Pancreatic encephalopathy

Wernicke's encephalopathy after acute pancreatitis with upper gastrointestinal obstruction: A case report and literature review

A 42-year-old female was admitted with upper abdominal pain. Imaging studies and laboratory tests were performed to consider acute lipogenic pancreatitis. After symptomatic treatment, her abdominal pain was significantly relieved. However, the patient was accompanied by upper gastrointestinal obstruction, which was gradually relieved after long-term fasting, gastrointestinal decompression, and fluid rehydration. The patient developed dizziness and ataxia, which worsened. Cranial magnetic resonance imaging (MRI) indicated patchy abnormal signal shadows in the bilateral thalami and dorsal brainstem and suggested metabolic encephalopathy. Wernicke's encephalopathy (WE) was the initial diagnosis of suspicion, adequate vitamin B1 was immediately replenished until the complete resolution of symptoms, and the patient made a rapid and dramatic recovery.

Cognitive impairments induced by severe acute pancreatitis are attenuated by berberine treatment in rats

Cognitive impairments induced by severe acute pancreatitis (SAP) are severe complications, for which there are a lack of effective pharmacological treatment strategies. Berberine is an isoquinoline alkaloid extracted from the Chinese herb, Coptis rhizome, which exhibits numerous biological effects on gastrointestinal disorders. However, the effects of berberine on SAP‑induced cognitive impairments remain unknown. The present study aimed to investigate the effects of berberine on cognitive impairments associated with SAP. Wistar rats were randomly divided into Sham, Sham + berberine, SAP and SAP + berberine groups. Rats were intraperitoneally injected with L‑arginine (3 g/kg) to induce SAP. Subsequently, selected rats were intragastrically administered berberine (100 mg/kg) once daily for 6 consecutive days. Disease severities of rats were investigated 48 h post‑induction of SAP via determination of serum amylase levels and hematoxylin and eosin staining. Survival rates, performance of behavioral tests (automated rotarod and fear conditioning tests), blood brain barrier (BBB) permeability, and the expression levels of tumor necrosis factor (TNF)‑α and interleukin (IL)‑1β in hippocampal tissues were also determined. Proteins associated with apoptosis and necroptosis in the hippocampal tissues of SAP rats, including caspase‑3, receptor‑interacting protein kinase (RIP)1 and RIP3, were detected via western blotting. The results revealed that treatment with L‑arginine induced SAP, which subsequently resulted in increased BBB permeability, mortality rates and cognitive deficits in rats. The expression levels of TNF‑α, IL‑1β, caspase‑3, RIP1 and RIP3 were significantly increased in the hippocampal tissues of SAP rats, thus suggesting that neuroinflammation, apoptosis and necroptosis may be involved in neurodegeneration associated with the development of SAP. Notably, administration of berberine protected the integrity of the BBB, decreased levels of brain inflammation and mortality rates, and attenuated increased levels of proteins associated with apoptosis and necroptosis and cognitive deficits associated with SAP in rats. The results of the present study demonstrated that daily treatment with berberine may attenuate cognitive deficits and reduce associated mortality via exhibition of anti‑neuroinflammatory effects and attenuation of neuronal apoptosis and necroptosis in the hippocampal tissues of SAP rats.

Indoleamine 2,3-dioxygenase is upregulated in the brain of rats with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) has an effect on both inflammatory/autoimmune processes and psychological states, but the pathophysiological causes of pancreatic encephalopathy in the brain are unclear. We hypothesized that the peripheral immune/inflammatory response during AP can affect indolamine 2,3-dioxygenase (IDO) expression and serotonin content in the brain.

METHODS

About 210 male Sprague Dawley rats were randomly divided into five groups: control (0 h) and 6 h, 24 h, 48 h and 72 h experimental groups. Acute pancreatitis was induced by an injection of a sodium taurocholate solution via a cannulated bile-pancreatic duct. We measured the plasma TNF-α and IL-6 levels; serotonin, 5-HIAA and the protein concentration levels of IDO and monoamine oxidase A (MAO-A) were evaluated in the striatum, hippocampus and left prefrontal cortex.

