Management of Severe Acute Pancreatitis

Clinical Effect of the Traditional Japanese Herbal Medicine "Goreisan" on Water Balance in Patients With Severe Acute Pancreatitis

BACKGROUND

Since severe acute pancreatitis (SAP) involves inflammatory mediators produced by local inflammation of the pancreas that trigger a systemic inflammatory response, intensive fluid management is required to maintain hemodynamics in the early stages of the onset of SAP. Goreisan is considered to have a diuretic effect in a state of excess water and an antidiuretic effect in a state of dehydration, regulating water balance in both directions. We investigated the clinical effects of Goreisan on water balance in SAP patients. Patients and methods: SAP patients admitted to our ICU within 72 hours of being diagnosed with SAP were divided into two groups: the Rikkunshito group (before October 2015) and the Goreisan group (after November 2015). Cumulative volume of fluid infusion, urine, fluid removal by CHF, nasogastric tube drainage, and water balance from day 1 to day 5 of ICU admission.

RESULTS

Thirty patients were included. The median age was 57 (40-69) years, and 21/30 (70%) were male. The prognostic factor score in Japanese criteria for acute pancreatitis was 5.5 (3.3-7). Of the thirty patients, 14 were in the Rikkunshito group, and 16 were in the Goreisan group. There were no differences in the cumulative volume of fluid infusion, urine, fluid removal by CHF, or nasogastric tube drainage from day 1 to day 5 of ICU admission between the two groups. However, the cumulative water balance from day 1 to day 5 of admission was 4,957 ± 6,091 mL in the Rikkunshito group, whereas it was lower in the Goreisan group at 498 ± 3,918 mL (P = 0.023).

CONCLUSION

Our study showed that Goreisan administration in patients with severe acute pancreatitis might improve water balance in the early phase of onset. Early administration of Goreisan at the onset of severe acute pancreatitis may regulate fluid movement between capillaries and interstitium and alleviate fluid overload due to water refill.

Intravenous Hemin, a potential heme oxygenase-1 activator, does not protect from post-ERCP acute pancreatitis in humans: Results of a randomized multicentric multinational placebo-controlled trial

OBJECTIVE

Hemin, a heme oxygenase 1 activator has shown efficacy in the prevention and treatment of acute pancreatitis in mouse models. We conducted a randomized controlled trial (RCT) to assess the protective effect of Hemin administration to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients at risk.

METHODS

In this multicenter, multinational, placebo-controlled, double-blind RCT, we assigned patients at risk for PEP to receive a single intravenous dose of Hemin (4 mg/kg) or placebo immediately after ERCP. Patients were considered to be at risk on the basis of validated patient- and/or procedure-related risk factors. Neither rectal NSAIDs nor pancreatic stent insertion were allowed in randomized patients. The primary outcome was the incidence of PEP. Secondary outcomes included lipase elevation, mortality, safety, and length of stay.

RESULTS

A total of 282 of the 294 randomized patients had complete follow-up. Groups were similar in terms of clinical, laboratory, and technical risk factors for PEP. PEP occurred in 16 of 142 patients (11.3%) in the Hemin group and in 20 of 140 patients (14.3%) in the placebo group (p = 0.48). Incidence of severe PEP reached 0.7% and 4.3% in the Hemin and placebo groups, respectively (p = 0.07). Significant lipase elevation after ERCP did not differ between groups. Length of hospital stay, mortality and severe adverse events rates were similar between groups.

CONCLUSION

We failed to detect large improvements in PEP rate among participants at risk for PEP who received IV hemin immediately after the procedure compared to placebo.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov number, NCT01855841).

