Acute Pancreatitis Has a Long-term Deleterious Effect on Physical Health Related Quality of Life

Narrative nursing for negative emotions in patients with acute pancreatitis: Based on model construction and application

BACKGROUND

Acute pancreatitis (AP), as a common acute abdomen disease, has a high incidence rate worldwide and is often accompanied by severe complications. Negative emotions lead to increased secretion of stress hormones, elevated blood sugar levels, and enhanced insulin resistance, which in turn increases the risk of AP and significantly affects the patient's quality of life. Therefore, exploring the intervention effects of narrative nursing programs on the negative emotions of patients with AP is not only helpful in alleviating psychological stress and improving quality of life but also has significant implications for improving disease outcomes and prognosis.

AIM

To construct a narrative nursing model for negative emotions in patients with AP and verify its efficacy in application.

METHODS

Through Delphi expert consultation, a narrative nursing model for negative emotions in patients with AP was constructed. A non-randomized quasi-experimental study design was used in this study. A total of 92 patients with AP with negative emotions admitted to a tertiary hospital in Nantong City of Jiangsu Province, China from September 2022 to August 2023 were recruited by convenience sampling, among whom 46 patients admitted from September 2022 to February 2023 were included in the observation group, and 46 patients from March to August 2023 were selected as control group. The observation group received narrative nursing plan, while the control group was given with routine nursing. Self-rating anxiety scale (SAS), self-rating depression scale (SDS), positive and negative affect scale (PANAS), caring behavior scale, patient satisfaction scale and 36-item short form health survey questionnaire (SF-36) were used to evaluate their emotions, satisfaction and caring behaviors in the two groups on the day of discharge, 1-and 3-month following discharge.

RESULTS

According to the inclusion and exclusion criteria, a total of 45 cases in the intervention group and 44 cases in the control group eventually recruited and completed in the study. On the day of discharge, the intervention group showed significantly lower scores of SAS, SDS and negative emotion (28.57 ± 4.52 vs 17.4 ± 4.44, P < 0.001), whereas evidently higher outcomes in the positive emotion score, Caring behavior scale score and satisfaction score compared to the control group (P < 0.05). Repeated measurement analysis of variance showed that significant between-group differences were found in time effect, inter-group effect and interaction effect of SAS and PANAS scores as well as in time effect and inter-group effect of SF-36 scores (P < 0.05); the SF-36 scores of two groups at 3 months after discharge were higher than those at 1 month after discharge (P < 0.05).

CONCLUSION

The application of narrative nursing protocols has demonstrated significant effectiveness in alleviating anxiety, ameliorating negative emotions, and enhancing satisfaction among patients with AP.

Prevalence of exocrine pancreatic insufficiency at 12 months after acute pancreatitis: a prospective, multicentre, longitudinal cohort study

Background

Exocrine Pancreatic insufficiency (EPI) occurs following acute pancreatitis (AP) at variably reported rates and with unclear recovery timeline. The aim of this study was to establish the prevalence and predictors of EPI at 12 months after AP in a prospective cohort.

Methods

In this prospective, multicentre, longitudinal cohort study, adult participants (≥18 years) admitted to the hospital with an AP attack (defined by Revised Atlanta Classification) were enrolled in a United States multi-centre longitudinal cohort (Sites: The Ohio State University, University of Pittsburgh, and Johns Hopkins University). Patients were excluded if they had pancreatic cancer, chronic pancreatitis, or malabsorptive disease (including previously diagnosed EPI). Participant data was obtained by interview and by review of the electronic medical record. EPI was assessed by stool fecal elastase (FE-1) levels collected at baseline, 3 months, and 12 months (primary endpoint). EPI was defined by FE-1 <200 μg/g; severe FE-1 level ≤100 μg/g; mild FE-1 101-200 μg/g. Multivariable logistic regression was used to identify predictors of EPI at 12 months. This study is registered with ClinicalTrials.gov, NCT03063398.

Findings

EPI was observed in 29 (34.1%) of the 85 participants [44 (51.8%) male, mean age 54.7 ± 14.1 years] who provided stool samples at 12 months. For the study overall, participants were recruited between June 22, 2017 and October 18, 2021. A total of 5794 individuals were screened, 311 of whom were eligible for the study. 112 participants provided stool samples at baseline, 79 completed stool samples at 3 months, and 85 completed samples at 12 months. 64 participants included samples at all 3 timepoints. In univariable analysis, factors significantly associated with EPI at 12 months included recurrent (versus index) AP, pre-existing diabetes, alcohol, and idiopathic etiologies, and increasing severity of AP. In multivariable analysis, the odds of having EPI at 12 months increased 4-fold with idiopathic AP etiology (Odds Ratio 4.095, 95% Confidence Interval [CI] 1.418, 11.826), and 3-fold with moderately severe or severe AP (Odds Ratio 3.166, 95% CI 1.156, 8.670), and baseline diabetes mellitus (Odds Ratio 3.217, 95% CI 1.113, 9.298). Even individuals with an index mild attack of AP (n = 39) developed severe EPI at 12 months (prevalence 12.8%).

Interpretation

EPI as diagnosed by FE-1 is present in over one third of prospectively assessed patients at 12 months post-AP. Since EPI develops in patients with mild AP, investigations are needed to understand the mechanisms of injury and identify methods for tailored screening.

Funding

This study was supported by an Investigator Initiated Research Grant from AbbVie, Inc.

From pancreas to lungs: The role of immune cells in severe acute pancreatitis and acute lung injury

BACKGROUND

Severe acute pancreatitis (SAP) is a potentially lethal inflammatory pancreatitis condition that is usually linked to multiple organ failure. When it comes to SAP, the lung is the main organ that is frequently involved. Many SAP patients experience respiratory failure following an acute lung injury (ALI). Clinicians provide insufficient care for compounded ALI since the underlying pathophysiology is unknown. The mortality rate of SAP patients is severely impacted by it.

OBJECTIVE

The study aims to provide insight into immune cells, specifically their roles and modifications during SAP and ALI, through a comprehensive literature review. The emphasis is on immune cells as a therapeutic approach for treating SAP and ALI.

FINDINGS

Immune cells play an important role in the complicated pathophysiology ofSAP and ALI by maintaining the right balance of pro- and anti-inflammatory responses. Immunomodulatory drugs now in the market have low thepeutic efficacy because they selectively target one immune cell while ignoring immune cell interactions. Accurate management of dysregulated immune responses is necessary. A critical initial step is precisely characterizing the activity of the immune cells during SAP and ALI.

CONCLUSION

Given the increasing incidence of SAP, immunotherapy is emerging as a potential treatment option for these patients. Interactions among immune cells improve our understanding of the intricacy of concurrent ALI in SAP patients. Acquiring expertise in these domains will stimulate the development of innovative immunomodulation therapies that will improve the outlook for patients with SAP and ALI.

Recurrence of hypertriglyceridemia-associated acute pancreatitis: A multicenter, prospective cohort study

OBJECTIVES

There are scarce prospective data on recurrent hypertriglyceridemia-associated acute pancreatitis (HTG-AP). This study aimed to investigate the incidence, potential prognostic factors, and clinical relevance of recurrent HTG-AP.

