Acute pancreatitis and organ failure: pathophysiology, natural history, and management strategies

KAN0438757, a novel PFKFB3 inhibitor, prevent the progression of severe acute pancreatitis via the Nrf2/HO-1 pathway in infiltrated macrophage

Acute pancreatitis (AP) is a non-infectious pancreatic enzyme-induced disorder, a life-threatening inflammatory condition that can cause multi-organ dysfunction, characterized by high morbidity and mortality. Several therapies have been employed to target this disorder; however, few happen to be effectively employable even in the early phase. PFKFB3(6-phosphofructo-2-kinase/fructose-2,6-biphosphatase-3) is a critical regulator of glycolysis and is upregulated under inflammatory, mitogenic, and hypoxia conditions. Essential information on the targeting of the inflammatory pathway will present the termination of the disorder and recovery. Herein we investigated the protective function of KAN0438757, a potent inhibitor of PFKFB3, and its mechanism of impeding AP induced in mice. KAN0438757 was confirmed to activate the Nrf2/HO-1 inflammatory signaling pathways in response to caerulein induced acute pancreatitis (CAE-AP) and fatty acid ethyl ester induced severe acute pancreatitis (FAEE-SAP). Additionally, KAN0438757 alleviated the inflammatory process in infiltrated macrophage via the Nrf2/HO-1 inflammatory signaling pathway and demonstrated a significant effect on the growth of mice with induced AP. And more importantly, KAN0438757 displayed negligible toxicity in vivo. Taken together our data suggest KAN0438757 directly suppresses the inflammatory role of PFKFB3 and induces a protective role via the Nrf2/HO-1 pathway, which could prove as an excellent therapeutic platform for SAP amelioration.

Severe, Complicated Pancreatitis With an Unclear Etiology

Acute pancreatitis is an inflammatory process. There can be many causes of pancreatitis, which include alcohol or gallstones but can also be due to hypercalcemia, infections, or hypertriglyceridemia. Most cases of pancreatitis are mild and without complications. Severe cases of pancreatitis can cause complications, including organ failure. Pseudocysts are a rare complication of pancreatitis and may require management. We present a patient with severe acute pancreatitis with organ failure admitted to the intensive care unit, stabilized, and required subsequent management of a pseudocyst with cystogastrostomy with a lumen-apposing metal stent. The patient subsequently improved and is doing well today. Herein, we present an acute severe pancreatitis case report with an extensive workup complicated by pseudocyst development. We review pancreatitis causes, including rare causes and management.

Tropolone derivative hinokitiol ameliorates cerulein-induced acute pancreatitis in mice

Hinokitiol is a natural bio-active tropolone derivative with promising antioxidant and anti-inflammatory properties. This study was conducted to evaluate the ameliorative effects of hinokitiol against acute pancreatitis induced by cerulein. Mice were pre-treated with hinokitiol intraperitoneally for 7 days (50 and 100 mg/kg), and on the final day of study, cerulein (6 × 50 μg/kg) was injected every hour for six times. Six hours after the last dose of cerulein, blood was collected from the mice through retro-orbital plexus for biochemical analysis. After blood collection, mice were euthanized and the pancreas was harvested for studying effects on oxidative stress, pro-inflammatory cytokines, immunohistochemistry and histopathology of tissue sections. Hinokitiol treatment significantly reduced edema of the pancreas and reduced the plasma levels of lipase and amylase in mice with cerulein-induced acute pancreatitis. It also attenuated the oxidative and nitrosative stress related damage as evident from the reduced malondialdehyde (MDA) and nitrite levels, which were significantly increased in the mice with acute pancreatitis. Furthermore, hinokitiol administration significantly reduced the pancreatitis-evoked decrease in the activity of catalase, glutathione (GSH) and superoxide dismutase (SOD) in the pancreatic tissue. Pre-treatment with hinokitiol significantly reduced the elevated levels of pro-inflammatory cytokines like interleukin-6 (IL-6), interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α) as well as increased the levels of anti-inflammatory cytokine interleukin-10 (IL-10) in the pancreatic tissue of mice with acute pancreatitis. The immunohistochemical expression of nuclear factor kappa light chain enhancer of activated B cells (NF-κB), cyclooxygenase (COX-2) and TNF-α were significantly decreased by hinokitiol in mice with cerulein-induced acute pancreatitis. In conclusion, the results of the present study demonstrate that hinokitiol has significant potential to prevent cerulein-induced acute pancreatitis.

Comparative Analysis of Early Clinical Features and Complications of Different Types of Acute Pancreatitis

Background

Acute pancreatitis (AP) is a common surgical acute abdomen. Different kinds of pancreatitis may have different pathophysiological characteristics each other. The objective of this research was to investigate the early clinical features and complications of different types of acute pancreatitis.

Methods

787 AP patients admitted in the Huadu District People's Hospital of Guangzhou during January 2009 and December 2019 were analyzed retrospectively. Among 787 AP patients, 520 (66.1%) were biliary AP (group I), 69 (8.7%) were alcoholic AP (group II), and 198 (25.2%) were hypertriglyceridemic AP (group III). According to the local and systemic complications and mortality in the early stage, we compared and analyzed the clinical characteristics and prognosis of different types of pancreatitis.

Results

Mild acute pancreatitis accounted for the highest proportion (79.4%) in group I, while moderately severe acute pancreatitis in group II (36.2%) and severe acute pancreatitis in group III (62.6%). In terms of severity score of the pancreatitis, the average scores of BISAP, Ranson, APACHE-II, and MCTSI of the patients in group III were the highest (p < 0.01). The incidence of acute peripancreatic fluid collection and infectious pancreatic necrosis was the highest in group III. The incidences of acute necrotic collection, pancreatic pseudocyst, and walled-off necrosis in group III were significantly higher than those in the other two groups (p < 0.01). The incidences of systemic inflammatory response syndrome, sepsis, multiple organ failure, intra-abdominal hypertension, and mortality were highest in group III.

Conclusions

There is an upward trend of the incidence rate of hypertriglyceridemic AP in recent years; it has been gradually developed into the second type of acute pancreatitis which is second only to the acute biliary pancreatitis. It is worthy to pay more and more attentions to it due to the feature of its younger onset, high incidence of complications, and high mortality.

Ketorolac and Predicted Severe Acute Pancreatitis: A Randomized, Controlled Clinical Trial

Objective: We evaluated the effect of ketorolac on reducing the severity of acute pancreatitis.Design and Setting: Randomized clinical trial performed in a University hospital.Participants: There were 56 adult patients, with predicted severe acute pancreatitis, randomly divided into two groups.Methods: The patients in the study group received intravenous ketorolac, 10 mg, three times daily from the time of enrollment for a maximum of 5 days, as needed, along with standard medical treatment. Primary outcome measure was the change in the serum level of high sensitive C-reactive protein (hs-CRP). Patients were also followed up in terms of hospitalization duration, need for intensive care unit (ICU), organ failure development, persistent organ failure, pancreatic necrosis, nutritional assessment, and mortality. The study continued to gather clinical follow-up information up to 4 months.Results: Serum level of hs-CRP was significantly lower in the ketorolac group compared with the control group on days 3, 4, and 5. There were no significant differences in organ failure, pseudocyst formation, acute necrotic collection, mortality, and ICU transfer between groups. Days of hospitalization were significantly lower in the study group. The feeding start time was significantly shorter in the study group with no need for tube feeding in the ketorolac group. Frequency of NPO (not per oral) was significantly lower in the ketorolac group.Conclusion: The use of ketorolac may improve feeding outcomes and shorten length of hospitalization in predicted severe acute pancreatitis.

Calycosin attenuates severe acute pancreatitis-associated acute lung injury by curtailing high mobility group box 1 - induced inflammation

BACKGROUND

Acute lung injury (ALI) is a common and life-threatening complication of severe acute pancreatitis (SAP). There are currently limited effective treatment options for SAP and associated ALI. Calycosin (Cal), a bioactive constituent extracted from the medicinal herb Radix Astragali exhibits potent anti-inflammatory properties, but its effect on SAP and associated ALI has yet to be determined.

AIM

To identify the roles of Cal in SAP-ALI and the underlying mechanism.

METHODS

SAP was induced via two intraperitoneal injections of L-arg (4 g/kg) and Cal (25 or 50 mg/kg) were injected 1 h prior to the first L-arg challenge. Mice were sacrificed 72 h after the induction of SAP and associated ALI was examined histologically and biochemically. An in vitro model of lipopolysaccharide (LPS)-induced ALI was established using A549 cells. Immunofluorescence analysis and western blot were evaluated in cells. Molecular docking analyses were conducted to examine the interaction of Cal with HMGB1.