Proteomic analysis of serum extracellular vesicles from biliary tract infection patients to identify novel biomarkers

Biliary tract infection (BTI), a commonly occurring abdominal disease, despite being extensively studied for its initiation and underlying mechanisms, continues to pose a challenge in the quest for identifying specific diagnostic biomarkers. Extracellular vesicles (EVs), which emanate from diverse cell types, serve as minute biological entities that mirror unique physiological or pathological conditions. Despite their potential, there has been a relatively restricted exploration of EV-oriented methodologies for diagnosing BTI. To uncover potent protein biomarkers for BTI patients, we applied a label-free quantitative proteomic method known for its unbiased and high-throughput nature. Furthermore, 192 differentially expressed proteins surfaced within EVs isolated from individuals afflicted with BTI. Subsequent GO and KEGG analyses pinpointed Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) and Crumbs homolog 3 (CRB3) as noteworthy biomarkers. Validation via data analysis of plasma-derived EV samples confirmed their specificity to BTI. Our study leveraged an unbiased proteomic tool to unveil CEACAM1 and CRB3 as promising protein biomarkers in serum EVs, presenting potential avenues for the advancement of diagnostic systems for BTI detection.

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.

Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review

Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.

Thioredoxin-interacting protein deficiency protects against severe acute pancreatitis by suppressing apoptosis signal-regulating kinase 1

Acute pancreatitis is a common acute inflammatory abdominal disease. When acute pancreatitis progresses to severe acute pancreatitis (SAP), it can lead to systemic inflammation and even multiple organ failure. Thioredoxin-interacting protein (TXNIP) is an important protein involved in redox reactions of the inflammatory response. However, the specific role of TXNIP in SAP remains unclear. In this study, we investigated the role of thioredoxin interacting protein (TXNIP) in acute pancreatitis when induced by high doses of arginine. We found that pancreatic damage and the inflammatory response associated with acute pancreatitis were largely restrained in TXNIP knock-out mice but were enhanced in mice overexpressing TXNIP. Interestingly, the phosphorylation of p38, JNK, and ASK1 diminished in TXNIP-KO mice with pancreatitis in comparison with wild-type mice. The role of oxidative stress in SAP was explored in two models: TXNIP and AVV-TXNIP. TXNIP knockdown or the inhibition of ASK1 by gs-4997 abrogated the increase in p-p38, p-JNK, and p-ASK1 in AR42J cells incubated with L-Arg. The administration of gs-4997 to mice with pancreatitis largely reduced the upregulation of IL-6, IL-1β, TNF-α, and MCP-1. Systemic inflammatory reactions and injury in the lungs and kidneys were assessed in TXNIP-KO and AVV-TXNIP mice with expected outcomes. In conclusion, TXNIP is a novel mediator of SAP and exerts action by regulating inflammatory responses and oxidative stress via the ASK1-dependent activation of the JNK/p38 pathways. Thus, targeting TXNIP may represent a promising approach to protect against SAP.

Nutrition in acute pancreatitis: when, what and how

PURPOSE OF REVIEW

This review intends to discuss recently available evidence in three topics related to nutrition in patients with acute pancreatitis, namely timing of refeeding, type of nutritional therapy and its route of administration.

RECENT FINDINGS

Recent lines of research confirm that early oral feeding leads to shorter length of stay, fewer complications and lower costs in patients with acute pancreatitis. Moreover, early (<48 h) enteral nutrition led to decreased hospital mortality in patients with mild and severe acute pancreatitis; thus, in case of intolerance to oral feeding or severe disease, nutritional therapy should be offered within 24-72 h. Furthermore, enteral nutrition should be preferred against parenteral nutrition, as it is related to shorter length of stay and less complications, while initial data bring to light the potential role of the soluble dietary fibre polydextrose as an agent that could lead to faster achievement of energy goal with concomitant lower rates of feeding intolerance. Finally, enteral nutrition can be administered through gastric or jejunal feeding, depending on digestive tolerance, whereas latest data also address the safety of percutaneous gastrostomy with a jejunal extension for enteral nutrition administration. However, more data about its real benefit are warranted.

SUMMARY

Accumulating evidence confirms the importance of early oral refeeding or early administration of enteral nutrition as vital parts of the armamentarium for the management of patients with acute pancreatitis.

Construction of a Nomogram Model for Predicting Pleural Effusion Secondary to Severe Acute Pancreatitis

Background

This study aims to investigate the risk factors of pleural effusion (PE) secondary to severe acute pancreatitis (SAP) and to build a nomogram model.

