Pancreatic encephalopathy. A case report and review of the literature

Predisposing Factors and Neurologic Outcomes of Patients with Elevated Serum Amylase and/or Lipase after Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study

This study investigated the patient outcomes, incidence, and predisposing factors of elevated pancreatic enzyme levels after OHCA. We conducted a retrospective cohort study of patients treated with targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA). Elevation of pancreatic enzyme levels was defined as serum amylase or lipase levels that were at least three times the upper limit of normal. The factors associated with elevated pancreatic enzyme levels and their association with neurologic outcomes and mortality 28 days after OHCA were analyzed. Among the 355 patients, 166 (46.8%) patients developed elevated pancreatic enzyme levels. In the multivariable analysis (odds ratio, 95% confidence interval), initial shockable rhythm (0.62, 0.39−0.98, p = 0.04), time from collapse to return of spontaneous circulation (1.02, 1.01−1.04, p < 0.001), and history of coronary artery disease (1.7, 1.01−2.87, p = 0.046) were associated with elevated pancreatic enzyme levels. After adjusting for confounding factors, elevated pancreatic enzyme levels were associated with neurologic outcomes (5.44, 3.35−8.83, p < 0.001) and mortality (3.74, 2.39−5.86, p < 0.001). Increased pancreatic enzyme levels are common in patients treated with TTM after OHCA and are associated with unfavorable neurologic outcomes and mortality at 28 days after OHCA.

Fatal cerebral hemorrhage associated with acute pancreatitis: A case report

RATIONALE

Pancreatic encephalopathy (PE) refers to the abnormalities in mental status that complicate acute pancreatitis (AP). We report the case of a patient who developed AP that was complicated by PE and followed by fatal cerebral hemorrhage.

PATIENT CONCERNS

A 41-year-old male patient with AP that initially manifested with PE and was subsequently complicated by fatal cerebral hemorrhage.

DIAGNOSES

A head computed tomography (CT) scan showed a fatal intracerebral hemorrhage located in the occipital lobe, and an abdominal CT scan presented a large amount of peripancreatic fluid collections.

INTERVENTIONS

The patient received a hematoma evacuation. The volume of the hematoma was approximately 15 mL. A consequent open pancreatic necrosectomy was performed to remove all necrotic tissues and to drain the peripancreatic fluid collections.

OUTCOMES

The patient could perform his normal daily activities efficiently, and no abnormality was observed in the physical examination 3 months after his discharge.

LESSONS

Although uncommon, PE should be properly monitored. Once the neurological symptoms of a patient dramatically worsen within a short time, the possibility of fatal cerebral hemorrhage should be considered.

[Pancreatic encephalopathy: about 2 cases and review of the literature]

L'encéphalopathie pancréatique, est une complication rare de la pancréatite aiguë, notre étude porte sur 02 cas d'encéphalopathie pancréatique, hospitalisés et traités au sein du service de Réanimation chirurgicale de l'Hôpital Militaire d'Instruction Mohamed V de Rabat. L'âge des patients était compris entre 43 ans et 54 ans, nos 02 cas sont repartis en une femme et un homme. Le mécanisme physiopathologique de l'EP n'est pas encore bien élucidé, de nombreuses hypothèses ont été rapportées dans la littérature, certains auteurs suggèrent que la lipase et la Phospholipase A2 jouent un rôle dans le processus pathologique de l'EP. D'autres facteurs tels que les infections, les troubles hydroélectrolytiques, l'hypoxémie et la perturbation de la glycémie, peuvent être déclencheurs. Le diagnostic de l'encéphalopathie pancréatique est facile à établir, la symptomatologie clinique se résume le plus souvent à une confusion, avec stupeur, et agitation psychomotrice, Il s'y ajoute parfois des atteintes neurologiques comme des convulsions, une céphalée, des hémiparésies passagères, une dysarthrie, enfin des difficultés d'expression verbale et une amnésie. Les examens paracliniques, notamment L'IRM cérébrale et l'électroencéphalogramme, permettent de confirmer le diagnostic. Le traitement est d'abord symptomatique, il a comme objectif de lutter contre les facteurs qui favorisent l'apparition des signes neurologiques par les mesures de réanimation que réclame la gravité de la situation. L'évolution de l'EP est le plus souvent favorable, avec une disparition progressive des symptômes, cependant la persistance de quelques séquelles, est décrite dans la littérature. Le pronostic est fonction de la gravité de la pancréatite aigüe et des complications associées. Dans notre étude les données sont globalement comparables à celles publiées actuellement par la majorité des auteurs.

Metabolische Störungen

Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.

Protective effect of resveratrol in severe acute pancreatitis-induced brain injury

OBJECTIVES

The aim of this study was to study the effects of resveratrol on severe acute pancreatitis (SAP)-induced brain injury.

METHODS

Ninety-six male Sprague-Dawley rats were randomly divided into 4 equal groups: sham operation, SAP, resveratrol-treated (RES), and dexamethasone-treated. Each group was evaluated at 3, 6, and 12 hours. Levels of serum myelin basic protein and zonula occludens 1 (Zo-1) were determined by enzyme-linked immunosorbent assay. The brain and pancreatic tissues were examined using electron microscopy. Expressions of Bax, Bcl-2, and caspase-3 were observed using immunohistochemistry, reverse transcriptase polymerase chain reaction, and Western blotting. Cytochrome c was detected using Western blotting alone.

RESULTS

Myelin basic protein and Zo-1 levels of the RES group were lower than the SAP group at all time points (P < 0.05). The RES group had significantly improved pathologic brain, increase in Bcl-2 expression, and decrease in Bax and caspases-3 expressions compared with the SAP group.

CONCLUSIONS

The degradation of Zo-1 is involved in the pathophysiology of brain injury in SAP; MBP can be used as a marker of brain injury in SAP. The protective effect of resveratrol might be associated with the up-regulation of Bcl-2 and down-regulation of Bax and caspase-3.

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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Experimental acute pancreatitis results in increased blood-brain barrier permeability in the rat: a potential role for tumor necrosis factor and interleukin 6

Pancreatic encephalopathy is a severe complication of acute pancreatitis. Proinflammatory cytokines may play a role in the development of multi-organ failure during pancreatitis. In the present study, we measured the changes in the blood-brain barrier (BBB) permeability concomitantly with the determination of serum tumor necrosis factor (TNF) and interleukin-6 (IL-6) levels in rats before, as well as 6, 24 and 48 h after the beginning of intraductal taurocholic acid-induced acute pancreatitis. Cytokine concentrations were measured in bioassays with specific cell lines (WEHI-164 for TNF and B-9 for IL-6), while the BBB permeability was determined for a small (sodium fluorescein, molecular weight (MW) 376 Da), and a large (Evans' blue-albumin, MW 67000 Da) tracer by spectrophotometry in the parietal cortex, hippocampus, striatum, cerebellum and medulla of rats. The serum TNF level was significantly (P < 0.05) increased 6 and 24 h after the induction of pancreatitis, while the IL-6 level increased after 24 and 48 h. A significant (P < 0.05) increase in BBB permeability for both tracers developed at 6 and 24 h in different brain regions of animals with acute pancreatitis. We conclude that cytokines, such as TNF and IL-6, may contribute to the vasogenic brain edema formation during acute pancreatitis.