RESULTS

Cal treatment substantially reduced the serum amylase levels and alleviated histopathological injury associated with SAP and ALI. Neutrophil infiltration and lung tissue levels of neutrophil mediator myeloperoxidase were reduced in line with protective effects of Cal against ALI in SAP. Cal treatment also attenuated the serum levels and mRNA expression of pro-inflammatory cytokines tumor necrosis factor-α, interleukin-6, IL-1β, HMGB1 and chemokine (CXC motif) ligand 1 in lung tissue. Immunofluorescence and western blot analyses showed that Cal treatment markedly suppressed the expression of HMGB1 and phosphorylated nuclear factor-kappa B (NF-κB) p65 in lung tissues and an in vitro model of LPS-induced ALI in A549 cells suggesting a role for HGMB1 in the pathogenesis of ALI. Furthermore, molecular docking analysis provided evidence for the direct interaction of Cal with HGMB1.

CONCLUSION

Cal protects mice against L-arg-induced SAP and associated ALI by attenuating local and systemic neutrophil infiltration and inflammatory response via inhibition of HGMB1 and the NF-κB signaling pathway.

Acute Pancreatitis During COVID-19 Pandemic: An Overview of Patient Demographics, Disease Severity, Management and Outcomes in an Acute District Hospital in Northern Ireland

Background Acute pancreatitis (AP) is a common disease requiring admissions under surgical and critical care units. The two most common causes are alcohol and gallstones. Coronavirus disease 2019 (COVID-19) pandemic had a significant impact on service delivery and patient management throughout all surgical specialties. In this study, the primary aim was to ascertain the incidence of COVID-19 in acute pancreatitis patients. Secondary objectives were to study aetiology, demographics, severity, 30-day mortality, outcomes and management of acute pancreatitis patients from 1st March, 2020 till 31st August, 2020. Methods A retrospective observational review of all patients admitted under the General Surgical team was performed. Information regarding demographics, severity of AP (using Glasgow score, Atlanta classification and CT severity index score), ICU admission and organ support, treatment modalities and follow-up data for outcomes was collected based on data collection tool used by COVID-PAN study and results were compared to outcomes results of COVID-PAN study. Results Forty-three (43) patients were admitted with AP. Only one patient (2.3%) was diagnosed with COVID-19 at the time of pancreatitis. Gallstones were noted to be the most common cause of AP in our population. Mortality was 7% (3 patients). Five patients (11%) needed ITU admission due to organ dysfunction. Three patients (7%) developed ARDS. Conclusion The overall incidence of COVID-19 in pancreatitis in our population of the study was low. The incidence of COVID-19 during the first wave in Derry/Londonderry area was low and this may explain why the incidence was low in our study as well. Patients with AP in our target population were mostly elderly, one in five had moderate to severe or severe pancreatitis and in 16.3% the aetiology could not be identified. As observed in other centres globally, urgent cholecystectomy for gallstone pancreatitis faced significant delays with no patients being offered index cholecystectomy and only 4 out of 19 patients having undergone interval cholecystectomy within six months of index admission for gallstone pancreatitis in our centre.

Reducing the risk of developing walled-off necrosis in patients with acute necrotic collection using recombinant human soluble thrombomodulin

BACKGROUND/PURPOSE

The purpose of the present study was to investigate the possibility of reducing clinical impacts of acute necrotic collection (ANC) on patients with acute pancreatitis (AP) using recombinant human soluble thrombomodulin (rTM).

METHODS

In this retrospective multicenter study, 233 consecutive AP patients with ANC and acute peripancreatic fluid collection (APFC) from 2012 to 2016 were enrolled. To assess clinical impacts of ANC, severity on admission (JPN score, JPN CT grade, and Modified CT severity index), development of walled-off necrosis (WON), imaging costs for follow-up, and mortality were recorded. Finally, we investigated whether rTM could reduce the clinical impacts, adjusting the severity using propensity analysis with Inverse probability of treatment weighting.

RESULTS

Patients with ANC developed WON with higher ratio than APFC (58/98 [59.2%] vs 20/135 [14.8%], OR = 8.3, P < .01]. Severity on admission and imaging costs for follow-up in ANC patients were significantly higher than those in APFC (P < .01). However, regarding mortality, there was no significant difference between patients with ANC and APFC (P = .41). Adjusting severity, it was revealed that rTM administration significantly reduced the risk of ANC developed WON (OR = 0.23, P = .01).

CONCLUSIONS

While ANC had a higher clinical impact than that of APFC, we found that early administration of rTM may reduce the impact.

Cashew (Anacardium occidentale L.) Nuts Modulate the Nrf2 and NLRP3 Pathways in Pancreas and Lung after Induction of Acute Pancreatitis by Cerulein

BACKGROUND

One of the most common co-morbidities, that often leads to death, associated with acute pancreatitis (AP) is represented by acute lung injury (ALI). While many aspects of AP-induced lung inflammation have been investigated, the involvement of specific pathways, such as those centered on nuclear factor E2-related factor 2 (Nrf2) and nucleotide-binding domain leucine-rich repeat (NLR) and pyrin domain containing receptor 3 (NLRP3), has not been fully elucidated.

METHODS

To investigate the effect of cashew (Anacardium occidentale L.) nuts on pancreatic and lung injury induced by cerulein injection, cerulein (50 μg/kg) was administered to CD1 mice for 10 h. Oral treatment with cashew nuts at a dose of 100 mg/kg was given 30 min and 2 h after the first cerulein injection. One hour after the final cerulein injection, mice were euthanized and blood, lung and pancreatic tissue samples were collected.

RESULTS

Cashew nuts were able to (1) reduce histological damage; (2) mitigate the induction of mast cell degranulation as well as the activity of myeloperoxidase and malondialdehyde; (3) decrease the activity levels of amylase and lipase as well as the levels of pro-inflammatory cytokines; and (4) enhance the activation of the Nrf2 pathway and suppress the activation of the NLRP3 pathway in response to cerulein in both pancreas and lung.

CONCLUSIONS

Cashew nuts could have a beneficial effect not only on pancreatitis but also on lung injury induced by cerulein.

Severe acute pancreatitis: surgical indications and treatment

Background

Acute pancreatitis (AP) is defined as an acute inflammatory attack of the pancreas of sudden onset. Around 25% of patients have either moderately severe or severe disease with a mortality rate of 15–20%.

Purpose

The aim of this article was to summarize the advances being made in the understanding of this disease and the important role of surgery.

Results and conclusions

An accurate diagnosis should be made a soon as possible, initiating resuscitation with large volume intravenous fluids and oxygen by mask. Predicted severe disease will require intensive monitoring. Most deaths within the first week are due to multi-organ failure; thus, these patients will require intensive therapy unit management. During the second phase of the disease, death is due to local complications arising from the pancreatic inflammation, requiring accurate identification to determine the correct form of treatment. Acute peripancreatic fluid collections arise < 4 weeks after onset of interstitial edematous pancreatitis, not requiring any treatment. Most pancreatic pseudocysts arise > 4 weeks and largely resolve on conservative management. Necrotizing pancreatitis causing acute necrotic collections and later walled-off necrosis will require treatment if symptomatic or infected. Initial endoscopic transgastric or percutaneous drainage will resolve less serious collections but necrosectomy using minimally invasive approaches will be needed for more serious collections. To prevent recurrent attacks of AP, causative factors need to be removed where possible such as cholecystectomy and cessation of alcohol. Future progress requires improved management of multi-organ failure and more effective minimally invasive techniques for the removal of necrosis.

Efficacy of Recombinant Human-Soluble Thrombomodulin for Severe Acute Pancreatitis in a Rat Experimental Model

OBJECTIVES

Early death in severe acute pancreatitis (SAP) is caused by pancreatic necrosis and multiple-organ failure due to microcirculation disorder. The aim of this study was to prove that recombinant human-soluble thrombomodulin (rTM) has therapeutic effects on SAP by preventing pancreatic necrosis and organ failure.

METHODS

Male Wister rats were used. Cerulein was administered intraperitoneally 4 times every 1 hour, and lipopolysaccharide was administered intraperitoneally 3 hours after. One hour after administration of lipopolysaccharide, rTM was injected intravenously. Rats were observed for 24 hours after starting the experiment, and the survival rate was evaluated. All surviving rats were killed, and the blood sample, liver, and pancreas were excised. Serum amylase, aspartate aminotransferase, alanine aminotransferase, and high mobility group box 1 were measured, and the liver and pancreas were examined histologically. For the evaluation of microcirculation, von Willebrand factor staining was performed.

RESULTS

Serum amylase, aspartate aminotransferase, and alanine aminotransferase were significantly decreased. The survival rate was significantly improved to 100%. Moreover, serum high mobility group box 1 was decreased. Liver injury and pancreatic necrosis became less severe, and microcirculation was preserved histologically.

CONCLUSIONS

Early administration of rTM prevents organ failure by maintenance of microcirculation and improves prognoses of SAP.