METHODS

This study is a multicenter, prospective cohort study. Adult patients with the first HTG-AP attack enrolled in the PERFORM registry between November 2020 and December 2021 were involved. All the study patients were followed up for more than two years with a two-round schedule. The Cox proportional-hazards model was applied to analyze the potential factors. Quality of life was evaluated using the EuroQol five-dimensional five-level health scale (EQ-5D-5L).

RESULTS

A total of 184 patients from 25 sites were included in the study, and 161 patients completed the two-round follow-up. Among them, the mean follow-up time for the study patients was 31±4 months, and the incidence rate of recurrent HTG-AP attack was 23 % (37/161). All patients with recurrent episodes required readmission to the hospital. The EQ visual analog scale (VAS) score was significantly lower in patients with recurrent episodes compared to those without (76±10 vs. 82±12; P = 0.02) at the latest follow-up. Age <40 years old (hazard ratio [HR], 3.6; 95 % confidence interval [CI], 1.5-8.7; P = 0.004) and a history of diabetes (HR, 2.6; 95 %CI, 1.3-5.1; P = 0.005) were identified as potential predictor factors for recurrence.

CONCLUSIONS

Recurrence of HTG-AP is common, especially for younger patients with diabetes. Recurrence necessitated additional hospital readmissions and was associated with compromised quality of life.

Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach

BACKGROUND

Pancreatitis is a common surgical emergency, associated with pain and poor quality of life for patients. However, assessment of patient-reported outcome measures in these patients is unclear. This study aimed to identify and evaluate the methodological quality of the health-related quality of life instruments used for patients with acute or chronic pancreatitis.

METHODS

Prospective studies that evaluated health-related quality of life in acute or chronic pancreatitis were identified from systematic review of MEDLINE, EMBASE, and Web of Science until 28th June 2023 (PROSPERO: CRD42021274743). Instrument characteristics were extracted, and methodological quality assessed using COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines and GRADE approach. Narrative synthesis was conducted, with recommendations for use based on COSMIN criteria, evaluated according to World Health Organisation (WHO) quality of life domains.

RESULTS

From 3850 records screened, 41 quality of life instruments were identified across 138 studies included. The majority (69.8%, n = 26) were designed to assess general health-related quality of life, whereas the remainder were abdominal-specific (n = 5) or pancreas-specific (n = 10). Only ten instruments (24.3%) demonstrated sufficient content validity, incorporating items in ≥5 WHO quality of life domains. However, only nine instruments (21.9%) incorporated public and patient involvement. Only the Gastrointestinal Quality of Life Index and PAN-PROMISE met the criteria to be recommended for use based on COSMIN methodological assessment.

CONCLUSION

There is significant heterogeneity in instruments used to assess quality of life after pancreatitis, with almost all instruments considered insufficient. Robust, validated, and relevant instruments are needed to better understand and determine appropriate interventions to improve quality of life for these patients.

Long-term follow-up study of necrotising pancreatitis: interventions, complications and quality of life

OBJECTIVE

To describe the long-term consequences of necrotising pancreatitis, including complications, the need for interventions and the quality of life.

DESIGN

Long-term follow-up of a prospective multicentre cohort of 373 necrotising pancreatitis patients (2005-2008) was performed. Patients were prospectively evaluated and received questionnaires. Readmissions (ie, for recurrent or chronic pancreatitis), interventions, pancreatic insufficiency and quality of life were compared between initial treatment groups: conservative, endoscopic/percutaneous drainage alone and necrosectomy. Associations of patient and disease characteristics during index admission with outcomes during follow-up were assessed.

RESULTS

During a median follow-up of 13.5 years (range 12-15.5 years), 97/373 patients (26%) were readmitted for recurrent pancreatitis. Endoscopic or percutaneous drainage was performed in 47/373 patients (13%), of whom 21/47 patients (45%) were initially treated conservatively. Pancreatic necrosectomy or pancreatic surgery was performed in 31/373 patients (8%), without differences between treatment groups. Endocrine insufficiency (126/373 patients; 34%) and exocrine insufficiency (90/373 patients; 38%), developed less often following conservative treatment (p<0.001 and p=0.016, respectively). Quality of life scores did not differ between groups. Pancreatic gland necrosis >50% during initial admission was associated with percutaneous/endoscopic drainage (OR 4.3 (95% CI 1.5 to 12.2)), pancreatic surgery (OR 3.2 (95% CI 1.1 to 9.5) and development of endocrine insufficiency (OR13.1 (95% CI 5.3 to 32.0) and exocrine insufficiency (OR6.1 (95% CI 2.4 to 15.5) during follow-up.

CONCLUSION

Acute necrotising pancreatitis carries a substantial disease burden during long-term follow-up in terms of recurrent disease, the necessity for interventions and development of pancreatic insufficiency, even when treated conservatively during the index admission. Extensive (>50%) pancreatic parenchymal necrosis seems to be an important predictor of interventions and complications during follow-up.

Nutrition therapy in critically ill patients with severe acute pancreatitis

A significant proportion of patients (10%-20%) with acute pancreatitis develop severe acute pancreatitis characterized by pancreatic necrosis, systemic inflammation, and organ failure, commonly requiring intensive care unit (ICU) admission. In this specific population, nutrition therapy is more challenging than that in the general ICU population, primarily because of inevitable gastrointestinal involvement by pancreatic inflammation. In this review, we discussed several key aspects of nutrition therapy in this population, including key pathophysiology that may impede nutrition therapy, the timing and implementation of enteral nutrition and parenteral nutrition, the importance of specific nutrient supplements, and the long-term outcomes that may be addressed by nutrition therapy.

Development and validation of a practical clinical risk prediction model for post-endoscopic retrograde cholangiopancreatography pancreatitis

Background

Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) can lead to significant morbidity and mortality. We aimed to develop an accurate post-ERCP pancreatitis risk prediction model using easily obtainable variables.

Methods

Using prospective multi-center ERCP data, we performed logistic regression using stepwise selection on several patient-, procedure-, and endoscopist-related factors that were determined a priori. The final model was based on a combination of the Bayesian information criterion and Akaike's information criterion performance, balancing the inclusion of clinically relevant variables and model parsimony. All available data were used for model development, with subsequent internal validation performed on bootstrapped data using 10-fold cross-validation.

Results

Data from 3021 ERCPs were used to inform models. There were 151 cases of post-ERCP pancreatitis (5.0% incidence). Variables included in the final model included female sex, pancreatic duct cannulation, native papilla status, pre-cut sphincterotomy, increasing cannulation time, presence of biliary stricture, patient age, and placement of a pancreatic duct stent. The final model was discriminating, with a receiver operating characteristic curve statistic of 0.79, and well-calibrated, with a predicted risk-to-observed risk ratio of 1.003.

