A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis

Serum uric acid concentration in acute pancreatitis is significantly higher than healthy population

Acute pancreatitis (AP) is a common disease caused by a variety of causes. Is uric acid associated with the onset of AP? The objective of this study was to assess whether uric acid concentration in AP patients was higher than that in healthy population, and whether there were associations between uric acid concentration and serological indicators related to AP. A total of 205 AP patients were included in this study. Two hundred and five people who underwent physical examination in our hospital were randomly selected as controls. We analyzed whether there was difference in uric acid concentrations between the two groups. If the difference was statistically significant, the correlations between uric acid concentration and serological indicators in AP patients was further analyzed. There was significant difference in uric acid concentration (P < 0.001) between AP patients and healthy population. Serum uric acid concentration in AP group was significantly higher than that in control group. Two hundred and five AP patients were divided into mild AP group and non-mild AP group. There was no statistically significant difference in uric acid concentration between the two groups (P = 0.176). There was a low linear correlation between serum uric acid concentration and triglyceride level (r = 0.316, P < 0.001). But there was no linear correlation between serum uric acid concentration and hypersensitive C-reactive protein (r = 0.126, P = 0.072), white blood cell (r = 0.192, P = 0.006), albumin (r = 0.183, P = 0.009), total cholesterol concentration (r = 0.133, P = 0.058), fasting blood-glucose (r = 0.133, P = 0.058) and blood calcium (r = 0.155, P = 0.026). Uric acid concentration in patients with AP was significantly higher than healthy population. There was correlation between uric acid concentration and triglyceride in AP patients.

Clinical characteristics and pregnancy outcome analysis of 20 cases of acute pancreatitis during pregnancy

OBJECTIVE

This study investigated the clinical characteristics and pregnancy outcomes of acute pancreatitis during pregnancy (APIP).

METHODS

A retrospective analysis was conducted on 20 cases of APIP admitted to Hubei Maternal and Child Health Hospital from January 2017 to September 2021. The etiology, clinical manifestations, and perinatal outcomes of APIP were analyzed using descriptive statistical analysis of the collected data.

RESULTS

The incidence of APIP in our hospital was 20 (0.02%) cases, all of which occurred in the late stage of pregnancy. Hypertriglyceridemic acute pancreatitis (HTG-AP) was the primary cause of APIP in 10 (50.0%) patients. A total of 11 (55.0%), seven (35.0%) and two (10.0%) patients had mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP), respectively. Pregnant women with HTG-AP had significantly elevated serum triglyceride levels, had higher prepregnancy body mass indices, were more prone to developing diabetes and were more likely to progress to SAP. With a multidisciplinary approach and individualized treatment plans, there were no maternal deaths, and fetal death only occurred in one (5.0%) case.

CONCLUSION

HTG-AP is prone to advancing to more severe states, and it is becoming more common every year. Therefore, blood lipid management during pregnancy should be emphasized. Pregnant women with digestive symptoms or severe hyperlipidaemia should be screened for APIP in a timely manner and receive clinical intervention to improve maternal and fetal outcomes during the perinatal period.

Clinical study of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in hypertriglyceridemia-induced acute pancreatitis and acute biliary pancreatitis with persistent organ failure

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are novel inflammatory indicators that can be used to predict the severity and prognosis of various diseases. We categorize acute pancreatitis by etiology into acute biliary pancreatitis (ABP) and hypertriglyceridemia-induced acute pancreatitis (HTGP).

AIM

To investigate the clinical significance of NLR and PLR in assessing persistent organ failure (POF) in HTGP and ABP.

METHODS

A total of 1450 patients diagnosed with acute pancreatitis (AP) for the first time at Shanxi Bethune Hospital between January 2012 and January 2023 were enrolled. The patients were categorized into two groups according to the etiology of AP: ABP in 530 patients and HTGP in 241 patients. We collected and compared the clinical data of the patients, including NLR, PLR, and AP prognostic scoring systems, within 48 h of hospital admission.

RESULTS

The NLR (9.1 vs 6.9, P < 0.001) and PLR (203.1 vs 160.5, P < 0.001) were significantly higher in the ABP group than in the HTGP group. In the HTGP group, both NLR and PLR were significantly increased in patients with severe AP and those with a SOFA score ≥ 3. Likewise, in the ABP group, NLR and PLR were significantly elevated in patients with severe AP, modified computed tomography severity index score ≥ 4, Japanese Severity Score ≥ 3, and modified Marshall score ≥ 2. Moreover, NLR and PLR showed predictive value for the development of POF in both the ABP and HTGP groups.

CONCLUSION

NLR and PLR vary between ABP and HTGP, are strongly associated with AP prognostic scoring systems, and have predictive potential for the occurrence of POF in both ABP and HTGP.

Triglycerides: A Sensitizer but Not a Trigger for Hypertriglyceridemic Acute Pancreatitis

BACKGROUND

The incidence of hypertriglyceridemic acute pancreatitis (HTG-AP) is increasing. Although the guideline defines the diagnostic criteria as triglyceride (TG) greater than 11.3 mmol/L, there is actually no specific threshold. Many people with hypertriglyceridemia (HTG) or obvious chyloid blood do not develop acute pancreatitis (AP).

AIMS

To explore the role of HTG in the pathogenesis of AP.

METHODS

Thirty-six male SD rats were randomly assigned into normal control, AP, HTG, HTG-AP, low-dose fenofibrate and high-dose fenofibrate groups. Serum indices and cytokine levels in serum, and pathological changes in pancreatic tissues were observed. The expression levels of TLR4 and NF-κBp65 in pancreatic tissues were detected by immunohistochemistry and Western blot.

RESULTS

In normal rats, HTG alone did not induce AP. However, after establishing the HTG-AP model with Poloxam 407 and L-arginine, serum-free fatty acid and TG levels were positively correlated with the levels of lipase, amylase, IL-1β, IL-6, pancreatic inflammation scores, and the expressions of TLR4 and NF-κBp65 (all P < 0.001). Expressions of TLR4 and NF-κBp65 were significantly increased in the pancreatic tissues of HTG-AP rats. Fenofibrate effectively decreased TG levels in HTG-AP rats and reduced the expression of TLR4 and NF-κBp65 (all P < 0.001).

CONCLUSIONS

HTG does not directly cause AP, but rather increases the susceptibility to AP or aggravates the inflammatory response. It is more like a sensitizer of inflammation rather than an activator.

Association of admission serum triglyceride levels with intensive care unit hospitalization rates in acute pancreatitis patients: A retrospective study

Acute pancreatitis (AP) is a complex and unpredictable condition, of which hypertriglyceridemia (HTG) is the third most prevalent cause. This study aimed to conduct a retrospective analysis of clinical data from hospitalized AP patients to uncover a potential correlation between triglyceride (TG) levels and the necessity for intensive care unit (ICU) admission. This retrospective cohort study utilized the Medical Information Mart for Intensive Care IV 2.2 (MIMIC-IV) critical care dataset, incorporating data from 698 patients with hypertriglyceridemic acute pancreatitis (HTG-AP). The analysis employed the RCS model along with univariate and multivariate logistic regression methods to affirm the association between triglyceride levels and ICU admission. Subgroup analysis was performed to investigate specific populations. The study included 698 patients with AP, 42.41% of whom experienced HTG during hospitalization. RCS analysis revealed a linear association between TG levels and risk of ICU admission (p for nonlinear = .219, p for overall = .009). Multivariate logistic regression analysis indicated an increased risk of ICU admission in the TG range of 1.7-5.65 mmol/L (aOR = 1.83, 95% CI 1.12-2.99, P = .015) and TG >11.3 mmol/L (aOR = 5.69, 95% CI 2.36-13.74, P < .001) compared to the normal group. Similar results were observed across the various subgroups. As triglyceride levels increased, there was a corresponding increase in ICU admissions. Patients within the 1.7 to 5.65 mmol/L and > 11.3 mmol/L triglyceride groups exhibited higher rates of ICU admissions. Moreover, we observed a higher risk of ICU hospitalization even with mild TG elevation.