Lipoxin A4 Ameliorates Acute Pancreatitis-Associated Acute Lung Injury through the Antioxidative and Anti-Inflammatory Effects of the Nrf2 Pathway

Acute lung injury (ALI) is a critical event involved in the pathophysiological process of acute pancreatitis (AP). Many methods have been widely used for the treatment of AP-ALI, but few are useful during early inflammation. Lipoxin A4 (LXA4), a potent available anti-inflammatory and novel antioxidant mediator, has been extensively studied in AP-ALI, but its underlying mechanism as a protective mediator is not clear. This research was conducted to identify the possible targets and mechanisms involved in the anti-AP-ALI effect of LXA4. First, we confirmed that LXA4 strongly inhibited AP-ALI in mice. Next, using ELISA, PCR, and fluorescence detection to evaluate different parameters, LXA4 was shown to reduce the inflammatory cytokine production induced by AP and block reactive oxygen species (ROS) generation in vivo and in vitro. In addition, TNF-α treatment activated the nuclear factor E2-related factor 2 (Nrf2) signaling pathway and its downstream gene heme oxygenase-1 (HO-1) in human pulmonary microvascular endothelial cells (HPMECs), and LXA4 further promoted their expression. This study also provided evidence that LXA4 phosphorylates Ser40 and triggers its nuclear translocation to activate Nrf2. Moreover, when Nrf2-knockout (Nrf2^−/−) mice and cells were used to further assess the effect of the Nrf2/HO-1 pathway, we found that Nrf2 expression knockdown partially eliminated the effect of LXA4 on the reductions in inflammatory factor levels while abrogating the inhibitory effect of LXA4 on the ROS generation stimulated by AP-ALI. Overall, LXA4 attenuated the resolution of AP-induced inflammation and ROS generation to mitigate ALI, perhaps by modulating the Nrf2/HO-1 pathway. These findings have laid a foundation for the treatment of AP-ALI.

Antithrombin III Attenuates AKI Following Acute Severe Pancreatitis

BACKGROUND

Antithrombin III (ATIII), the predominant coagulation factor inhibitor, possesses anti-inflammatory properties and exerts renoprotective effects on renal ischemia-reperfusion injury in animal models. However, the ATIII's protective effects of ATIII on acute kidney injury (AKI) following severe acute pancreatitis (SAP) need to be confirmed.

METHODS

We assessed the association between ATIII activities and the incidence of AKI in patients with SAP, and explored therapeutic effects and potential mechanisms of ATIII on kidney injury in sodium taurocholate induced SAP rat model. Rats were intravenously injected with ATIII (500 μg/kg) before or after the induction of SAP.

RESULTS

The results demonstrated ATIII did not attenuate pancreatic injury, but significantly ameliorate renal dysfunction and renal histological injury. ATIII administration alleviated renal inflammation response, oxidative stress, and cell apoptosis. Moreover, ATIII attenuated tumor necrosis factor α (TNFα)-stimulated intercellular cell adhesion molecule 1(ICAM-1) and monocyte chemotactic protein 1 (MCP-1) upregulation in cultured renal tubular epithelial cells.

CONCLUSION

ATIII appears to ameliorate SAP-induced kidney injury by inhibiting inflammation, oxidative stress, and apoptosis. ATIII supplementation may have a potential prophylactic and therapeutic effect on SAP induced AKI.

Development and validation of a risk prediction score for severe acute pancreatitis

INTRODUCTION

The available prognostic scoring systems for severe acute pancreatitis (SAP) have limitations that restrict their clinical value. The aim of this study was to develop a simple model (score) that could rapidly identify those at risk for SAP.

METHODS

We derived a risk model using a retrospective cohort of 700 patients by logistic regression and bootstrapping methods. The discriminative power of the risk model was assessed by calculating the area under the receiver operating characteristic curves (AUC). The classification and regression tree (CART) analysis was used to create risk categories. The model was internally validated by a tenfold cross-validation and externally validated in a separate prospective cohort of 194 patients.

RESULTS

The incidence of SAP was 9.7% in the derivation cohort and 9.3% in the validation cohort. A prognostic score (We denoted it as the SABP score), ranging from 0 to 10, consisting of systemic inflammatory response syndrome, serum albumin, blood urea nitrogen and pleural effusion, was developed by logistic regression and bootstrapping analysis. Patients could be divided into three risk categories according to total SABP score based on CART analysis. The mean probability of developing SAP was 1.9%, 12.8% and 41.6% in patients with low (0-3), moderate (4-6) and high (7-10) SABP score, respectively. The AUCs of prognostic score in tenfold cross-validation was 0.873 and 0.872 in the external validation.

CONCLUSION

Our risk prediction score may assist physicians in predicting the development of SAP.

Survival and new-onset morbidity after critical care admission for acute pancreatitis in Scotland: a national electronic healthcare record linkage cohort study

INTRODUCTION

Severe acute pancreatitis (AP) requiring critical care admission (ccAP) impacts negatively on long-term survival.

OBJECTIVE

To document organ-specific new morbidity and identify risk factors associated with premature mortality after an episode of ccAP.

DESIGN

Cohort study.

SETTING

Electronic healthcare registries in Scotland.

PARTICIPANTS

The ccAP cohort included 1471 patients admitted to critical care with AP between 1 January 2008 and 31 December 2010 followed up until 31 December 2014. The population cohort included 3450 individuals from the general population of Scotland frequency-matched for age, sex and social deprivation.

METHODS

Record linkage of routinely collected electronic health data with population matching.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient demographics, comorbidity (Charlson Comorbidity Index), acute physiology, organ support and other critical care data were linked to records of mortality (death certificate data) and new-onset morbidity. Kaplan-Meier and Cox regression analyses were used to identify risk factors associated with mortality.

RESULTS

310 patients with AP died during the index admission. Outcomes were not ascertained for five patients, and the deprivation quintile was not known for six patients. 340 of 1150 patients in the resulting postdischarge ccAP cohort died during the follow-up period. Greater comorbidity measured by the Charlson score, prior to ccAP, negatively influenced survival in the hospital and after discharge. The odds of developing new-onset diabetes mellitus after ccAP compared with the general population were 10.70 (95% CI 5.74 to 19.94). A new diagnosis of myocardial infarction, stroke, heart failure, liver disease, peptic ulcer, renal failure, cancer, peripheral vascular disease and lung disease was more frequent in the ccAP cohort than in the general population.

CONCLUSIONS

The persistent deleterious impact of severe AP on long-term outcome and survival is multifactorial in origin, influenced by pre-existing patient characteristics and acute episode features. Further mechanistic and epidemiological investigation is warranted.

RCAN1 is a marker of oxidative stress, induced in acute pancreatitis

BACKGROUND

To date, there still is a lack of specific acute pancreatitis markers and specifically an early marker that can reliably predict disease severity. The inflammatory response in acute pancreatitis is mediated in part through oxidative stress and calcineurin-NFAT (Nuclear Factor of Activated T-cells) signaling, which is inducing its own negative regulator, regulator of calcineurin 1 (RCAN1). Caerulein induction is a commonly used in vivo model of experimental acute pancreatitis. Caerulein induces CN-NFAT signaling, reactive oxygen species and inflammation.

METHODS

To screen for potential markers of acute pancreatitis, we used the caerulein model of experimental acute pancreatitis (AP) in C57Bl/6 J mice. Pancreata from treated and control mice were used for expression profiling. Promising gene candidates were validated in cell culture experiments using primary murine acinar cells and rat AR42J cells. These candidates were then further tested for their usefulness as biomarkers in mouse and human plasma.

RESULTS

We identified a number of novel genes, including Regulator of calcineurin 1 (Rcan1) and Sestrin 2 (Sesn2) and demonstrated that they are induced by oxidative stress, by stimulation with H₂O₂ and by inhibiting caerulein stimulated expression with the antioxidant N-acetylcysteine. We found Rcan1 protein to be significantly elevated in AP-induced mouse plasma as well as in plasma from AP patients.

CONCLUSION

We demonstrated that Rcan1 is regulated by oxidative stress and identified RCAN1 as a potential diagnostic marker of AP.

RNA sequence analysis reveals pathways and candidate genes associated with liver injury in a rat pancreatitis model

BACKGROUND

The morbidity and mortality associated with acute pancreatitis (AP) are largely attributable to abnormalities that occur in distant organs, such as liver and lungs. Pancreatitis-associated liver injury (PALI) remains a serious and even fatal complication during the progression of AP. However, the exact pathophysiological mechanism is still unclear.

METHODS

In the present study, we used, for the first time, RNA-seq method to reveal pathways and candidate genes associated with PALI in rats. AP was induced by retrograde injection of sodium taurocholate (5%) into the biliopancreatic duct. The RNA-seq results of selected genes were validated by RT-PCR and immunohistochemistry assay.

