Evaluation of intestinal mucosal permeability function in patients with acute pancreatitis

Dietary taurine effect on intestinal barrier function, colonic microbiota and metabolites in weanling piglets induced by LPS

Diarrhea in piglets is one of the most important diseases and a significant cause of death in piglets. Preliminary studies have confirmed that taurine reduces the rate and index of diarrhea in piglets induced by LPS. However, there is still a lack of relevant information on the specific target and mechanism of action of taurine. Therefore, we investigated the effects of taurine on the growth and barrier functions of the intestine, microbiota composition, and metabolite composition of piglets induced by LPS. Eighteen male weaned piglets were randomly divided into the CON group (basal diet + standard saline injection), LPS group (basal diet + LPS-intraperitoneal injection), and TAU + LPS group (basal diet + 0.3% taurine + LPS-intraperitoneal injection). The results show that taurine significantly increased the ADG and decreased the F/G (p < 0.05) compared with the group of CON. The group of TAU + LPS significantly improved colonic villous damage (p < 0.05). The expression of ZO-1, Occludin and Claudin-1 genes and proteins were markedly up-regulated (p < 0.05). Based on 16s rRNA sequencing analysis, the relative abundance of Lactobacilluscae and Firmicutes in the colon was significantly higher in the LPS + TAU group compared to the LPS group (p < 0.05). Four metabolites were significantly higher and one metabolite was significantly lower in the TAU + LPS group compared to the LPS group (p < 0.01). The above results show that LPS disrupts intestinal microorganisms and metabolites in weaned piglets and affects intestinal barrier function. Preventive addition of taurine enhances beneficial microbiota, modulates intestinal metabolites, and strengthens the intestinal mechanical barrier. Therefore, taurine can be used as a feed additive to prevent intestinal damage by regulating intestinal microorganisms and metabolites.

Acute pancreatitis is characterized by generalized intestinal barrier dysfunction in early stage

BACKGROUND AND AIMS

The role of intestinal-barrier in acute pancreatitis(AP) is poorly understood. We aimed to assess structural and functional changes in the intestinal-barrier in patients with early AP (time from onset<2 weeks) and the effect of enteral nutrition on them.

METHODS

In this prospective observational study, patients with early AP not on enteral nutrition were compared with controls for baseline intestinal-permeability(lactulose: mannitol ratio(L:M)), endotoxinemia(serum IgM/IgG anti-endotoxin antibodies), bacterial-translocation(serum bacterial 16S rRNA) and duodenal epithelial tight-junction structure by immunohistochemistry(IHC) for tight-junction proteins(claudin-2,-3,-4, zonula occludens-1(ZO1), junctional adhesion molecule(JAM) and occludin) and electron microscopy. These parameters were reassessed after 2 weeks enteral feeding in a AP patients subset.

RESULTS

96 patients with AP(age: 38.0 ± 14.5 years; etiology: biliary[46.8%]/alcohol[39.6%]; severe:53.2%, mortality:11.4%) and 40 matched controls were recruited. Patients with AP had higher baseline intestinal permeability(median L:M 0.176(IQR 0.073-0.376) vs 0.049(0.024-0.075) in controls; p < 0.001) and more frequent bacteraemia(positive bacterial 16S rRNA in 24/48 AP vs 0/21 controls; p < 0.001) with trend towards higher serum endotoxinemia(median IgG anti-endotoxin 78(51.2-171.6) GMU/ml vs 51.2(26.16-79.2) in controls; p = 0.061). Claudin-2, claudin-3, ZO1 were downregulated in both duodenal crypts and villi while claudin-4 and JAM were downregulated in duodenal villi and crypts respectively. 22 AP patients reassessed after initiation of enteral nutrition showed trend towards improving intestinal permeability, serum endotoxinemia and bacteraemia, with significant improvement in claudin-2,-3 in duodenal villi.

CONCLUSION

Patients with AP have significant disturbances in intestinal barrier structure and function in first 2 weeks from onset that persist despite institution of enteral nutrition.

