New Risk Factors for Infected Pancreatic Necrosis Secondary to Severe Acute Pancreatitis: The Role of Initial Contrast-Enhanced Computed Tomography

Chronic liver disease is an important risk factor for worse outcomes in acute pancreatitis: a systematic review and meta-analysis

Chronic liver diseases (CLD) affect 1.5 billion patients worldwide, with dramatically increasing incidence in recent decades. It has been hypothesized that the chronic hyperinflammation associated with CLD may increase the risk of a more severe course of acute pancreatitis (AP). This study aims to investigate the underlying impact of CLD on the outcomes of AP. A systematic search was conducted in Embase, Medline, and Central databases until October 2022. Studies investigating patients with acute pancreatitis and CLD, were included in the meta-analysis. A total of 14,963 articles were screened, of which 36 were eligible to be included. CLD was a risk factor for increased mortality with an odds ratio (OR) of 2.53 (CI 1.30 to 4.93, p = 0.01). Furthermore, renal, cardiac, and respiratory failures were more common in the CLD group, with ORs of 1.92 (CI 1.3 to 2.83, p = 0.01), 2.11 (CI 0.93 to 4.77, p = 0.062) and 1.99 (CI 1.08 to 3.65, p = 0.033), respectively. Moreover, the likelihood of developing Systemic Inflammatory Response Syndrome (SIRS) was significantly higher, with an OR of 1.95 (CI 1.03 to 3.68, p = 0.042). CLD is an important risk factor for worse outcomes in AP pancreatitis, leading to higher mortality and increased rates of local and systemic complications.

Dynamic nomogram for predicting infected pancreatic necrosis in female patients of childbearing age with hypertriglyceridemia-induced acute pancreatitis

BACKGROUND

Hypertriglyceridemia is a common cause of acute pancreatitis. Pregnant women are at risk of developing hypertriglyceridemia-induced acute pancreatitis (HTG-AP); however, whether pregnancy increases the risk of infected pancreatic necrosis (IPN) is unknown.

AIM

We aimed to assess the association between pregnancy and IPN.

METHODS

This 10-year retrospective cohort study was conducted at Jinling Hospital. Adult female patients of childbearing age with HTG-AP between January 2013 and September 2022 were screened. Logistic regression analyses were performed to assess the risk factors for IPN. Patients admitted within 7 days were assigned to the training and validation sets to develop a dynamic nomogram for IPN prediction.

RESULTS

489 patients were included, and 144 developed IPN. Logistic regression analyses revealed pregnancy (OR: 2.578 95% CI: 1.474-4.510) as an independent risk factor for IPN. Gestation weeks, ARDS, albumin level, and serum creatinine level were selected as the predictors of the dynamic nomogram for IPN prediction, with good discrimination in the training set (AUC 0.867 95% CI: 0.794-0.940) and validation set (AUC 0.957 95% CI: 0.885-1.000).

CONCLUSION

Pregnancy increases the risk of IPN in adult patients of childbearing age with HTG-AP, and the dynamic nomogram may help risk stratification for IPN.

Acute pancreatitis: A review of diagnosis, severity prediction and prognosis assessment from imaging technology, scoring system and artificial intelligence

