Antithrombin titer in acute pancreatitis

Identification of Early Derangements of Coagulation, Hematological and Biochemical Profiles in Patients with Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a severe disease involving various pathological processes. We aimed to use rapid -thromboelastography (r-TEG) combined with conventional coagulation assays (CCAs) and other laboratory tests, to identify early derangements in coagulation, hematological, and biochemical profiles in patients with AP.

METHODS

We enrolled 177 patients diagnosed with AP and 121 controls. Blood samples were analyzed using r-TEG, CCAs, and hematological and biochemical tests within 2 h of patient admission. All testing parameters were compared between the patients and the controls. Pearson's correlation coefficient was used to determine the correlation between the parameters among the patients. Logistic regression analysis was performed to evaluate the effects of the variables (demographic, coagulation, hematological and biochemical) on AP.

RESULTS

Using r-TEG and CCAs, we observed differences in coagulation parameters between the patients with AP and the controls. The r-TEG results showed a pro-coagulant state and increased platelet activation in AP patients. Pearson's correlation analysis showed that inflammatory indicators were strongly correlated with coagulation/platelets in the pathological process of AP. Logistic regression analysis revealed that age, K, neutrophil (NEUT), triglyceride (TG) and blood amylase (AMY) were significantly associated with the development of AP.

CONCLUSION

Coagulation profile and platelet play essential roles in the pathogenesis of AP. Pro-coagulant state and increased platelet activation in patients with AP were demonstrated using r-TEG. The r-TEG parameter K, age, NEUT, TG, and AMY may be used as potential indicators of AP.

Acute pancreatitis in Soweto, South Africa: relationship between trypsinogen load, trypsinogen activation, and fibrinolysis

OBJECTIVE

It is not known why acute pancreatitis in Soweto, South Africa, pursues an aggressive course. We sought clues from circulating trypsinogen load at admission as marker of initial acinar injury, trypsinogen activation using the carboxypeptidase B activation peptide as surrogate, proteinase inhibitors, the coagulation-fibrinolysis axis, indicators of inflammation, oxidative stress markers, and antioxidant status. This article reports on the first four aspects.

METHODS

The study involved 24 consecutive patients with a first attack. All of them were admitted within 24 h, and 22 were alcoholic. Urine was analyzed for anionic trypsinogen and the carboxypeptidase B activation peptide. Serum was tested for anionic and cationic trypsinogen, alpha1 proteinase inhibitor and alpha2 macroglobulin. Plasma from a subset was assayed for soluble fibrin, cross-linked fibrin degradation products (surrogates for thrombin and plasmin activity, respectively), and tissue-type plasminogen activator and inhibitor.

RESULTS

Soweto controls had higher serum anionic trypsinogen (p = 0.004) and plasminogen activator:inhibitor ratio (p = 0.047) than U.K. controls. The outcome of acute pancreatitis was mild in 17 but severe in seven with three deaths, two on day 2. In mild pancreatitis, intense plasmin activity (p < 0.001) accompanied the surge in trypsinogen, especially anionic (p < 0.001), but without increased thrombin activity and in five patients without trypsinogen activation. In severe pancreatitis, further significant increments in plasmin activity and trypsinogens were accompanied by increased thrombin activity (p = 0.013) and trypsinogen activation (p = 0.046). There was no correlation between surrogates of plasmin and thrombin activity, or between either and the carboxypeptidase B activation peptide, which showed a curvilinear relationship to total serum trypsinogen.

CONCLUSIONS

The aggressive nature of alcoholic acute pancreatitis in Soweto seems to reflect early profound fibrinolysis, which precedes coagulation and is initially independent of trypsin. Subclinical acinar-cell injury and a profibrinolytic diathesis in outwardly healthy Sowetans may predispose to this problem.

Effect of drugs on the pulmonary changes in experimental acute pancreatitis in the rat

Respiratory complications of acute pancreatitis are well recognised and are closely related to a poor prognosis. Using an experimental model in the rat, a decrease in lung compliance and an increase in lung weight were produced in acute pancreatitis. The effects of dexamethasone, heparin, and aspirin on these changes were studied. The mean specific lung compliance was reduced by 16% in the pancreatitis group compared with the control group (p less than 0.05) and this change was abolished by dexamethasone (p less than 0.02), heparin (p less than 0.01), and aspirin (p less than 0.001). Percentage lung weight (as percentage of total body weight) was raised by 22% in the pancreatitis group compared with the sham operation group (p less than 0.01) and this change was abolished by heparin (p less than 0.01) and aspirin (p less than 0.05), but not affected by dexamethasone (p less than 0.5). The results indicate that 'stiff' and heavy lungs occur in experimental acute pancreatitis. The fact that these changes are abolished by heparin and improved by aspirin suggests that intrapulmonary fibrin deposition is a factor in the pathogenesis of the important respiratory complications of this condition.

Pulmonary function and fibrinogen metabolism in acute pancreatitis

Respiratory complications were studied in 50 patients with acute pancreatitis, and the relationship of these complications to parameters of fibrinogen metabolism was investigated. The mean arterial P02 of the patients was 9.85 +/- 3.8 kPa (s.d.). Forty-three per cent of patients on admission were hypoxaemic. The mean PO2 was lower in patients who subsequently developed complications of acute pancreatitis (mean P02 7.85 +/- 1.42 kPa (s.d.), P less than 0.01). Vital capacity on admission was decreased by 50 per cent in 41 per cent of patients and by 20 per cent decrease in their vital capacity. Fibrinogen levels were elevated in 80 per cent of of patients on admission and there was a negative correlation between these levels and the arterial P02 (r = -0.6, P less than 0.001). Fibrinogen degradation products were elevated in 45 per cent of patients. The results confirm that marked lung damage occurs in acute pancreatitis and suggest that the effects are prolonged. The possibility that this damage may be related to pulmonary fibrin deposition is discussed.

Coagulation problems in patients with cancer

The cases of 43 cancer patients and nine patients without cancer were reviewed to assess the coagulation mechanism in patients with cancer. Of the 43 patients with cancer, at least one factor known to be associated with coagulation disturbances was present in 26. Hematologic or coagulation studies disclosed one or more abnormalities in 34 of the patients. A subgroup of 17 patients had no clinical or laboratory evidence of ongoing variables that should interfere with coagulation or hemostasis. Of these, 11, or 65%, had one or more abnormal results from coagulation studies. Of the nine members of the control group (patients without cancer), no patient had a positive history for a clinical coagulation disorder except for one incidence of thrombophlebitis in the year preceding the study. During the study, at least one coagulation abnormality was disclosed by hematologic testing. The results support the concept that coagulation problems in cancer patients are attributable to debilitation, multiple organ involvement, and coagulation-interfering variables rather than to a primary effect of the malignant tumor.

Haematological abnormalities in acute pancreatitis. A prospective study

Twenty-five patients with acute pancreatitis were studied prospectively in the first week of their admission using haematological and coagulation tests. Platelet counts initially fell and later returned to admission levels. Rising levels of plasma fibrinogen were recorded. The kaolin cephalin clotting time was shorter than its control in twenty-one patients. Eighteen patients had elevated fibrinogen degradation products and fourteen had a positive ethanol gelation test. It is suggested that by taking into account the results in series of individual patients a degree of intravascular coagulation may be a common feature of acute pancreatitis. In one patient (presented in detail) strong evidence for disseminated intravascular coagulation was found