Carbachol protects the intestinal barrier in severe acute pancreatitis by regulating Cdc42/F-actin cytoskeleton

The present study aimed to investigate the effect of carbachol on the intestinal tight-junction barrier in a rat model of severe acute pancreatitis (SAP) without aggravating pancreatic injury, and to determine whether cell division cycle 42 (Cdc42)/F-actin could have a regulatory role. Rats were separated into a sham-operation (SO) group (n=10), SO + carbachol group (n=10), SAP group (n=60) and SAP + carbachol group (n=60). Sodium taurocholate (5%) was retrogradely injected into the biliopancreatic duct of rats to induce SAP. Subsequently, 16S rRNA sequencing was used to detect bacterial translocation (BT) in the gut of surviving animals. Hematoxylin and eosin staining was used to detect morphological changes in the pancreas and intestine. The expression of F-actin and tight junction proteins was analyzed by western blotting and immunofluorescence, and Cdc42 expression was analyzed by immunohistochemistry and western blotting. The results demonstrated that the intestinal injury in SO and SO + carbachol groups was lower than that in the SAP + carbachol group (P<0.05); however, the intestinal injury was similar in the SO and SO + carbachol groups (P>0.05), and was significantly more severe in the SAP group compared with the SAP + carbachol group (P<0.05). Similarly, pancreatic injury in the SAP and SAP + carbachol groups was significantly higher compared with the SO and SO + carbachol groups (P<0.05); however, pancreatic injury was similar in the SAP and SAP + carbachol groups (P>0.05), and in the SO and SO + carbachol groups (P>0.05). Furthermore, the mortality rate and BT in the SAP group were significantly higher compared with the SAP + carbachol group (mortality rate, 50% vs. 30%, P<0.05; BT, 60% vs. 33.3%, P<0.05). In addition, the expression of Cdc42, F-actin and claudin-2 was significantly higher in the SAP and SAP + carbachol groups compared with the SO and SO + carbachol groups (P<0.05), and the expression of occludin and zonula occludens-1 were significantly higher in the SO and SO + carbachol groups compared with the SAP and SAP + carbachol groups (P<0.05). In conclusion, these findings demonstrated that carbachol may protect the intestinal barrier in the SAP rat model without aggravating pancreatic injury via regulation of Cdc42/F-actin expression.

Confocal laser endomicroscopy reveals alterations in duodenal permeability in patients with acute pancreatitis

Objective

Intestinal permeability increases during the course of acute pancreatitis (AP). We assessed duodenal permeability alterations in patients with AP by confocal laser endomicroscopy (CLE).

Methods

Thirty patients with AP underwent CLE evaluation of the antral and duodenal mucosa. Images were graded based on the appearance of capillaries and the degree of fluorescein leakage.

Results

Patients with AP had increased duodenal mucosal permeability that could be detected by CLE. The mucosal permeability progressively increased in the gastric antrum, duodenal bulb, and descending duodenum. The CLE parameters in the antrum and duodenal bulb were not significantly different between patients with mild and severe AP. The CLE grades in the descending duodenum were higher in patients with severe than mild AP. The C-reactive protein level in AP was positively correlated with the permeability in the duodenal bulb and descending duodenum, while the computed tomography severity index score was positively correlated with the mucosal permeability in the duodenal bulb and descending duodenum.

Conclusion

CLE revealed increased duodenal permeability in patients with AP. Higher permeability in the descending duodenum was observed in severe than mild AP. Further large-scale studies are needed to confirm the relationship between altered duodenal permeability and the severity of AP.

Fushen Granule, A Traditional Chinese Medicine, ameliorates intestinal mucosal dysfunction in peritoneal dialysis rat model by regulating p38MAPK signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Fushen Granule (FSG) is a Chinese medicinal formular prepared in hospital to treat intestinal mucosal dysfunction induced by peritoneal dialysis (PD). However, the mechanisms of this formular has not been studied yet.

AIM OF THE STUDY

The present study was designed to investigate the effect of FSG against intestinal dysfunction during PD treatment and explore the potential mechanisms using a rat PD model.

METHODS AND METHODS

In the present study, the effect of FSG on improving intestinal mucosal architecture injury was intuitively shown by hematoxylin-eosin staining, the serum levels of DAO and D-lactate were measured to evaluate the intestinal permeability by the DAO Assay Kit and D-Lactic Acid ELISA Kit. The expression of the intestinal mucosal barrier related inflammation factor by real-time PCR. The main effective constituents of FSG were characterized by UPLC/Q-TOF analysis, and the targets and pathways of the constituents were predicted via TCMSP database and IPA. the activation of p38MAPK signaling pathway by western blotting.

RESULTS

HE staining results showed that FSG protected against intestinal mucosal injury in pathology in PD rats. FSG decreased the intestinal mucosal permeability by increasing the transepithelial electrical resistance (TER) level and decreasing the intestinal clearance of fluorescein-isothiocyanate dextran (FD4) and the level of D-lactate and diamine oxidase (DAO). FSG significantly decreased the expression of ICAM-1, IL-1β, iNOS and TNF-α, and further inhibited the activation of p38MAPK signaling pathway via down-regulating the expression of P-p38MAPK and up-regulating the expression of DUSP1, occludin, and ZO-1.

