this study aims to evaluate the relationship between RAR and all-cause mortality in AP.

Method

Patients with AP in the Critical Care Medical Information Market (MIMIC-IV) database who met criteria were included in this retrospective study. Associated baseline data was obtained, cleaned and analyzed. Kaplan Meier (K-M) survival curve and Cox proportional hazards regression model were utilized to evaluate the relationship between RAR and all-cause mortality. Restricted Cubic Spline (RCS) was used for exploring how hazard ratio (HR) changes as RAR varied. Additionally, Receiver Operating Characteristic (ROC) analysis and subgroup analysis were conducted to assess the predictive value and to explore the significance of RAR in different populations.

Results

499 patients were included in this study. Survival curve showed that patients with RAR > 5.14 had higher mortality rate at 7-day (d), 14-d, 21-d, 28-d, 90-d, 180-d and 1-year (y). The univariate and multivariate Cox models revealed an independent association between high-level RAR and all-cause mortality at 28-d, 90-d and 1-y. RCS showed that RAR became a risk factor when exceeding 5.14. RAR only had linear relationship with mortality at 1-y after adjusting for the potential confounders. Subgroup analysis suggested that increased RAR caused higher risk of death in male, non-white people or those patients without respiratory failure (RF). ROC analysis indicated that compared with other parameters such as SOFA score, RAR exhibited higher efficiency in predicting in-hospital and all-cause mortality at 14-d, 21-d, 28-d, 90-d. Combined RAR with BISAP, RAR-modified BISAP showed superiority in predicting short-term mortality (28-d).

Conclusion

For patients with AP in ICU, RAR has a strong association with short- and long-term prognosis. Especially, RAR is a promising indicator for short-term all-cause mortality in patients with AP. For males, non-white patients and those without RF, elevated RAR may be a more dangerous signal of mortality.

Diagnosis and Management of Acute Pancreatitis

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

Pancreatitis in children: practical management from the BSPGHAN Pancreatitis Working Group

Pancreatitis, a condition characterised by inflammation of the pancreas, has multiple aetiologies. Improving clinical proficiency in prompt diagnosis and effective management leads to better outcomes for children with acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Establishing consensus guidance via the British Society of Paediatric Gastroenterology Hepatology and Nutrition Pancreatitis Working Group has ensured further focus on these patients who are often cared for in a multidisciplinary framework and may prompt future research in this area. Initial assessment includes serum amylase/lipase, triglyceride levels, full blood count, C reactive protein, renal and liver function profile, glucose, calcium and capillary blood gas. Fasted transabdominal ultrasound for all children and young people with suspected pancreatitis is recommended to identify pancreatic parenchyma and pancreatobiliary ductal changes, and complications. For fluid resuscitation, use crystalloids or Ringer’s lactate: initial bolus of 10 to 20 mL/kg, 1.5–2 times maintenance volume, with hourly monitoring of urine output over the initial 24–48 hours. Initiate oral intake within the first 24 hours after fluid resuscitation; fat restriction is not recommended. For suspected autoimmune pancreatitis, workup includes immunoglobulin levels (IgG, IgM, IgA, IgG subclasses), complement components and autoantibody profile to confirm diagnosis. Significant interventional management for pancreatitis and related complications is performed via endoscopic retrograde cholangiopancreatography or endoscopic ultrasound; referral to a specialised paediatric hepatobiliary surgical team is highly recommended. Close collaboration with a specialist centre can improve diagnostic and management pathways and outcomes for children.

Pancreatic Morphology, Immunology, and the Pathogenesis of Acute Pancreatitis

Acute pancreatitis is a complex inflammatory disorder with significant morbidity and mortality. This review aims to integrate the current knowledge of pancreatic morphology and immunology with the pathogenesis of acute pancreatitis, providing a comprehensive understanding of this critical condition. We conducted an extensive literature review, synthesizing data from recent studies and authoritative sources on pancreatic anatomy, histology, immunology, and the pathophysiology of acute pancreatitis. We also incorporated epidemiological data, clinical features, diagnostic criteria, and prognostic factors. The pancreas exhibits a complex morphology with intricate interactions between its exocrine and endocrine components. Its unique immunological landscape plays a crucial role in maintaining homeostasis and orchestrating responses to pathological conditions. In acute pancreatitis, the disruption of intracellular calcium signaling leads to premature enzyme activation, triggering a cascade of events including mitochondrial dysfunction, ATP depletion, and the release of proinflammatory mediators. This process can escalate from localized inflammation to systemic complications. The interplay between pancreatic morphology, immune responses, and pathophysiological mechanisms contributes to the varied clinical presentations and outcomes observed in acute pancreatitis. Understanding the intricate relationships between pancreatic morphology, immunology, and the pathogenesis of acute pancreatitis is crucial for developing more effective diagnostic and therapeutic strategies. This integrated approach provides new insights into the complex nature of acute pancreatitis and may guide future research directions in pancreatic disorders.

Impact of renal dysfunction on the diagnosis of acute pancreatitis using urinary trypsinogen-2: A retrospective study

AIM

Early diagnosis of acute pancreatitis is crucial, and urinary trypsinogen has been recently reported as a useful biomarker for diagnosing acute pancreatitis. We aimed to evaluate the impact of renal dysfunction on the diagnostic performance of urinary trypsinogen-2 for acute pancreatitis.

METHODS

We conducted a retrospective study using the clinical data of patients who visited the Department of Emergency and Critical Care at the University of Tokyo Hospital between 1 October, 2021, and 30 June, 2022. Patients with available data on qualitative urinary trypsinogen-2 levels were identified. We compared the urinary trypsinogen-2 levels among patients who were clinically diagnosed with acute pancreatitis. We further stratified the patients according to renal function parameters, such as serum creatinine level, blood urea nitrogen level, and estimated glomerular filtration rate, and evaluated the performance of urinary trypsinogen-2 as a biomarker for acute pancreatitis.

RESULTS

Within 9 months, 35 patients were identified. Of them, 22 patients showed positive results and 13 showed negative results on the urinary trypsinogen-2 test. The sensitivity, specificity, positive predictive value, and negative predictive value were 0.80, 0.40, 0.18, and 0.92, respectively. Based on the blood urea nitrogen level and estimated glomerular filtration rate, the prevalence of false-positive results was significantly higher in patients with reduced renal function than in those with normal renal function.

CONCLUSION

In patients with reduced renal function, the urinary trypsinogen-2 qualitative test results might be interpreted with caution when used for diagnosing acute pancreatitis.

Non-pancreatic hyperlipasemia: A puzzling clinical entity

BACKGROUND

Increased lipase level is a serological hallmark of the diagnosis of acute pancreatitis (AP) but can be detected in various other diseases associated with lipase leakage due to inflammation of organs surrounding the pancreas or reduced renal clearance and/or hepatic metabolism. This non-pancreatic hyperlipasemia (NPHL) is puzzling for attending physicians during the diagnostic procedure for AP. It would be clinically beneficial to identify the clinical and laboratory variables that hinder the accuracy of lipase diagnosis with the aim of improve it. A more precise description of the NPHL condition could potentially provide prognostic factors for adverse outcomes which is currently lacking.

AIM

To perform a detailed clinical and laboratory characterization of NPHL in a large prospective patient cohort with an assessment of parameters determining disease outcomes.

METHODS

A Hungarian patient cohort with serum lipase levels at least three times higher than the upper limit of normal (ULN) was prospectively evaluated over 31 months. Patients were identified using daily electronic laboratory reports developed to support an ongoing observational, multicenter, prospective cohort study called the EASY trial (ISRCTN10525246) to establish a simple, easy, and accurate clinical scoring system for early prognostication of AP. Diagnosis of NPHL was established based on ≥ 3 × ULN serum lipase level in the absence of abdominal pain or abdominal imaging results characteristic of pancreatitis.

RESULTS

A total of 808 patients [male, n = 420 (52%); median age (IQR): 65 (51-75) years] were diagnosed with ≥ 3 × ULN serum lipase levels. A total of 392 patients had AP, whereas 401 had NPHL with more than 20 different etiologies. Sepsis and acute kidney injury (AKI) were the most prevalent etiologies of NPHL (27.7% and 33.2%, respectively). The best discriminative cut-off value for lipase was ≥ 666 U/L (sensitivity, 71.4%; specificity, 88.8%). The presence of AKI or sepsis negatively affected the diagnostic performance of lipase. NPHL was associated with a higher in-hospital mortality than AP (22.4% vs 5.1%, P < 0.001). In multivariate binary logistic regression, not lipase but increased amylase level (> 244 U/L) and neutrophil-to-lymphocyte ratio (NLR) (> 10.37, OR: 3.71, 95%CI: 2.006-6.863, P < 0.001), decreased albumin level, age, and presence of sepsis were independent risk factors for in-hospital mortality in NPHL.