Novel anthropometric indicators of visceral obesity predict the severity of hyperlipidemic acute pancreatitis

BACKGROUND

Obesity substantially contributes to the onset of acute pancreatitis (AP) and influences its progression to severe AP. Although body mass index (BMI) is a widely used anthropometric parameter, it fails to delineate the distribution pattern of adipose tissue. To circumvent this shortcoming, the predictive efficacies of novel anthropometric indicators of visceral obesity, such as lipid accumulation products (LAP), cardiometabolic index (CMI), body roundness index (BRI), visceral adiposity index (VAI), A Body Shape Index (ABSI), and Chinese visceral adiposity index (CVAI) were examined to assess the severity of AP.

METHOD

The body parameters and laboratory indices of 283 patients with hyperlipidemic acute pancreatitis (HLAP) were retrospectively analysed, and the six novel anthropometric indicators of visceral obesity were calculated. The severity of HLAP was determined using the revised Atlanta classification. The correlation between the six indicators and HLAP severity was evaluated, and the predictive efficacy of the indicators was assessed using area under the curve (AUC). The differences in diagnostic values of the six indicators were also compared using the DeLong test.

RESULTS

Patients with moderate to severe AP had higher VAI, CMI, and LAP than patients with mild AP (all P < 0.001). The highest AUC in predicting HLAP severity was observed for VAI, with a value of 0.733 and 95% confidence interval of 0.678-0.784.

CONCLUSIONS

This study demonstrated significant correlations between HLAP severity and VAI, CMI, and LAP indicators. These indicators, particularly VAI, which displayed the highest predictive power, were instrumental in forecasting and evaluating the severity of HLAP.

Therapeutic plasma exchange decreases serum triglyceride level rapidly and reduces early recurrence rate but no advantages in improving outcomes for patients with hyperlipidemic acute pancreatitis: a retrospective propensity score matching analysis based on twenty year's experience

BACKGROUND

Hyperlipidaemic acute pancreatitis (HLAP) has become the most common cause of acute pancreatitis (AP) not due to gallstones or alcohol (Mosztbacher et al, Pancreatology 20:608-616, 2020; Yin et al, Pancreas 46:504-509, 2017). Therapeutic plasma exchange (TPE) has been reported to be effective in reducing serum TG levels which is important in management of HLAP (World J Clin Cases 9:5794-803, 2021). However, studies on TPE are mostly focusing on cases reports, TPE remains poorly evaluated till date and need to be compared with conservative therapy with a well-designed study.

METHODS

A retrospectively cohort study on HLAP patients between January 2003 and July 2023 was conducted. Factors correlated with efficacy of TPE were included in a propensity model to balance the confounding factors and minimize selection bias. Patients with and without TPE were matched 1:2 based on the propensity score to generate the compared groups. Lipid profiles were detected on admission and consecutive 7 days. The triglyceride (TG) level decline rates, percentage of patients to reach the target TG levels, early recurrence rate, local complications and mortality were compared between groups.

RESULTS

A total of 504 HLAP patients were identified. Since TPE was scarcely performed on patients with TG < 11.3 mmol/L, 152 patients with TG level 5.65 to 11.3 mmol/L were excluded while 352 with TG ≧11.3 mmol/L were enrolled. After excluding 25 cases with incomplete data or pregnancy, 327 patients, of whom 109 treated without TPE while 218 treated with TPE, were included in data analysis. One-to-two propensity-score matching generated 78 pairs, 194 patients with well-balanced baseline characteristics. Of 194 patients enrolled after matching done, 78 were treated without while 116 with TPE. In the matched cohort (n = 194), patients treated with TPE had a higher TG decline rate in 48 h than those without TPE (70.00% vs 54.00%, P = 0.001); the early recurrence rates were 8.96% vs 1.83%, p = 0.055. If only SAP patients were analyzed, the early recurrence rates were 14.81% vs 0.00% (p = 0.026) respectively. For patients with CT severity index (CTSI) rechecked within 14 days, early CTSI improment rate were 40.90% vs 31.91%. Local complications checked 6 months after discharge were 44.12% vs 38.30%. Mortality was 1.28% vs 1.72%. No differences were found in early stage CTSI improment rate (P = .589), local complications (P = .451) or motality between two groups.

CONCLUSIONS

TPE reduces TG levels more quickly in 48 h compared with those with conservative treatment, but no difference in the consecutive days. TPE tends to reduce the early recurrence rate comparing with conventional therapy, but TPE has no advantages in improving CTSI in early stage, and no improvement for outcomes including local complications and mortalty.

Viral pancreatitis: research advances and mechanisms

Acute pancreatitis is caused by trypsinogen activation in acinar cells caused by various injury forms (gallstone, high triglycerides, alcohol, etc.). Viral pancreatitis is a clinically rare disease type, which is easily neglected by clinicians and causes serious adverse consequences. Viral pancreatitis involves the entry of viruses into pancreatic cells, triggering inflammation, immune response activation, and enzymatic autodigestion, leading to tissue damage and potential complications. At present, there are few available reports on viral pancreatitis, most of which are case reports. This review brings attention to clinicians by describing the incidence of viral pancreatitis to enhance clinical understanding and patient care.

The pathogenic mutations of APOA5 in Chinese patients with hyperlipidemic acute pancreatitis

BACKGROUND AND AIMS

To study the role of gene mutations in the development of severe hypertriglyceridemia (HTG) in patients with hyperlipidemic acute pancreatitis (HLAP), especially different apolipoprotein A5 (APOA5) mutations.

METHODS

Whole-exome sequencing was performed on 163 patients with HLAP and 30 patients with biliary acute pancreatitis (BAP). The pathogenicity of mutations was then assessed by combining clinical information, predictions of bioinformatics programs, information from multiple gene databases, and residue location and conservation. The pathogenic mutations of APOA5 were visualized using the software.

RESULTS

1. Compared with BAP patients, pathogenic mutations of APOA5 were frequent in HLAP patients; among them, the heterozygous mutation of p.G185C was the most common. 2. All six pathogenic mutations of APOA5 identified in this study (p.S35N, p.D167V, p.G185C, p.K188I, p.R223C, and p.H182fs) were positively correlated with severe HTG; they were all in the important domains of apolipoprotein A-V (apoA-V). Residue 223 is strictly conserved in multiple mammals and is located in the lipoprotein lipase (LPL)-binding domain (Pro215-Phe261). When Arg 223 is mutated to Cys 223, the positive charge of this residue is reduced, which is potentially destructive to the binding function of apoA-V to LPL. 3. Four new APOA5 mutations were identified, namely c.563A > T, c.667C > T, c.788G > A, and c.544_545 insGGTGC.

CONCLUSIONS

The pathogenic mutations of APOA5 were specific to the patients with HLAP and severe HTG in China, and identifying such mutations had clinical significance in elucidating the etiology and subsequent treatment.

ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

A nomogram for predicting in-hospital overall survival of hypertriglyceridemia-induced severe acute pancreatitis: A single center, cross-sectional study

Background

Hypertriglyceridemia-induced severe acute pancreatitis (HTG-SAP) is a type of pancreatitis characterized by an abnormal elevation of plasma triglyceride. HTG-SAP has been associated with various complications and a high mortality rate. In this study, we established a nomogram for predicting the overall survival (OS) of HTG-SAP patients during hospitalization.