RESULTS

The IL-6 and the TNF-α levels increased in the 24 h, 48 h and 72 h groups. The IDO concentrations of both the 72 h group in the hippocampus and 48 h, 72 h groups in the prefrontal cortex increased; in the corpus striatum, the IDO concentrations fluctuated without statistical significance. The MAO-A protein concentration of the 6 h and 24 h groups decreased in the striatum, hippocampus and prefrontal cortex. There were no statistically significant differences found in the serotonin and 5-HIAA concentrations.

CONCLUSIONS

During the process of AP, cytokines, such as IL-6 and TNF-α, may play a role in activation of neuronal pathways utilizing the metabolic enzyme IDO, which may play an important role in determining the mental symptomatology accompanying AP.

Acute pancreatitis affects the metabolism of catecholamine neurotransmitters in rats

Abnormalities of mental status represent a severe complication and an important cause of death in acute pancreatitis (AP), which is characterized by a pattern of neurological signs and symptoms. As some of the symptoms of AP are also affected by catecholamine neurotransmitters, they cannot be ruled out of the pathophysiology of AP; however, little research has been performed exploring this hypothesis. Our study aimed to elucidate whether AP affects the metabolism of catecholamine neurotransmitters in rats. A total of 300 male SD rats were randomly divided into five groups: control, 6H, 24H, 48H and 72H experimental groups. AP was induced in rats by an injection of a sodium taurocholate solution via a cannulated bile-pancreatic duct. In the striatum, hippocampus and cerebellum, catecholamine neurotransmitters were tested using high performance liquid chromatography equipped with a electrochemical detector, and the activities and protein concentration levels of monoamine oxidase A (MAO-A) and tyrosine hydroxylase (TH) were also evaluated using ELISA and Western blotting analyses. In the hippocampus, the dopamine (DA) concentrations increased in the 48-h and 72-h groups. The 3,4-dihydroxyphenylacetic acid (DOPAC) concentration of the 72-h group also increased. The MAO-A and TH activity of the 6-h and 24-h groups decreased, respectively. The TH activities of the 48-h groups also decreased. The MAO-A and TH protein concentration of the 6-h and 24-h groups decreased. In the corpus striatum, the homovanillic acid concentration of the 72-h group and norepinephrine concentrations of the 24-h and 48-h groups increased, respectively. The MAO-A and TH activities of the 6-h and 24-h groups decreased. The MAO-A and TH protein concentrations of the 6-h and 24-h groups decreased. In the prefrontal cortex (left prefrontal lobe), the DA and DOPAC concentrations of the 48-h group increased. The MAO-A and TH activities of the 6-h, 24-h and 48-h groups decreased. The MAO-A and TH protein concentrations of the 6-h and 24-h groups also decreased. The other catecholamine concentration and enzyme activities fluctuated, but there was no statistically significant difference compared with the control group. Catecholamine neurotransmitter metabolic systems are widely affected in AP, and these fluctuations may play an important role in determining the symptomatology of AP.

Protective effect of low-molecular-weight heparin on pancreatic encephalopathy in severe acute pancreatic rats

BACKGROUND AND AIMS

Pancreatic encephalopathy (PE) is a severe complication and significant cause of death in patients with severe acute pancreatitis (SAP). We have reported previously that low-molecular-weight heparin (LMWH) treatment could reduce incidence of PE in SAP patients. Our objective here was to investigate the protective effect of LMWH and its mechanism on PE in SAP rats.

METHODS

SD rats were randomly divided into three groups: (1) Sham-operation (S) group, (2) SAP group, and (3) LMWH treatment (LMWH) group. LMWH was administrated 4 h after the SAP model conducted. The levels of serum amylase, myelin basic protein (MBP), tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), brain water content, occurrence of apoptosis, and pathological changes of pancreas and brain were measured at 1 day after models were set up in the SAP and S groups, and 1 day after LMWH treatment was administrated in the LMWH group.