CONCLUSION

NPHL is a common cause of lipase elevation and is associated with high mortality rates. Increased NLR value was associated with the highest mortality risk. The presence of sepsis/AKI significantly deteriorates the serological differentiation of AP from NPHL.

Association between serum creatinine to albumin ratio and short- and long-term all-cause mortality in patients with acute pancreatitis admitted to the intensive care unit: a retrospective analysis based on the MIMIC-IV database

Background

Serum creatinine (Cr) and albumin (Alb) are important predictors of mortality in individuals with various diseases, including acute pancreatitis (AP). However, most previous studies have only examined the relationship between single Cr or Alb levels and the prognosis of patients with AP. To our knowledge, the association between short- and long-term all-cause mortality in patients with AP and the blood creatinine to albumin ratio (CAR) has not been investigated. Therefore, this study aimed to evaluate the short- and long-term relationships between CAR and all-cause mortality in patients with AP.

Methods

We conducted a retrospective study utilizing data from the Medical Information Market for Intensive Care (MIMIC-IV) database. The study involved analyzing various mortality variables and obtaining CAR values at the time of admission. The X-tile software was used to determine the optimal threshold for the CAR. Kaplan-Meier (K-M) survival curves and multivariate Cox proportional hazards regression models were used to assess the relationship between CAR and both short- and long-term all-cause mortality. The predictive power, sensitivity, specificity, and area under the curve (AUC) of CAR for short- and long-term mortality in patients with AP after hospital admission were investigated using Receiver Operating Characteristic analysis. Additionally, subgroup analyses were conducted.

Results

A total of 520 participants were included in this study. The CAR ideal threshold, determined by X-tile software, was 0.446. The Cox proportional hazards model revealed an independent association between CAR≥0.446 and all-cause mortality at 7-day (d), 14-d, 21-d, 28-d, 90-d, and 1-year (y) before and after adjustment for confounders. K-M survival curves showed that patients with CAR≥0.446 had lower survival rates at 7-d, 14-d, 21-d, 28-d, 90-d, and 1-y. Additionally, CAR demonstrated superior performance, with higher AUC values than Cr, Alb, serum total calcium, Glasgow Coma Scale, Systemic Inflammatory Response Syndrome score, and Sepsis-related Organ Failure Assessment score at 7-d, 14-d, 21-d, 28-d, 90-d, and 1-y intervals. Subgroup analyses showed that CAR did not interact with a majority of subgroups.

Conclusion

The CAR can serve as an independent predictor for short- and long-term all-cause mortality in patients with AP. This study enhances our understanding of the association between serum-based biomarkers and the prognosis of patients with AP.

Somatic symptom severity, depression and anxiety associations with pancreatitis and undifferentiated abdominal pain in surgical inpatients

BACKGROUND

Somatic Symptom Disorder is a psychiatric diagnosis that describes the experience of physical symptoms and associated distress, that is disproportionate to recognized organic pathology. Somatic symptom severity (SSS) may be associated with some surgical diagnoses; particularly the complex pain associated with pancreatitis, or the diagnostic ambiguity of undifferentiated abdominal pain (UAP). We aimed to estimate the prevalence of SSS in different diagnostic groups in surgical inpatients with abdominal pain; and to estimate the magnitude and direction of any association of SSS, anxiety and depression.

METHODS

Cross sectional analysis (n = 465) of adult admissions with non-traumatic abdominal pain, at a tertiary hospital in Australia. We estimated SSS with the Patient Health Questionnaire-15 (PHQ-15), depression with the Patient Health Questionnaire (PHQ-9) and anxiety with the General Anxiety Disorder (GAD-7), at standard cut-points ≥ 10; comparing acute pancreatitis (n = 20), chronic pancreatitis (n = 18) and UAP (n = 64) versus other causes of abdominal pain.

RESULTS

Somatic symptoms were common, 52% having moderate and 19.6% severe SSS. There was an association between moderate SSS and pancreatitis (OR 2.11, 95% CI 1.05-4.25) and depressive symptoms and chronic pancreatitis (OR = 3.47, 95% CI 1.31-9.24). There was no significant association between the four mental health categories and UAP.

CONCLUSIONS

SSS and psychological comorbidity were common in a surgical inpatients admitted for abdominal pain and equally represented across most diagnostic sub-groups. However, the pancreatitis sub-group had greater proportions with clinically significant SSS and depression, suggesting that they have a higher requirement for psychological assessment and intervention.

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Drug-Induced Acute Pancreatitis in Adults: Focus on Antimicrobial and Antiviral Drugs, a Narrative Review

Acute pancreatitis (AP) is an acute inflammation of the pancreas caused by the activation of digestive enzymes in the pancreatic tissue. The main causes of AP are cholelithiasis and alcohol abuse; less commonly, it can be caused by drugs, with a prevalence of up to 5%. Causal associations between drugs and pancreatitis are largely based on case reports or case series with limited evidence. We reviewed the available data on drug-induced AP, focusing on antimicrobial drugs and antivirals, and discussed the current evidence in relation to the classification systems available in the literature. We found 51 suspected associations between antimicrobial and antiviral drugs and AP. The drugs with the most evidence of correlation are didanosine, protease inhibitors, and metronidazole. In addition, other drugs have been described in case reports demonstrating positive rechallenge. However, there are major differences between the various classifications available, where the same drug being assigned to different probability classes. It is likely that the presence in multiple case reports of an association between acute pancreatitis and a drug should serve as a basis for conducting prospective randomized controlled trials to improve the quality of the evidence.

Pancreatic Cancer and Detection Methods

The pancreas is a vital organ with exocrine and endocrine functions. Pancreatitis is an inflammation of the pancreas caused by alcohol consumption and gallstones. This condition can heighten the risk of pancreatic cancer (PC), a challenging disease with a high mortality rate. Genetic and epigenetic factors contribute significantly to PC development, along with other risk factors. Early detection is crucial for improving PC outcomes. Diagnostic methods, including imagining modalities and tissue biopsy, aid in the detection and analysis of PC. In contrast, liquid biopsy (LB) shows promise in early tumor detection by assessing biomarkers in bodily fluids. Understanding the function of the pancreas, associated diseases, risk factors, and available diagnostic methods is essential for effective management and early PC detection. The current clinical examination of PC is challenging due to its asymptomatic early stages and limitations of highly precise diagnostics. Screening is recommended for high-risk populations and individuals with potential benign tumors. Among various PC screening methods, the N-NOSE plus pancreas test stands out with its high AUC of 0.865. Compared to other commercial products, the N-NOSE plus pancreas test offers a cost-effective solution for early detection. However, additional diagnostic tests are required for confirmation. Further research, validation, and the development of non-invasive screening methods and standardized scoring systems are crucial to enhance PC detection and improve patient outcomes. This review outlines the context of pancreatic cancer and the challenges for early detection.

Repetitive Cerulein-Induced Chronic Pancreatitis in Growing Pigs-A Pilot Study

Chronic pancreatitis (CP) is an irreversible and progressive inflammatory disease. Knowledge on the development and progression of CP is limited. The goal of the study was to define the serum profile of pro-inflammatory cytokines and the cell antioxidant defense system (superoxidase dismutase-SOD, and reduced glutathione-GSH) over time in a cerulein-induced CP model and explore the impact of these changes on selected cytokines in the intestinal mucosa and pancreatic tissue, as well as on selected serum biochemical parameters. The mRNA expression of CLDN1 and CDH1 genes, and levels of Claudin-1 and E-cadherin, proteins of gut barrier, in the intestinal mucosa were determined via western blot analysis. The study showed moderate pathomorphological changes in the pigs' pancreas 43 days after the last cerulein injection. Blood serum levels of interleukin (IL)-1-beta, IL-6, tumor necrosis factor alpha (TNF-alpha), C-reactive protein (CRP), lactate dehydrogenase (LDH), gamma-glutamyl transpeptidase (GGTP), SOD and GSH were increased following cerulein injections. IL-1-beta, IL-6, TNF-alpha and GSH were also increased in jejunal mucosa and pancreatic tissue. In duodenum, decreased mRNA expression of CDH1 and level of E-cadherin and increased D-lactate, an indicator of leaky gut, indicating an inflammatory state, were observed. Based on the current results, we can conclude that repetitive cerulein injections in growing pigs not only led to CP over time, but also induced inflammation in the intestine. As a result of the inflammation, the intestinal barrier was impaired.

A new model for predicting the outcome and effectiveness of drug therapy in patients with severe fever with thrombocytopenia syndrome: A multicenter Chinese study

BACKGROUND

There are a few models for predicting the outcomes of patients with severe fever with thrombocytopenia syndrome (SFTS) based on single-center data, but clinicians need more reliable models based on multicenter data to predict the clinical outcomes and effectiveness of drug therapy.