RESULTS

GO (Gene Ontology) and KEGG (Kyoto Encyclopedia of Genes and Genomes) pathway analysis indicated that Toll like receptor 4 (TLR4) signaling pathway and transforming growth factor β1 (TGF-β1) and p38 mitogen-activated protein kinase (MAPK) signaling pathway (TGF-β1-p38 MAPK) were involved in the course of PALI. In addition, other factors were also found to be involved in the course of PALI, such as the decreased antioxidant activity, excessive production of inflammatory mediators and alterations in liver metabolism.

CONCLUSIONS

The study sheds some new insight on our understanding of the pathophysiology of PALI and provides some clues to the identification of potential therapeutic targets.

Early ultrasound-guided percutaneous catheter drainage in the treatment of severe acute pancreatitis with acute fluid accumulation

The clinical effect of early percutaneous ultrasound guided percutaneous catheter drainage (PCD) in treating severe acute pancreatitis complicated with acute fluid accumulation in the abdominal cavity was analyzed. A total of 178 patients with severe acute pancreatitis complicated with acute fluid accumulation in peritoneal cavity admitted from January, 2011 to January, 2015 to Chuiyangliu Hospital were retrospectively analyzed. Based on the treatment, patients were divided into the following groups: PCD group and conservative treatment control group. Time-period of systemic inflammatory response (SIRS), time-period of abdominal pain, bowel sounds recovery time, dietary recovery time, hospitalization days, white blood cell count, serum amylase, C-reactive protein, serum calcium and complications in both groups were observed and compared. The measurement data between the two groups were presented as mean ± standard deviation (±SD), and analyzed by t-test. Classification data were analyzed by the Chi-square test, with P<0.05 indicating a statistically significant difference. Time-period of systemic inflammatory response (SIRS), time-period of abdominal pain, bowel sounds recovery time, dietary recovery time and hospitalization days were shorter in the PCD group than those in the control group (P=0.001). Improvements of white blood cell count, serum amylase, C-reactive protein and serum calcium were better than those of the control group (P<0.001), the rate of transferring to surgical department in the PCD group was lower than that of the control group (P=0.042), and complications of severe acute pancreatitis were not significantly different in the two groups (P>0.05). In this study, 6 adverse events occurred in the PCD group, accounting for 7.9% (6/76), including 1 case of puncture bleeding and 5 cases of obstruction. In conclusion, early ultrasound-guided PCD in treating severe acute pancreatitis is effective and safe.

Inhibition of 5-lipoxygenase represses neutrophils activation and activates apoptosis in pancreatic tissues during acute necrotizing pancreatitis

Pancreatic glandular necrosis is rapid inflammation of the pancreas and contributes to severe acute pancreatitis in humans. The pathogenesis of pancreatic tissue inflammation during acute pancreatitis is still largely unknown. Recent studies suggest that 5-lipoxygenase (5-LOX) is an essential mediator in modulating cell death pathways in human diseases. In this study, we aimed to evaluate the effects of a 5-LOX inhibitor, zileuton, on tissue apoptosis and neutrophils activation in pancreatic tissues during acute necrotizing pancreatitis (ANP) in a rat model. In this present study, both mRNA and protein levels of 5-LOX are upregulated during ANP and zileuton treatment is shown to repress ANP-induced upregulation of 5-LOX levels. In addition, zileuton treatment is found to repress blood biomarkers of neutrophils activation such as soluble intercellular adhesive molecular 1 (ICAM-1), soluble E-selectin (E-selectin), soluble P-selectin (P-selectin), leukotriene B4 (LTB4), and myeloperoxidase (MPO). Also, zileuton treatment attenuates pancreatic tissue pathology, upregulates caspase-3, downregulates B-cell lymphoma 2 (Bcl-2), and activates tissue apoptosis evaluated by TUNEL staining. Our results show that 5-LOX plays an important role in activating apoptosis and repressing neutrophils activation during ANP. The current study suggests that 5-LOX can be used as a potential target for the treatment of ANP.

Recent Advances on Nutrition in Treatment of Acute Pancreatitis

Acute pancreatitis (AP) is a common abdominal acute inflammatory disorder and the leading cause of hospital admission for gastrointestinal disorders in many countries. Clinical manifestations of AP vary from self-limiting local inflammation to devastating systemic pathological conditions causing significant morbidity and mortality. To date, despite extensive efforts in translating promising experimental therapeutic targets in clinical trials, disease-specific effective remedy remains obscure, and supportive care has still been the primary treatment for this disease. Emerging evidence, in light of the current state of pathophysiology of AP, has highlighted that strategic initiation of nutrition with appropriate nutrient supplementation are key to limit local inflammation and to prevent or manage AP-associated complications. The current review focuses on recent advances on nutritional interventions including enteral versus parenteral nutrition strategies, and nutritional supplements such as probiotics, glutamine, omega-3 fatty acids, and vitamins in clinical AP, hoping to advance current knowledge and practice related to nutrition and nutritional supplements in clinical management of AP.

Antithrombin III and D-dimer levels as indicators of disease severity in patients with hyperlipidaemic or biliary acute pancreatitis

Objective To assess changes in anticoagulation and fibrinolytic systems between biliary and hyperlipidaemic acute pancreatitis (AP). Methods Patients with biliary or hyperlipidaemic AP were enrolled. Demographic and clinical data were collected, and antithrombin III (ATIII), protein C, protein S, and D-dimer levels were investigated. Results A total of 45 patients with biliary AP and 50 patients with hyperlipidaemic AP were included (68 with mild AP and 27 with moderately-severe AP). ATIII and protein C levels in the mild AP group were significantly higher, but prothrombin time and D-dimer were significantly lower, versus the moderately-severe AP group. ATIII and D-dimer were found to be risk factors for moderately-severe AP. ATIII could predict AP severity, particularly in patients with biliary AP. D-dimer was a sensitive and specific predictor for disease severity in patients with AP, particularly in patients with hyperlipidaemic AP. Conclusion ATIII and protein C levels decreased as severity of AP increased, particularly in cases of biliary AP. D-dimer levels increased with severity of AP, particularly in hyperlipidaemic AP. ATIII and D-dimer may be useful biomarkers for assessing AP severity in patients with biliary and hyperlipidaemic AP, respectively.

Role of Daphnetin in Rat Severe Acute Pancreatitis Through the Regulation of TLR4/NF-[Formula: see text]B Signaling Pathway Activation

Severe acute pancreatitis (SAP) often results in multiple-organ dysfunction syndrome with high mortality. There is no effective clinical therapy for SAP, yet daphnetin, a coumarin extracted from Dracaena marginata, has analgesic and anti-inflammatory effects, and has been used clinically in several diseases. The objective of this study was to investigate the role and underlying mechanisms of daphnetin in a rat SAP model. Male Wistar rats were pretreated with daphnetin via intraperitoneal injection, 30[Formula: see text]min before retrograde infusion of 5% sodium taurocholate into the biliopancreatic duct. Twelve hours after sodium taurocholate administration, rats were sacrificed and tissues and blood were harvested. Then, histological, chemical, and molecular analyses were performed. Daphnetin treatment reduced the levels of serum alanine transaminase and creatinine (CR), increased superoxide dismutase(SOD) activity, and decreased neutrophil infiltration and cell apoptosis of the pancreatic tissues in rat SAP. Daphnetin treatment significantly decreased expression of pro-inflammatory cytokines and increased expression of anti-inflammatory cytokines in rat SAP. Molecular analyses revealed that daphnetin reduced TLR4 expression and inhibited NF-[Formula: see text]B signaling pathway activation. These findings demonstrate that daphnetin attenuates acute pancreatic injury by regulating the TLR4/NF-[Formula: see text]B signaling pathway and inflammation in rat SAP model. Daphnetin may be a potential therapeutic agent for SAP.

Early Prediction of Persistent Organ Failure by Serum Angiopoietin-2 in Patients with Acute Pancreatitis

BACKGROUND

Biomarkers for the early prediction of the severity of acute pancreatitis (AP) are urgently needed for clinical management of the disease. Angiopoietin-2 (Ang-2), one of the autocrine peptides that reduce endothelial permeability, has been found to be associated with various diseases, including inflammatory disorders.

AIMS

This study aimed to determine whether serum Ang-2 could serve as a noninvasive biomarker for the early prediction of persistent organ failure (POF) in acute pancreatitis.

METHODS

A total of 120 AP patients were prospectively enrolled at Jinling Hospital. Serum samples were collected on admission. Clinical and laboratory data were recorded. Ang-2 levels were measured by enzyme-linked immunosorbent assay.

RESULTS

A total of 37 patients developed POF and were classified as having severe AP (SAP). Ang-2 was significantly higher on admission in patients who developed POF than in those who did not (p < 0.001 for all). Furthermore, receiver operating characteristic (ROC) curve analysis revealed that Ang-2 could distinguish patients who developed POF from mild AP (MAP, area under ROC curve [AUC] = 0.88, 95 % CI 0.78-0.94) and moderately severe AP patients (MSAP, AUC = 0.74, 95 % CI 0.63-0.83). In addition, multivariate logistic regression showed that increased Ang-2 was an independent predictor of developing POF between subgroups with MSAP and SAP (OR 7.2, 95 % CI 2.7-19.4) and among all AP patients (OR 12.1, 95 % CI 4.8-30.3).