Methods

128 HTG-SAP cases hospitalized at the Affiliated Huadu Hospital, Southern Medical University, from 2019 to 2022 were analyzed retrospectively. A nomogram including prognostic factors correlated with OS during hospitalization was established by multivariate Cox regression analysis. We internally validated the nomogram using time-dependent (at 1-, 2-, and 3- months) survival receiver operating characteristic (SROC) and calibration curve with 500 iterations of bootstrap resampling. Time-dependent decision curve analysis (DCA) was employed to validate the clinical value of the nomogram.

Results

Multivariate Cox regression indicated that serum triglyceride, red blood cell distribution width (RDW), lactic acid, and interleukin-6 (IL6) were independent prognostic factors for OS of HTG-SAP patients during hospitalization and were used to construct a nomogram. The time-dependent area under the curve (AUC) values at 1-, 2-, and 3- months were 0.946, 0.913, and 0.929, respectively, and the Concordance index (C-index) of the nomogram was 0.916 (95%CI 0.871-0.961). The time-dependent calibration curves indicated good consistency between the observed and predicted outcomes. The time-dependent DCAs also revealed that the nomogram yielded a high clinical net benefit. After stratifying the included cases into two risk groups based on the risk score obtained from the nomogram, the high-risk group exhibited a significantly inferior overall survival (OS) compared to the low-risk group (p < 0.0001).

Conclusions

Our nomogram exhibited good performance in predicting the overall survival of HTG-SAP patients during hospitalization.

Identification of novel biomarkers based on lipid metabolism-related molecular subtypes for moderately severe and severe acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is an unpredictable and potentially fatal disorder. A derailed or unbalanced immune response may be the root of the disease's severe course. Disorders of lipid metabolism are highly correlated with the occurrence and severity of AP. We aimed to characterize the contribution and immunological characteristics of lipid metabolism-related genes (LMRGs) in non-mild acute pancreatitis (NMAP) and identify a robust subtype and biomarker for NMAP.

METHODS

The expression mode of LMRGs and immune characteristics in NMAP were examined. Then LMRG-derived subtypes were identified using consensus clustering. The weighted gene co-expression network analysis (WGCNA) was utilized to determine hub genes and perform functional enrichment analyses. Multiple machine learning methods were used to build the diagnostic model for NMAP patients. To validate the predictive effectiveness, nomograms, receiver operating characteristic (ROC), calibration, and decision curve analysis (DCA) were used. Using gene set variation analysis (GSVA) and single-cell analysis to study the biological roles of model genes.

RESULTS

Dysregulated LMRGs and immunological responses were identified between NMAP and normal individuals. NMAP individuals were divided into two LMRG-related subtypes with significant differences in biological function. The cluster-specific genes are primarily engaged in the regulation of defense response, T cell activation, and positive regulation of cytokine production. Moreover, we constructed a two-gene prediction model with good performance. The expression of CARD16 and MSGT1 was significantly increased in NMAP samples and positively correlated with neutrophil and mast cell infiltration. GSVA results showed that they are mainly upregulated in the T cell receptor complex, immunoglobulin complex circulating, and some immune-related routes. Single-cell analysis indicated that CARD16 was mainly distributed in mixed immune cells and macrophages, and MGST1 was mainly distributed in exocrine glandular cells.

CONCLUSIONS

This study presents a novel approach to categorizing NMAP into different clusters based on LMRGs and developing a reliable two-gene biomarker for NMAP.

Role of obesity in pathogenesis of acute pancreatitis

Acute pancreatitis (AP) is one of the most common digestive disorders that cause hospitalization. While most of patients with AP have a mild to moderate disease and recover rapidly, about 20% of patients with AP have a severe disease and experience substantial morbidity and mortality from local and/or systemic compli-cations. The incidence of obesity has increased worldwide, and its epidemiological characteristics and rising trend are consistent with those of AP. Therefore, obesity has probably contributed to the increase in the incidence and severity of AP. However, previous studies have generated conflicting results, and some studies demonstrated that obesity is a protective factor in patients with AP. Here we discuss the role of obesity in the pathogenesis of AP and the underlying mechanisms based on clinically relevant studies.

Comparison of different intensive triglyceride-lowering therapies in patients with hyperlipidemic acute pancreatitis

OBJECTIVES

The goal of this study was to investigate the clinical value of emergent triglyceride (TG)-lowering therapies for hyperlipidemic acute pancreatitis (HLAP).

METHODS

126 HLAP patients were assigned randomly to receive either conventional treatment (CT), normal saline (NS) alone, or continuous veno-venous hemofiltration (CVVH) as an intensive TG-lowering therapy. TG levels, clinical outcomes, and inflammatory biomarkers were compared among the three groups.

RESULTS

Baseline characteristics did not differ significantly among the groups. CVVH removed TG from the plasma and achieved its target TG (<500 mg/dL) in approximately 25 h, compared to 40 h in the NS alone group and no targeted effect within 48 h in the CT group (P < 0.05). Although the majority of clinical outcomes did not differ significantly, an unexpectedly higher incidence of organ failure occurred in the CVVH group compared to the others. Hospital costs, severe AP patients and length of stay were significantly higher in the CVVH group compared to the other groups (P < 0.005).

CONCLUSIONS

Early CVVH lowers TG levels more efficiently than NS alone or CT therapy, but is not superior in terms of clinical outcomes and costs. NS also lowers TG levels and is significantly less costly than the other two treatments. Further multicenter studies are needed to determine the feasibility of NS alone treatment for HLAP patients.

A protocol for an international, multicenter, prospective, non-interventional observational registry for patients with hypertriglyceridemia

BACKGROUND

In the study on triglyceride-induced pancreatitis (TG-IAP), a core clinical dataset using the Jandhyala method was developed to collect the minimum amount of information for each patient presenting with TG-IAP globally. This approach offered a unified framework for observing multiple populations of TG-IAP patients using the same set of indicators, resulting in a considerably larger and uniform real-world population. It was understood that when this core dataset is implemented in a patient registry it could address the issue of missing data in observational studies and produce higher-quality research. In this paper, the protocol used to design and implement a patient registry for this core dataset to generate real-world evidence from multiple sites is described.

METHOD

The study is designed as an international, multicenter, non-interventional, observational registry that will enroll adult patients with hypertriglyceridemia to collect natural history data on the treatment, progression, and long-term outcomes of hypertriglyceridemia-induced acute pancreatitis. Patients with both hypertriglyceridemia and pancreatitis will be invited to participate in the registry at participating hospitals and centers worldwide.

DISCUSSION

Data from this registry, and others like it, is intended for healthcare providers to optimize clinical decision-making through an enhanced understanding of the variability, progression, and natural history of hypertriglyceridemia as well as the burden of disease.

CONCLUSION

Global epidemiological data on hypertriglyceridemia and its role in acute pancreatitis is limited. Using real-world evidence, this registry, along with others like it, may help healthcare providers understand the variability, progression, natural history, and burden of the disease, and improve the diagnosis and management of HTG and TG-IAP.

Association of Cardiovascular Disease and Pancreatitis: What Came First, the Chicken or the Egg?