METHODOLOGY/PRINCIPAL FINDINGS

This retrospective multicenter study analyzed data from 377 patients with SFTS, including a modeling group and a validation group. In the modeling group, the presence of neurologic symptoms was a strong predictor of mortality (odds ratio: 168). Based on neurologic symptoms and the joint indices score, which included age, gastrointestinal bleeding, and the SFTS virus viral load, patients were divided into double-positive, single-positive, and double-negative groups, which had mortality rates of 79.3%, 6.8%, and 0%, respectively. Validation using data on 216 cases from two other hospitals yielded similar results. A subgroup analysis revealed that ribavirin had a significant effect on mortality in the single-positive group (P = 0.006), but not in the double-positive or double-negative group. In the single-positive group, prompt antibiotic use was associated with reduced mortality (7.2% vs 47.4%, P < 0.001), even in individuals without significant granulocytopenia and infection, and early prophylaxis was associated with reduced mortality (9.0% vs. 22.8%, P = 0.008). The infected group included SFTS patients with pneumonia or sepsis, while the noninfected group included patients with no signs of infection. The white blood cell count and levels of C-reactive protein and procalcitonin differed significantly between the infection and non-infection groups (P = 0.020, P = 0.011, and P = 0.003, respectively), although the absolute difference in the medians were small.

CONCLUSIONS/SIGNIFICANCE

We developed a simple model to predict mortality in patients with SFTS. Our model may help to evaluate the effectiveness of drugs in these patients. In patients with severe SFTS, ribavirin and antibiotics may reduce mortality.

Etiology and severity features of acute pancreatitis in HIV-positive patients with different immune status

Objectives

Acute pancreatitis is common in HIV-infected patients; however, the causes and severity of pancreatitis in HIV-positive patients have a number of significant features that affect both the severity of destruction of the pancreas and the methods of diagnosis and treatment.

Material and Methods

Anamnestic data, results of diagnosis and treatment of two groups of patients with acute pancreatitis were analyzed. The first group included 79 patients with acute pancreatitis combined with HIV infection who were admitted to the clinic for the period from 2017 to 2021. In people living with HIV, drugs and infectious agents caused acute pancreatitis in 11.4% and 24.1% of the cases, respectively. As our study showed, in patients with normal immune status, the drug etiology of pancreatitis prevailed in the structure of the causes of AP, in patients with immunodeficiency, infectious causes of pancreatitis were dominant.

Results

According to the results of data analysis, it is clear that HIV infection is a factor that makes the course of pancreatitis about two times worse regardless of the presence of immunosuppression. The etiological structure of HIV-associated acute pancreatitis directly depends on the patient's immune status and differs in many ways from that of HIV-negative patients or patients receiving ART.

Conclusion

The severity of the disease and the risk of death remain high in acute pancreatitis caused by infectious agents against the background of immunosuppression.

Acute Pancreatitis: Diagnosis and Treatment

Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.

Guidewire-assisted cannulation of the common bile duct for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis

BACKGROUND

Cannulation techniques have been recognized as being important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guidewire-assisted cannulation technique for the prevention of PEP.

OBJECTIVES

To assess the effectiveness and safety of the guidewire-assisted cannulation technique compared to the conventional contrast-assisted cannulation technique for the prevention of PEP in people undergoing diagnostic or therapeutic ERCP for biliary or pancreatic diseases.

SEARCH METHODS

For the previous version of this review, we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL and major conference proceedings, up to February 2012, with no language restrictions. An updated search was performed on 26 February 2021 for the current version of this review. Two clinical trial registries, clinicaltrials.gov and WHO ICTRP, were also searched in this update.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the guidewire-assisted cannulation technique versus the contrast-assisted cannulation technique in people undergoing ERCP.

DATA COLLECTION AND ANALYSIS

Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test (P < 0.10) and I² statistic (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, publication type, risk of bias, use of precut sphincterotomy, inadvertent guidewire insertion or contrast injection of the pancreatic duct (PD), use of a PD stent, cannulation device, and trainee involvement in cannulation. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects) and per-protocol analysis.

MAIN RESULTS

15 RCTs comprising 4426 participants were included. There was moderate heterogeneity among trials for the outcome of PEP (P = 0.08, I² = 36%). Meta-analyses suggest that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique (RR 0.51, 95% CI 0.36 to 0.72, 15 studies, moderate-certainty evidence). In addition, the guidewire-assisted cannulation technique may result in an increase in primary cannulation success (RR 1.06, 95% CI 1.01 to 1.12, 13 studies, low-certainty evidence), and probably reduces the need for precut sphincterotomy (RR 0.79, 95% CI 0.64 to 0.96, 10 studies, moderate-certainty evidence). Compared to the contrast-assisted cannulation technique, the guidewire-assisted cannulation technique may result in little to no difference in the risk of post-sphincterotomy bleeding (RR 0.87, 95% CI 0.49 to 1.54, 7 studies, low-certainty evidence) and perforation (RR 0.93, 95% CI 0.11 to 8.23, 8 studies, very low-certainty evidence). Procedure-related mortality was reported by eight studies, and there were no cases of deaths in both arms (moderate-certainty evidence). Subgroup analyses suggest that the heterogeneity for the outcome of PEP could be explained by differences in trial design. The results were robust in sensitivity analyses.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that the guidewire-assisted cannulation technique probably reduces the risk of PEP compared to the contrast-assisted cannulation technique. There is low-certainty evidence that the guidewire-assisted cannulation technique may result in an increase in primary cannulation success. There is low- and very low-certainty evidence that the guidewire-assisted cannulation technique may result in little to no difference in the risk of bleeding and perforation. No procedure-related deaths were reported. Therefore, the guidewire-assisted cannulation technique appears to be superior to the contrast-assisted cannulation technique considering the certainty of evidence and the balance of benefits and harms. However, the routine use of guidewires in biliary cannulation will be dependent on local expertise, availability, and cost. Future research should assess the effectiveness and safety of the guidewire-assisted cannulation technique in the context of other pharmacologic or non-pharmacologic interventions for the prevention of PEP.

Unilateral versus bilateral Y-type stent-in-stent metal stent insertions in inoperable malignant hilar biliary strictures: A multicenter retrospective study

BACKGROUND

To date, there is controversy regarding unilateral versus bilateral stent placement in patients with malignant hilar biliary strictures (MHBSs). The aim of this study was to compare the clinical outcomes and complications of unilateral and bilateral (stent-in-stent method) stent placements for these patients.

METHODS

We conducted a multicenter retrospective analysis of patients with inoperable MHBS who underwent endoscopic self-expandable metal stent (SEMS) placement from January 2009 to December 2019. Two groups classified according to the stent procedure method were compared for demographic, procedural, and postprocedure factors. Survival analysis for patency loss and overall survival was also conducted.

RESULTS

A total of 236 subjects were included. A superior technical success rate was found in the unilateral stent group (98.8% vs. 82.5%, P < 0.001), whereas the clinical success rate was higher in the bilateral group (85.7% vs. 70.5%, P = 0.028). There was no significant difference with respect to complications or patency loss, and the bilateral group had better overall survival (P < 0.01). In the Cox proportional hazard model, MHBSs from lymph node compression were associated with a higher risk of death (HR = 9.803, P = 0.003). In contrast, bilateral SEMS insertion showed reduced postprocedural mortality (HR = 0.316, P = 0.001).

CONCLUSIONS

Y-type stent-in-stent bilateral SEMSs are technically difficult but demonstrated more favorable overall survival for palliative bile drainage of inoperable MHBS patients compared to unilateral insertions.

Evaluation of diagnostic and prognostic usefulness of abdominal ultrasonography in dogs with clinical signs of acute pancreatitis

OBJECTIVE

To report abdominal ultrasonography (AUS) findings in dogs with clinical signs of acute pancreatitis (AP) during the first 2 days of hospitalization and to compare AUS findings with severity of disease and mortality rate.

ANIMALS

37 client-owned dogs with clinical signs of AP.

PROCEDURES

Dogs suspected of having AP with complete medical records, AUS examinations performed throughout the first 2 days of hospitalization, and available frozen surplus serum samples for quantitative measurement of canine pancreatic lipase (cPL) concentrations at hospital admission met the criteria for study inclusion. Dogs were grouped as AUS+ or AUS- on the basis of positive or negative findings for AP on AUS, respectively. Abdominal ultrasonography findings of AP were stratified (as mild, moderate, or severe) by use of an AUS severity index, and a canine acute pancreatitis severity score was calculated.