CONCLUSION

This study demonstrates that FSG ameliorated intestinal mucosal dysfunction in PD by decreasing expression of pro-inflammatory cytokines and inhibiting the activation of p38MAPK signaling pathway. The results provide a promising basis for the alternative medicine treatment of intestinal mucosal dysfunction in PD.

Association of endotoxaemia & gut permeability with complications of acute pancreatitis: Secondary analysis of data

Background & objectives:

In acute pancreatitis (AP) gut barrier dysfunction is considered as an important predisposing factor leading to increased intestinal permeability (IP). In this study a pooled analysis of data published in our previous four studies on various aspects of gut permeability and endotoxaemia in patients with AP was attempted to find an association between increased IP and severity of disease and associated complications.

Methods:

This study was a pooled analysis of data of four previously published prospective studies on AP. Gut permeability, assessed by lactulose/mannitol excretion in urine and endotoxin core antibodies type IgG and IgM (EndoCab IgG and IgM) were measured on days zero and seven (D0 and D7) of admission. All patients received standard treatment of AP. We studied whether IgG and IgM anti-endotoxin titres and lactulose-mannitol ratio (LMR) at admission and D7 were associated with organ failure, infection and mortality.

Results:

The titres of anti-endotoxin IgG and IgM were lower in all patients of AP (n=204), both in mild AP (n=24) and severe AP (n=180) in the first week, compared to controls (n=15). There was no significant difference in serum IgG and IgM anti-endotoxin levels and LMR at baseline and at D7 among patients with organ failure, infection and mortality.

Interpretation & conclusions:

Our findings showed that serum IgG and IgM anti-endotoxin titres and LMR at admission and at day 7 were not associated with organ failure, infection, and death of patients with AP.

Simulated altitude exercise training damages small intestinal mucosa barrier in the rats

This study investigated the effect of simulated altitude training on the changes of small intestinal mucosa barrier, bacterial overgrowth and inflammatory response in the small intestine of rat. Male 8-week-old Sprague-Dawley rats were randomly divided into four groups: normal oxygen sedentary group (n=30), normal oxygen exercise group (n=30), low oxygen sedentary group (n=30) and low oxygen exercise group (n=30). Exercise training was on a treadmill for 1 hr per day on days 3, 6, and 9 in the hypoxia condition. Hematological profiles, hematolxylin and eosin staining, fluorescence in situ hybridization, reverse transcription-polymerase chain reaction and Western blot were used to analyze the effect of simulated altitude training on the amount of bacteria, and expression of mRNA and protein. Simulated exercise training significantly increased red blood cells and hematocrit. The small intestinal mucosa barrier was significantly injured by the simulated altitude exercise training. Comparatively more bacterial growth was evident in the small intestine by the simulated altitude exercise training. mRNA levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) and protein expression of nuclear factor-kappa B (NF-κB) were significantly elevated by simulated altitude exercise training. These results suggest that the simulated altitude exercise training may impair the small intestinal mucosa barrier via elevation of bacterial growth and inflammatory cytokines (IL-6, TNF-α) and the up-regulation of NF-κB in the rats.

Effect of intestinal epithelial autophagy on bacterial translocation in severe acute pancreatitis

BACKGROUND AND OBJECTIVE

We examined the impact of autophagy activation on bacterial translocation (BT) and tight junction (TJ) proteins in the intestinal mucosa of patients with severe acute pancreatitis (SAP).

METHODS

Thirty-one SAP patients were divided into two groups, BT(+) and BT(-), according to the presence of BT in the blood, as detected by 16S rDNA sequencing. Eight healthy individuals were included in the control group. Serum endotoxin levels were measured by ELISA. Colonic mucosal tissue was obtained by endoscopy, and the TJ proteins and phosphatidylethanolamine-conjugated microtubule-associated protein light chain 3 (LC3-II) were analyzed using immunofluorescence and Western blotting.

RESULTS

The expression of LC3II in patients with SAP was higher than that observed in healthy controls. Patients who tested positive for the presence of BT had a higher level of claudins-2 (CL-2) and a lower level of occludin and Zonula occluden-1 (ZO-1) than BT(-) patients. Moreover, the levels of LC3II in BT(-) patients was higher than that found in BT(+) patients, and occludin and ZO-1 were positively correlated with LC3II.

CONCLUSIONS

Autophagy activation in the intestinal epithelial cells of patients with SAP and its effects on BT may act through enhancing para-cellular TJs.