Methods

The clinical parameters of SAP patients admitted to the emergency department of the First Affiliated Hospital of Bengbu Medical College from January 2019 to August 2021 were retrospectively collected. The independence risk factors of PE secondary to SAP were analyzed by univariate analysis and multivariate logistic regression analysis. A nomogram risk prediction model was established and validated through the area under the ROC curve.

Result

Two hundred twenty-two SAP patients were included for analysis, of which 65 patients experienced secondary PE. The incidence of PE secondary to SAP was 29.28% (65/222). Logistic regression analysis showed that serum albumin (ALB) (OR = 0.830, 95% CI: 0.736∼0.936), fibrinogen (FIB) (OR = 4.573, 95% CI: 1.795∼11.648), C-reactive protein (CRP) (OR = 1.046, 95% CI: 1.009∼1.083), acute physiology, chronic health score system (APACHE-II) score (OR = 1.484, 95% CI: 1.106∼1.990), and sequential organ failure score (SOFA) (OR = 43.038, 95% CI: 2.030∼4.548) were independent risk factors for PE secondary to SAP (P < 0.05) and entered into the nomogram. The nomogram showed robust discrimination with an index of concordance of 0.755 and an area under the receiver operating characteristic curve of 0.837 (95% CI: 0.779∼0.894).

Conclusion

We developed a nomogram model for PE secondary to SAP with ALB, FIB, CRP, APACHE-II scores, and SOFA scores. The nomogram model showed good discrimination and consistency, and it can better predict the risk of PE secondary to SAP.

Acute Responses to Infectious and Inflammatory Disorders of the Gastrointestinal System

Infectious and inflammatory disorders of the gastrointestinal system are life-threatening and occur frequently in hospitalized adults. Inflammatory and inflammation-related diseases of the gastrointestinal tract seen in the acutely and critically ill have numerous causes. In acute pancreatitis and toxic infections caused by the bacterium Clostridium difficile, where severe infections can develop, inflammation plays a causative and crucial role. Severe acute pancreatitis puts a patient at risk for infected necrosis, which can result in septicemia and shock. Similarly, patients treated with antibiotics are at risk for C difficile colitis, which can progress to toxic megacolon. These conditions require volume resuscitation and interventions supported by current evidence. Percutaneous or surgical interventions are often undertaken at a critical point in these illnesses. Patients who require surgery for these diagnoses present challenges for the interprofessional team. Inflammatory and infectious disorders often can lead to complications of systemic inflammatory response syndrome, sepsis, and multiorgan failure. New strategies are on the horizon to prevent the onset of and improve care for patients with severe acute pancreatitis, fulminant C difficile infection, and megacolon.

Pancreatitis after endoscopic retrograde cholangiopancreatography: A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a feared and potentially fatal complication that can be as high as up to 30% in high-risk patients. Pre-examination measures, during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events. Several studies have debated on the subject, however, numerous topics remain controversial, such as the effectiveness of prophylactic medications and the amylase dosage time. This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.

[Interventions for pancreatitis]

Approximately 20% of patients with acute pancreatitis develop complications that require surgical or radiological intervention. Radiology plays a central role, not only for imaging (course of the disease, detection of superinfection and their related complications, and development of necrosis) but also for the treatment of vascular and nonvascular complications. In the treatment of severe or necrotizing pancreatitis, a multidisciplinary staged approach with minimally invasive therapies such as endoscopic or percutaneous drainage should be used. Applying a sufficient number of drains of sufficient size, strict irrigation therapy under computed tomographic (CT) control and repositioning of the drains can successfully treat pancreatic and peripancreatic necrosis often without the need for subsequent surgical debridement. Arterial complications affect 1-10% of all patients with pancreatitis, most of which are ruptured pseudoaneurysms, which represent the most dangerous bleeding complication of pancreatitis and can be treated with a high technical success rate through embolization and/or use of an endovascular stent-graft.