RESULTS

24 of 37 (64.8%) dogs had AUS findings of AP at hospital admission, whereas 10 had positive findings for AP on AUS within 2 days of hospitalization. Three (8%) dogs were AUS- but had serum cPL concentrations > 400 μg/L (ie, values considered diagnostic for AP). On the AUS severity index, 5 of 34 (14.7%) AUS+ dogs had mild findings, 18 (52.9%) AUS+ dogs had moderate findings, and 11 (32.4%) AUS+ dogs had severe findings. Severe findings were associated with a higher risk of death than mild and moderate findings. A significant association was found between canine acute pancreatitis severity scores and mortality rates.

CONCLUSIONS AND CLINICAL RELEVANCE

For dogs with clinical signs of AP, repeated AUS examinations during hospitalization should be performed, severe findings on the AUS severity index may indicate an increased risk of death, and serum cPL concentrations may increase earlier than findings on AUS of AP.

Immune Checkpoint Inhibitor-Induced Pancreatic Injury: Imaging Findings and Literature Review

The immunotherapy revolution in cancer treatment involves a variety of specialists, not only oncologists, but also internal medicine physicians, endocrinologists, dermatologists, gastroenterologists, rheumatologists, and radiologists, introducing new scenarios and novel challenges in the diagnosis and management of a number of novel immune-related adverse events. Among these, immune checkpoint inhibitor-induced pancreatic injury has been described (occurring in up to 4% of patients) and has been reported to be responsible for visits to the emergency departments in up to 1.9% of patients treated with immune checkpoint inhibitors. This side effect can be symptomatic or non-symptomatic, and can be associated with the development of long-term damage to the pancreas, requiring the involvement of different specialists, including radiologists and gastroenterologists in the multidisciplinary team that manages these patients. The aim of this narrative review is to provide a summary of the available literature related to immune checkpoint inhibitor-induced pancreatic injury including the epidemiology, the clinical findings, and the management algorithm for diagnosis with a detailed analysis of the differential diagnosis at imaging, and treatment. A more in-depth focus is dedicated to symptomatic acute pancreatitis with its peculiar findings at imaging (ultrasound, computed tomography, and magnetic resonance imaging).

The positive effect of eugenol on acute pancreatic tissue injury: a rat experimental model

Introduction

we present a rat experimental model used to evaluate the possible reduction in the extent of pancreatic tissue injury in acute pancreatitis cases, after administration of eugenol.

Methods

one hundred and twenty Wistar rats were used, which were randomly assigned in 3 groups: sham (n=20), control (n=50) and eugenol (n=50). Acute pancreatitis was induced by biliopancreatic ligation in the control and eugenol groups, but not in the Sham group. In the eugenol group, eugenol was administered per-os. Five histopathological parameters, such as edema, inflammatory infiltration, duct dilatation, hemorrhage and acinar necrosis were evaluated.

Results

at 72 h from acute pancreatitis induction, the total histological score was diminished in the eugenol group (p<0.0005) and duct dilatation and inflammatory infiltration were reduced compared to the control group (p<0.05). In addition, at 72 h, eugenol reduced pancreatic myeloperoxidase activity (p<0.0005).

Conclusion

eugenol, a highly free radical scavenger agent, may have a preventive role in acute pancreatic injury, as it was evident in our rat experimental model.

The LipoxinA4 receptor agonist BML-111 ameliorates intestinal disruption following acute pancreatitis through the Nrf2-regulated antioxidant pathway

Acute pancreatitis (AP) is characterized by excessive release of pro-inflammatory cytokines and provokes multiorgan dysfunction. Disruption of the intestinal epithelium often occurs during and following acute pancreatitis and may aggravate systemic organ injuries. Although it has been widely investigated, to date, there is no satisfactory clinical therapy to restore the inflammatory damage. BML-111 is an endogenous lipid mediator that is analogous to LipoxinA4. It has been shown that BML-111 has a stable and potent anti-inflammatory ability. However, it is unclear whether BML-111 is involved in the process of relieving acute pancreatitis and its induced intestinal barrier damage, and the underlying mechanism of this effect. Here, we demonstrated that BML-111 could enhance the expression of E-cadherin, alleviate apoptosis, and mitigate the accumulation of reactive oxygen species in intestinal epithelial cells, thereby contributing to the anti-inflammatory efficacy in vitro and in vivo. Mechanistically, BML-111 upregulates the expression of Nrf2, which is a key regulator of the antioxidant response, and activates its downstream HO-1/NQO-1 pathway to protect against oxidative stress-induced cell death and tissue injury, consequently ameliorating pancreatitis and intestinal epithelium injury. In Nrf2-deficient cell and Nrf2-knockout mouse models, the depletion of Nrf2 blocked BML-111-induced antioxidant effects and thus was unable to exert protective effects in tissue. Taken together, BML-111 attenuated AP-related intestinal injury via an Nrf2-dependent antioxidant mechanism. Targeting this pathway is a potential therapeutic approach for AP-related intestinal injury.

Adherence to the evidence-based guidelines in the management of acute biliary pancreatitis: A case series

BACKGROUND

Acute pancreatitis (AP) is considered one of the most common gastrointestinal disorders; the annual worldwide incidence for AP is 4.9-73.4 cases / 100,000 people and the total mortality rate is 4-8%, increasing to 33% in patients with infected necrosis. This study aims to assess the outcome of providing standardized evidence-based care to patients with acute biliary pancreatitis.

METHODS

Thirty patients diagnosed with acute biliary pancreatitis, were enrolled in this study and managed according to the Japanese guidelines, 2015 with a complementary scope on other recent guidelines.

RESULTS

Out of 30 patients in the study, 60% were females. Twenty-five cases were presented in the early phase of the disease while the rest presented in the late phase. Gallstones were the commonest cause (80%). The complications encountered were a systemic complication in one case, organ failure in three cases, and the local complications in the form of fluid collections in (43.3%) of cases.Out of 30 patients, 6 patients had an intervention. The main approach was minimally invasive techniques (4 cases), Open approach was performed in 2 cases. The total mortality rate was 10%. Most mild cases were discharged within one week from admission. Cases readmitted with recurrent attacks of acute pancreatitis were 3 cases, one male and 2 females.

CONCLUSION

By applying guidelines in the management of acute biliary pancreatitis, we can reduce disease-related morbidity and mortality. Besides, we can reduce the costs of medical services with the proper investment of healthcare resources.

Clinical practice of acute pancreatitis in Japan: An analysis of nationwide epidemiological survey in 2016

BACKGROUND

To provide updates on clinical practice of acute pancreatitis (AP) in Japan, we conducted a nationwide epidemiological survey.

METHODS

This study consisted of a two-staged survey; the number of AP patients was estimated by the first-stage survey and their clinical features were examined by the second-stage survey. We surveyed AP patients who had visited hospitals in 2016.

RESULTS

The estimated number of AP patients in 2016 was 78,450, with an overall incidence of 61.8 per 100,000 persons. We obtained detailed clinical information of 2994 AP patients, including 706 (23.6%) severe cases classified according to the Japanese severity criteria. The male-to-female sex ratio was 2.0, and the mean age at onset was 59.9 years in males and 66.5 years in females. Alcohol was the most common etiology (42.8%) in males and gallstones in females (37.7%). The AP-associated mortality was 6.1% in severe AP cases, which was decreased by 40% compared to the 2011 survey. Antibiotics were administered to most cases, with carbapenem being frequently used. Enteral nutrition was given in 31.8% of severe cases, but majority cases received after 48 h. Among the 107 patients who received intervention for walled-off necrosis, five patients received surgery-first approach, 66 received endoscopic ultrasound-guided transluminal drainage, and 19 underwent step-up approach.

CONCLUSIONS

We clarified the current status of AP in Japan including the significant reduction of mortality in severe cases, shift to endoscopic approaches for walled-off necrosis, and poor compliance of the recommendations in the guidelines including management of enteral nutrition and antibiotic administration.

Magnetic resonance cholangiopancreatography findings in early chronic pancreatitis diagnosed according to the Japanese Diagnostic Criteria

OBJECTIVES

It is important for diagnosing early chronic pancreatitis (CP), which may be improved by therapeutic intervention. We aimed to examine the pancreatic ductal changes on magnetic resonance cholangiopancreatography (MRCP) in patients with early CP defined by the Japanese Diagnostic Criteria.

METHODS

This retrospective study included patients suspected early CP and performed both endoscopic ultrasonography (EUS) and MRCP from January 2010 to August 2018. We assessed the diameter of the main pancreatic duct (MPD) and the number of irregularly dilated duct branches using MRCP imaging in early CP.