Acute pancreatitis (AP) is a potentially life-threatening inflammatory disease of the pancreas, with clinical management determined by the severity of the disease. Diagnosis, severity prediction, and prognosis assessment of AP typically involve the use of imaging technologies, such as computed tomography, magnetic resonance imaging, and ultrasound, and scoring systems, including Ranson, Acute Physiology and Chronic Health Evaluation II, and Bedside Index for Severity in AP scores. Computed tomography is considered the gold standard imaging modality for AP due to its high sensitivity and specificity, while magnetic resonance imaging and ultrasound can provide additional information on biliary obstruction and vascular complications. Scoring systems utilize clinical and laboratory parameters to classify AP patients into mild, moderate, or severe categories, guiding treatment decisions, such as intensive care unit admission, early enteral feeding, and antibiotic use. Despite the central role of imaging technologies and scoring systems in AP management, these methods have limitations in terms of accuracy, reproducibility, practicality and economics. Recent advancements of artificial intelligence (AI) provide new opportunities to enhance their performance by analyzing vast amounts of clinical and imaging data. AI algorithms can analyze large amounts of clinical and imaging data, identify scoring system patterns, and predict the clinical course of disease. AI-based models have shown promising results in predicting the severity and mortality of AP, but further validation and standardization are required before widespread clinical application. In addition, understanding the correlation between these three technologies will aid in developing new methods that can accurately, sensitively, and specifically be used in the diagnosis, severity prediction, and prognosis assessment of AP through complementary advantages.

Dynamic Changes and Nomogram Prediction for Sinistral Portal Hypertension in Moderate and Severe Acute Pancreatitis

Objectives

To investigate the dynamic changes in gastric varices in patients with acute pancreatitis (AP) and to develop a novel nomogram for the early prediction of sinistral portal hypertension (SPH).

Methods

This was a retrospective, case-control study with an analysis of the quantitative, dynamic computed tomography imaging results of SPH in patients with moderate and severe AP with a long-term follow-up. Multivariate logistic regression analysis and nomogram were employed.

Results

The SPH group (n = 94) and non-SPH group (n = 94) were matched. The dynamic changes showed an increasing trend in the diameter of gastric fundus, short gastric, gastric coronary, and gastroepiploic veins, which did not recover during the one-year follow-up. Multivariate analysis showed that male (adjusted odds ratio (adjOR), 8.71; 95% confidence interval (CI), 2.86–26.53; P < 0.001), body mass index ≥27.5 kg/m² (adjOR, 5.49; 95% CI, 1.85–16.29; P = 0.002), prothrombin time ≥12.6 s (adjOR, 2.82; 95% CI, 1.11–7.17; P = 0.03), and the patency of splenic vein [stenosis (adjOR, 8.48; 95% CI, 2.13–33.71; P = 0.002), and occlusion (adjOR, 34.57; 95% CI, 10.87–110.00; P < 0.001)] were independently associated with the development of SPH. The nomogram incorporating these factors demonstrated good discrimination, calibration and clinical utility. The area under the curve was as high as 0.92 (95% CI, 0.87–0.95).

Conclusion

The dynamic changes in varices in SPH are long-term and slowly progressing. Males and obese patients with abnormal splenic veins and coagulopathies are at high risk for developing SPH. A simple nomogram tool helps in the early, accurate prediction of SPH.

Volume, but Not the Location of Necrosis, Is Associated with Worse Outcomes in Acute Pancreatitis: A Prospective Study

Background and Objectives: The course and clinical outcomes of acute pancreatitis (AP) are highly variable. Up to 20% of patients develop pancreatic necrosis. Extent and location of it might affect the clinical course and management. The aim was to determine the clinical relevance of the extent and location of pancreatic necrosis in patients with AP. Materials and Methods: A cohort of patients with necrotizing AP was collected from 2012 to 2018 at the Hospital of Lithuanian University of Health Sciences. Patients were allocated to subgroups according to the location (entire pancreas, left and right sides of pancreas) and extent (<30%, 30−50%, >50%) of pancreatic necrosis. Patients were reviewed for demographic features, number of performed surgical interventions, local and systemic complications, hospital stay and mortality rate. All contrast enhanced computed tomography (CECT) scans were evaluated by at least two experienced abdominal radiologists. All patients were treated according to the standard treatment protocol based on current international guidelines. Results: The study included 83 patients (75.9% males (n = 63)) with a mean age of 53 ± 1.7. The volume of pancreatic necrosis exceeded 50% in half of the patients (n = 42, 51%). Positive blood culture (n = 14 (87.5%)), multiple organ dysfunction syndrome (n = 17 (73.9%)) and incidences of respiratory failure (n = 19 (73.1%)) were significantly more often diagnosed in patients with pancreatic necrosis exceeding 50% (p < 0.05). Patients with >50% of necrosis were significantly (p < 0.05) more often diagnosed with moderately severe (n = 24 (41.4%)) and severe (n = 18 (72%)) AP. The number of surgical interventions (n = 18 (72%)) and ultrasound-guided interventions (n = 26 (65%)) was also significantly higher. In patients with whole-pancreas necrosis, incidence of renal insufficiency (n = 11 (64.7%)) and infected pancreatic necrosis (n = 19 (57.6%)) was significantly higher (p < 0.05). Conclusions: The clinical course and outcome were worse in the case of pancreatic necrosis exceeding 50%, rendering the need for longer and more complex treatment.