CONCLUSIONS

Elevated serum Ang-2 levels on admission may be a promising biomarker for the prediction of POF in AP.

Role of tuftsin and its inhibitor in progression of acute pancreatitis

AIM: To investigate the role of tuftsin and its inhibitor in acute pancreatitis (AP).

METHODS: Twenty-four SD rats were randomly divided into five groups: a blank control group, a tuftsin group, an AP group, an AP + tuftsin group, and an AP + tuftsin inhibitor group. AP was induced in rats by injecting sodium taurocholate in the pancreatic duct. Tuftsin or its inhibitor (75 μg/kg) was injected via the femoral vein at 20 min after model induction. At 3, 6, and 12 h after model induction, pancreatic samples were taken for HE staining to detect pancreatic pathology, and serum samples were taken for tumor necrosis factor (TNF) and interleukin-1 (IL-1) measurement by ELISA.

RESULTS: Serum levels of TNF and IL-1 were significantly higher in the AP group than in the control group, and in the AP + tuftsin group than in the AP group. Serum levels of TNF and IL-1 were significantly decreased in the AP + tuftsin inhibitor group at 6 h and 12 h, but showed no significant change at 3 h. Correlation analysis showed that serum levels of TNF/IL-1 were positively correlated with pancreatic pathology.

CONCLUSION: Tuftsin accelerates the deve-lopment of AP by inducing TNF and IL-1. The inhibitor of tuftsin can alleviate AP by downregulating TNF and IL-1.

Mitogen-Activated Protein Kinases Are Activated in Placental Injury in Rat Model of Acute Pancreatitis in Pregnancy

OBJECTIVES

To establish a rat model of acute pancreatitis in pregnancy (APIP) and evaluate its general presentations, assess placental injury, and discuss possible mechanisms.

METHODS

The APIP rat model was induced by sodium taurocholate in Sprague-Dawley rats of later gestation. Normal and sham-operated (SO) rats in later gestation were set as controls, 3 time points were set in SO and APIP groups to determine optimal modeling time. Histological changes of pancreas and placenta were assessed. Placental injury was determined by immunohistochemistry stain of caspase-3. Serum levels of amylase, lipase, and Ca; proinflammatory cytokines as tumor necrosis factor-α, interleukin-1β (IL-1β), IL-6, and anti-inflammatory cytokine IL-10 by enzyme-linked immunosorbent assay; mitogen-activated protein kinases and their phosphorylated forms by Western blotting.

RESULTS

Pancreatic necrotizing and placental injury occurred in time-dependent patterns. Serum levels of amylase and lipase significantly increased but Ca decreased; tumor necrosis factor-α, IL-1β, IL-6, and IL-10 were all increased in the APIP group; c-Jun N-terminal kinase, p38, and ERK1/2 were activated but with different distributing patterns in the placenta.

CONCLUSIONS

Placental injury is involved in the rat model of APIP, and a modeling time of 6 hours is optimal and conducive to further studies; c-Jun N-terminal kinase and p38 may play important roles in placental injury during APIP.

Synthetic Triterpenoid RTA dh404 (CDDO-dhTFEA) Ameliorates Acute Pancreatitis

OBJECTIVES

Nuclear factor-erythroid-2-related factor (Nrf2) is a ubiquitous transcriptional factor that regulates expression of cellular antioxidant and detoxifying molecules. This study was undertaken to test the hypothesis that administration of the Nrf2 activator (dh404) may attenuate acute pancreatitis.

METHODS

Rats were treated with dh404 (1 mg/kg) 24 hours before induction of pancreatitis and for 3 days thereafter. Pancreatitis was induced with L-arginine (600 mg/100 g) or cerulein (40 μg/kg). Pancreases were processed for histology and malondialdehyde, whereas serum was analyzed for amylase. Islet extracted human pancreatic tissue from organ donors were used for in vitro studies. The tissues were incubated with dh404 at 0, 250, and 500 nM for 30 minutes, 60 minutes, 12 hours, and 24 hours. Nuclear factor-erythroid-2-related factor nuclear translocation and expression of Nrf2's target genes and inflammatory mediators were determined.

RESULTS

The dh404-treated rat pancreases demonstrated significantly less infiltration of inflammatory cells, destruction of acinar architecture, perilobar edema, and necrosis. Serum amylase and pancreatic malondialdehyde in the dh404-treated rats were significantly lower. dh404-treated human pancreatic tissue showed a significantly higher expression of antioxidant enzymes, lower expression of inflammatory mediators, and greater viability against oxidative stress.

CONCLUSION

Administration of dh404 attenuates acute pancreatitis by lowering oxidative stress and reducing proinflammatory mediators.

Effects of everolimus on a rat model of cerulein-induced experimental acute pancreatitis

OBJECTIVE

To analyze the biochemical and histopathological effects of everolimus in an experimental rat model of cerulein-induced acute pancreatitis. The aim of the present study was to determine the effects of everolimus on blood biochemical parameters and tissue histopathology in an experimental rat model of cerulein-induced acute pancreatitis.

MATERIAL AND METHODS

In 30 Wistar albino rats (male; 240-260 g), acute pancreatitis was induced by an intraperitoneal injection of cerulein (50 μg/kg) administered twice in 2 h. They were equally divided into the following three groups: 0.9% isotonic solution (Group 1; control), everolimus once (Group 2), and everolimus twice (Group 3) by oral gavage after cerulein injection. Thirty hours after the induction of pancreatitis, blood samples were collected by direct intracardiac puncture, rats were sacrificed, and pancreatic tissue samples were obtained.

RESULTS

Biochemical analyses of the blood samples showed statistically significant difference in red blood cell count as well as hemoglobin, hematocrit, urea, and alanine transaminase levels among the study groups (p<0.05 in all). Everolimus proved to significantly increase red blood cell count in a dose-independent manner. Hemoglobin and hematocrit levels significantly increased only after treatment with one dose of everolimus. Urea level was significantly different between the Groups 2 and 3; however, no change was observed in both groups when compared with the control. Alanine transaminase level significantly decreased only after treatment with two doses of everolimus. Histopathological analyses revealed that everolimus significantly decreased inflammation and perivascular infiltrate in a dose-dependent manner (35% in Group 2, 75% in Group 3; p=0.048).

CONCLUSION

Treatment with two doses of everolimus improved some biochemical and histopathological parameters of experimental rat models of cerulein-induced acute pancreatitis and implied the specific inhibition of inflammatory response pathways.

Coagulopathy and the prognostic potential of D-dimer in hyperlipidemia-induced acute pancreatitis

BACKGROUND

Coagulopathy and its association with disease severity in hyperlipidemia (HL)- and non-hyperlipidemia (NHL)-induced acute pancreatitis (AP) are not clear. The present study was to evaluate the relationship between coagulation homeostasis and AP.

METHODS

This study included 106 AP patients admitted to our hospital between October 2011 and January 2013. Stratified by disease severity, the patients were divided into two groups: a mild AP (MAP) group (n=69); and a moderately severe AP (MSAP) group (n=37). Based on disease etiology, there were 31 HL-induced AP (HLP) cases and 75 NHL-induced AP (NHLP) cases. The HLP and NHLP groups were compared for parameters of coagulation homeostasis, lipid metabolism, and disease severity. Correlations between disease severity and levels of D-dimer and protein C were investigated, and the prognostic potential of D-dimer was evaluated.

RESULTS

Compared with MAP patients, MSAP patients showed higher levels of D-dimer and lower levels of protein C. HLP patients had higher protein C levels than NHLP patients. Both D-dimer and protein C levels were significantly associated with the disease severity, not the disease etiology. D-dimer levels correlated positively with low density lipoprotein cholesterol levels and performed well as a sensitive and specific predictor of disease severity in AP patients, especially in HLP patients.

CONCLUSIONS

The coagulation homeostasis is different between HLP and NHLP patients, and HL may be a contributing factor for thrombosis and fibrinolysis in HLP. D-dimer may be a robust marker of disease severity in HLP.

Efficacy of recombinant human soluble thrombomodulin in preventing walled-off necrosis in severe acute pancreatitis patients

OBJECTIVE

To investigate the efficacy of recombinant human soluble thrombomodulin (rTM) in preventing the development of walled-off necrosis (WON) in severe acute pancreatitis (SAP) patients.