RESULTS

We enrolled 165 patients and 25 patients (15%) fulfilled the diagnostic criteria for early CP. Irregular dilatation of ≥ 3 duct branches on MRCP was more often observed in early CP compared to non-early CP (P = 0.004), although MPD diameter was comparable (2.06 mm in early CP vs. 1.96 in non-early CP, P = 0.698). The sensitivity and specificity were 45% and 74%, respectively. The prevalence of positive MRCP findings in patients with ≥ 2 positive EUS findings was higher than that in patients with 1 positive EUS finding (P = 0.08) and in patients without an EUS finding (P < 0.001). There was no difference in the average diameter of MPD.

CONCLUSION

Patients with early CP often exhibit alteration in duct branches and not in MPD in addition to parenchymal alteration. Both pancreatic parenchyma and duct branches might need to be evaluated by EUS and MRCP.

Characteristics and outcome of patients presenting with acute Pancreatitis: A one-year descriptive study from a tertiary care center in Lebanon

AIM

To determine the aetiology, hospital course, and outcome of patients diagnosed with acute pancreatitis (AP) presenting to the Emergency Department (ED) of a tertiary care center in Lebanon.

PATIENTS AND METHODS

Using a retrospective cross-sectional study design, records of all patients presenting to the ED with elevated lipase over one calendar year (2016) were reviewed. Patients diagnosed with AP according to the revised Atlanta classification were identified.

RESULTS

Over one year, a total of 24,133 adult patients visited the ED and 4,976 had serum lipase determination. Of those, 75 patients (mean age 59.4 ± 16.1; range 20-95; M:F 2.1) had confirmed AP accounting for 0.3% of adult ED visits. The most common etiologies were biliary (36%), idiopathic (16%), drugs (13%), and alcohol (11%). Intake of drugs known to be associated with AP was identified in 26% of patients. Alcoholic pancreatitis was more common in males, while biliary pancreatitis was more common in females (p less than 0.05 in both). 63 patients (84%) required regular hospital admission and only 1 (1.3%) required intensive care unit admission and passed away after multiorgan failure. Mean hospital stay was 4.0 ± 4.0 days (range 0-23) with mean hospital charges of $6,637 ± 8,496.

CONCLUSION

Acute pancreatitis accounts for a relatively small number of emergency visits in Lebanon. Leading etiologies are biliary and drugs, with a low contribution of alcohol compared to the West. The economic burden of AP is important, but outcomes appear largely favorable with an overall mortality of less than 2%.

Superfluous amylase/lipase testing at a tertiary care hospital: a retrospective study

BACKGROUND

Measuring both serum amylase and lipase in the setting of acute pancreatitis is not recommended and monitoring changes in amylase and lipase levels after diagnostic results is of little added value. The extent of the two types of superfluous amylase/lipase testing at our institution is unknown.

OBJECTIVE

Explore the extent of superfluous amylase/lipase testing.

DESIGN

Medical record review.

SETTINGS

Tertiary care, teaching hospital.

PATIENTS AND METHODS

We retrospectively reviewed all amylase and lipase tests performed over a recent 12-month period. Amylase tests were considered superfluous if they were ordered with lipase tests at the same time or if they were repeated after diagnostic amylase results. They were considered questionably superfluous if they were repeated alone after non-diagnostic amylase results. Lipase tests were considered superfluous if they were repeated after diagnostic lipase results and questionably superfluous if they were repeated after non-diagnostic lipase results.

MAIN OUTCOME MEASURES

Number and percentage of lipase and amylase tests that were superfluous or questionably superfluous.

SAMPLE SIZE

23 950.

RESULTS

Superfluous testing was identified in 30.6% of 23 950 amylase/lipase tests and questionably superfluous testing in 12.4%. Of the 7330 superfluous tests, 94.8% were due to simultaneous amylase/lipase testing and 5.2% to repeated lipase testing after diagnostic results. The rate of superfluous and questionably superfluous testing was significantly higher in the inpatient setting compared to emergency department or outpatient settings ( P<.0001). Of the 6483 amylase tests obtained simultaneously with non-diagnostic lipase tests, only 36 (0.6%) showed a diagnostic result. Furthermore, only 0.7% and 3.6% of amylase tests that were repeated after normal and borderline results, respectively, were diagnostic and 1.1% and 9.3% of lipase tests that were repeated after normal and borderline results, respectively, were diagnostic.

CONCLUSIONS

About one third of amylase/lipase testing appears to be superfluous, mainly due to simultaneous amylase/lipase testing. Since only 0.6% of simultaneous amylase/lipase tests showed diagnostic amylase with non-diagnostic lipase levels, quality improvement initiatives should be directed at reducing this low-value practice. Repeating amylase/lipase tests following normal results is of little value.

LIMITATIONS

Clinical notes and imaging studies were not reviewed.

CONFLICT OF INTEREST

None.

Usefulness of urinary trypsinogen-2 and trypsinogen activation peptide in acute pancreatitis: A multicenter study in Japan

BACKGROUND

Rapid urinary trypsinogen-2 dipstick test and levels of urinary trypsinogen-2 and trypsinogen activation peptide (TAP) concentration have been reported as prognostic markers for the diagnosis of acute pancreatitis.

AIM

To reconfirm the validity of all these markers in the diagnosis of acute pancreatitis by undertaking a multi-center study in Japan.

METHODS

Patients with acute abdominal pain were recruited from 17 medical institutions in Japan from April 2009 to December 2012. Urinary and serum samples were collected twice, at enrollment and on the following day for measuring target markers. The diagnosis and severity assessment of acute pancreatitis were assessed based on prognostic factors and computed tomography (CT) Grade of the Japanese Ministry of Health, Labour, and Welfare criteria.

RESULTS

A total of 94 patients were enrolled during the study period. The trypsinogen-2 dipstick test was positive in 57 of 78 patients with acute pancreatitis (sensitivity, 73.1%) and in 6 of 16 patients with abdominal pain but without any evidence of acute pancreatitis (specificity, 62.5%). The area under the curve (AUC) score of urinary trypsinogen-2 according to prognostic factors was 0.704, which was highest in all parameter. The AUC scores of urinary trypsinogen-2 and TAP according to CT Grade were 0.701 and 0.692, respectively, which shows higher than other pancreatic enzymes. The levels of urinary trypsinogen-2 and TAP were significantly higher in patients with extended extra-pancreatic inflammation as evaluated by CT Grade.

CONCLUSION

We reconfirmed urinary trypsinogen-2 dipstick test is useful as a marker for the diagnosis of acute pancreatitis. Urinary trypsinogen-2 and TAP may be considered as useful markers to determine extra-pancreatic inflammation in acute pancreatitis.

Detection of Common Bile Duct Stones in Mild Acute Biliary Pancreatitis Using Magnetic Resonance Cholangiopancreatography

Background

All patients with mild acute biliary pancreatitis should undergo early cholecystectomy. Whether routine common bile duct (CBD) imaging should be employed before the surgical procedure in these patients is a matter of current controversy. The aim of this study was to investigate the rate of detection of CBD stones using magnetic resonance cholangiopancreatography (MRCP) at different time intervals from admission.

Methods

From January 1, 2011, through December 31, 2016, 72 patients with acute biliary pancreatitis underwent MRCP. Fifty-six (n=56) of them with mild biliary pancreatitis met the study criteria. The patients were divided into two groups. Group A did not have stones in the CBD (n=45), and Group B had stones in the CBD (n=11). The time from admission to MRCP was divided into several periods (day 1 through day 180), and the presence of the CBD stones on MRCP was weighted against remoteness from admission. Liver chemistry profiles were compared between the groups on admission and before the MRCP.

Results

The cumulative rate of choledocholithiasis was 19.7% (Group B, n=11). Forty-five patients (Group A, n=45, 80.3%) did not have gallstones in the CBD. Eight patients with choledocholithiasis (8/56, 14.2%) were detected during the first 10 days from admission out of 27 patients. In patients who underwent MRCP between days 11 and 20, choledocholithiasis was found in two patients (2/56, 3.5%) and in one patient between days 21 and 30 (1/56, 1.8%). No stones were found in patients who underwent MRCP beyond 30 days from admission. Liver chemistry profiles did not show a significant difference in both groups. CBD dilatation was observed at presentation in 11 patients (n=11/56), 6 in Group A (6/45, 13.3%) and 5 in Group B (5/11, 45.5%) (p=0.016).

Conclusions

Routine CBD evaluation should be encouraged after mild acute biliary pancreatitis. Early performance of MRCP gives high yield in selecting the patients for endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy. A liver chemistry profile either on admission or before MRCP cannot predict the presence of CBD stones.

Value of the revised Atlanta classification (RAC) and determinant-based classification (DBC) systems in the evaluation of acute pancreatitis

OBJECTIVE

Since increasing acute pancreatitis (AP) severity is significantly associated with mortality, accurate and rapid determination of severity is crucial for effective clinical management. This study investigated the value of the revised Atlanta classification (RAC) and the determinant-based classification (DBC) systems in stratifying severity of acute pancreatitis.