Prognostic factors associated with development of infected necrosis in patients with acute necrotizing or severe pancreatitis-A systematic review and meta-analysis

PURPOSE

Acute pancreatitis is a potentially life-threatening condition with a wide spectrum of clinical presentation and illness severity. An infection of pancreatic necrosis (IPN) results in a more than twofold increase in mortality risk as compared with patients with sterile necrosis. We sought to identify prognostic factors for the development of IPN among adult patients with severe or necrotizing pancreatitis.

METHODS

We conducted this prognostic review in accordance with systematic review methodology guidelines. We searched six databases from inception through March 21, 2021. We included English language studies describing prognostic factors associated with the development of IPN. We pooled unadjusted odds ratio (uOR) and adjusted odds ratios (aOR) for prognostic factors using a random-effects model. We assessed risk of bias using the Quality in Prognosis Studies tool and certainty of evidence using the GRADE approach.

RESULTS

We included 31 observational studies involving 5,210 patients. Factors with moderate or higher certainty of association with increased IPN risk include older age (uOR, 2.19; 95% confidence interval [CI], 1.39-3.45, moderate certainty), gallstone etiology (aOR, 2.35; 95% CI, 1.36-4.04, high certainty), greater than 50% necrosis of the pancreas (aOR, 3.61; 95% CI, 2.15-6.04, high certainty), delayed enteral nutrition (aOR, 2.09; 95% CI, 1.26-3.47, moderate certainty), multiple or persistent organ failure (aOR, 11.71; 95% CI, 4.97-27.56, high certainty), and invasive mechanical ventilation (uOR, 12.24; 95% CI, 2.28-65.67, high certainty).

CONCLUSION

This meta-analysis confirms the association between several clinical early prognostic factors and the risk of IPN development among patients with severe or necrotizing pancreatitis. These findings provide the foundation for the development of an IPN risk stratification tool to guide more targeted clinical trials for prevention or early intervention strategies.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, Level IV.

JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis

BACKGROUND

In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan METHOD: In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system.

RESULTS

Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Base on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced CT grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which was shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 hours of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics in mild pancreatitis.

CONCLUSION

All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.

Genomic New Insights Into Emergence and Clinical Therapy of Multidrug-Resistant Klebsiella pneumoniae in Infected Pancreatic Necrosis