Mechanism of Increased Intestinal Permeability in Acute Pancreatitis: Alteration in Tight Junction Proteins

BACKGROUND AND AIMS

Intestinal permeability (IP) has been shown to be increased in acute pancreatitis (AP) and is considered to be responsible for development of septic complications. However, the mechanism of increase in IP is not well studied. We studied whether alteration in tight junction proteins (TJP) has any role in altered IP in patients with AP.

MATERIALS AND METHODS

This is a prospective study conducted at a tertiary care referral center. Twenty consecutive moderate and severe AP patients fulfilling the study criteria were included along with 20 controls that underwent gastroduodenoscopy for dyspepsia. IP was measured with lactulose mannitol (LM) ratio and TJP were studied by measuring expression of claudin-2 and claudin-4 in duodenal biopsy samples. Statistical analysis was done with STATA 13.0.

RESULTS

IP as depicted by LM ratio was significantly higher in AP patients as compared with controls (4.659±10.4 vs. 0.101±0.297; P<0.001). Claudin-4 expression was reduced in duodenal biopsies in AP patients (P<0.001 for crypt intercellular junction and P=0.007 for crypt cytoplasm). However, LM ratio was not associated with either mortality (P=0.12) or development of infected pancreatic necrosis (P=0.3).

CONCLUSIONS

IP is increased in AP. Alteration in TJP in the form of reduced claudin-4 expressions could be the possible mechanism for increased IP.

Early enteral nutrition improves intestinal immune barrier in a rat model of severe acute pancreatitis

BACKGROUND

The aim of the present study was to investigate the role of early enteral nutrition (EEN) in the intestinal immune barrier in severe acute pancreatitis (SAP), and to explore its potential mechanisms.

METHODS

Sixty rats were randomly assigned to three groups: sham-operated group (SO group, n = 20), SAP group receiving EEN (SAP + EEN group, n = 20), and SAP group receiving total parental nutrition (SAP + TPN group, n = 20). SAP was induced by infusion of sodium taurocholate. Rats were killed 5 days after nutritional support. The pathological damage of the intestine was determined using HE staining. The expression of MAdCAM-1, CD⁴⁺ , and CD⁸⁺ in Peyer's lymph nodes of the distal ilium was examined by immunohistochemistry. Serum levels of endotoxin and bacterial translocation were determined.

RESULTS

The survival rate in the SAP + TPN (50%) and SAP + EEN (75%) groups was significantly lower than in the SO group (100%) (P < 0.05). The survival rate in the SAP + EEN group was significantly higher than in the SAP + TPN group (P < 0.05). The expression of MAdCAM-1, CD⁴⁺ and CD⁸⁺ in the intestine was decreased in SAP rats. EEN significantly increased the expression of MAdCAM-1, CD⁴⁺ and CD⁸⁺ compared with TPN, accompanied by a decrease in the serum levels of endotoxin and bacterial translocation.

CONCLUSIONS

Early enteral nutrition improves intestinal immune barrier, thus reducing bacterial and endotoxin translocation and improving the survival rate in SAP rats.

Partial Enteral Nutrition Mitigated Ischemia/Reperfusion-Induced Damage of Rat Small Intestinal Barrier

Background and Aims: This study was designed to investigate a relatively optimum dose of partial enteral nutrition (PEN) which effectively attenuates intestinal barrier dysfunction initiated by ischemia/reperfusion injury (IRI). Methods: In experiment 1, 60 male Sprague-Dawley (SD) rats were subjected to intestinal IRI and assigned to six groups according to the different proportion of EN administrations: namely total parenteral nutrition (TPN or 0%EN), 10%EN, 20%EN, 40%EN, 60%EN, and total enteral nutrition (TEN or 100%) groups, the deficits of intraluminal calorie were supplemented by PN. In experiment 2, 50 male SD rats were subjected to intestinal IRI and divided into five groups based on the results of experiment 1: TPN, TEN, 20%EN, TPN plus pretreatment with NF-κB antagonist 30 min before IRI (TPN+PDTC), and TPN plus pretreatment with HIF-1α antagonist 30 min before IRI (TPN+YC-1) groups. Results: In experiment 1, previous IRI combined with subsequent EN shortage disrupted the structure of intestinal epithelial cell and tight junctions (TJs). While 20% dose of EN had an obviously protective effect on these detrimental consequences. In experiment 2, compared with TPN only, 20%EN exerted a significant protection of barrier function of intestinal epithelium. Analogous results were observed when TPN combined with specific NF-κB/HIF-1α inhibitors (PDTC and YC-1). Meanwhile, the expression of NF-κB/HIF-1α had a similar trend among the groups. Conclusions: Our findings indicate that 20%EN is the minimally effective dosage of EN which promotes the recovery of intestinal barrier function after IRI in a rat model. Furthermore, we discreetly speculate that this benefit is, at least partly, related to NF-κB/HIF-1α pathway expression.

Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis

BACKGROUND

The gut is implicated in the pathogenesis of acute pancreatitis but there is discrepancy between individual studies regarding the prevalence of gut barrier dysfunction in patients with acute pancreatitis. The aim of this study was to determine the prevalence of gut barrier dysfunction in acute pancreatitis, the effect of different co-variables, and changes in gut barrier function associated with the use of various therapeutic modalities.

METHODS

A literature search was performed using PRISMA and MOOSE guidelines. Summary estimates were presented as pooled prevalence of gut barrier dysfunction and the associated 95 per cent c.i.

RESULTS

A total of 44 prospective clinical studies were included in the systematic review, of which 18 studies were subjected to meta-analysis. The pooled prevalence of gut barrier dysfunction was 59 (95 per cent c.i. 48 to 70) per cent; the prevalence was not significantly affected by disease severity, timing of assessment after hospital admission or type of test used, but showed a statistically significant association with age. Overall, nine of 13 randomized clinical trials reported a significant improvement in gut barrier function following intervention compared with the control group, but only three of six studies that used standard enteral nutrition reported a statistically significant improvement in gut barrier function after intervention.

CONCLUSION

Gut barrier dysfunction is present in three of five patients with acute pancreatitis, and the prevalence is affected by patient age but not by disease severity. Clinical studies are needed to evaluate the effect of enteral nutrition on gut function in acute pancreatitis.

Nutrition, inflammation, and acute pancreatitis

Acute pancreatitis is acute inflammatory disease of the pancreas. Nutrition has a number of anti-inflammatory effects that could affect outcomes of patients with pancreatitis. Further, it is the most promising nonspecific treatment modality in acute pancreatitis to date. This paper summarizes the best available evidence regarding the use of nutrition with a view of optimising clinical management of patients with acute pancreatitis.

Nutrition and acute pancreatitis: review of the literature and pediatric perspectives

Acute pancreatitis is being diagnosed more frequently in pediatrics and there is limited published research to guide management. In contrast, multiple prospective studies in the adult population have resulted in significant changes in the way the disease is managed, especially with regard to severe disease. The nutritional management of pediatric acute pancreatitis appears to lag behind current adult recommendations, likely resulting from a lack of awareness of the adult data, inherent differences between pediatric and adult pancreatitis, and the paucity of research performed in children. The purpose of this review is to examine the adult literature regarding the nutritional management of acute pancreatitis and discuss the possible relevance of this data in the pediatric population.

N-3 PUFAs attenuate ischemia/reperfusion induced intestinal barrier injury by activating I-FABP-PPARγ pathway

BACKGROUND & AIMS

This study was designed to investigate whether n-3 PUFAs attenuate ischemia/reperfusion (I/R) induced intestinal barrier injury by activating I-FABP-PPARγ pathway.

METHODS

24 Male Sprague-Dawley rats were assigned to 4 groups: control group, I/R group, pretreated with n-3 PUFAs for 7 days before I/R (group 3), pretreated with peroxisome proliferator-activated receptor (PPARγ) agonist 30 min before I/R (group 4). The serum and intestinal mucosa samples were collected.

RESULTS

I/R disrupted the structure of intestinal tight junctions (TJs) and reduced occludin expression. The intestinal fatty acid binding protein (I-FABP) was elevated in plasma while decreased in cells. PPARγ expression in nucleus of intestinal mucosa was attenuated. N-3 PUFAs attenuated the damaged TJ structure and elevated occludin, intracellular I-FABP and PPARγ expression. A PPARγ agonist had the same effect as n-3 PUFAs.

CONCLUSIONS

The intestinal barrier is severely damaged after I/R, which is related to the redistribution of I-FABP. Our findings firstly indicate that n-3 PUFAs protect the intestinal barrier by modifying intracellular I-FABP, activating the PPARγ pathway, and then upregulating TJ protein expression.

The day when infection is confirmed is a better time point for mortality prediction in patients with severe acute pancreatitis

OBJECTIVES

The objective of the study was to compare the accuracy of predictive methods for mortality in patients with severe acute pancreatitis (SAP) on admission and on the day when infection was confirmed.

METHODS

Medical records of patients admitted for SAP in our hospital during January 2000 to November 2010 were retrospectively reviewed. Among those with infectious complications, time when infection was confirmed (TIC) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission and at the time when infection was confirmed (APACHE II OTIC) were studied. The correlations among the APACHE II score on admission, APACHE II OTIC score, and TIC were analyzed. The predictive accuracy was assessed by the area under the receiver operating characteristic curve.