METHODS

This retrospective observational cohort study included 480 AP patients. Patient demographics and clinical characteristics were recorded. The primary outcome was mortality, and secondary outcomes were admission to intensive care unit (ICU), duration of ICU stay, and duration of hospital stay.

RESULTS

Based on the RAC classification, there were 295 patients with mild AP (MAP), 146 patients with moderate-to-severe AP (MSAP), and 39 patients with severe AP (SAP). Based on the DBC classification, there were 389 patients with MAP, 41 patients with MSAP, 32 patients with SAP, and 18 patients with critical AP (CAP). ROC curve analysis showed that the DBC system had a significantly higher accuracy at predicting organ failure compared to the RAC system (p < .001). Multivariate regression analysis showed that age and ICU stay were independent risk factors of mortality.

CONCLUSION

The DBC system had a higher accuracy at predicting organ failure. Age and ICU stay were significantly associated with risk of death in AP patients. A classification of CAP by the DBC system should warrant close attention, and rapid implementation of effective measures to reduce mortality.

Neutrophil-lymphocyte ratio, gamma-glutamyl transpeptidase, lipase, high-density lipoprotein as a panel of factors to predict acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a rare but dangerous complication. APIP has common symptoms with acute abdomen. Assessment of an acute abdomen is more complicated during pregnancy because the gravid uterus could mask most of symptomatic signs. It has been a challenge to diagnose APIP by physical examination or diagnostic imaging. Case studies on APIP are also limited for analysis on the risk factors associated with the disease. This retrospective study evaluated a series of risk factors from a relatively substantial number of APIP cases to determine early predictors or prognosis markers for APIP.Fifty-nine APIP patients together with 179 random normal pregnant women in Shengjing Affiliated Hospital of China Medical University were included for this retrospective study. Medical parameters of blood test in biochemistry and hematology were compared between 2 groups using t test. Multivariate logistic regression analysis was performed to investigate the relationship between various factors and APIP using Statistical Applied Software (SAS student version).Compared with normal pregnant women, APIP patients have elevated values in alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen, creatinine, C-reactive protein, direct bilirubin, fibrin degradation products, gamma-glutamyl transpeptidase (GGT), glucose, lipase, pH and decreased values in albumin, fibrinogen, high-density lipoprotein (HDL), hemoglobin, low-density lipoprotein cholesterol (LDL-D), and total proteins from their blood tests. In addition, APIP patients have decreased numbers in red cells but increased numbers in white blood cells and increased ratio of neutrophil/lymphocyte (N/L). Among these factors, N/LR, GGT, lipase, and HDL are significantly associated with APIP. This study suggests that the combination of those factors serve as a panel of indicators for early-onset prognosis of APIP.GGT, lipase, HDL, and N/LR can serve as a panel of factors to predict APIP. More case studies are important to further evaluate the predicting power of this panel factors in APIP.

Prediabetes Directly Deteriorates into Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome Triggered by Acute Pancreatitis: A Case Report Illustrating a "Chicken and Egg" Paradigm in Ketosis-Prone Diabetes

INTRODUCTION

Diabetic crises occur most often in patients with type 1 diabetes and occasionally in type 2 diabetes, especially under stressful conditions. However, a diabetic crisis occurring directly from prediabetes is an unusual phenomenon.

CASE REPORT

A 45-year-old woman presented with postprandial left upper quadrant abdominal pain, nausea, and vomiting. She had a past medical history of prediabetes with impaired fasting glucose and HbA1c 6.4%. On admission, routine laboratory tests showed high anion gap metabolic acidosis (pH 6.92), anion gap 41 mmol/L, blood glucose 931 mg/dL, beta-hydroxybutyrate 28 mmol/L, and calculated effective osmolarity 322 mOsm/kg; she was diagnosed with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS), and DKA-related abdominal pain. Later, the patient was found to have elevated lipase and amylase, and diagnosed with acute pancreatitis. Since DKA can induce abdominal pain and nonspecific lipase elevation, both of which are characteristics of acute pancreatitis, while acute pancreatitis can conversely trigger DKA, there exists a "chicken and egg" paradigm. Therefore, the differential diagnosis is discussed.

CONCLUSION

It is important to differentiate DKA from concomitant causes of abdominal pain to avoid missing the underlying etiology, which can be the trigger for DKA. During diabetic crises, treating the underlying trigger is just as important as managing metabolic derangements in order to achieve favorable outcomes; meanwhile, managing acute pancreatitis-associated hyperglycemia can promote recovery. Additionally, diabetic crisis that directly evolves from prediabetes illustrates an atypical form of diabetes called ketosis-prone diabetes; we briefly discuss its clinical characteristics, classification, and follow-up.

Henoch-Schönlein purpura with acute pancreatitis: analysis of 13 cases

BACKGROUND

Henoch-Schönlein purpura is a common small vessel vasculitis in children. Acute pancreatitis rarely presents as a complication of Henoch-Schönlein purpura and has not been well characterized.

METHODS

We retrospectively reviewed 13 cases of Henoch-Schönlein purpura with acute pancreatitis among 3212 patients who attended our hospital between January 2003 and June 2016 and analyzed their clinical characteristics, laboratory findings, imaging findings, treatment and overall prognosis.

RESULTS

All patients had abdominal manifestations, including significant abdominal pain (13/13), vomiting (9/13), abdominal distension (3/13) and melena (6/13). Serum amylase level significantly increased in all patients, and urine amylase was increased in 7 cases (7/10). However, increased urine lapse was only noted in 2 cases (2/5), and diffuse swelling of the pancreas was seen in 2 cases (2/13) by abdominal ultrasonography. Although all patients had typical skin purpura (13/13), 5 patients (5/13) with acute pancreatitis initially experienced acute abdominal pain in clinical onset of Henoch-Schönlein purpura. Glucocorticoid therapy was effective in alleviating abdominal symptoms of Henoch-Schönlein purpura patients with acute pancreatitis. All patients were in good general condition without any abdominal complications 6-12 months after discharge.

CONCLUSIONS

Acute pancreatitis is rarely observed in Henoch-Schönlein purpura children and has no specific clinical features that differentiate it from abdominal manifestations of Henoch-Schönlein purpura. Therefore, in Henoch-Schönlein purpura patients with severe abdominal pain, serum amylase levels should be assessed to confirm the diagnosis of acute pancreatitis. Early diagnose of Henoch-Schönlein purpura with acute pancreatitis and treatment timely was very important for good clinical outcomes.

An 18-Year-Old With Acute-on-Chronic Abdominal Pain

An 18-year-old woman with a complex past medical history presented with 2 days of vomiting and lower abdominal pain. She had been admitted for the majority of the previous 5 months for recurrent pancreatitis and had undergone a cholecystectomy. Additional symptoms included nausea, anorexia, constipation, and a 40-lb weight loss over 4 months. She appeared uncomfortable, and an examination was remarkable for tachycardia, hypertension, and diffuse abdominal tenderness to light palpation. Her initial laboratory test results revealed mildly elevated liver enzymes (aspartate aminotransferase 68 U/L, alanine aminotransferase 80 U/L) and a normal lipase. She was admitted for pain control and nutritional support. Over the next few days, the lipase increased to 1707 U/L. Despite optimizing her management for acute pancreatitis, the patient's symptoms persisted. Further history gathering and laboratory testing ultimately revealed her diagnosis. Our expert panel reviews her hospital course and elucidates the management of our eventual diagnosis.

Number of Endoscopic Retrograde Cholangiopancreatography Procedures Required for Short Biliary Cannulation Time

Background. Several previous studies assessed the competence in endoscopic retrograde cholangiopancreatography (ERCP) using the bile duct cannulation success rate. However, the cannulation time is also important, because a long cannulation time was reported to be a risk factor for post-ERCP pancreatitis. Aim. To determine the number of ERCP procedures required for short cannulation time of the bile duct. Methods. We retrospectively analyzed 605 ERCP procedures performed for bile duct cannulation in patients with native papilla at our institution between March 2012 and December 2015. The successful procedures were divided into 2 groups: group L and group S (cannulation time > 15 minutes and ≤15 minutes, resp.). An analysis of the relationship among the biliary cannulation time, ERCP experience, and other factors was then conducted. Results. Multivariate analysis showed that the ERCP experience of ≤300 procedures (odds ratio, 2.080; 95% confidence interval, 1.337–3.142; P = 0.001) and malignant biliary stricture due to pancreatic cancer (odds ratio, 1.912; 95% confidence interval, 1.072–3.412; P = 0.028) were found to be significantly associated with a cannulation time of >15 minutes. Conclusions. Our findings suggested that an ERCP experience of ≤300 procedures and malignant biliary stricture due to pancreatic cancer were associated with prolonged biliary cannulation time.