Conclusions

We successfully developed and internally validated a promising post-ERCP pancreatitis clinical prediction model using easily obtainable variables that are known at baseline or observed during the ERCP procedure. The model achieved an area under the curve of 0.79. External validation is planned as additional data becomes available.

Prognostic significance of organ failure and infected pancreatic necrosis in acute pancreatitis: An updated systematic review and meta-analysis

OBJECTIVES

In patients with acute pancreatitis (AP), minimally invasive treatment and the step-up approach have been widely used to deal with infected pancreatic necrosis (IPN) in the last decade. It is unclear whether IPN has become a less important determinant of mortality relative to organ failure (OF). We aimed to statistically aggregate recent evidence from published studies to determine the relative importance of IPN and OF as determinants of mortality in patients with AP (PROSPERO: CRD42020176989).

METHODS

Relevant studies were sourced from MEDLINE and EMBASE databases. Relative risk (RR) or weighted mean difference (WMD) was analyzed as outcomes. A two-sided P value of less than 0.05 was regarded as statistical significance.

RESULTS

Forty-three studies comprising 11 601 patients with AP were included. The mortality was 28% for OF patients and 24% for those with IPN. Patients with OF without IPN had a significantly higher risk of mortality compared to those with IPN but without OF (RR 3.72, P < 0.0001). However, patients with both OF and IPN faced the highest risk of mortality. Additionally, IPN increased length of stay in hospital for OF patients (WMD 28.75, P = 0.032).

CONCLUSION

Though IPN remains a significant concern, which leads to increased morbidity and longer hospital stay, it is a less critical mortality determinant compared to OF in AP.

Female patients delay seeking medical care with alcohol-associated acute pancreatitis

BACKGROUND/OBJECTIVE

Alcohol consumption is increasing in women, who more frequently report abdominal symptoms compared to men. We aimed to examine differences in presentation of acute pancreatitis [AP] in male and female patients hospitalized with alcohol-associated AP.

METHODS

We analyzed 138 patients enrolled in an ongoing case-crossover study of alcohol-associated AP conducted across 5 medical centers in the U.S. Patients meeting the Revised Atlanta Classification of AP and who scored 3 or higher on the AUDIT-C instrument were invited to participate in the study and were interviewed while hospitalized with AP. Sex differences in the timing and type of pancreas-associated pain, alcohol consumption, clinical presentation, and quality of life were examined by Chi-squared tests, Wilcoxon rank sum tests and t-tests.

RESULTS

Female patients reported significantly longer interval from onset of pain to deciding to seek medical attention (median 40 h, interquartile range [IQR] 14, 74) as compared to males (14 h, IQR 4, 50; p = 0.005). While male patients were more likely to have been admitted to the intensive care unit [ICU] (21%) as compared to female patients (7%; p = 0.04), the incidence of SIRS or severe AP did not differ by sex. Quality of life measures as reported through the PROMIS-29 instrument were equally suboptimal in both sexes. Anxiety disorders were diagnosed more frequently among females (61%) than in males (41%, p = 0.009).

CONCLUSION

In a large case series of alcohol-associated AP, we found that female patients delayed seeking medical care compared to males. However, there were no differences in the type, location and intensity of abdominal pain.

Quality of life after severe acute pancreatitis: systematic review

BACKGROUND

Severe acute pancreatitis, the most severe form of acute pancreatitis, can alter pancreatic morphology, physiology, and function resulting in long-term morbidity, even after a single episode. This review assesses long-term outcomes and quality of life of severe acute pancreatitis.

METHODS

A comprehensive literature review was conducted across MEDLINE, Embase, Scopus, and PubMed electronic databases on 18 January 2021 and updated on 26 April 2022 to ensure no new literature had been omitted. All studies were prospective or retrospective, included adult patients (>18 years) presenting with acute pancreatitis for whom data on long-term outcomes specifically after severe acute pancreatitis were reported. Quantitative and qualitative data extraction and synthesis were carried out and no meta-analysis was performed. Outcome measures included aetiology and mortality of severe acute pancreatitis, length of stay, endocrine and exocrine pancreatic insufficiency, chronic symptoms, and quality of life compared with healthy controls as assessed by validated questionnaires.

RESULTS

Fourteen retrospective cohort studies were included, for a total of 779 patients, using quality of life questionnaires. The most common aetiology of severe acute pancreatitis was biliary (36 per cent) followed by alcoholic (29 per cent). Mortality rate ranged from 5 to 35 per cent and length of stay ranged from 2 to 367 days. Quality of life was somewhat lower in patients with exocrine insufficiency, but unaffected by endocrine insufficiency or chronic symptoms. Quality of life was more likely to be reduced in the first 4 years but normalize thereafter and was more likely to be negatively affected where alcohol was the aetiology. In four studies, the relationship between disease severity and lower quality of life was investigated, and a significant correlation was found.

CONCLUSION

The review shows how a single episode of severe acute pancreatitis can have a variable effect on long-term quality of life, which is different to previous studies showing a strong reduction in quality of life. This could indicate that in current times treatment modalities are more effective.

Prevalence of Gastrointestinal Symptoms and Impact on Quality of Life at 1-Year Follow-Up of Initial Attack of Acute Pancreatitis

OBJECTIVES

This study aims to describe the prevalence of gastrointestinal (GI) symptoms following the first time occurrence of acute pancreatitis (AP) and to measure the impact of the episode on patient health-related quality of life (HRQOL) from the perspectives of patients and parents.

METHODS

Questionnaires regarding GI symptoms 1 year following the initial occurrence of AP were obtained from 74 pediatric patients. Thirty of these patients completed both the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and the PedsQL Gastrointestinal Symptoms and Worry Scales. These data were compared to legacy-matched healthy controls.

RESULTS

Children with a standalone occurrence of AP experienced a similar rate of GI symptoms compared to those who progressed to acute recurrent pancreatitis (ARP) within 1 year. PedsQL 4.0 Generic Core Scales scores were significantly lower for children self-report and parent proxy-report for patients that experienced AP compared to healthy controls. AP patients also demonstrated significantly more symptoms than healthy controls in the Gastrointestinal Symptoms and Worry Scales across multiple domains.

CONCLUSIONS

Gastrointestinal symptoms affect many children who experience a single AP event even without recurrent attacks. The burden of symptoms is not significantly different from those who develop ARP. This is a novel study that evaluates patient-reported outcomes in children following an AP attack and demonstrates there is a significant impact on HRQOL in children and family experiences post AP. More data are needed to study the progression of disease and the extended impact of AP following an initial AP attack in pediatric patients.

The effect of anxiety and depression on the health-related quality of life of severe acute pancreatitis survivors: structural equation modeling approach

Background

Understanding the relationship between anxiety, depression and health-related quality of life (HRQOL) provides important clues to alleviate anxiety, depression and improve HRQOL in patients after severe acute pancreatitis (SAP). The aim of this study was to examine the effects of anxiety and depression on HRQOL in post-SAP patients using structural equation modeling.