(1) Background: Recent studies suggest an association between pancreatitis and cardiovascular disease. This article aims to review the available evidence linking cardiovascular disease with acute and chronic pancreatitis. (2) Methods: A comprehensive search was conducted on the PubMed/MEDLINE database from inception to April 2022 using Medical Subject Heading and keywords related to pancreatitis and cardiovascular disease. The search was limited to English-language literature involving human subjects, and various study types, including observational studies, case-control studies, cohort studies, and clinical trials, were screened for eligibility. Following data extraction, the authors conducted a narrative synthesis of the studies. (3) Results: Longitudinal studies indicate that a history of acute pancreatitis is associated with an increased risk of acute atherosclerotic cardiovascular disease and acute coronary syndrome. Elevated triglyceride levels (>2000 mg/dL) have a temporal relationship with acute pancreatitis. Cross-sectional studies have shown that acute pancreatitis is associated with cardiac injury during the acute phase. Based on longitudinal studies, chronic pancreatitis is associated with an increased risk of cerebrovascular diseases. However, data regarding the relationship between chronic pancreatitis and myocardial infarction are conflicting. (4) Conclusions: Based on the available evidence, having a history of acute pancreatitis appears to increase the risk of acute atherosclerotic cardiovascular disease. However, there is insufficient evidence to conclude whether chronic pancreatitis is associated with cardiovascular disease, and no definitive studies have yielded conflicting results.

Comprehensive review on the pathogenesis of hypertriglyceridaemia-associated acute pancreatitis

It is well known, that the inflammatory process that characterizes acute pancreatitis (AP) can lead to both pancreatic damage and systemic inflammatory response syndrome (SIRS). During the last 20 years, there has been a growing incidence of episodes of acute pancreatitis associated with hypertriglyceridaemia (HTAP). This review provides an overview of triglyceride metabolism and the potential mechanisms that may contribute to developing or exacerbating HTAP. The article comprehensively discusses the various pathological roles of free fatty acid, inflammatory response mechanisms, the involvement of microcirculation, serum calcium overload, oxidative stress and the endoplasmic reticulum, genetic polymorphism, and gut microbiota, which are known to trigger or escalate this condition. Future perspectives on HTAP appear promising, with ongoing research focused on developing more specific and effective treatment strategies.

Hypertriglyceridemia-Associated Pancreatitis: New Concepts and Potential Mechanisms

BACKGROUND

Triglycerides are a major source of energy, while high plasma triglycerides are a risk factor for various diseases and premature death. Severely elevated plasma triglycerides are a well-established cause of acute pancreatitis with high mortality, likely due to the presence of elevated levels of chylomicrons and large very low-density lipoproteins in plasma. As markedly elevated levels of these very large lipoproteins are not generally found in mild to moderate hypertriglyceridemia, this was previously not regarded as a cause or marker of increased risk of acute pancreatitis. However, mild to moderate hypertriglyceridemia may identify individuals who at a later timepoint develop severe hypertriglyceridemia and acute pancreatitis.

CONTENT

We describe measurement of plasma triglycerides and studies on plasma triglycerides and risk of acute pancreatitis. Further, we summarize current European and American guidelines for the prevention of acute pancreatitis and, finally, the potential for future prevention of acute pancreatitis through lowering of plasma triglycerides.

SUMMARY

Recent observational and genetic studies indicate that mild to moderate hypertriglyceridemia is causally related to increased risk of acute pancreatitis, most likely as a marker of future severe hypertriglyceridemia. Current guidelines do not mention individuals with mild to moderate hypertriglyceridemia, even though newer evidence suggests an unmet medical need. Treatment could include plasma triglyceride-lowering therapy targeting the pathway for lipoprotein lipase as the main triglyceride degrading enzyme in plasma. Angiopoietin-like 3 and apolipoproteinC-III are inhibitors of lipoprotein lipase, and blocking of these 2 inhibitors is showing promising results in relation to marked triglyceride-lowering and could perhaps be used to prevent acute pancreatitis in the future.

Preventative plasmapheresis in a diabetic pregnant patient with hypertriglyceridemia and distal pancreatectomy

BACKGROUND

Pregnant patients with a history of hypertriglyceridemia are at increased risk for development of acute pancreatitis. When conservative management fails to maintain triglyceride levels less than 250-500 mg dL-1 , implementation of pregnancy category C medications to prevent pancreatitis must be considered. Plasmapheresis rapidly reduces triglyceride levels and has been reported as a successful third-line therapy for hypertriglyceridemia-induced acute pancreatitis in a limited number of pregnant patients. Use of preventative plasmapheresis as a bridge to delivery is not well characterised.

CASE PRESENTATION

We report an outpatient plasmapheresis regimen for the control of hypertriglyceridemia in a pregnant patient with a history of diabetes mellitus, hypertriglyceridemia, distal pancreatectomy, and repeat pregnancy loss. During the second trimester, refractory triglyceride levels increased up to 3438 mg dL-1 by 28 weeks gestation. Given the patient's high risk for recurrent pancreatitis and limited remaining pancreatic parenchyma, she was treated acutely with two single-plasma-volume exchanges with 100% albumin over 2 days, decreasing the triglyceride level to 559 mg dL-1 . Subsequent plasmapheresis every 7 to 9 days maintained a triglyceride level of 320-1296 mg dL-1 . The patient experienced no adverse effects and remained outpatient until successful scheduled delivery for hypertension at 33 weeks gestation.

DISCUSSION

For select patients, early escalation to plasmapheresis may prevent morbidity and mortality associated with acute pancreatitis. An individualised plasmapheresis regimen can serve as a bridge to delivery, which requires close observation and the coordination of a multidisciplinary team.

Early Plasmapheresis Among Patients With Hypertriglyceridemia-Associated Acute Pancreatitis

Importance

The incidence of hypertriglyceridemia-associated acute pancreatitis (HTG-AP) is increasing. Plasmapheresis is theoretically effective in removing triglyceride from plasma, but whether it confers clinical benefits is unclear.

Objective

To assess the association between plasmapheresis and the incidence and duration of organ failure among patients with HTG-AP.

Design, Setting, and Participants

This is an a priori analysis of data from a multicenter, prospective cohort study with patients enrolled from 28 sites across China. Patients with HTG-AP were admitted within 72 hours from the disease onset. The first patient was enrolled on November 7th, 2020, and the last on November 30th, 2021. The follow-up of the 300th patient was completed on January 30th, 2022. Data were analyzed from April to May 2022.

Exposures

Receiving plasmapheresis. The choice of triglyceride-lowering therapies was at the discretion of the treating physicians.

Main Outcomes and Measures

The primary outcome was organ failure-free days to 14 days of enrollment. Secondary outcomes included other measures for organ failure, intensive care unit (ICU) admission, duration of ICU and hospital stays, incidence of infected pancreatic necrosis, and 60-day mortality. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analyses were used to control potential confounders.

Results

Overall, 267 patients with HTG-AP were enrolled (185 [69.3%] were male; median [IQR] age, 37 [31-43] years), among whom 211 underwent conventional medical treatment and 56 underwent plasmapheresis. PSM created 47 pairs of patients with balanced baseline characteristics. In the matched cohort, no difference was detected concerning organ failure-free days between patients undergoing plasmapheresis or not (median [IQR], 12.0 [8.0-14.0] vs 13.0 [8.0-14.0]; P = .94). Moreover, more patients in the plasmapheresis group required ICU admission (44 [93.6%] vs 24 [51.1%]; P < .001). The IPTW results conformed to the results from the PSM analysis.

Conclusions and Relevance

In this large multicenter cohort study of patients with HTG-AP, plasmapheresis was commonly used to lower plasma triglyceride. However, after adjusting for confounders, plasmapheresis was not associated with the incidence and duration of organ failure, but with increased ICU requirements.

Inhibition of TRAF6 improves hyperlipidemic acute pancreatitis by alleviating pyroptosis in vitro and in vivo rat models

OBJECTIVE

Hypertriglyceridemia (HTG) is one of the common causes of acute pancreatitis (AP). Hyperlipidemic acute pancreatitis (HTG-AP) is associated with higher mortality owing to its tendency for greater severity and rapid progression. The purpose of this study was to explore the mechanism of involvement of tumor necrosis factor receptor-related factor 6 (TRAF6) in pyroptosis during HTG-AP.