METHODS

We retrospectively analyzed 54 SAP patients divided into two groups: SAP patients treated by rTM (rTM group, 24 patients) and not treated by rTM (control group, 30 patients). rTM was administered to patients with disseminated intravascular coagulation (DIC). Initially, on the admission day, we recorded patient severity and pancreatic necrosis/ischemia positive or negative. Then we investigated development of WON using 4 weeks later CT/MRI. Finally we compared the proportions of patients developing WON in the rTM group and the control group.

RESULTS

On the admission day, the condition of patients treated by rTM was significantly worse than patients in the control group; rTM group vs.

CONTROL

71.8 ± 13.9 vs. 59.8 ± 15.3 years for age, 10.7 ± 3.5 vs. 8.0 ± 4.4 for Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and 3.3 ± 1.8 vs. 2.2 ± 1.8 for sequential organ failure assessment (SOFA) score (p < 0.05). We found no significant differences on the admission day in rate of pancreatic necrosis/ischemia between patients treated by rTM and controls (58.3% vs. 63.3%, p = 0.71). Nevertheless, the proportion of patients developing WON was significantly lower among those administered rTM than in those not administered rTM {29.2% (7/24 patients) vs. 56.7% (17/30 patients), p < 0.05}.

CONCLUSION

Treatment of SAP patients treated by rTM may prevent progression from pancreatic necrosis/ischemia to WON.

Hydrogen-rich saline attenuates acute renal injury in sodium taurocholate-induced severe acute pancreatitis by inhibiting ROS and NF-κB pathway

Hydrogen (H₂), a new antioxidant, was reported to reduce ^•OH and ONOO⁻ selectively and inhibit certain proinflammatory mediators to product, without disturbing metabolic redox reactions or ROS involved in cell signaling. We herein aim to explore its protective effects on acute renal injury in sodium taurocholate-induced acute pancreatitis and its possible mechanisms. Rats were injected with hydrogen-rich saline (HRS group) or normal saline (SO and SAP group) through tail intravenously (6 mL/kg) and compensated subcutaneously (20 mL/kg) after successful modeling. Results showed that hydrogen-rich saline attenuated the following: (1) serum Cr and BUN, (2) pancreatic and renal pathological injuries, (3) renal MDA, (4) renal MPO, (5) serum IL-1β, IL-6, and renal TNF-α, HMGB1, and (6) tyrosine nitration, IκB degradation, and NF-κB activation in renal tissues. In addition, it increased the level of IL-10 and SOD activity in renal tissues. These results proved that hydrogen-rich saline attenuates acute renal injury in sodium taurocholate-induced acute pancreatitis, presumably because of its detoxification activity against excessive ROS, and inhibits the activation of NF-κB by affecting IκB nitration and degradation. Our findings highlight the potential value of hydrogen-rich saline as a new therapeutic method on acute renal injury in severe acute pancreatitis clinically.

Pharmacologic therapy for acute pancreatitis

While conservative management such as fluid, bowel rest, and antibiotics is the mainstay of current acute pancreatitis management, there is a lot of promise in pharmacologic therapies that target various aspects of the pathogenesis of pancreatitis. Extensive review of preclinical studies, which include assessment of therapies such as anti-secretory agents, protease inhibitors, anti-inflammatory agents, and anti-oxidants are discussed. Many of these studies have shown therapeutic benefit and improved survival in experimental models. Based on available preclinical studies, we discuss potential novel targeted pharmacologic approaches that may offer promise in the treatment of acute pancreatitis. To date a variety of clinical studies have assessed the translational potential of animal model effective experimental therapies and have shown either failure or mixed results in human studies. Despite these discouraging clinical studies, there is a great clinical need and there exist several preclinical effective therapies that await investigation in patients. Better understanding of acute pancreatitis pathophysiology and lessons learned from past clinical studies are likely to offer a great foundation upon which to expand future therapies in acute pancreatitis.

The effect of erythropoietin to pulmonary injury and mast cells secondary to acute pancreatitis

Background

Acute pancreatitis is a life-threatening necroinflammatory disease that is characterized by systemic inflammatory response syndrome and acute lung injury even in its very first days. Erythropoietin (EPO) is a hormone considered as an antiapoptotic and cytoprotective with observed receptors of anti-inflammatory effect on organs apart from the liver and the kidneys. In this study, the effects of EPO on pulmonary mast cells and on secondary injury caused by acute pancreatitis are investigated.

Methods

Twenty one Wistar Albino rats were divided into three groups—sham, control, and EPO groups—with 7 rats per group. Pancreatitis was induced by administering 4.5% sodium taurocholate into the pancreatic duct. A 1000 U/kg/day dosage (three times) of EPO was administered to the EPO group. Blood urea nitrogen (BUN), creatinine, amylase, and troponin I in the serum were studied; and lung, kidney, brain, and heart tissues were examined histopathologically.

Results

There were no histopathological changes in the other organ tissues except for the lung tissue. Compared to the control group, the EPO group showed significantly reduced alveolar hemorrhage, septal neutrophil infiltration, lung wall thickness score, and mast cell count in the lung tissue.

Conclusions

Administration of EPO reduces the mast cell count and lung wall thickness, and it reduces the alveolar hemorrhage and septal infiltration induced by acute pancreatitis.

Expression of human cationic trypsinogen (PRSS1) in murine acinar cells promotes pancreatitis and apoptotic cell death

Hereditary pancreatitis (HP) is an autosomal dominant disease that displays the features of both acute and chronic pancreatitis. Mutations in human cationic trypsinogen (PRSS1) are associated with HP and have provided some insight into the pathogenesis of pancreatitis, but mechanisms responsible for the initiation of pancreatitis have not been elucidated and the role of apoptosis and necrosis has been much debated. However, it has been generally accepted that trypsinogen, prematurely activated within the pancreatic acinar cell, has a major role in the initiation process. Functional studies of HP have been limited by the absence of an experimental system that authentically mimics disease development. We therefore developed a novel transgenic murine model system using wild-type (WT) human PRSS1 or two HP-associated mutants (R122H and N29I) to determine whether expression of human cationic trypsinogen in murine acinar cells promotes pancreatitis. The rat elastase promoter was used to target transgene expression to pancreatic acinar cells in three transgenic strains that were generated: Tg(Ela-PRSS1)NV, Tg(Ela-PRSS1*R122H)NV and Tg(Ela-PRSS1*N29I)NV. Mice were analysed histologically, immunohistochemically and biochemically. We found that transgene expression is restricted to pancreatic acinar cells and transgenic PRSS1 proteins are targeted to the pancreatic secretory pathway. Animals from all transgenic strains developed pancreatitis characterised by acinar cell vacuolisation, inflammatory infiltrates and fibrosis. Transgenic animals also developed more severe pancreatitis upon treatment with low-dose cerulein than controls, displaying significantly higher scores for oedema, inflammation and overall histopathology. Expression of PRSS1, WT or mutant, in acinar cells increased apoptosis in pancreatic tissues and isolated acinar cells. Moreover, studies of isolated acinar cells demonstrated that transgene expression promotes apoptosis rather than necrosis. We therefore conclude that expression of WT or mutant human PRSS1 in murine acinar cells induces apoptosis and is sufficient to promote spontaneous pancreatitis, which is enhanced in response to cellular insult.

Prognostic markers in acute pancreatitis

Acute pancreatitis has a mortality rate of 5-10%. Early deaths are mainly due to multiorgan failure and late deaths are due to septic complications from pancreatic necrosis. The recently described 2012 Revised Atlanta Classification and the Determinant Classification both provide a more accurate description of edematous and necrotizing pancreatitis and local complications. The 2012 Revised Atlanta Classification uses the modified Marshall scoring system for assessing organ dysfunction. The Determinant Classification uses the sepsis-related organ failure assessment scoring system for organ dysfunction and, unlike the 2012 Revised Atlanta Classification, includes infected necrosis as a criterion of severity. These scoring systems are used to assess systemic complications requiring intensive therapy unit support and intra-abdominal complications requiring minimally invasive interventions. Numerous prognostic systems and markers have been evaluated but only the Glasgow system and serum CRP levels provide pragmatic prognostic accuracy early on. Novel concepts using genetic, transcriptomic and proteomic profiling and also functional imaging for the identification of specific disease patterns are now required.

Protective effects of fucoidan, a P- and L-selectin inhibitor, in murine acute pancreatitis

OBJECTIVE

The objective of this study was to investigate the potential protective effects of fucoidan, an L- and P-selectin modulator, in 2 murine models of acute pancreatitis.

METHODS

Acute pancreatitis was induced in mice either by the retrograde infusion of taurolithocholic acid sulfate into the pancreatic duct or by intraperitoneal injections of cerulein (50 μg/kg per hour). The experimental groups received fucoidan (25 mg/kg, intravenously) before pancreatitis induction, whereas control groups received only saline. After 24 hours, serum amylase, lipase, interleukin 1β (IL-1β), tumor necrosis factor α (TNF-α), and nitrite were measured. In addition, myeloperoxidase (MPO) activity (lung and pancreas) and histological assessment (pancreas) were determined.