Methods

A cross-sectional study design was used and 134 patients with SAP from the Affiliated Hospital of Zunyi Medical University were recruited. Data collected included demographic and clinical characteristics, the English Standard Short Form 36 (SF-36) Health Survey, The Self-rating Anxiety Scale (SAS) and The Self-rating Depression Scale (SDS). Structural equation modeling analysis was conducted using the AMOS 24.0 program.

Results

The mean of HRQOL score was 49.42 (SD = 23.01). The prevalence of anxiety and depression in post-SAP patients was 33.6 and 34.3%, respectively. Both anxiety and depression have a direct negative impact on HRQOL (β = -0.360, p < 0.001; β = -0.202, p = 0.034). Anxiety also negatively affects HRQOL indirectly through depression (β = -0.118, p = 0.043). The analysis of the covariance structure revealed that the resulting model had a reasonable goodness of fit.

Conclusion

Anxiety and depression reduce the quality of life of SAP patients during recovery. Regular assessment and management of the anxiety and depression status of SAP patients is necessary and will help them improve their HRQOL more effectively.

AGA-PancreasFest Joint Symposium on Exocrine Pancreatic Insufficiency

Exocrine pancreatic insufficiency (EPI) is a clinically defined syndrome based on the physician's assessment of a patient's maldigestion. However, current clinical definitions are inadequate in determining (1) the threshold of reduced pancreatic digestive enzyme secretion that determines "pancreatic insufficiency" in an individual patient; (2) the role of pancreatic function tests; (3) effects of differing metabolic needs, nutrition intake, and intestinal function/adaptation (4) when pancreatic enzyme replacement therapy is needed; and (5) how to monitor and titrate multiple therapies. Experts and key opinion leaders were invited to PancreasFest 2021 to discuss and help clarify mechanistic issues critical to defining EPI and to address misconceptions and barriers limiting advancements in patient care. Clinically EPI is defined as inadequate delivery of pancreatic digestive enzymes to meals to meet nutritional needs and is reversed with appropriate treatment. A new mechanistic definition of EPI was proposed that includes the disorders essence and character: (1) EPI is a disorder caused by failure of the pancreas to deliver a minimum/threshold level of specific pancreatic digestive enzymes to the intestine in concert with ingested nutrients, followed by enzymatic digestion of a series of individual snacks and meals over time to meet nutritional and metabolic needs, given (a) the specific macronutritional and micronutritional needs; (b) nutrient intake; (c) exocrine pancreatic function; and (d) intestinal anatomy, function, diseases, and adaptative capacity. (2) EPI is characterized by variable deficiencies in micronutrients and macronutrients, especially essential fats and fat-soluble vitamins, by gastrointestinal symptoms of nutrient maldigestion and by improvement or correction of nutritional state with lifestyle changes, disease treatment, optimized diet, dietary supplements, and/or administration of adequate pancreatic enzyme replacement therapy. EPI is complex and individualized and multidisciplinary approaches are needed to optimize therapy. Better pancreas function tests and biomarkers are needed to diagnose EPI and guide treatment.

People's perceptions and experience of managing life after recurrent pancreatitis: a qualitative study in eastern China

There is a high rate of recurrent hypertriglyceridemic acute pancreatitis (HTG-RAP) and risk of developing into chronic pancreatitis among recurrent hypertriglyceridemic acute pancreatitis. The key to avoiding recurrence is home-based self-management. However, self-management has proven to be difficult. Exploring experiences and perceptions of home-based self-management among patients with HTG-RAP could inform intervention development and policy making in primary care. To explore experiences and perceptions of home-based self-management among patients with HTG-RAP. This is primarily a qualitative study involving patients from eastern China. The study was designed using semi-structured interviews combined with open interviews among individuals and focus groups. Interviews with patients (n = 25) and relatives (n = 2) were conducted from October to December, 2021. Data were analyzed using the thematic analysis approach. Five themes were identified: (1) pity, (2) sense of uncertainty, (3) contradiction, (4) the way to cope, and (5) benefits. The themes constituted a continuous process where a final coping strategy was confirmed. Patients expressed sorrow, struggle, pity, adaptation, and benefits. The disease still bothered them without attack, both mentally and physically. These key points deserve considerable attention to improve the quality of life of patients and lifestyle modification. Patients with pancreatitis were more likely to manage the disease but under a tough process, and during the struggle, they experienced a continuous and contradictory period. Ultimately, the final condition was reached.

Severe acute pancreatitis exhibits distinct cytokine signatures and trajectories in humans: a prospective observational study

Severe acute pancreatitis (SAP) is associated with substantial morbidity and mortality. Several cytokines have been identified to have pathophysiological significance in SAP, but studies characterizing their early trajectories are lacking. Here we characterize the early trajectories of seven key cytokines associated with SAP and compare them with non-SAP subjects. Five proinflammatory cytokines (angiopoietin-2, interleukin-6, interleukin-8, monocyte chemoattractant protein-1, resistin) and two anti-inflammatory cytokines (hepatocyte growth factor, and soluble tumor necrosis factor-α receptor-1A) were measured in a prospective cohort of acute pancreatitis subjects (2012-2016) at the time of enrollment and then every 24 h for 5 days or until discharge. The cytokines' levels and trajectories were calibrated based on date of pain onset and were compared between healthy controls and three severity categories (mild, moderate, and severe). The cohort (n = 170) consisted of 27 healthy controls, 65 mild, 38 moderate, and 40 SAP. From day 1 of symptom onset, SAP subjects exhibited significantly higher levels of both pro- and anti-inflammatory cytokines compared with non-SAP and healthy subjects. But in SAP subjects, all proinflammatory cytokines' levels trended downward after day 2 (except for a flat slope for angiopoeitin-2) whereas for non-SAP subjects, the trajectory was upward: this trajectory difference between SAP versus non-SAP subjects resulted in narrowing of the differences initially seen on day 1 for proinflammatory cytokines. For anti-inflammatory cytokines, the trajectories were uniformly upward for both SAP and non-SAP subjects. Proinflammatory cytokine response is an early and time-sensitive event in SAP that should be accounted for when designing future biomarker studies and/or therapeutic trials.NEW & NOTEWORTHY In this study, we showed that the proinflammatory cytokine response in SAP is an early event, with subsequent downregulation of proinflammatory cytokines beginning at day 1 of symptom onset. Our findings underscore the importance of enrolling subjects very early in the disease course when conducting studies to investigate early immune events of SAP; this current study also serves as an important reference for the design of future biomarker studies and therapeutic trials in SAP.

Pancreatitis associated anxiety, depression, and stress: Hypothesis, definition, and intervention

Necrotizing pancreatitis is characterized by a prolonged disease course requiring frequent hospitalization and intervention. Necrotizing pancreatitis patients have high rates of intensive care unit admission and organ failure. Critical illness is an identified risk factor for the development of anxiety, depression, and posttraumatic stress disorder. Limited literature examines quality of life in necrotizing pancreatitis patients, and studies examining psychiatric sequalae of necrotizing pancreatitis including depression, anxiety, and posttraumatic stress disorder are virtually nonexistent. Here, we review critical literature examining risk factors for poor mental health outcomes during and after necrotizing pancreatitis, identify several screening instruments to quantify mental health outcomes, and propose an intervention to improve mental health outcomes in patients with necrotizing pancreatitis. We conclude that establishing the incidence of mental health disorders and implementing strategies to improve mental health outcomes are critical to holistic care of necrotizing pancreatitis patients.