Comparison of rectal indomethacin, diclofenac, and naproxen for the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIM

NSAIDs are commonly utilized for the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, not much is known about the most effective drug in preventing this complication. This study aims to clarify which drug (indomethacin, diclofenac, or naproxen) is most effective for the prevention of post endoscopic retrograde cholangiopancreatography (ERCP).

MATERIALS AND METHODS

In a double-blind, randomized study, patients received a single rectal dose of one of the three drugs 30 min before undergoing ERCP: diclofenac (100 mg), indomethacin (100 mg), or naproxen (500 mg). The primary outcome measured was the development of pancreatitis. The levels of serum amylase, lipase, lipoxin A4, and resolvin E1 were measured before ERCP, and at 24 h after the procedure.

RESULTS

Three hundred and seventy-two patients completed the study. The overall incidence of PEP was 8.6%, which occurred in five of the 124 (4%) patients who received diclofenac, seven of the 122 (5.8%) patients who received indomethacin, and 20 of the 126 (15.9%) patients who received naproxen. There were no significant differences in amylase and lipase levels among the three groups (P=0.183 and 0.597, respectively). Unlike patients in the naproxen group, patients in the diclofenac and indomethacin groups showed a significant increase in lipoxin A4 and resolvin E1 (P=0.001 and 0.02, respectively).

CONCLUSION

Diclofenac and indomethacin patient groups had a lower incidence of PEP than the naproxen group.

Prognostic impact of type of preoperative biliary drainage in patients with distal cholangiocarcinoma

BACKGROUND

Surgical results of patients with resected distal cholangiocarcinoma (DCC) were evaluated to elucidate prognostic impact of the type of preoperative biliary drainage (PBD).

METHODS

Eighty-eight patients with resected DCC were stratified into two groups according to the type of PBD: the percutaneous transhepatic biliary drainage (PTBD) group (n = 25) and the endoscopic biliary drainage (EBD) group (n = 63).

RESULTS

Overall 5-year survival rate of the patients in the PTBD group was poorer than in the EBD group (24% vs. 52%, P = 0.020). On univariate analysis, PTBD, pancreatic invasion, perineural invasion, and lymph node involvement were significant prognostic factors for poor overall survival. On multivariate analysis, PTBD was the only significantly independent prognostic factor for poor overall survival. The incidence of liver metastasis was significantly higher in the PTBD group than in the EBD group (32.0% vs. 13.3%, P = 0.034).

CONCLUSIONS

PTBD should be avoided as much as possible in patients with DCC since the patients who underwent PTBD had poorer overall survival and higher incidence of liver metastasis than those who underwent EBD.

Thrombosis of pancreatic arteriovenous malformation induced by diagnostic angiography: case report

Background

We report on a case of pancreatic arteriovenous malformation (PAVM) that obliterated shortly after diagnostic angiography (DSA). PAVM is a rare anomaly that presents with upper abdominal pain, signs of acute pancreatitis and massive gastrointestinal bleeding. The management of PAVM is rather complex, with complete treatment usually accomplished only by a total extirpation of the affected organ or at least its involved portion. DSA prior to treatment decisions is helpful for characterizing symptomatic PAVM, since it can clearly depict the related vascular networks. In addition, interventional therapy can be performed immediately after diagnosis.

Case presentation

A 39-old male was admitted due to recurring upper abdominal pain that lasted several weeks. Initial examination revealed the absence of fever or jaundice, and the laboratory tests, including that for pancreatic enzymes, were unremarkable. An abdominal ultrasound (US) showed morphological and Doppler anomalies in the pancreas that were consistent with a vascular formation. A subsequent DSA depicted a medium-sized nidus, receiving blood supply from multiple origins but with no dominant artery. Coil embolization was not possible due to the small caliber of the feeding vessels. In addition, sclerotherapy was not performed so as to avoid an unnecessary wash out to the non-targeted duodenum. Consequently, the patient received no specific treatment for his symptomatic PAVM. A large increase in pancreatic enzymes was noticed shortly after the DSA procedure. Imaging follow-up by means of CT and MRI showed small amounts of peripancreatic fluid along with a limited area of intra-parenchymal necrosis, indicating necrotizing pancreatitis. In the post-angiography follow-up the patient was hemodynamically stable the entire time and was treated conservatively. The symptoms of pancreatitis improved over a few days, and the laboratory findings returned to normal ranges. Long-term follow-up by way of a contrast-enhanced CT revealed no recanalization of the thrombosed PAVM.

Conclusion

The factors associated with the obliteration of PAVM during or after DSA are poorly understood. In our case it may be attributed to the low flow dynamics of PAVM, as well as to the local administration of a contrast agent. Asymptomatic PAVM, as diagnosed with non-invasive imaging techniques, should not be evaluated with DSA due to the potential risk of severe complications, such as acute pancreatitis.

Pancreatic duct guidewire placement for biliary cannulation for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis

BACKGROUND

Difficult cannulation is a risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). It has been postulated that the pancreatic duct guidewire (PGW) technique may improve biliary cannulation success and reduce the risk of PEP in people with difficult cannulation.

OBJECTIVES

To systematically review evidence from randomised controlled trials (RCTs) assessing the effectiveness and safety of the PGW technique compared to persistent conventional cannulation (CC) (contrast- or guidewire-assisted cannulation) or other advanced techniques in people with difficult biliary cannulation for the prevention of PEP.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL databases, major conference proceedings, and for ongoing trials on the ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to March 2016, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions.

SELECTION CRITERIA

RCTs comparing the PGW technique versus persistent CC or other advanced techniques in people undergoing ERCP with difficult biliary cannulation.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted study selection, data extraction, and methodological quality assessment. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi(2) test (P < 0.15) and I(2) test (> 25%). To explore sources of heterogeneity, we conducted a priori subgroup analyses according to trial design, use of pancreatic duct (PD) stent, involvement of trainees in cannulation, publication type, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed-effect versus random-effects).

MAIN RESULTS

We included seven RCTs comprising 577 participants. There was no significant heterogeneity among trials for the outcome of PEP (P = 0.32; I(2) = 15%). The PGW technique significantly increased PEP compared to other endoscopic techniques (RR 1.98, 95% CI 1.14 to 3.42; low-quality evidence). The number needed to treat for an additional harmful outcome was 13 (95% CI 5 to 89). Among the three studies that compared the PGW technique with persistent CC, the incidence of PEP was 13.5% for the PGW technique and 8.7% for persistent CC (RR 1.58, 95% CI 0.83 to 3.01; low-quality evidence). Among the two studies that compared the PGW technique with precut sphincterotomy, the incidence of PEP was 29.8% in the PGW group versus 10.3% in the precut group (RR 2.92, 95% CI 1.24 to 6.88; low-quality evidence). Among the two studies that compared the PGW technique with PD stent placement, the incidence of PEP was 11.7% for the PGW technique and 5.0% for PD stent placement (RR 1.75, 95% CI 0.08 to 37.50; very low-quality evidence). There was no significant difference in common bile duct (CBD) cannulation success with the randomised technique (RR 1.04, 95% CI 0.87 to 1.24; low-quality evidence) or overall CBD cannulation success (RR 1.04, 95% CI 0.91 to 1.18; low-quality evidence) between the PGW technique and other endoscopic techniques. There was also no statistically significant difference in the risk of other ERCP-related complications (bleeding, perforation, cholangitis, and mortality). The results were robust in sensitivity analyses. The overall quality of evidence for the outcome of PEP was low or very low because of study limitations and imprecision.

AUTHORS' CONCLUSIONS

In people with difficult CBD cannulation, sole use of the PGW technique appears to be associated with an increased risk of PEP. Prophylactic PD stenting after use of the PGW technique may reduce the risk of PEP. However, the PGW technique is not superior to persistent attempts with CC, precut sphincterotomy, or PD stent in achieving CBD cannulation. The influence of co-intervention in the form of rectal peri-procedural nonsteroidal anti-inflammatory drug administration is unclear.

Abdominal Pain in the Geriatric Patient

Abdominal pain in the elderly can be a challenging and difficult condition to diagnose and treat. The geriatric population has significant comorbidities and often takes polypharmacy that can mask symptoms. The presentation of common conditions can be different than that in the younger population, often lacking the traditional indicators of disease, making it of pivotal importance for the clinician to consider a wide differential during their workup. It is also important to consider extra-abdominal abnormality that may manifest as abdominal pain.

Time Trend of Outcomes for Severe Acute Pancreatitis After Publication of Japanese Guidelines Based on a National Administrative Database

OBJECTIVES

This study aimed to investigate the recent time trend of outcomes for severe acute pancreatitis after publication of Japanese guidelines based on a national administrative database.