RESULTS

Time when infection was confirmed correlated negatively with the APACHE II score on admission and the APACHE II OTIC score (P < 0.05). The optimum cutoff value and the corresponding areas under the receiver operating characteristic curve for APACHE II score on admission, APACHE II OTIC score, and TIC were greater than 8, greater than 5, 12 days or less, and 0.67 (95% confidence interval [CI], 0.54-0.77), 0.84 (95% CI, 0.73-0.91), and 0.73 (95% CI, 0.61-0.82), respectively. Compared with the APACHE II score on admission, the APACHE II OTIC score was more accurate in predicting mortality (P = 0.029).

CONCLUSIONS

The time when infection is confirmed is a better time point for the reassessment of the outcome in patients with SAP.

Protective effect of clodronate-containing liposomes on intestinal mucosal injury in rats with severe acute pancreatitis

BACKGROUND

Severe acute pancreatitis (SAP) can result in intestinal mucosal injury. This study aimed to demonstrate the protective effect of clodronate-containing liposomes on intestinal mucosal injury in rats with SAP.

METHODS

Liposomes containing clodronate or phosphate buffered saline (PBS) were prepared by the thin-film method. SAP models were prepared by a uniform injection of sodium taurocholate (2 mL/kg body weight) into the subcapsular space of the pancreas. Sprague-Dawley rats were randomly divided into a control group (C group), a SAP plus PBS-containing liposomes group (P group) and a SAP plus clodronate-containing liposomes group (T group). At 2 and 6 hours after the establishment of SAP models, 2 mL blood samples were taken from the superior mesenteric vein to measure the contents of serum TNF-alpha and IL-12. Pathological changes in the intestine and pancreas were observed using hematoxylin and eosin staining, while apoptosis was detected using TUNEL staining. In addition, the macrophage markers cluster of differentiation 68 (CD68) in the intestinal tissue was assessed with immunohistochemistry.

RESULTS

At the two time points, the levels of TNF-alpha and IL-12 in the P group were higher than those in the C group (P<0.05). Compared with the P group, the levels of TNF-alpha and IL-12 decreased in the T group (P<0.05). The pathological scores of the intestinal mucosa and pancreas in the T group were lower than those of the P group. In the T group, large numbers of TUNEL-positive cells were observed, but none or few in the C and P groups. The number of CD68-positive macrophages decreased in the T group.

CONCLUSIONS

Clodronate-containing liposomes have protective effects against intestinal mucosal injury in rats with SAP. The blockade of macrophages may provide a novel therapeutic strategy in SAP.

Inflammatory cytokines and intestinal barrier dysfunction in patients with severe acute pancreatitis

Severe acute pancreatitis (SAP) is often associated with intestinal barrier dysfunction (IBD). IBD is a sophisticated pathophysiological process that can lead to intestinal endotoxemia and induce systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). Inflammatory cytokines play an important role in the pathogenesis of SAP with IBD. Nuclear factor- kappa B and high mobility group box l (HMGB1) are important inflammatory cytokines that mediate the systemic inflammatory response in patients with SAP and IBD.

The intestinal fatty acid binding protein diagnosing gut dysfunction in acute pancreatitis: a pilot study

OBJECTIVES

To study the use of intestinal fatty acid binding protein (I-FABP) in diagnosing gut dysfunction in patients with acute pancreatitis (AP).

METHODS

Thirty-two patients with AP onset within 7 days were enrolled in our study. The severity of disease and the gut dysfunction were evaluated as follows: on admission, on the seventh day of disease attack, and on the third day after enteral nutrition. Serum levels of I-FABP, citrulline, and C-reactive protein (CRP) and the lactulose and mannitol absorption ratio in urine were measured in parallel.

RESULTS

The serum level of I-FABP increased on admission, and it was more pronounced in severe attacks. All patients had increased gut dysfunction score, serum level of CRP, and urine level of lactulose and mannitol absorption ratio with decreased serum level of citrulline. A positive correlation was found between the following pairs of measurement on admission: serum level of I-FABP and gut dysfunction score, serum level of I-FABP and Acute Physiology and Chronic Health Evaluation II score, I-FABP and serum level of CRP, and serum level of I-FABP and the length of ICU stay. A reverse correlation between the serum level of I-FABP and the serum level of citrulline was found.

CONCLUSIONS

The serum level of I-FABP can be used for assessing the gut dysfunction and disease severity of AP.

Psoriasis vulgaris and digestive system disorders: is there a linkage?