Psychological experience of inpatients with acute pancreatitis: a qualitative study

OBJECTIVE

This study aimed to better understand the psychological experiences of inpatients with acute pancreatitis (AP).

DESIGN

We used a qualitative descriptive study design to capture patients with AP's thoughts, feelings and behavioural responses.

SETTING

We conducted this study in the gastroenterology departments of two tertiary hospitals in Eastern China.

PARTICIPANTS

We used a convenience sampling approach to recruit 28 inpatients with AP from 1 August 2020 to 25 December 2020. The interviews were audio-recorded and transcribed verbatim. We employed an adapted version of Colaizzi's qualitative analysis approach to examine the data.

RESULTS

We extracted three themes and eight subthemes regarding the participants' psychological experiences: (1) feeling that their disease is unpredictable (the inability to recognise the disease, uncertainty about the illness and fear of progression or recurrence); (2) various kinds of stress and support (feeling different degrees of stress, perceiving social support, seeking and craving social support); and (3) developing self-adaptability in the disease process (treating one's illness negatively or positively).

CONCLUSIONS

Cognitive and emotional responses vary in patients with AP during hospitalisation. Moreover, patients with distinct conditions demonstrate significant differences in their responses and coping mechanisms. Healthcare providers need to mobilise social support and formulate comprehensive intervention strategies according to patients' individual characteristics.

A prediction model with measured sentiment scores for the risk of in-hospital mortality in acute pancreatitis: a retrospective cohort study

Background

Accurate and prompt clinical assessment of the severity and prognosis of patients with acute pancreatitis (AP) is critical, particularly during hospitalization. Natural language processing algorithms gain an opportunity from the growing number of free-text notes in electronic health records to mine this unstructured data, e.g., nursing notes, to detect and predict adverse outcomes. However, the predictive value of nursing notes for AP prognosis is unclear. In this study, a predictive model for in-hospital mortality in AP was developed using measured sentiment scores in nursing notes.

Methods

The data of AP patients in the retrospective cohort study were collected from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Sentiments in nursing notes were assessed by sentiment analysis. For each individual clinical note, sentiment polarity and sentiment subjectivity scores were assigned. The in-hospital mortality of AP patients was the outcome. A predictive model was built based on clinical information and sentiment scores, and its performance and clinical value were evaluated using the area under curves (AUCs) and decision-making curves, respectively.

Results

Of the 631 AP patients included, 88 cases (13.9%) cases were dead in hospital. When various confounding factors were adjusted, the mean sentiment polarity was associated with a reduced risk of in-hospital mortality in AP [odds ratio (OR): 0.448; 95% confidence interval (CI): 0.233–0.833; P=0.014]. A predictive model was established in the training group via multivariate logistic regression analysis, including 12 independent variables. In the testing group, the model showed an AUC of 0.812, which was significantly greater than the sequential organ failure assessment (SOFA) of 0.732 and the simplified acute physiology score-II (SAPS-II) of 0.792 (P<0.05). When the same level of risk was considered, the clinical benefits of the predictive model were found to be the highest compared with SOFA and SAPS-II scores.

Conclusions

The model combined sentiment scores in nursing notes showed well predictive performance and clinical value in in-hospital mortality of AP patients.

Cohort profile: the Swedish Pancreatitis Cohort (SwePan)

PURPOSE

The Swedish Pancreatitis Cohort (SwePan) was designed to study long-term outcomes following an episode of acute pancreatitis. It can also be used to study various risk factors for developing acute pancreatitis.

PARTICIPANTS

The SwePan is a register-based nationwide matched cohort. It includes all Swedish cases of acute pancreatitis during 1990-2019. It contains 95 632 individuals with acute pancreatitis and 952 783 pancreatitis-free individuals matched on sex, age and municipality of residence. Follow-up was censored at death, emigration or end of study (31 December 2019). The dataset includes comprehensive information based on several registries, and includes diagnoses, prescribed medications and socioeconomic factors both prior to inclusion and during follow-up.

FINDINGS TO DATE

During the study period, the number of cases of acute pancreatitis in Sweden has more than doubled from 1977 cases in 1990 to 4264 cases in 2019. The median age of first episode of acute pancreatitis has increased from 58 years (IQR 44-73 years) in 1990 to 64 years (IQR 49-76 years) in 2019. Cases with acute pancreatitis were generally less healthy compared with the pancreatitis-free individuals (Charlson Comorbidity Index of 0 in 59.2% and 71.4%, respectively).

FUTURE PLANS

SwePan will be used to determine the incidence of acute pancreatitis in Sweden over time and assess long-term all-cause and cause-specific mortality after an episode of acute pancreatitis. Some examples of additional planned studies are (1) assessment of long-term risk of diabetes and (2) risk of malignancy in adjacent organs following acute pancreatitis and (3) assessment of risk factors for development of acute pancreatitis including various drugs.

Recurrent acute biliary pancreatitis - A frequent and preventable condition potentially associated with morbidity and mortality

Recurrent acute biliary pancreatitis (RABP) is a common condition associated with an increase in hospital admissions, morbidity, mortality, and healthcare costs. This editorial will attempt to discuss the issue's current status as well as actions for its prevention.

The Effects of NLRP3 Inflammasome Inhibition in Experimental Acute Pancreatitis: A Systematic Review and Meta-Analysis

ABSTRACT

Acute pancreatitis (AP) is an inflammatory disease, and NLRP3 inflammasome activation is involved in the pathogenesis of AP. Previous research showed that inhibition of NLRP3 inflammasome may exert protective effects on animal models of AP and reduces disease severity. The aim of this systematic review and meta-analysis is to evaluate the effects of drug treatment of NLRP3 inflammasome on the outcomes of experimental AP. PubMed, Embase, Medline, and Web of Science databases were searched for relevant articles without language restrictions. The main outcomes for this study included local pancreatic injury, the incidence of systemic inflammatory responses, and the incidence of organ failure. Twenty-eight animal studies including 556 animals with AP were included in the meta-analysis. Compared with controls, inhibition of NLRP3 inflammasome significantly reduced the pancreatic histopathological scores, serum amylase, and lipase levels. In addition, inhibition of NLRP3 inflammasome reduced the levels of circulating inflammatory cytokines, as well as mitigating severity of AP-associated acute lung injury and acute intestinal injury. To conclude, inhibition of NLRP3 inflammasome has protective effects on AP by mitigating organ injury and systemic inflammation in animal studies, indicating that NLRP3 inflammasome holds promise as a target for specific AP therapy.

Patient-reported outcomes after minimally invasive retroperitoneal pancreatic necrosectomy to treat acute pancreatitis: An exploratory study

OBJECTIVE

The aim of this study (abbreviated as QUANTUM) was to assess the quality of life (QoL) of patients who underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRPN) for acute pancreatic necrosis with or without infection of necrotic tissue collections after discharge and to compare the patient-reported outcomes (PRO) in these patients with published data in normative population.