METHODS

A total of 10,400 patients with severe acute pancreatitis were referred to 1021 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare in-hospital mortality (within 28 days and overall), length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into 3 groups according to fiscal year: 2010 (n = 2698), 2011 (n = 3842), and 2012 (n = 3860).

RESULTS

In-hospital mortality within 28 days and overall in-hospital mortality were significantly decreased according to fiscal year (6.3% [2010] vs 5.7% [2011] vs 4.5% [2012], P = 0.005; 7.6% vs 7.1% vs 5.6%, P = 0.002, respectively). However, mean LOS and medical costs were not different between fiscal years (27.0 vs 27.1 vs 26.9 days, P = 0.218; 13,998.0 vs 14,156.4 vs 14,319.2 USD, P = 0.232, respectively).

CONCLUSIONS

This study shows that mortality of severe acute pancreatitis was reduced according to the time course, whereas LOS or medical costs were stable after publication of the Japanese guidelines.

Effect of Somatostatin, Ulinastatin and Gabexate on the Treatment of Severe Acute Pancreatitis

OBJECTIVE

The objective of this study is to evaluate the efficacy of somatostatin, ulinastatin and gabexate for the treatment of severe acute pancreatitis.

MATERIALS AND METHODS

A total of 492 patients with severe acute pancreatitis were assigned randomly into the following 4 groups: (1) somatostatin; (2) somatostatin + ulinastatin; (3) somatostatin + gabexate and (4) somatostatin + ulinastatin + gabexate. Acute physiology and chronic health evaluation II scores; clinical parameters including time of abdominal pain and distention extinct; recovering to normality of heart rate and respiration rate; amylase and blood glucose; ratios of efficacy; multiple organ dysfunction syndrome (MODS); mortality; complication; levels of endotoxin; tumor necrosis factor alpha; interleukin-6 (IL-6), IL-8 and IL-10 and side effects were analyzed.

RESULTS

Acute physiology and chronic health evaluation II scores, time of abdominal pain extinct and distention extinct, time of recovering to normality of heart rate, time of recovering to normality of respiration rate and time of recovering to normality of amylase and blood glucose were significantly decreased in the somatostatin + ulinastatin, the somatostatin + gabexate and the somatostatin + ulinastatin + gabexate subgroups compared with the somatostatin subgroup. Ratios of efficacy were significantly improved, whereas ratios of MODS, mortality and complication were significantly decreased in the somatostatin + ulinastatin and the somatostatin + ulinastatin + gabexate subgroups compared with the somatostatin subgroup. Tumor necrosis factor alpha, IL-6 and IL-8 levels on the fourth day after treatment showed significant decrease in the somatostatin + ulinastatin, the somatostatin + gabexate and the somatostatin + ulinastatin + gabexate subgroups compared with the somatostatin subgroup. The IL-10 levels on the fourth day were significantly improved in the somatostatin + ulinastatin, the somatostatin + gabexate and the somatostatin + ulinastatin + gabexate subgroups compared with the somatostatin subgroup.

CONCLUSIONS

Somatostatin is effective for the treatment of acute pancreatitis, ulinastatin demonstrates improvement in therapeutic benefits and gabexate can relieve the clinical symptoms and shorten the course of disease but cannot improve the effective ratio or decrease MODS, mortality and complication.

Revised Japanese guidelines for the management of acute pancreatitis 2015: revised concepts and updated points

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.

Clinical and therapeutic correlations in patients with slight acute pancreatitis

Background

Acute pancreatitis is an inflammatory disease of the pancreas due to enzymatic autodigestion which can cause necrosis or multiple organ failure; its pathophysiology is not fully known yet.

Aim

To evaluate the correlation between clinical and therapeutic data in patients with mild acute pancreatitis.

Methods

A retrospective study in 55 medical records of patients admitted with acute mild pancreatitis was realized to analyze the association between age, leukocytosis, serum glutamic-oxaloacetic transaminase and lactate dehydrogenase, glucose, antibiotics, time admission and Ranson´s scores.

Results

There was a positive association between less intensive care (strict hydration, analgesia and monitoring of vital signs), early antibiotic therapy (monotherapy), early return to diet after 48 hours and laboratory control of the serum amylase and lipase (high in the first week and decreasing after 10 days, without any prognostic value).

Conclusions

Changes in the management of patients with mild acute pancreatitis, such as enteral nutrition, rational use of lower spectrum antibiotics and intensive care, have contributed significantly to the reduction of hospitalization time and mortality.

Predictors and Diagnostic Strategies for Early-Stage Pancreatic Ductal Adenocarcinoma: A Retrospective Study

OBJECTIVES

As a strategy to diagnose early-stage pancreatic ductal adenocarcinoma (PDAC) is urgently needed, we aimed to clarify characteristics of early-stage PDAC.

METHODS

We retrospectively reviewed medical records of 299 consecutive patients who underwent R0 or R1 surgical resection for PDAC between 1994 and 2013 and compared clinical characteristics between patients with early-stage (stages 0-I by Japanese General Rules for Pancreatic Cancer) and advanced-stage (stages II-IV) disease. Diagnostic processes were also analyzed.

RESULTS

Twenty-four patients (8%) had early-stage PDAC (stage 0: 11; stage I: 13). Univariate and multivariate analyses showed that presence or history of intraductal papillary mucinous neoplasm (P < 0.01), history of pancreatitis (P < 0.01), and presence or history of extrapancreatic malignancies (P = 0.01) independently predicted detection of early-stage PDAC. Cytological examination during endoscopic retrograde pancreatography cytology was ∼65% sensitive in preoperative diagnosis of early-stage PDAC, whereas other imaging modalities were only 29% to 38% sensitive; 9 of 24 early-stage PDACs were diagnosed by endoscopic retrograde pancreatography cytology alone.

CONCLUSIONS

Endoscopic retrograde pancreatography cytology for patients with intraductal papillary mucinous neoplasm or pancreatitis may help diagnose early-stage PDAC. Surveillance of extrapancreatic malignancies might also provide opportunities to detect early-stage PDAC as a second malignancy.

Usefulness of scheduled follow-up CT in discharged patients with acute pancreatitis

BACKGROUND AND AIM

Follow-up computed tomography (CT) in patients with acute pancreatitis has been advocated but rarely studied. The aim of this study was to determine whether follow-up CT for acute pancreatitis might be helpful in establishing the prognosis or complications, and in determining a selected subgroup of patients for whom computed tomography could be beneficial.

METHODS

Between January 2010 and December 2012, patients with acute pancreatitis who underwent follow-up CT in the outpatient department between one and three months after discharge were retrospectively enrolled. Events discovered on follow-up CT were defined as newly developed or increased pancreatic collection such as pseudocyst or walled off necrosis, and diagnosis of pancreatic cancer.

RESULTS

Ultimately, 106 asymptomatic patients were enrolled (mean age 50.24 ± 16, 74.5% male, 31.1% moderately severe and severe acute pancreatitis). The median duration of follow-up CT was 69 (31-90) days. On follow-up CT, 23 patients showed events (2 pancreatic cancer, 21 increasing or developed pancreatic collections). In multivariate analysis, the predictive factors for events on follow-up CT were CTSI ≥3 (OR 4.46, CI 1.08-18.43, p = 0.039) and BISAP ≥ 2 (OR 4.83, CI 1.08-21.55, p = 0.039).

CONCLUSIONS

Follow-up CT within three months after discharge may be helpful for acute pancreatitis patients with CTSI ≥ 3 points or BISAP score ≥ 2 points.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

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.

Prevalence and clinicopathological features of autoimmune pancreatitis in Japanese patients with inflammatory bowel disease

OBJECTIVES

The purpose of this study was to clarify the clinicopathological characteristics of autoimmune pancreatitis (AIP) in Japanese patients with inflammatory bowel disease (IBD).

METHODS

The clinicopathological findings of 7 patients with IBD whose definite AIP was diagnosed in our hospital according to the International Consensus Diagnostic Criteria were reviewed.

RESULTS

Five (0.5%) of 961 patients with ulcerative colitis (UC) and 2 (0.3%) of 790 patients with Crohn disease had AIP. All of 7 patients whose AIP was diagnosed were type 2. The rate of elevated values of serum immunoglobulin G4 was 0%. Most patients with the diagnosis of IBD preceded that of AIP, and disease activity of IBD were active. Granulocyte epithelial lesion is similar to the cryptitis seen in colonic tissue of UC. All of 7 patients were given corticosteroids, immunomodulators, and/or biological agents for IBD. One patient had a recurrence.

CONCLUSIONS

The frequency of AIP in Japanese patients with IBD was low. All cases were type 2 and responded well to corticosteroids, immunomodulators, and biological agents. Autoimmune pancreatitis in UC patients may be an extraintestinal manifestation of UC.