Infected pancreatic necrosis (IPN) is a key risk factor in the progression of severe acute pancreatitis, and use of antibiotics is one of the main clinical actions. However, early prophylactic or unreasonable use of antibiotics promotes drug resistance in bacteria and also delays optimum treatment. To explore genomic evidence of rational antibiotic use in intensive care units, we isolated Klebsiella pneumoniae from IPN samples that showed the highest positive-culture rate in 758 patients. Based on whole-genome sequencing from eight strains, 42 antibiotic-resistant genes were identified in the chromatin and 27 in the plasmid, which included classic resistance-mechanism factors such as β-lactamases [16.67% (7/42) in the chromatin and 25.93% (7/27) in the plasmid]. The K. pneumoniae isolates were identified to be resistant to multiple antibiotics used in clinics. In vivo and in vitro, ceftazidime-avibactam (CZA) plus aztreonam (ATM) (2.5:1) showed more significant antibacterial effectiveness than CZA alone. The isolated K. pneumoniae were of three different types according to the resistance phenotypes for CZA and ATM. Those co-harboring bla _NDM-5, bla _CTX-M-15, bla _OXA-1, and bla _SHV-187 showed higher resistance to CAZ than bla _NDM-5. Those co-harboring bla _CTX-M-65, bla _SHV-182, and bla _TEM-181 were significantly less resistant to β-lactam than to other extended-spectrum β-lactamases. However, β-lactamases were inhibited by avibactam (AVI), except for NDM-5. ATM plus AVI showed a significant inhibitory effect on K. pneumoniae, and the minimum dosage of ATM was < 1 mg/L. In conclusion, we propose that ATM plus AVI could be a major therapy for complex infectious diseases caused by multidrug-resistant K. pneumoniae.

Occurrence and Risk Factors of Infected Pancreatic Necrosis in Intensive Care Unit-Treated Patients with Necrotizing Severe Acute Pancreatitis

BACKGROUND

In patients with severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN) is associated with a worsened outcome. We studied risk factors and consequences of IPN in patients with necrotizing SAP.

METHODS

The study consisted of a retrospective cohort of 163 consecutive patients treated for necrotizing SAP at a university hospital intensive care unit (ICU) between 2010 and 2018.

RESULTS

All patients had experienced at least one persistent organ failure and approximately 60% had multiple organ failure within the first 24 h from admission to the ICU. Forty-seven (28.8%) patients had IPN within 90 days. Independent risk factors for IPN were more extensive anatomical spread of necrotic collections (unilateral paracolic or retromesenteric (OR 5.7, 95% CI 1.5-21.1) and widespread (OR 21.8, 95% CI 6.1-77.8)) compared to local collections around the pancreas, postinterventional pancreatitis (OR 13.5, 95% CI 2.4-76.5), preceding bacteremia (OR 4.8, 95% CI 1.3-17.6), and preceding open abdomen treatment for abdominal compartment syndrome (OR 3.6, 95% CI 1.4-9.3). Patients with IPN had longer ICU and overall hospital lengths of stay, higher risk for necrosectomy, and higher readmission rate to ICU.

CONCLUSIONS

Wide anatomical spread of necrotic collections, postinterventional etiology, preceding bacteremia, and preceding open abdomen treatment were identified as independent risk factors for IPN.

Fatty Liver Disease and Non-Alcoholic Fatty Liver Disease Worsen the Outcome in Acute Pancreatitis: A Systematic Review and Meta-Analysis

The prevalence of fatty liver disease (FLD) and that of non-alcoholic fatty liver disease (NAFLD) share some risk factors known to exacerbate the course of acute pancreatitis (AP). This meta-analysis aimed to investigate whether FLD or NAFLD carry a higher risk of untoward outcomes in AP. In accordance with PRISMA guidelines, we performed a systematic search in seven medical databases for cohort studies that compared the outcomes of AP for the presence of FLD or NAFLD, and we calculated pooled odds ratio (OR) or weighted mean difference (WMD) with 95% confidence interval (CI). We included 13 articles in our meta-analysis. AP patients with FLD were more likely to die (5.09% vs 1.89%, OR = 3.56, CI = 1.75-7.22), develop severe AP (16.33% vs 7.87%, OR = 2.67, CI = 2.01-3.56), necrotizing pancreatitis (34.83% vs 15.75%, OR = 3.08, CI = 2.44-3.90) and had longer in-hospital stay (10.8 vs 9.2 days, WMD = 1.46, OR = 0.54-2.39). Patients with NAFLD were more likely to have severe AP and longer hospital stay. Both FLD and NAFLD proved to be independent risk factors of a more severe disease course (OR = 3.68, CI = 2.16-6.29 and OR = 3.39, CI = 1.52-7.56 for moderate/ severe vs. mild AP, respectively). FLD and NAFLD worsen the outcomes of AP, which suggests that incorporating FLD or NAFLD into prognostic scoring systems of AP outcomes might improve the prediction of severity and contribute to a more individualized patient care.