Psoriasis is well-known immune-mediated skin disease often associated with co-morbidities, including dyslipidaemia and obesity. Few reports imply that the disease might be also related to pathology of mucosal surfaces, especially that of the digestive system. The authors present a case of psoriasis and concurrent digestive system abnormalities, and review the literature regarding the topic. A 40-year-old man suffered from an exacerbation of exudative psoriasis for about 6 months. Topical antipsoriatics proved ineffective and the disease gradually progressed to a severe disseminated form. Subsequent detailed examinations revealed persistent gastroduodenitis due to H. pylori infection, pancreatic dysfunction and fatty change of the liver, although the patient denied any gastrointestinal symptoms. As a result appropriate treatment of the diagnosed digestive system disorders was added to topical antipsoriatic therapy. Within 2 weeks of treatment clinical symptoms and laboratory signs showed a marked trend to normalisation. The presented medical history seems to suggest that there may be some kind of interplay between psoriasis and digestive system disorders.

Influence of Salvia miltiorrhizae on the mesenteric lymph node of rats with severe acute pancreatitis or obstructive jaundice

Objective. To observe the effect of salvia miltiorrhizae injection on inflammatory mediator levels and mesenteric lymph nodes in severe acute pancreatitis (SAP) and obstructive jaundice (OJ) rats and explore the protective mechanism of salvia miltiorrhizae on the lymph nodes of these rats. Methods. A total of 288 rats were used in SAP-associated and OJ-associated experiments. The rats were randomly divided into sham-operated group, model control group, and treated group. At various time points after operation, the pathological changes in mesenteric lymph nodes of rats in each group were observed, respectively. Results. The pathological severity scores in lymph nodes of SAP rats in treated group were significantly lower than those in model control group (P < .05) while the pathological changes in lymph nodes of OJ rats in treated group also showed varying degrees of mitigation. Conclusion. Salvia miltiorrhizae can exert protective effects on the lymph nodes of SAP or OJ rats via a mechanism that is associated with reducing the contents of inflammatory mediators in blood.

A systematic review on the timing of artificial nutrition in acute pancreatitis

Artificial nutrition is an inherent part of management in acute pancreatitis. However, there is no consensus regarding the optimal time of the commencement of feeding in these patients. Our aim was to compare the effect of enteral v. parenteral nutrition with regard to the time points when they were administered in the randomised controlled trials. The search was undertaken in the Cochrane Central Register of Controlled Trials, MEDLINE and Science Citation Index as well as in the proceedings of major gastroenterology meetings. The summary estimate of the effect associated with artificial nutrition was calculated using a random-effects model and presented as a risk ratio (RR) and 95 % CI. A total of eleven randomised controlled trials were included. When started within 48 h of admission, enteral nutrition, in comparison with parenteral nutrition, resulted in a statistically significant reduction in the risks of multiple organ failure (RR 0.44; 95 % CI 0.23, 0.84), pancreatic infectious complications (RR 0.46; 95 % CI 0.27, 0.77) and mortality (RR 0.46; 95 % CI 0.20, 0.99). After 48 h of admission, enteral nutrition, in comparison with parenteral nutrition, did not result in a statistically significant reduction in the risks of multiple organ failure (RR 0.73; 95 % CI 0.33, 1.63), pancreatic infectious complications (RR 0.31; 95 % CI 0.07, 1.34) and mortality (RR 0.67; 95 % CI 0.22, 2.10). Enteral nutrition is more effective than parenteral nutrition in reducing the risk of multiple organ failure, pancreatic infectious complications and mortality in patients with acute pancreatitis. The magnitude of these benefits may depend on the timing of the commencement of nutrition.

A decade of HPLC-MS/MS in the routine clinical laboratory--goals for further developments

During the past decade, tandem mass spectrometry hyphenated to liquid chromatography separation systems (HPLC-MS/MS) has developed to an important technology in clinical chemistry - not only for research purposes but also for routine use. At present, most important application fields are target analyses in therapeutic drug monitoring (TDM) and metabolic disorders diagnosis. The essential strengths of HPLC-MS/MS include potentially high analytical specificity, wide range of applicability to small and large molecules, capability of multi- and mega-parametric tests, and the opportunity to develop powerful assays with a high degree of flexibility within a short time frame. The technique has overcome important limitations of GC-MS and is characterized by short analytical runtimes, applicability to thermo labile, polar and large molecules, and straightforward sample preparation. However, implementation of HPLC-MS/MS assays still requires substantial expertise and know-how. At the present, its application is limited to a rather small number of clinical routine laboratories. Nonetheless, HPLC-MS/MS has the potential to be further developed to a commonly applied high-throughput technique in clinical chemistry, complementary to present standard techniques as photometry and ligand binding methods. This review intends to characterize working characteristics of present day HPLC-MS/MS instrumentations used in clinical routine laboratories. Limitations of currently available systems and applications will be critically discussed. Required instrument improvements supporting the successful spreading of HPLC-MS/MS in laboratory medicine within the next decade will be outlined.