RESULTS

(1) The levels of serum amylase, TNF-α, and IL-6 in the SAP group were increased significantly more than those in the S and LMWH groups (all P < 0.001), as were the levels of serum MBP in the SAP group compared to those in the S and LMWH groups (P < 0.01, <0.05 respectively). However, while the level of serum amylase and IL-6 in the LMWH group were significantly increased compared to those in the S group (P < 0.05, <0.001 respectively), the levels of TNF-α and MBP showed no significant difference between the LMWH and S groups (all P > 0.05). (2) The brain water content in the SAP group was significantly increased compared to the S group and LMWH group (P < 0.01, <0.05 respectively). (3) Neuronal apoptosis, demyelination, and mitochondrial vacuolation in neuronal cells were observed in the SAP group; in contrast, in the LMWH group, significantly lower rates of neuronal apoptosis, demyelination and mitochondrial edema were observed in neuronal cells.

CONCLUSIONS

The protective effect of LMWH on PE progression in SAP rats might result from inhibition of inflammatory activation and reduction of the occurrence of neuronal apoptosis.

Effect of lower-molecular weight heparin in the prevention of pancreatic encephalopathy in the patient with severe acute pancreatitis

OBJECTIVE

To study the effect of lower-molecular weight heparin in the prevention of pancreatic encephalopathy (PE) in the patient with severe acute pancreatitis (SAP).

METHODS

Two hundred sixty-five SAP patients were randomly divided into 2 groups: (1) conventional treatment group (C group, n = 130) and (2) conventional treatment plus lower-molecular weight heparin treatment group (LT group, n = 135). The clinical parameters, laboratory parameters and computed tomographic (CT) score of pancreatic necrosis (CTSPN), incidence of PE, and mortality in the 2 groups were compared.

RESULTS

On admission, all the clinical parameters, laboratory parameters, and CTSPN in the 2 groups were not significantly different (P > 0.05). However, 1 to 2 weeks after treatment, the symptoms and signs improvement rate, the levels of blood and urine amylase, the CT score, and the Acute Physiology and Chronic Health Evaluation II score in the LT group were obviously lower than those in the C group (P < 0.05-0.01), and PE occurrence rate, mortality, and mean hospital stay in LT group were obviously lower than those in the C group (P < 0.05-0.01).

CONCLUSIONS

Lower-molecular weight heparin can enhance the effect of conventional treatment of SAP and can markedly decrease the PE incidence and improve the survival rate of SAP. Lower-molecular weight heparin is a simple, safe, less expensive, and effective method for treatment of SAP. It can be used in every hospital.

Combined perioperative plasma endoglin and VEGF--a assessment in colorectal cancer patients

Colorectal cancer growth and spread is absolutely dependent on angiogenesis with vascular endothelial growth factor (VEGF) being the most important cytokine involved in the process. Endoglin, a membrane co-receptor for TGF-beta, has recently emerged as a sensitive index of cancer stage. There is now sufficient evidence indicating that microvessel density assessed by endoglin-immunostaining can correlate with stage of colorectal cancer and patient survival. An association of a soluble form of endoglin with lymph node and distant metastases has recently been reported in two studies. Both of them used local elaborated immunoassays for endoglin assessment. The aim of our study was to determine the efficacy of plasma endoglin, assessed using a commercial kit, as a marker of tumor spread and distant metastases in colorectal cancer patients. We studied 48 colorectal cancer patients, compared with 22 healthy subjects, using ELISA. We observed that colorectal cancer patients had increased plasma VEGF-A, but not endoglin levels. However, we found an association of plasma endoglin with the stage of malignancy. Endoglin levels were increased in metastasis-positive patients when compared to both metastasis-negative patients and healthy volunteers. Plasma endoglin correlated with VEGF-A, CEA and CA19.9. Endoglin assessment in plasma does not seem useful as a maker of colorectal cancer. Our observations indicate however that it might be helpful in selecting patients with metastatic disease.