RESULTS

Serum amylase, lipase, nitrite, TNF-α, and IL-1β, and pancreatic and lung MPO were increased in both taurolithocholic acid sulfate and cerulein acute pancreatitis compared with the respective control groups. Fucoidan significantly decreased the augmented levels of amylase, lipase, pancreatic and lung MPO, TNF-α, IL-1β, and nitrite in both models. Pancreas histological changes observed in both acute pancreatitis models were significantly attenuated by fucoidan.

CONCLUSIONS

Fucoidan reduced the severity of acute pancreatitis in mice by decreasing neutrophil infiltration and systemic inflammation, suggesting that modulation of selectins may constitute a promising therapeutic approach.

An evidence-based proposal for predicting organ failure in severe acute pancreatitis

OBJECTIVES

Early, efficient, and accurate evaluation for organ failure is an important step for improving outcome in severe acute pancreatitis (SAP). We aim to develop a method that can early, efficiently, and accurately evaluate the in-hospital organ failure in patients with SAP.

METHODS

Using multivariate logistic regression analysis, the associative factors for in-hospital organ failure were evaluated retrospectively from conventional data obtained from 393 patients with SAP from 2000 to 2012. In classification and regression tree analysis, a new clinical scoring system was developed for the evaluation of in-hospital organ failure in SAP. We also compared the accuracy of our new scoring system with multiple organ dysfunction score and Acute Physiology and Chronic Health Examination II score by the receiver operating characteristic curve.

RESULTS

Laboratory results revealed serum calcium level greater than or equal to 1.84 mmol/L, serum creatinine level greater than or equal to 110 µmol/L, age greater than or equal to 72 years, activated partial thromboplastin time less than or equal to 30.95 seconds, and Balthazar computed tomography score greater than or equal to 7 (CCAAB) score system, each contributed 1 point for the prediction of organ failure. The area under the curve of the CCAAB score system was similar to multiple organ dysfunction scores and Acute Physiology and Chronic Health Examination II scores.

CONCLUSIONS

The new scoring system CCAAB is an efficient and accurate method for the early evaluation of patients with SAP for in-hospital organ failure.

Specific lipase-responsive polymer-coated gadolinium nanoparticles for MR imaging of early acute pancreatitis

Currently, available methods for diagnosis of acute pancreatitis (AP) are mainly dependent on serum enzyme analysis and imaging techniques that are too low in sensitivity and specificity to accurately and promptly diagnose AP. The lack of early diagnostic tools highlights the need to search for a highly effective and specific diagnostic method. In this study, we synthesized a conditionally activated, gadolinium-containing, nanoparticle-based MRI nanoprobe as a diagnostic tool for the early identification of AP. Gadolinium diethylenetriaminepentaacetic fatty acid (Gd-DTPA-FA) nanoparticles were synthesized by conjugation of DTPA-FA ligand and gadolinium acetate. Gd-DTPA-FA exhibited low cytotoxicity and excellent biocompatibility when characterized in vitro and in vivo studies. L-arginine induced a gradual increase in the intensity of the T1-weighted MRI signal from 1 h to 36 h in AP rat models. The increase in signal intensity was most significant at 1 h, 6 h and 12 h. These results suggest that the Gd-DTPA-FA as an MRI contrast agent is highly efficient and specific to detect early AP.

Neuronostatin ameliorates sodium taurocholate-induced acute pancreatitis in rats

BACKGROUND AND AIMS

Neuronostatin is encoded in the preprosomatostatin gene and exerts important physiological actions on neuronal and cardiovascular regulation and metabolism in diverse tissues. An intraperitoneal injection of neuronostatin can induce c-Jun expression in the periphery of pancreatic islets. Because of the relatively high amount of neuronostatin present in the pancreas, it is necessary to investigate the effects of neuronostatin on pancreas. Furthermore, little is known about the effect of neuronostatin on acute pancreatitis.

METHODS

Neuronostatin (30, 60, and 120 nmol) was injected in to the external jugular vein 30 min before retrograde infusion of 2 % sodium taurocholate into the pancreaticobiliary duct. After 6 h, histological damage of the pancreas was evaluated by pancreas weight and paraffin section. A blood sample was collected to determine the serum amylase and lipase activities.

RESULTS

In our findings, neuronostatin groups had a reduction in interstitial edema, acinar cell vacuolization, and inflammatory infiltration of the pancreas compared with the model group. Biochemical data showed that serum amylase and lipase activities were significantly decreased in neuronostatin-pretreated groups by comparison with the model group.

CONCLUSIONS

Histopathologic examination suggests that neuronostatin ameliorated the histological damage of sodium taurocholate-induced acute pancreatitis in rats. The biochemical analysis was consistent with that obtained from histopathologic examination, which was toward a trend of attenuating acute pancreatitis. In summary, neuronostatin might be potentially capable of ameliorating pancreatic damage in acute pancreatitis in rats.

[Fluid therapy in acute pancreatitis]

Severe acute pancreatitis (AP) is associated with an increased need for fluids due to fluid sequestration and, in the most severe cases, with decreased peripheral vascular tone. For several decades, clinical practice guidelines have recommended aggressive fluid therapy to improve the prognosis of AP. This recommendation is based on theoretical models, animal studies, and retrospective studies in humans. Recent studies suggest that aggressive fluid administration in all patients with AP could have a neutral or harmful effect. Fluid therapy based on Ringer's lactate could improve the course of the disease, although further studies are needed to confirm this possibility. Most patients with AP do not require invasive monitoring of hemodynamic parameters to guide fluid therapy administration. Moreover, the ability of these parameters to improve prognosis has not been demonstrated.

Retroperitoneal laparoscopic debridement and drainage of infected retroperitoneal necrosis in severe acute pancreatitis

OBJECTIVE

To explore the effect of retroperitoneal laparoscopic debridement and drainage on infected necrosis in severe acute pancreatitis.

MATERIALS AND METHODS

This retrospective study included 18 patients with severe acute pancreatitis (SAP) undergoing retroperitoneal laparoscopic debridement and drainage from May 2006 to April 2012 in our hospital. All patients had infected retroperitoneal necrosis and single or multiple peritoneal abscesses. Eleven patients transferred to our hospital were treated with the retroperitoneal laparoscopic debridement and drainage within 24-72 hours after admission. Conservative treatments were given to eight patients. Retroperitoneal laparoscopic debridement and drainage were applied 3-11 days after admission.

RESULTS

All patients had infection of necrotic pancreas or peripancreatic tissues. Twelve patients had organ failure. Three patients underwent secondary surgery. Laparotomy with debridement and drainage were applied to one patient who had a huge lesser sac abscess 7 days after first surgery. The other two patients were given secondary retroperitoneal laparoscopic debridement and drainage. One case was complicated by retroperitoneal hemorrhage, four cases had pancreatic leakage, and no intestinal fistula was found. The patients' heart rate, respiration, temperature, and white blood cell count were significantly improved 48 hours after surgery compared with those prior to surgery (p<0.05). The average length of stay in hospitals was 40.8 days (range, 6-121 days), and the drainage tube indwelling time was 44.4 days (range, 2-182 days).

CONCLUSION

Retroperitoneal laparoscopic debridement and drainage is an SAP surgical treatment with a minimally invasive procedure and a good effect, and can be applied for infected retroperitoneal necrosis in early SAP.

Inhibition of poly(ADP-ribose) polymerase attenuates acute kidney injury in sodium taurocholate-induced acute pancreatitis in rats

OBJECTIVES

The aim of our present study was to investigate the efficacy of poly(adenosine diphosphate-ribose) polymerase (PARP) inhibition in the development of acute kidney injury in an experimental model of severe acute pancreatitis induced by retrograde infusion of sodium taurocholate into the bile-pancreatic duct.

METHODS

Severity of pancreatitis was evaluated by serum amylase, lipase, tumor necrosis factor α, interleukin-1β, interleukin-6, and histological grading. The following markers of renal dysfunction and injury were measured: serum creatinine level, urea nitrogen level, myeloperoxidase activity, and histology. Activation of PARP, intercellular adhesion molecule-1, and P-selectin protein in the kidney was studied using Western blot analysis.

RESULTS

3-Aminobenzamide attenuated the following: (1) serum amylase, lipase, and renal dysfunction; (2) serum concentrations of proinflammatory cytokines; (3) pancreatic and renal pathological injury; (4) renal myeloperoxidase activity; and (5) activation of PARP, intercellular adhesion molecule-1, and P-selectin in the kidney.

CONCLUSIONS

Our results suggest that PARP activation may contribute to kidney injury and that PARP inhibitors may be beneficial in renal disorders associated with severe acute pancreatitis.