METHODS

Patients with acute pancreatitis who underwent MIRPN between January 2010 and December 2016 were identified and invited to complete the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC PAN28(CP) questionnaires. PRO were compared using Pearson correlation coefficient and ANOVA (significance P < 0.01) with an age- and sex-matched normative population of western Europe, stratified by age, and also the time duration after MIRPN (<3 y and >3 y). A change >15 points in the PRO score was taken as clinically important.

RESULTS

Among 52 eligible patients identified, 46 (88%) agreed to participate, 74% returned questionnaires. After the MIRPN all patients had worse physical and social functioning scores with a clinically important (>15 points) reduction in those ≤50 years; while fatigue, pain and insomnia symptom scales had the highest scores (42, 26 and 30 points, respectively). Patients <3 years after MIRPN had similar scores for all functional scales and global health-related quality of life (HRQoL) compared to the normative population. However, over time their global HRQoL deteriorated and after 3 years their scores for functioning and symptoms were statistically (P < 0.0001) and clinically (>15 points) worse than those in age-matched controls.

CONCLUSIONS

During the first 3 years after the MIRPN patients have a relatively high QoL but report worse fatigue than the normative population. However, patients should be informed that their HRQoL deteriorates with time, often due to chronic pancreatitis and pancreatic insufficiency. This study supports the use of MIRPN and prospective studies of HRQoL in this setting are indicated.

The association of triglyceride levels with the incidence of initial and recurrent acute pancreatitis

Background

This retrospective cohort study assessed the annualized incidence rate (IR) of acute pancreatitis (AP) in a nationally representative US adult population, as well as the variation in the risk of AP events across strata of triglyceride (TG) levels.

Methods

Data were obtained from IQVIA’s US Ambulatory Electronic Medical Records (EMR) database linked with its LRxDx Open Claims database. Inclusion criteria included ≥1 serum TG value during the overlapping study period of the EMR and claims databases, ≥1 claim in the 12-month baseline period, and ≥ 1 claim in the 12 months post index. All TG measurements were assigned to the highest category reached: < 2.26, ≥2.26 to ≤5.65, > 5.65 to ≤9.94, > 9.94, and > 11.29 mmol/L (< 200, ≥200 to ≤500, > 500 to ≤880, > 880, and > 1000 mg/dL, respectively). The outcome of interest was AP, defined as a hospitalization event with AP as the principal diagnosis.

Results

In total, 7,119,195 patients met the inclusion/exclusion criteria, of whom 4158 (0.058%) had ≥1 AP events in the prior 12 months. Most patients (83%) had TGs < 2.26 mmol/L (< 200 mg/dL), while < 1% had TGs > 9.94 mmol/L (> 880 mg/dL). Overall, the IR of AP was low (0.08%; 95% confidence internal [CI], 0.08–0.08%), but increased with increasing TGs (0.08% in TGs < 2.26 mmol/L [< 200 mg/dL] to 1.21% in TGs > 11.29 mmol/L [> 1000 mg/dL]). In patients with a prior history of AP, the IR of AP increased dramatically; patients with ≥2 AP events at baseline had an IR of 29.98% (95% CI, 25.1–34.9%).

Conclusion

The risk of AP increases with increasing TG strata; however, the risk increases dramatically among patients with a recent history of AP.

A Practical Approach to Management of Acute Pancreatitis: Similarities and Dissimilarities of Disease in Children and Adults

Acute pancreatitis (AP) is associated with significant morbidity and mortality, and it substantially contributes to the healthcare burden of gastrointestinal disease and quality of life in children and adults. AP across the lifespan is characterized by similarities and differences in epidemiology, diagnostic modality, etiologies, management, adverse events, long-term outcomes, and areas in greatest need of research. In this review, we touch on each of these shared and distinctive features of AP in children and adults, with an emphasis on recent advances in the conceptualization and management of AP.

Post-Acute Pancreatitis Pancreatic Exocrine Insufficiency: Rationale and Methodology of a Prospective, Observational, Multicenter Cohort Study

OBJECTIVES

We describe the methodology of Post-Acute Pancreatitis Pancreatic Exocrine Insufficiency (PAPPEI), a prospective, observational, multicenter cohort study. The objectives of PAPPEI are to estimate the incidence rate of post-acute pancreatitis (AP) pancreatic exocrine insufficiency (PEI), define factors that determine the development of post-AP PEI, and evaluate the impact of post-AP PEI on nutritional status and quality of life.

METHODS

Enrollment started in June 2017 in 3 expert academic centers in the United States. Data were collected during hospitalization (baseline) at 3 and 12 months after enrollment. Fecal elastase-1 was used to assess PEI. Study questionnaires are completed by patient interview and review of electronic medical records. Blood is obtained to evaluate vitamin deficiencies and nutritional markers.

RESULTS

As of August 2020, 77 subjects have completed the baseline evaluation. The median age was 58 years (interquartile range, 39-67 years), 38% were male, and 90% were white. The etiology of AP was biliary in 39 subjects (51%), and 51 subjects (66%) had mild AP. Three- and 12-month follow-up data have been collected in 29 and 13 subjects, respectively.

CONCLUSION

The PAPPEI study aims to expand our understanding of post-AP PEI incidence, including its impact on nutritional status and quality of life.

A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management

Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca²⁺) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.

Assessment of Weight Loss and Gastrointestinal Symptoms Suggestive of Exocrine Pancreatic Dysfunction After Acute Pancreatitis

INTRODUCTION

Studies evaluating the natural history of exocrine pancreatic dysfunction (EPD) after acute pancreatitis (AP) are sparse. This study aims to assess incidence and predictors of weight loss and gastrointestinal (GI) symptoms suggestive of EPD 12 months after an AP episode.

METHODS

Patients enrolled in the Pancreatitis-associated Risk of Organ Failure Study at the time of an AP episode were included. Weight and GI symptom data were prospectively collected by self-report at enrollment and at 3- and 12-month (windows 2-7 and 8-20) telephone follow-ups. Multivariable logistic regression was used to assess factors associated with ≥10% total body weight loss (EPD surrogate) at 12 months. A generalized estimating equation was used to measure each factor's population effect (in pounds) over 12 months after AP.

RESULTS

Follow-up at 12 months in 186 patients (median age = 54 years, 46% men, 45% biliary, 65% first AP attack) revealed weight loss ≥10% from baseline, occurring in 44 patients (24%). Risk of weight loss increased with higher baseline body mass index, previous diagnosis of diabetes mellitus, and worsening AP severity (all P < 0.010). GI symptoms were reported in 13/31 (42%) patients at 12 months. AP severity was independently associated with ≥10% weight loss at 12 months. Over 12 months, men lost more weight than women (average 9.5 lbs); patients with severe AP lost, on average, 14 lbs.

DISCUSSION

Weight loss after AP occurs in one-quarter of patients and is associated with AP severity. EPD incidence after AP is likely underappreciated. Further work is needed to assess EPD and potential for pancreatic enzyme supplementation.