Low molecular weight heparin in the treatment of severe acute pancreatitis: a multiple centre prospective clinical study

OBJECTIVE

To study the effect of low molecular weight heparin (LMWH) in the treatment of severe acute pancreatitis (SAP).

METHODS

A total of 265 SAP patients were randomly divided into two groups: firstly, the conventional treatment group (C group, n = 130; and secondly the conventional treatment plus the LMWH treatment group (LT group, n = 135). The clinical parameters, laboratory parameters and computed tomography (CT) score of pancreatic necrosis (CTSPN) in the two groups were compared.

RESULTS

On admission, all the clinical parameters, laboratory parameters and CTSPN in the two groups were not significantly different (p > 0.05). However, after treatment, in LT group, the clinical presentation improvement rate and laboratory parameters improvement were significantly higher than those in C group (p < 0.05-0.01), and the acute physiology and chronic health evaluation (APACHE) II score, complication rate, mortality and mean hospital stay in LT group were obviously lower than those in C group (p < 0.05-0.01). The CT score in LT group was much lower than that in C group (p < 0.05). Two weeks after treatment FBI decreased obviously in C group, but not in LT group, and no haemorrhagic complications occurred.

CONCLUSIONS

LMWH can enhance the effect of conventional treatment for SAP, and can markedly decrease the mortality of SAP. LMWH is a simple, safe, economic and effective method for treatment of SAP. It is can be used in every hospital.

Pancreatic encephalopathy and Wernicke encephalopathy in association with acute pancreatitis: A clinical study

AIM: To investigate clinical characteristics and therapy of pancreatic encephalopathy (PE) and Wernicke encephalopathy (WE).

METHODS: In a retrospective study of 596 patients with acute pancreatitis (AP), patients with PE were compared to those with WE in regards to history, clinical manifestation, diagnosis, treatment and outcome.

RESULTS: There were 93 patients with severe acute pancreatitis (SAP). Encephalopathies were discovered in 10 patients (1.7%). Six patients with PE all developed in SAP (6.5%), and three of them died (3% of SAP, 50% of PE). Four patients with WE developed in AP (0.7%), and two of them died (0.3% of AP, 50% of WE). Two patients with WE were treated with parenteral thiamine and survived. Global confusions were seen in all patients with encephalopathy. Ocular abnormalities were found. Conjugate gaze palsies were seen in 1 of 6 (16.7%) patients with PE. Of 4 patients with WE, one (25%) had conjugate gaze palsies, two (50%) had horizontal nystagmus, three (75%) had diplopia, and one (25%) had myosis. Ataxia was not seen in all patients. None of patients with WE presented with the classic clinical triad. CSF examinations for 2 patients with WE showed lightly-increased proteins and glucose. CT and MRI of the brain had no evidence of characteristic abnormalities.

CONCLUSION: PE occurs in early or reiteration stage of SAP, and WE in restoration stage of SAP/AP. Ocular abnormalities are the hallmarks of WE, and horizontal nystagmus is common. It is difficult to diagnose earlier an encephalopathy as PE or WE, as well as differentiate one from the other. Long fasting, hyperemesis and total parenteral nutrition (TPN) without thiamine are main causes of thiamine deficiency in the course of pancreatitis.

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Fatal brain stem event complicating acute pancreatitis

Acute pancreatitis, developing in a patient with chronic renal failure, was complicated by a fatal neurological illness during which MRI showed pontine and extrapontine changes consistent with pontine and extrapontine myelinolysis. At post mortem, acute pancreatitis was confirmed but the neuropathological findings were more in keeping with an unusual presentation of acute haemorrhagic leucoencephalitis, perhaps even representing a form of 'pancreatic encephalopathy'. Although the development of CT and MRI scanning has greatly increased the resolution of neuroimaging and facilitated diagnosis during life, the value of autopsy examination is confirmed in cases such as this. Sometimes the findings may raise more questions than may have been answered - this too is an important function!