Age-dependent vulnerability to experimental acute pancreatitis is associated with increased systemic inflammation and thrombosis

The severity and mortality rates of acute pancreatitis (AP) are significantly elevated in the elderly population. However, due to a lack of appropriate animal models, the underlying mechanisms for this age-dependent vulnerability remain largely unknown. The purpose of this study was to characterize a murine model of AP, which displays age-associated severity, and to use this model to identify pathophysiologies that are distinctive of the aged with AP. AP was induced in young (4-5 months), middle-aged (12-13 months), and aged (23-25 months) C57BL/6 mice by repeated injection of caerulein, a homologue of the gastrointestinal hormone cholecystokinin. Approximately 10% of aged mice died during AP, while young and middle-aged mice showed no mortality. Although both young and aged mice exhibited early signs of edema and inflammation in the pancreas, kidney, and lung, young mice showed signs of recovery within 24 h, while aged mice exhibited increasingly severe tissue damage and cell death. There was a significant age-dependent increase in pancreatic neutrophil activation and systemic inflammation as assessed by pancreatic myeloperoxidase and plasma interleukin-6 (IL-6) concentration, respectively. Importantly, aged but not young mice with AP showed significantly elevated thrombosis in the lung and kidney as well as a marked increase in plasma concentration of plasminogen activator inhibitor-1 (PAI-1), a primary inhibitor of the fibrinolytic system. These results demonstrate that aging is associated with increased severity of AP characterized by augmented and prolonged pancreatic inflammation and the presence of multiple extra-pancreatic sequelae including thrombosis.

Oxymatrine ameliorates L-arginine-induced acute pancreatitis in rats

The aim of this study was to determine whether oxymatrine has a protective effect against acute pancreatitis (AP) in a rat model of L-arginine-induced AP. AP was induced by two intraperitoneal injections of L-arginine (250 mg/100 g) at a 1-h interval. Oxymatrine (50 mg/kg) was administered every 6 h after the induction of AP. Oxymatrine significantly reduced the plasma amylase, D-lactic acid and tumor necrosis factor alpha concentration, serum diamine oxidase and lipase activity, and pancreatic myeloperoxidase activity, which were increased in AP rats (P < 0.05). In addition, the pancreatic CD45 expression and the expression of claudin-1, but not zonula occludens-1 (ZO-1) and occludin, in the intestinal tissues were significantly reduced after the induction of AP. However, oxymatrine increased the expression of claudin-1 and CD45, but did not alter the expression of ZO-1 and occludin. In conclusion, our results demonstrated that oxymatrine is potentially capably of protecting against L-arginine-induced AP and attenuating AP-associated intestinal barrier injury by up-regulation of claudin-1.

Preventive action of curcumin in experimental acute pancreatitis in mouse

BACKGROUND & OBJECTIVES

Curcuma longa (turmeric) has a long history of use in Ayurvedic medicine as a treatment for inflammatory conditions. The purpose of the present study was to investigate the preventive effects of curcumin against acute pancreatitis (AP) induced by caerulein in mouse and to elucidate possible mechanism of curcumin action.

METHODS

Curcumin (50 mg/kg/day) was intraperitoneally injected to Kun Ming male mice for 6 days, followed by injection of caerulein to induce AP. GW9662 (0.3 mg/kg), a specific peroxisome proliferator-activated receptor gamma (PPARγ) antagonist, was intravenously injected along with curcumin. Murine macrophage RAW264.7 cells were treated with 100 μmol/l curcumin for 2 h, and then stimulated with 0.1 μ g/ml lipopolysaccharide (LPS). Serum amylase and transaminase levels were measured at 10 h after AP. TNF-α level in mouse serum and cell culture medium were detected by ELISA. Expression of PPARγ and NF-κB were analyzed by RT-PCR and Western blot.

RESULTS

Curcumin significantly decreased the pancreas injury and reversed the elevation of serum amylase, ALT and AST activities and TNF-α level in mice with AP. Curcumin treatment inhibited the elevation of NF-κB-p65 in the nucleus of mouse pancreas AP group and RAW264.7 cells, but significantly increased the expression of PPARγ. GW9662 could abolish the effects of curcumin on serum levels of amylase, ALT, AST, TNF-α, and NF-κB level.

INTERPRETATION & CONCLUSIONS

Our results suggest that curcumin could attenuate pancreas tissue and other organ injury by inhibiting the release of inflammatory cytokine TNF-α. These effects may involve upregulation of PPARγ and subsequent downregulation of NF-κB.

Early continuous blood purification for treatment of severe acute pancreatitis: an analysis of 14 cases

AIM: To evaluate the clinical efficacy of early continuous blood purification (CBP) in patients with severe acute pancreatitis (SAP).

METHODS: Fourteen patients who were diagnosed with SAP and were willing to undergo early (within 48 h after onset) CBP were included in test group, while 12 SAP patients were included in control group. All patients received mechanical ventilation, parenteral nutrition, antibiotics, vasoactive drugs, somatostatin, or anti-disseminated intravascular coagulation treatment according to indications. The test group began to receive CBP within 8 hours after the diagnosis of SAP. APACHE II score and plasma TNF-α levels were compared before treatment and 1, 3, 5 days after treatment between the two groups.

RESULTS: Early CBP significantly improved the signs and symptoms of SAP. On days 1, 3 and 5, APACHE II score and plasma TNF-α levels differed significantly between the control group and the test group (APACHE II score: 15.93 ± 4.81 vs 18.50 ± 4.77, 13.71 ± 4.01 vs 18.08 ± 4.83, 10.79 ± 2.39 vs 15.17 ± 4.59; TNF-α: 60.00 ± 15.27 vs 89.08 ± 25.56, 42.14 ± 6.94 vs 89.83 ± 23.19, 39.00 ± 6.04 vs 80.00 ± 23.02, all P < 0.05). APACHE II score and plasma TNF-α levels decreased significantly in the test group on days 1, 3 and 5 compared to before treatment (all P < 0.05).

CONCLUSION: Early CBP can significantly improve clinical symptoms, protect organ function, improve prognosis, and reduce mortality in SAP patients.

Organellar dysfunction in the pathogenesis of pancreatitis

SIGNIFICANCE

Acute pancreatitis is an inflammatory disease of exocrine pancreas that carries considerable morbidity and mortality; its pathophysiology remains poorly understood. During the past decade, new insights have been gained into signaling pathways and molecules that mediate the inflammatory response of pancreatitis and death of acinar cells (the main exocrine pancreas cell type). By contrast, much less is known about the acinar cell organellar damage in pancreatitis and how it contributes to the disease pathogenesis.

RECENT ADVANCES

This review summarizes recent findings from our group, obtained on experimental in vivo and ex vivo models, which reveal disordering of key cellular organelles, namely, mitochondria, autophagosomes, and lysosomes, in pancreatitis. Our results indicate a critical role for mitochondrial permeabilization in determining the balance between apoptosis and necrosis in pancreatitis, and thus the disease severity. We further investigate how the mitochondrial dysfunction (and hence acinar cell death) is regulated by Ca(2+), reactive oxygen species, and Bcl-xL, in relation to specific properties of pancreatic mitochondria. Our results also reveal that autophagy, the principal cellular degradative, lysosome-driven pathway, is impaired in pancreatitis due to inefficient lysosomal function, and that impaired autophagy mediates two key pathological responses of pancreatitis-accumulation of vacuoles in acinar cells and the abnormal, intra-acinar activation of digestive enzymes such as trypsinogen.

CRITICAL ISSUES AND FUTURE DIRECTIONS

The findings discussed in this review indicate critical roles for mitochondrial and autophagic/lysosomal dysfunctions in the pathogenesis of pancreatitis and delineate directions for detailed investigations into the molecular events that underlie acinar cell organellar damage.

Summary of integrative medicine for severe acute pancreatitis: 26-year clinical experiences and a report of 1 561 cases

OBJECTIVE

To investigate the changing trends of clinical management for severe acute pancreatitis (SAP) with integrative medicine.

METHODS

Clinical data of 1 561 patients with SAP from 1980 to 2005 was retrospectively analyzed. The mortality and morbidity of complications were compared.

RESULTS

Of the 1 561 patients, 400 patients accepted surgical operation, while the rest were treated conservatively with integrative medicine. There was a change toward conservative management together with Chinese purgative herbal medication use after 1990 (22.4% from 1980-1990 compared with 45.5% from 1991-1993) because of high postoperative mortality. From 1994-2005, the treatment integrating Western medicine with Chinese herbal medications came to be preferred over the classic Western operation-based method. This change was associated with decreased morbidity (35.4% in 1980-1990 compared with 24.7% in 1991-1993 and 11.0% in 1994-2005, P<0.05) and lower mortality (40.52% of 1980-1990 compared with 17.17% of 1991-1993 and <10.25% of 1994-2005, P<0.05).

CONCLUSION

The combination of conservative management with Chinese herbal medicines is preferable to classic Western medicine treatment to reduce morbidity and mortality of SAP, while surgery becomes a supplemental option.