Risk factors for walled-off necrosis associated with severe acute pancreatitis: A multicenter retrospective observational study

BACKGROUND

This study aimed to identify the risk factors for walled-off necrosis (WON) associated with severe acute pancreatitis (SAP).

METHODS

This retrospective study was conducted in eight institutions in Japan between 2014 and 2017. We analyzed WON incidence, patient characteristics, and risk factors for WON in patients with SAP who were observed for >28 days.

RESULTS

Of 134 patients with SAP, WON occurred in 40 (29.9%). Male sex (P = .045), body mass index (BMI) ≥25 (P < .001), post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (P = .020), and disseminated intravascular coagulation (DIC) (P = .001) were more frequent in the WON group than in the non-WON group. On admission, the frequency of white blood cell counts ≥ 12 000/µL (P = .037) and hypoenhanced pancreatic lesion on computed tomography (P = .047) were significantly higher in the WON group. In multivariate analysis, BMI ≥ 25 (odds ratio [OR] 5.73, 95% confidence interval [CI] 1.95-16.8; P = .002), post-ERCP (OR 8.08, 95% CI 1.57-41.7; P = .013), and DIC (OR 3.52, 95% CI 1.20-10.4; P = .022) were independent risk factors for WON.

CONCLUSIONS

High BMI, post-ERCP pancreatitis, and DIC are risk factors for the development of WON associated with SAP.

CT imaging, classification, and complications of acute pancreatitis

Acute pancreatitis is an increasingly common condition and can result in significant morbidity and mortality. Contrast enhanced computed tomography (CECT) is the primary initial imaging modality in the characterization of acute pancreatitis. In this article, we provide sample CECT technical acquisition parameters for pancreatic imaging. We also review the classification systems for acute pancreatitis and give examples of common and uncommon complications of acute pancreatitis.

Antibacterial and Antifungal Therapy for Patients with Acute Pancreatitis at High Risk of Pancreatogenic Sepsis (Review)

Controlling infection is crucial in treating patients with acute pancreatitis (AP). The infectious process in AP often predisposes to subsequent sepsis by damaging not only the pancreas, but retroperitoneal tissues as well. Among other AP-associated factors, are the rapidly developing immune imbalance, the poor penetration of antimicrobial agents into necrotic tissue, and the impossibility of a single surgical debridement. Antibacterial and antifungal therapy for patients with infected necrosis and AP-associated extra-pancreatic infections remains a complex and largely unresolved problem, partially due to the high occurrence of multiresistant pathogens. The preventive use of antimicrobial agents has been discussed in the literature; however, the lack of consistent results makes it difficult to develop a unified strategy and clinical guidelines on this specific issue. Recent meta-analyses provide no conclusive evidence that antibacterial prophylaxis reduces the infection rate, mortality, or the need for surgical treatment in patients with necrotizing pancreatitis. We found only two studies indicating the benefits of using carbapenems for prophylactic purposes and one meta-analysis indicating a reduction in mortality under antibiotic treatment started no later than 72 h after the onset of the attack. Selective bowel decontamination is considered as one of the preventive anti-infection measures, although the available data may not be fully reliable. The main indications for antibacterial therapy in patients with AP are confirmed infected necrosis or extra-pancreatic infection, as well as clinical symptoms of suspected infection. Intra-arterial administration or local treatment with antibiotics can increase the efficacy of antibacterial therapy. No randomized studies on antifungal prophylaxis in AP are available; some reports though recommend using such therapy among patients at high risk of invasive candidiasis.