The Atlanta Classification of acute pancreatitis revisited

BACKGROUND

In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed.

METHODS

A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used.

RESULTS

A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections.

CONCLUSION

The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.

New advances in pancreatic surgery

PURPOSE OF REVIEW

New understanding of the dynamic of acute pancreatitis, the clinical impact of local pathology in chronic pancreatitis and cystic neoplastic lesions bearing high potential for malignant transformation has changed the management of pancreatic diseases.

RECENT FINDINGS

In acute pancreatitis, risk factors independently determining outcome in severe acute pancreatitis are early and persistent multiorgan failure, infected necrosis and extended sterile necrosis. The management of severe acute pancreatitis is based on early intensive-care treatment and late surgical debridement. In chronic pancreatitis, recent data from randomized controlled clinical trials have demonstrated duodenum-preserving pancreatic head resection with an inflammatory mass of the head as superior to pylorus-preserving Whipple resection. Cystic neoplasms are local lesions of the pancreas with high malignant potential. Local organ-preserving resection techniques have been applied with low morbidity and mortality, replacing a Whipple-type resection. Resection of pancreatic cancer is ineffective to cure patients. After an R0-resection, a significant survival benefit has been achieved when adjuvant chemotherapy has additionally been applied.

SUMMARY

New knowledge about the nature of inflammatory diseases, cystic neoplastic lesions and malignant pancreatic tumours has changed the indication for surgical treatment and the application of organ-preserving surgical techniques.

Influence of enteral versus parenteral nutrition on blood glucose control in acute pancreatitis: a systematic review

BACKGROUND & AIMS

There is increasing evidence that tight glucose control may reduce infectious complications and mortality in surgical critically ill patients. However, data regarding the influence of artificial nutrition on glycemic homeostasis are limited. Our aim was to review all randomized controlled trials on enteral versus parenteral nutrition in acute pancreatitis to determine whether the route of feeding can affect the glucose control in the setting of this disease.

METHODS

Relevant literature cited in three electronic databases (Cochrane Central Register of Controlled Trials, EMBASE and Medline) were systematically reviewed. A meta-analysis was carried out using a random-effects model.

RESULTS

Thirteen randomized controlled trials on enteral versus parenteral nutrition in acute pancreatitis were identified. Seven studies were excluded from analysis, leaving 6 trials in which a total of 264 non-diabetic patients with acute pancreatitis were treated. Intake of nutrients did not differ among enterally and parenterally fed patients in 5 of 6 randomized controlled trials. Enteral nutrition reduced the risk of hyperglycemia (relative risk 0.53; 95% confidence interval 0.29-0.98; p = 0.04) and insulin requirement (relative risk 0.41; 95% confidence interval 0.24-0.70; p = 0.001).

CONCLUSIONS

Enteral nutrition, when compared with parenteral nutrition, is associated with better blood glucose control in patients with acute pancreatitis.

Management of severe acute pancreatitis: it's all about timing

PURPOSE OF REVIEW

This study provides an update on the treatment of severe acute pancreatitis (SAP) with emphasis on nutrition, infection-prophylaxis, biliary pancreatitis, surgical intervention and new randomized controlled trials.

RECENT FINDINGS

The most relevant new insights are: (i) early enteral nutrition in SAP is not only capable of reducing infectious complications but may also reduce mortality; (ii) there is increasing evidence that antibiotic-prophylaxis is not capable of preventing infectious complications in SAP; (iii) probiotic-prophylaxis is being considered as an alternative with promising experimental results; (iv) in biliary pancreatitis, early endoscopic retrograde cholangiography with sphincterotomy (within 48 h) is beneficial in case of ampullary obstruction, although it may be withheld in the event of negative endoscopic ultrasound; (v) surgical intervention for infected (peri-)pancreatic necrosis is increasingly being postponed; (vi) minimally invasive strategies are being considered as a full alternative for necrosectomy by laparotomy in infected (peri-)pancreatic necrosis; (vii) the Atlanta classification should no longer be used to describe computed tomography findings in acute pancreatitis; and (viii) only five randomized controlled trials of patients with acute pancreatitis are currently registered in the international trial registries.

SUMMARY

Timing of intervention is becoming increasingly important in SAP management.