METHODS

The HTG environment was simulated with palmitic acid treatment in vitro and a high-fat diet in vivo. Cerulein was used to establish the HTG-AP model, followed by genetic and pharmacological inhibition of TRAF6. Pyroptosis activation, inflammatory reaction, and the interaction between TRAF6 and pyroptosis in HTG-AP were assessed.

RESULTS

HTG was found to aggravate the development of pancreatitis, accompanied by increased pyroptosis and enhanced inflammatory response in HTG-AP models. Mechanistically, TRAF6 downregulation decreased the activation of pyroptosis in cerulein-induced HTG-AP.

CONCLUSION

Collectively, inhibition of TRAF6 improved HTG-AP and the associated inflammation by alleviating pyroptosis.

Apheresis Technique for Acute Hyperlipidemic Pancreatitis: A Systemic Review and Meta-Analysis

BACKGROUND

The apheresis technique is increasingly used in patients with hypertriglyceridemia-induced pancreatitis (HTGP), while its role in this context is still not well established. Thus, we aimed to evaluate the clinical outcomes of an apheresis therapy compared to usual care in such a patient population.

METHODS

We searched PubMed, Embase, and Cochrane library databases up to July 10, 2021. Studies were included if they focused on HTGP treated with or without apheresis technique. We used the Newcastle-Ottawa Scale to assess the quality of the included studies. The primary outcome was the mortality rate. We also explored the heterogeneity, sensitivity analysis, subgroup analysis, and publication bias.

RESULTS

Sixteen observational studies with 1476 adults were included. The overall quality of included studies was moderate. Despite better TG level reduction with apheresis therapy (mean difference [MD], 12.27 mmol/L, 95% CI, 3.74 to 20.81; I² = 78%; P = 0.005), use of apheresis did not reduce the mortality (odds ratio [OR], 1.01; 95% CI, 0.65 to 1.59; P = 0.95) compared with usual care. This result was further confirmed by sensitivity analysis, subgroup analysis. The length of stay in hospital (MD, 0.96 days; 95% CI, - 1.22 to 3.14; I² = 70%; P = 0.39) and most complications were similar between the groups, while hospital cost was significantly higher in the apheresis group.

CONCLUSIONS

The apheresis technique did not decrease the mortality in HTGP patients compared with usual care. Until the results of high-quality RCTs are known, these findings do not support the routine use of the apheresis technique in such a patient population.

Predictive Risk Factors of Pancreatic Exocrine Insufficiency Developed After Acute Pancreatitis: A Retrospective Cohort Study

Purpose

The aim of this study was to compare the clinical characteristics of acute pancreatitis (AP) patients between those who developed pancreatic exocrine insufficiency (PEI) and those who did not, and to investigate the predictive factors of PEI.

Patients and Methods

From October 1st 2019 to July 30th 2021, AP patients admitted at our center were included. The fecal elastase-1 assay was adopted for PEI diagnosis. The clinical characteristics, treatments, and outcomes between the patients with and without PEI were analyzed.

Results

In total, 63 males and 42 females were included. There were 27 patients with mild AP, 54 with moderately severe AP, and 24 with severe AP. The median modified computed tomography severity index (MCTSI) was 6.000(4.000, 8.000). During the follow-up, 38 patients developed PEI after AP. The univariate analysis showed that higher ASA grade (P = 0.006), more severe AP (P = 0.000), the presence of multiple organ dysfunction syndrome (P = 0.030), higher MCTSI (P = 0.000), the development of infected pancreatic necrosis (P = 0.002) and local complications (P = 0.000), higher levels of triacylglycerol (P = 0.022), video-assisted retroperitoneal debridement intervention (P = 0.015), and longer intensive care unit stay (P = 0.044) were correlated with PEI development. Furthermore, the logistic regression analyses showed that MCTSI during hospitalization is an independent risk factor for PEI development during the AP recovery period.

Conclusion

ASA grade, severity of AP, multiple organ dysfunction syndrome, MCTSI, infected pancreatic necrosis, local complications, higher levels of triacylglycerol, video-assisted retroperitoneal debridement intervention, and longer intensive care unit stay were potentially associated with PEI development during the AP recovery period. High MCTSI was independently associated with the development of PEI during the AP recovery period, which may help alert to the possibility of PEI to help with its early detection and treatment.

A simple core dataset for triglyceride-induced acute pancreatitis

OBJECTIVE

The objective of this study is to generate a core clinical dataset (CD) containing the minimum acceptable amount of information that should be collected for each patient presenting with triglyceride-induced acute pancreatitis within global treatment centres or sites.

METHOD

The Jandhyala Method, including systematic literature review and SMART interviews, was used to observe expert opinion from ten leaders in the treatment of triglyceride-induced acute pancreatitis (TG-IAP) across the US and EU.

RESULTS

Using the PRISMA Literature Review Protocol, data were extracted from 123 of the 6718 identified studies. A total of 243 items were identified from the data extracted from these studies and, combined with the unique items coded from the Awareness Round (1) survey, formed the Consensus Round (2) survey. One hundred and ninety-five of the 243 items (80%) met the consensus threshold and were included for appraisal in the SMART interview phase. A total of 109 items were agreed to form part of the current clinical diagnostic and monitoring procedure by all experts once the weights across all the stakeholder disciplines were balanced to eliminate bias. These items were further condensed to form the core dataset, comprising a total of 87 items.

CONCLUSION

Once validated and adopted, the TG-IAP CD will improve the overall management of patients with TG-IAP by speeding up diagnosis and detecting changes in disease severity and subsequent disease progression, informing personalized patient management plans, and improving patient outcomes.

Resveratrol pre-treatment alleviated caerulein-induced acute pancreatitis in high-fat diet-feeding mice via suppressing the NF-κB proinflammatory signaling and improving the gut microbiota

Background

hyperlipidemia acute pancreatitis (HTG-AP) is a major hidden danger affecting human health, however, whether there is a protective effect of resveratrol on HTG-AP is unclear. Therefore our study was aimed to investigate the preventive effect and the underlying mechanism of resveratrol in the HTG-AP mice model.

Methods

This research was divided into two parts. In the first part, mice were adaptively fed with normal chow or HFD for 6 weeks. From the second week, resveratrol-treated mice were in intragastric administration with resveratrol (45 mg/kg/d) for 4 weeks. In the second part, the procedures were the same as the first part. After the last intragastric administration with resveratrol, all mice were intraperitoneal injections of cerulean.

Results

We found resveratrol effectively inhibited pancreatic pathological injury in the HFD, AP, and HTG-AP mice. Resveratrol reduced the LPS, IL-6, TNF-α, and MCP-1 expressions in the HFD mice. Resveratrol also reduced TNF-α, MDA, and MCP-1 expressions and increased SOD and T-AOC expressions in the AP and HTG-AP mice. Furthermore, resveratrol suppressed the NF-κB pro-inflammatory signaling pathway in pancreatic tissues in the AP and HTG-AP mice. Moreover, resveratrol improved the gut microbiota in the HFD mice.

Conclusion

The resveratrol pre-treatment could attenuate pancreas injury, inflammation, and oxidative stress in the HTG-AP mice, via restraining the NF-κB signaling pathway and regulating gut microbiota. Therefore, Our study proved that the resveratrol pre-treatment had a preventive effect on HTG-AP.

Elevated hypertriglyceridemia and decreased gallstones in the etiological composition ratio of acute pancreatitis as affected by seasons and festivals: A two-center real-world study from China

Objective

The purpose of this study was to observe the annual variation in the etiology of acute pancreatitis (AP) and its relationship with seasons and festivals.