The continuum of complications in survivors of necrotizing pancreatitis

BACKGROUND

Necrotizing pancreatitis survivors develop complications beyond infected necrosis that often require invasive intervention. Remarkably few data have cataloged these late complications after acute necrotizing pancreatitis resolution. We sought to identify the types and incidence of complications after necrotizing pancreatitis.

DESIGN

An observational study was performed evaluating 647 patients with necrotizing pancreatitis captured in a single-institution database between 2005 and 2017 at a tertiary care hospital. Retrospective review and analysis of newly diagnosed conditions attributable to necrotizing pancreatitis was performed. Exclusion criteria included the following: death before disease resolution (n = 57, 9%) and patients lost to follow-up (n = 12, 2%).

RESULTS

A total of 578 patients were followed for a median of 46 months (range, 8 months to 15 y) after necrotizing pancreatitis. In 489 (85%) patients 1 or more complications developed and included symptomatic disconnected pancreatic duct syndrome (285 of 578, 49%), splanchnic vein thrombosis (257 of 572, 45%), new endocrine insufficiency (195 of 549, 35%), new exocrine insufficiency (108 of 571, 19%), symptomatic chronic pancreatitis (93 of 571, 16%), incisional hernia (89 of 420, 21%), biliary stricture (90 of 576, 16%), chronic pain (44 of 575, 8%), gastrointestinal fistula (44 of 578, 8%), pancreatic duct stricture (30 of 578, 5%), and duodenal stricture (28 of 578, 5%). During the follow-up period, a total of 340 (59%) patients required an invasive intervention after necrotizing pancreatitis resolution. Invasive pancreatobiliary intervention was required in 230 (40%) patients.

CONCLUSION

Late complications are common in necrotizing pancreatitis survivors. A broad variety of problems manifest themselves after resolution of the acute disease process and often require invasive intervention. Necrotizing pancreatitis patients should be followed lifelong by experienced clinicians.

High-density lipoprotein cholesterol to low-density lipoprotein cholesterol ratio in early assessment of disease severity and outcome in patients with acute pancreatitis admitted to the ICU

BACKGROUND

Patients with acute pancreatitis usually exhibit dyslipidemia and oxidative stress. However, the significance of high-density lipoprotein cholesterol (HDL-C) level, low-density lipoprotein cholesterol (LDL-C) level and the HDL-C/LDL-C ratio (H/L ratio) as markers for disease progression remain unknown.

AIM

The aim of this study was to evaluate the role of HDL-C levels, LDL-C levels and the H/L ratio as markers of disease progression in patients admitted to the intensive cate unit with acute pancreatitis.

METHODS

This retrospective study was conducted at a tertiary critical care center in China. Plasma HDL-C and LDL-C levels were measured in 166 patients with acute pancreatitis. The associations between HDL-C, LDL-C, H/L ratio, as well as other inflammatory index and mortality, were analyzed. Multivariate cox analysis based on two models was used to determine the independent prognostic factor. Predictive ability of in-hospital mortality for variables was determined using the receiver operating characteristics curves.

RESULTS

Significantly higher H/L ratios at admission were observed in patients with acute pancreatitis who died compared with survivors (0.93 vs. 0.64, p < 0.001). The area under the ROC curve for H/L ratio-based prediction of mortality was 0.658. When clinical confounders were included in multivariable cox regression analysis, the association was preserved (Model A HR = 1.587, p = 0.011; Model B HR = 1.332, p = 0.032). The mortality risk in different groups defined by an H/L ratio cutoff value was significantly different, based on survival curve analysis.

CONCLUSION

The H/L ratio at the time of admission to the ICU appears to be a biomarker of disease progression in patients with acute pancreatitis.

A small-molecule activator of mitochondrial aldehyde dehydrogenase 2 reduces the severity of cerulein-induced acute pancreatitis

Acute pancreatitis (AP) is one of the leading causes of hospital admission for gastrointestinal disorders. Although lipid peroxides are produced in AP, it is unknown if targeting lipid peroxides prevents AP. This study aimed to investigate the role of mitochondrial aldehyde dehydrogenase 2 (ALDH2), a critical enzyme for lipid peroxide degradation, in AP and the possible underlying mechanisms. Cerulein was used to induce AP in C57BL/6 J male mice and pancreatic acinar cells were used to elucidate underlying mechanisms in vitro. Pancreatic enzymes in the serum, lipid peroxidation products malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE), and Bcl-2, Bax and cleaved caspase-3 were measured. ALDH2 activation with a small-molecule activator, Alda-1, reduced the levels of the pancreatic enzymes in the serum and the lipid peroxidation products MDA and 4-HNE. In addition, Alda-1 decreased Bax and cleaved caspase-3 expression and increased Bcl-2 expression in vivo and in vitro. In conclusion, ALDH2 activation by Alda-1 has a protective effect in cerulein-induced AP by mitigating apoptosis in pancreatic acinar cells by alleviating lipid peroxidation.

Pharmacologic management and prevention of acute pancreatitis

PURPOSE OF REVIEW

The present article will focus in pharmacologic agents that have been studied to improve acute pancreatitis outcomes, and to prevent the disease at different levels.

RECENT FINDINGS

Too little and too much early fluid resuscitation can be harmful. The optimal volume, rate, and duration of intravenous fluid therapy is still unknown. Nonopioid analgesics should be the first line of analgesia in patients with acute pancreatitis. A few pharmacologic agents evaluated in acute pancreatitis have resulted in positive pilot trials; however, larger randomized clinical trials (RCTs) are needed before final conclusions. Statin use is associated with lower incidence of acute pancreatitis in the general population and ongoing studies are evaluating its preventive role in acute pancreatitis recurrences. The preventive role of rectal indomethacin in post-endoscopic retrograde cholangiopancreatography pancreatitis is indisputable, with subject selection and timing of administration requiring further investigation.

SUMMARY

There is still no proven effective disease-specific pharmacologic therapy that changes the natural history of acute pancreatitis. New therapeutic targets and pharmacologic agents are in the horizon. Careful refinement in study design is needed when planning future RCTs. There is also a need for drug development aiming at reducing the incidence of the disease and preventing its sequelae.

New insights into acute pancreatitis

The incidence of acute pancreatitis continues to increase worldwide, and it is one of the most common gastrointestinal causes for hospital admission in the USA. In the past decade, substantial advancements have been made in our understanding of the pathophysiological mechanisms of acute pancreatitis. Studies have elucidated mechanisms of calcium-mediated acinar cell injury and death and the importance of store-operated calcium entry channels and mitochondrial permeability transition pores. The cytoprotective role of the unfolded protein response and autophagy in preventing sustained endoplasmic reticulum stress, apoptosis and necrosis has also been characterized, as has the central role of unsaturated fatty acids in causing pancreatic organ failure. Characterization of these pathways has led to the identification of potential molecular targets for future therapeutic trials. At the patient level, two classification systems have been developed to classify the severity of acute pancreatitis into prognostically meaningful groups, and several landmark clinical trials have informed management strategies in areas of nutritional support and interventions for infected pancreatic necrosis that have resulted in important changes to acute pancreatitis management paradigms. In this Review, we provide a summary of recent advances in acute pancreatitis with a special emphasis on pathophysiological mechanisms and clinical management of the disorder.

Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management

INTRODUCTION

Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology.

METHODS

A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets.

RESULTS

Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary.

DISCUSSION

Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.

Accelerating the Drug Delivery Pipeline for Acute and Chronic Pancreatitis: Summary of the Working Group on Drug Development and Trials in Acute Pancreatitis at the National Institute of Diabetes and Digestive and Kidney Diseases Workshop

A workshop was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to focus on research gaps and opportunities on drug development for pancreatitis. This conference was held on July 25, 2018, and structured into 3 working groups (WG): acute pancreatitis (AP) WG, recurrent AP WG, and chronic pancreatitis WG. This article reports the outcome of the work accomplished by the AP WG to provide the natural history, epidemiology, and current management of AP; inform about the role of preclinical models in therapy selection; and discuss clinical trial designs with clinical and patient-reported outcomes to test new therapies.

Exocrine Pancreatic Insufficiency Following Acute Pancreatitis: Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

The epidemiology of exocrine pancreatic insufficiency (EPI) after acute pancreatitis (AP) is uncertain. We sought to determine the prevalence, progression, etiology and pancreatic enzyme replacement therapy (PERT) requirements for EPI during follow-up of AP by systematic review and meta-analysis.

METHODS

Scopus, Medline and Embase were searched for prospective observational studies or randomized clinical trials (RCTs) of PERT reporting EPI during the first admission (between the start of oral refeeding and before discharge) or follow-up (≥ 1 month of discharge) for AP in adults. EPI was diagnosed by direct and/or indirect laboratory exocrine pancreatic function tests.

RESULTS

Quantitative data were analyzed from 370 patients studied during admission (10 studies) and 1795 patients during follow-up (39 studies). The pooled prevalence of EPI during admission was 62% (95% confidence interval: 39-82%), decreasing significantly during follow-up to 35% (27-43%; risk difference: - 0.34, - 0.53 to - 0.14). There was a two-fold increase in the prevalence of EPI with severe compared with mild AP, and it was higher in patients with pancreatic necrosis and those with an alcohol etiology. The prevalence decreased during recovery, but persisted in a third of patients. There was no statistically significant difference between EPI and new-onset pre-diabetes/diabetes (risk difference: 0.8, 0.7-1.1, P = 0.33) in studies reporting both. Sensitivity analysis showed fecal elastase-1 assay detected significantly fewer patients with EPI than other tests.

CONCLUSIONS

The prevalence of EPI during admission and follow-up is substantial in patients with a first attack of AP. Unanswered questions remain about the way this is managed, and further RCTs are indicated.

Prevalence and Associated Factors of Abdominal Pain and Disability at 1-Year Follow-up After an Attack of Acute Pancreatitis

OBJECTIVE

The aim of the study was to report the prevalence and predictors of abdominal pain and disability 1 year after an acute pancreatitis (AP) attack.

METHODS

Patients were prospectively enrolled between December 2012 and April 2016. Enrolled subjects were contacted at a median of 13 months after enrollment. Multivariable regression models were used to determine factors independently associated with abdominal pain at follow-up.

RESULTS

Response rate was 71% (110/155). Of respondents, median age was 51 years, 58% were female, and 14% had severe AP. At follow-up, 24% of patients reported abdominal pain (65% intermittent, 35% constant), 10% used analgesics regularly, and 6% had regular opioids use. Furthermore, 41% of patients experienced pain-related interference with work or daily activities, and 8% developed disability. On regression analysis, idiopathic etiology (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1-13.6) persistent organ failure (OR, 3.3; 95% CI, 1.1-7.9), and recurrent AP (OR, 2.9; 95% CI, 1.1-10.6) were independently associated with abdominal pain at follow-up. Disability at follow-up was associated with younger age, current smoking, and intensive care unit admission (all P < 0.05).

CONCLUSIONS

Abdominal pain and disability are potential long-term sequelae of AP. Certain pre-existing factors and pancreatitis features are associated with these outcomes at one-year follow-up of AP.

Recurrent Acute Pancreatitis: Current Concepts in the Diagnosis and Management

PURPOSE OF REVIEW

There have been significant developments in the diagnosis, clinical approach, and management of patients with recurrent acute pancreatitis (RAP) in the last decade. This review systematically summarizes our current understanding of RAP.

NEW FINDINGS

Gallstones and alcohol are common causes of RAP. Non-alcohol non-biliary RAP (nAnB RAP) is a difficult group of patients after excluding these two causes because extensive workup is required to elucidate the etiology. Idiopathic RAP is diagnosed after excluding all the known causes and recurrence is noted to be higher in such patients. Patients with non-biliary RAP are prone to develop chronic pancreatitis (CP) suggesting a continuum from acute to recurrent to chronic pancreatitis. Often, patients destined to develop CP present at an earlier stage with RAP. Endoscopic ultrasound and magnetic resonance cholangiopancreatography (MRCP) are the investigations of choice to detect microlithiasis, choledocholithiasis, ductal abnormalities, peri-ampullary malignancies, and early changes of chronic pancreatitis. The role of pancreas divisum, sphincter of Oddi dysfunction, and anomalous pancreatobiliary union in causing RAP is controversial. Genetic testing may be advisable in younger patients.

CONCLUSION

With a focused approach and appropriate investigations, the etiology of RAP can be identified in a significant proportion of patients. Therapeutic options are limited and future research is needed to improve understanding of the disease.

Quality of life, performance status, and work capacity after post-endoscopic retrograde cholangiopancreatography pancreatitis

OBJECTIVES

This study evaluated the long-term consequences of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) on health related quality of life (HRQOL), performance status, and work capacity.

MATERIALS AND METHODS

A follow-up study with prospective outcome measurements on patients with previous PEP and matched controls from a Danish cohort of 772 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). HRQOL was evaluated by the short form 36 health surveys, performance status by the Zubrod score, and work capacity by employment status. Multivariable models were applied to adjust for potential confounders.

RESULTS

Twenty-nine cases and 49 controls were included. Twelve (41%), eight (28%), and nine (31%) patients had mild, moderate, and severe PEP, respectively. Mean follow-up time was 4.8 ± 1.7 years. PEP was associated with long-term reduced mental HRQOL (-13.0 role-emotional score points, 95% CI: -25.4; -0.52). An increased Zubrod score representing reduced performance status was present in 12 of the 29 cases (41.4%) and in nine of the 49 controls (18.4%), p = .002. Reduced work capacity was present in 14 of the 29 cases (48.2%) and in 12 of the 49 controls (24.4%), p = .023.

CONCLUSIONS

This study indicates that PEP has a detrimental effect on long-term HRQOL, performance score, and work capacity.

Recurrent Acute Pancreatitis: International State-of-the-Science Conference With Recommendations

Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.