Methods

From 2011 to 2017, 5146 adult patients with AP were studied, including 4110 patients from the First Affiliated Hospital of Nanchang University (South center) and 1036 patients from the First Affiliated Hospital of Harbin Medical University (North center). We analyzed the overall annual variation in the etiology of AP and then compared the differences in etiology between the two regions, as well as the effects of seasons and festivals on the etiology of AP.

Results

Gallstones, hypertriglyceridemia (HTG) and alcohol were the top three etiologies of AP. Gallstone AP showed a downward trend (P<0.001), and HTG-AP and alcohol AP showed an upward trend (both P<0.01). Among the etiologies of AP, gallstones and HTG were affected by seasons and festivals. The composition ratio of HTG-AP increased, while gallstone AP decreased in winter and in months with long holidays (all P<0.01). The composition ratio of gallstone AP in the south center was higher than that in the north center (59.5% vs. 49%), especially in summer (62.9% vs. 44.0%) and autumn (61.5% vs. 45.7%, all P<0.001).

Conclusions

The composition ratio of HTG-AP increased while gallstone AP decreased in the past 7 years, and they were affected by seasons and festivals.

Efficacy of insulin in treating severe hypertriglyceridaemia in the third trimester of pregnancy

This study aims to investigate the efficacy of insulin in treating severe hypertriglyceridaemia (HTG) during the third trimester of pregnancy. Women with severe HTG (TG ≥ 11.30 mmol/L) in the third trimester of pregnancy who received clinical examination and delivered in Hubei Maternal and Child Health Hospital from 01 January 2017 to 30 September 2021 were recruited. Patients with TG ≥ 11.30 mmol/L at 30–32 weeks of gestation were treated with a low-fat diet and insulin as the insulin treatment group. For the control group, patients with TGs of 5.65–11.30 mmol/L at 30–32 weeks of gestation who developed severe HTG (TG ≥ 11.30 mmol/L) before delivery were treated with a low-fat diet only. General maternal information, delivery, perinatal treatment and laboratory examination information were collected from electronic medical records and compared. We found that in the insulin treatment group, there were higher values of progestational body mass index (BMI) (Z = −2.281, P = 0.023), higher incidence of diabetes (χ2 = 20.618, P &lt; 0.001) and higher incidence of fatty liver (χ2 = 4.333, P = 0.037) than in the control group but also a higher pregnancy weight gain compliance rate (χ2 = 4.061, P = 0.044). Laboratory examination before delivery revealed that compared with the control group, insulin treatment significantly decreased prenatal TG (Z = −10.392, P &lt; 0.001), cholesterol (Z = −8.494, P &lt; 0.001), low-density lipoprotein (Z = −3.918, P &lt; 0.001), apolipoprotein A1 (t = 2.410, P = 0.019), cystatin (Z = −4.195, P &lt; 0.001), incidence of hypocalcaemia (P = 0.036), and absolute number of lymphocytes (Z = −3.426, P = 0.001). Delivery outcomes were also improved in the insulin treatment group compared with the control group, including lower neonatal weight (Z = −2.200, P = 0.028), incidence of macrosomia (χ2 = 4.092, P = 0.043), gestational age (Z = −3.427, P = 0.001), and rate of intensive care unit (ICU) conversion (P = 0.014). In conclusion, insulin therapy for HTG in the third trimester of pregnancy could increase the pregnancy weight gain compliance rate, decrease blood lipid levels and the incidence of severe complications such as HTG acute pancreatitis (HTG-AP), and improve pregnancy outcomes.

Insulin or blood purification treatment for hypertriglyceridaemia-associated acute pancreatitis: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Hypertriglyceridaemia increases risks from acute pancreatitis (HTG-AP) over other aetiologies, but optimal management for HTG-AP remains undefined. We performed a systematic review and meta-analysis of studies of insulin-based treatment (IT) versus blood purification treatment (BPT) for HTG-AP.

METHODS

Searches were conducted to identify randomised trials and observational studies published between 1946 and 2022 that compared IT and BPT for HTG-AP reporting baseline and post-treatment serum triglyceride (TG) levels with clinical outcomes. The primary outcome was serum TG reduction (Δ-TG) from baseline while secondary outcomes included complications, length of stay, adverse events, and cost.

RESULTS

Fifteen (1 randomised, 2 prospective case-controlled, and 12 retrospective cohort) studies were analysed comprising 909 cases with HTG-AP. Pooled results demonstrated IT was significantly less efficient than BPT in Δ-TG at 24 h (WMD -666.06, 95% CI -1130.18 to -201.94, P = 0.005; 12 studies), at 48 h (WMD -672.60, 95% CI -1233.44 to -111.77; 8 studies), and overall Δ-TG by day 7 (WMD -385.81, 95% CI -711.07 to -60.54; 8 studies) (both P = 0.02). IT, however, was associated with significantly fewer adverse events (OR 0.09, 95% CI 0.03 to 0.27, P < 0.0001; 7 studies) and significantly reduced cost (WMD -2.50, 95% CI -3.61 to -1.39, P < 0.00001; 3 studies). Other secondary outcomes were not significantly different between the two regimens (all P ≥ 0.11). In subgroup analysis Δ-TG at 24 h and overall Δ-TG became insignificant, while other results were unaffected.

CONCLUSION

Our findings support the general use of IT for inpatient management of HTG-AP, restricting BPT to those predicted or found to respond poorly to IT.

Plasmapheresis as an Alternative Treatment of Hypertriglyceridemia-Induced Pancreatitis: A Case Report

Hypertriglyceridemia-induced pancreatitis is a relatively common form of acute pancreatitis that may represent up to 10% of all etiologies of this condition. Due to its specific pathogenic mechanisms related to high serum triglyceride levels, different treatment options have been proposed, including insulin perfusion, heparin perfusion, and plasmapheresis. Although the superiority of plasmapheresis in this clinical setting has not been demonstrated in randomized clinical trials, many centers have reported its effectiveness and considered this as a possible alternative according to the current guidelines. We report a case of a young patient diagnosed with hypertriglyceridemia-induced pancreatitis that was successfully treated with plasmapheresis. Since complications associated with plasmapheresis are rare and other therapeutic options may not be so effective or safe, we believe that this should be a valid alternative treatment that may be offered to these patients. More studies are still needed to further evaluate its effectiveness and to elucidate if there is a subset of patients in whom treatment with plasmapheresis may be more beneficial.

Protective effects of HTD4010, a Reg3a/PAP-derived peptide, in a mouse model of hypertriglyceridemic acute pancreatitis: Involvement of TLR4/NF-kappa B

Acute pancreatitis (AP) is an inflammatory disorder of pancreas and common digestive diseases, effective drug for AP is few. As an analog of active center of Reg3α, the biological activities of HTD4010 are similar to Reg3α. This study aimed to explore whether HTD4010 could decrease the inflammatory response and pancreatic injury in hypertriglyceridemic-AP (HTG-AP), and explore underlying mechanisms. This study was shown that the administration of HTD4010 could decrease the inflammatory response, reduce acinar cell injury (both apoptosis and necroptosis) and damage of lung tissue in HTG-AP. Moreover, HTD4010 down-regulated the expression of TLR4 and NF-κB protein. These results showed that HTD4010 could alleviate the severity of AP possibly by TLR4/NF-κB signaling pathway in HTG-AP.

Blood Purification for Hypertriglyceridemia-Induced Acute Pancreatitis: A Meta-analysis

OBJECTIVES

The purpose of our study is to investigate the efficacy and safety of blood purification (BP) therapy in hypertriglyceridemia-induced acute pancreatitis.

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science databases for articles published.

RESULTS

The analysis included 13 studies with 934 patients (263 in BP group, 671 in control group). There was no difference in efficacy and safety between the BP group and the control group (all P > 0.05). Compared with conventional treatment, BP had shorter hospital stay (mean difference, -4.96; 95% confidence interval [CI], -8.81 to -1.11; P = 0.01) in the case of similar mortality and complications. Meanwhile, insulin treatment showed similar mortality to BP, but fewer local complications (odds risk, 2.18; 95% CI, 1.13-4.20; P = 0.02) and shorter hospital stay (mean difference, 5.46; 95% CI, 0.64-10.29; P = 0.03).

CONCLUSIONS

In the treatment of hypertriglyceridemia-induced acute pancreatitis, BP methods are effective in accelerating triglyceride level reduction and shortening hospital stay but do not affect the efficacy or reduce mortality significantly compared with conventional treatment. Insulin therapy has the same effect as BP but decreases incidence of complications and cost.

Effects of Lipolysis-Stimulated Lipoprotein Receptor on Tight Junctions of Pancreatic Ductal Epithelial Cells in Hypertriglyceridemic Acute Pancreatitis

Objective

We investigated the effects of lipolysis-stimulated lipoprotein receptor (LSR) on the tight junctions (TJs) of pancreatic ductal epithelial cells (PDECs) in hypertriglyceridemic acute pancreatitis (HTGAP).

Methods

Sprague-Dawley rats were fed standard rat chow or a high-fat diet and injected with sodium taurocholate to obtain normal and HTGAP rats, respectively. Serum triglyceride (TG) levels, pathological changes, TJ proteins in the pancreas, and TJ ultrastructure of PDECs were assessed. LSR overexpression (OE) and knockdown (KD) HPDE6-C7 models were designed and cultured in a high-fat environment. Protein levels were quantified by Western blotting. Cell monolayer permeability was detected using FITC-Dextran.

Results

Serum TG concentration and pancreatic scores were higher in the HTGAP group than in the normal group. Among the TJ proteins, LSR protein expression was significantly lower in the HTGAP group than in the acute pancreatitis (AP) group. Tricellulin (TRIC) expression in the pancreatic ductal epithelia was higher in the HTGAP group than in the AP group. The HTGAP group had lower TJ protein levels, wider intercellular space, and widespread cellular necrosis with disappearance of cell junction structures. In the cell study, TJ proteins were downregulated and the cellular barrier was impaired by palmitic acid (PA), which was reversed by LSR-OE, whereas LSR-KD downregulated the TJ proteins and aggravated PA-induced cellular barrier impairment.

Conclusions

Hypertriglyceridemia downregulates the TJ proteins in PDECs, which may impair the pancreatic ductal mucosal barrier function. LSR regulation can change the effects of HTG on cellular barrier function by upregulating the TJ proteins.

Hypertriglyceridaemia-Induced Acute Pancreatitis: A Different Disease Phenotype

Acute pancreatitis (AP) is the most common gastrointestinal indication requiring hospitalisation. Severe hypertriglyceridaemia (HTG) is the third most common aetiology of AP (HTGAP), with a complication rate and severity that are higher than those of other aetiologies (non-HTGAP). The aim of this study was to evaluate the supposedly higher complication rate of HTGAP compared to non-HTGAP. The secondary objectives were to find different biomarkers for predicting a severe form. This was a retrospective study that included patients admitted with AP in a tertiary department of gastroenterology and hepatology. The patients were divided into two groups: HTGAP and non-HTGAP. We searched for differences regarding age, gender, the presence of diabetes mellitus (DM), the severity of the disease, the types of complications and predictive biomarkers for severity, hospital stay and mortality. A total of 262 patients were included, and 11% (30/262) of the patients had HTGAP. The mean ages were 44.4 ± 9.2 in the HTGAP group and 58.2 ± 17.1 in the non-HTGAP group, p < 0.0001. Male gender was predominant in both groups, at 76% (23/30) in the HTGAP group vs. 54% (126/232) in non-HTGAP, p = 0.02; 53% (16/30) presented with DM vs. 18% (42/232), p < 0.0001. The patients with HTG presented higher CRP 48 h after admission: 207 mg/dL ± 3 mg/dL vs. non-HTGAP 103 mg/dL ± 107 mg/dL, p < 0.0001. Among the patients with HTGAP, there were 60% (18/30) with moderately severe forms vs. 30% (71/232), p = 0.001, and 16% (5/30) SAP vs. 11% (27/232) in non-HTGAP, p = 0.4 Among the predictive markers, only haematocrit (HT) and blood urea nitrogen (BUN) had AUCs > 0.8. According to a multiple regression analysis, only BUN 48 h was independently associated with the development of SAP (p = 0.05). Diabetes mellitus increased the risk of developing severe acute pancreatitis (OR: 1.3; 95% CI: 0.1963−9.7682; p = 0.7). In our cohort, HTGAP more frequently had local complications compared with non-HTGAP. A more severe inflammatory syndrome seemed to be associated with this aetiology; the best predictive markers for complicated forms of HTGAP were BUN 48 h and HT 48 h.

Randomized controlled trial: neostigmine for intra-abdominal hypertension in acute pancreatitis

Background

Intra-abdominal hypertension (IAH) in acute pancreatitis (AP) is associated with deterioration in organ function. This trial aimed to assess the efficacy of neostigmine for IAH in patients with AP.

Methods

In this single-center, randomized trial, consenting patients with IAH within 2 weeks of AP onset received conventional treatment for 24 h. Patients with sustained intra-abdominal pressure (IAP) ≥ 12 mmHg were randomized to receive intramuscular neostigmine (1 mg every 12 h increased to every 8 h or every 6 h, depending on response) or continue conventional treatment for 7 days. The primary outcome was the percent change of IAP at 24 h after randomization.

Results

A total of 80 patients were recruited to neostigmine (n = 40) or conventional treatment (n = 40). There was no significant difference in baseline parameters. The rate of decrease in IAP was significantly faster in the neostigmine group compared to the conventional group by 24 h (median with 25th–75th percentile: −18.7% [− 28.4 to − 4.7%] vs. − 5.4% [− 18.0% to 0], P = 0.017). This effect was more pronounced in patients with baseline IAP ≥ 15 mmHg (P = 0.018). Per-protocol analysis confirmed these results (P = 0.03). Stool volume was consistently higher in the neostigmine group during the 7-day observational period (all P < 0.05). Other secondary outcomes were not significantly different between neostigmine and conventional treatment groups.

Conclusion

Neostigmine reduced IAP and promoted defecation in patients with AP and IAH. These results warrant a larger, placebo-controlled, double-blind phase III trial.

Trial registration Clinical Trial No: NCT02543658 (registered August /27, 2015).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03922-4.

Hypertriglyceridemia Acute Pancreatitis: Animal Experiment Research

In recent years, the number of acute pancreatitis cases caused by hypertriglyceridemia has increased gradually, which has caught the attention of the medical community. However, because the exact mechanism of hypertriglyceridemic acute pancreatitis (HTG-AP) is not clear, treatment and prevention in clinical practice face enormous challenges. Animal models are useful for elucidating the pathogenesis of diseases and developing and testing novel interventions. Therefore, animal experiments have become the key research means for us to understand and treat this disease. We searched almost all HTG-AP animal models by collecting many studies and finally collated common animals such as rats, mice and included some rare animals that are not commonly used, summarizing the methods to model spontaneous pancreatitis and induce pancreatitis. We sorted them on the basis of three aspects, including the selection of different animals, analyzed the characteristics of different animals, different approaches to establish hypertriglyceridemic pancreatitis and their relative advantages and disadvantages, and introduced the applications of these models in studies of pathogenesis and drug therapy. We hope this review can provide relevant comparisons and analyses for researchers who intend to carry out animal experiments and will help researchers to select and establish more suitable animal experimental models according to their own experimental design.

Identification and Validation of Hub Genes in Acute Pancreatitis and Hypertriglyceridemia

BACKGROUND

The pathogenesis of acute pancreatitis (AP) and the relationship between acute pancreatitis and hypertriglyceridemia are complex and not fully understood. The purpose of this study was to identify the hub genes along with common differentially expressed genes (DEGs) between acute pancreatitis and hypertriglyceridemia.

METHODS

We downloaded three gene expression profiles of AP and one gene expression profile of hypertriglyceridemia from the Gene Expression Omnibus (GEO) database and filtered the DEGs based on the above four datasets. Next, we identified the hub genes by performing the Gene Ontology (GO) term analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis, and protein-protein interaction (PPI) construction. We also constructed the miRNA-hub gene network and established mouse models with hypertriglyceridemia and AP using a high-fat diet and injection of caerulein (CAE), respectively. Finally, the immunohistochemical analysis was used to verify the differential expressions of hub genes in AP, hypertriglyceridemia, and normal pancreatic tissue.

RESULTS

A total of 105 DEGs associated with AP and 149 DEGs associated with hypertriglyceridemia were identified. Additionally, we identified six hub genes of AP, all of which were closely related to the cytoskeleton while two DEGs genes were common in both AP and hypertriglyceridemia. We also verified their expression in mouse models. Finally, a network of miRNA-mRNA was also constructed, and the top seven interactive miRNAs (hsa-mir-1-3p, hsa-mir-5195-3p, hsa-mir-145-5p, hsa-let-7b-5p, hsa-mir-10b-5p, hsa-mir-206, and hsa-mir-613) targeting the most hub genes were identified.

CONCLUSION

Overall, we identified six hub genes associated with AP and two common DEGs associated with AP and hypertriglyceridemia along with seven miRNAs that may regulate AP. This study could provide new ideas for further elucidation of the pathogenesis of hypertriglyceridemia-induced acute pancreatitis in the future.

The Effect of Plasma Triglyceride-Lowering Therapy on the Evolution of Organ Function in Early Hypertriglyceridemia-Induced Acute Pancreatitis Patients With Worrisome Features (PERFORM Study): Rationale and Design of a Multicenter, Prospective, Observational, Cohort Study

Background: Acute pancreatitis (AP) is a potentially life-threatening inflammatory disease with multiple etiologies. The prevalence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) has been increasing in recent years. It is reported that early triglyceride (TG) levels were associated with the severity of the disease, and TG- lowering therapies, including medical treatment and blood purification, may impact the clinical outcomes. However, there is no consensus regarding the optimal TG-lowering therapy, and clinical practice varies greatly among different centers. Our objective is to evaluate the TG-lowering effects of different therapies and their impact on clinical outcomes in HTG-AP patients with worrisome features. Methods: This is a multicenter, observational, prospective cohort study. A total of approximately 300 patients with HTG-AP with worrisome features are planned to be enrolled. The primary objective of the study is to evaluate the relationship between TG decline and the evolution of organ failure, and patients will be dichotomized depending on the rate of TG decline. The primary outcome is organ failure (OF) free days to 14 days after enrollment. Secondary outcomes include new-onset organ failure, new-onset multiple-organ failure (MOF), new-onset persistent organ failure (POF), new receipt of organ support, requirement of ICU admission, ICU free days to day 14, hospital free days to day 14, 60-day mortality, AP severity grade (Based on the Revised Atlanta Classification), and incidence of systemic and local complications. Generalized linear model (GLM), Fine and Gray competing risk regression, and propensity score matching will be used for statistical analysis. Discussion: Results of this study will reveal the current practice of TG-lowering therapy in HTG-AP and provide necessary data for future trials.

Effect of abdominal fat distribution on severity of acute pancreatitis

Aim of the study

Obesity is a well-determined risk factor for acute pancreatitis. Increased visceral fat has been shown to increase the proinflammatory environment experienced by patients. In this study, we aimed to research the correlation between abdominal fat distribution parameters measured with computed tomography (CT) and severity of acute pancreatitis (AP).

Material and methods

The study included patients monitored due to AP in the internal medicine clinic of GOP Education and Research Hospital from January 2015 to December 2018. The Acute Physiology and Chronic Health Evaluation (APACHE) score, the Imrie score and the Bedside Index of Severity in Acute Pancreatitis (BISAP) scores were calculated. Advanced image processing analysis software (INFINIT Xelis, v 1.0.6.3) was used to calculate individual abdominal fat distribution parameters from CT screening with division of abdominal tissues. Measurements were performed from –50 to –250 Hounsfield units (HU) between vertebrae L2-L3.

Results

When mild and moderate AP groups were compared, there were statistically significant differences in duration of hospital stay and scoring (APACHE, Imrie and BISAP) (p < 0.001), while there were no significant differences in abdominal fat distribution parameters (p > 0.05). There was no significant correlation of visceral and subcutaneous fat volumes with development of systemic complications, while a significant correlation was identified for visceral to total fat tissue area ratio (VTR) with local complications (p < 0.001). Pearson correlation analysis found no correlations of mortality and pancreatitis severity with visceral (VFA) and subcutaneous fat area (SFA) (p > 0.05). Positive correlations were identified for VFA with Imrie, BISAP and APACHE scores (p < 0.01), and positive correlations were identified for visceral adipose tissue (VAT) with visceral to subcutaneous fat ratio (VSR) and APACHE scores (r = 0.256 and 0.252, respectively, p < 0.001). Positive correlations were identified for VTR and VSR ratios with BISAP scores (r = 0.266 and r = 0.277, respectively, p < 0.001).

Conclusions

In patients with AP diagnosis and abdominal CT scans, increased VFA and VTR ratio were found to be associated with increased AP clinical scores with no significant correlation identified in terms of local/systemic complication development. Our study shows that VFA is linked to AP clinical scoring systems and should be included in AP predictive scoring systems.

Acute pancreatitis due to severe hypertriglyceridemia in the COVID-19 era: The role of therapeutic plasma exchange

The psychosocial consequences of the COVID-19 pandemic caused multifaceted challenges in clinical and therapeutic practices. This was the case at the Therapeutic Apheresis Unit of the Padua University Hospital too. Several published reports describe the increase in alcohol and food addiction diseases. In this context, during the last months, the Padua Therapeutic Apheresis Unit treated many more patients with acute pancreatitis due to severe hypertriglyceridemia with therapeutic plasma exchange than in the previous ten years. Furthermore, retrospective cohort studies have been recently published describing the onset of acute pancreatitis during the COVID-19 infection even if, to date, there is still insufficient evidence to estabilish a direct causality. Anyway, the COVID-19 pandemic translated into changes of the overall disease prevalence scenario and therefore the Padua Therapeutic Apheresis Unit will need to reorganise its Therapeutic Apheresis activity.

Genetic Variants Associated With Increased Plasma Levels of Triglycerides, via Effects on the Lipoprotein Lipase Pathway, Increase Risk of Acute Pancreatitis

BACKGROUND & AIMS

Almost one third of adults in the West have increased plasma levels of triglycerides. Even mild to moderate hypertriglyceridemia (2-10 mmol/L or 177-886 mg/dL) is associated with an increased risk of acute pancreatitis. However, it is not clear whether hypertriglyceridemia is a cause or result of acute pancreatitis. Lipoprotein lipase degrades plasma triglycerides. Variants in LPL, APOA5, APOC3, ANGPTL3, and ANGPTL4, which regulate the lipoprotein lipase pathway, result in increased or reduced plasma triglyceride levels. We investigated associations between these variants and acute pancreatitis in a study of the general population.

METHODS

In a prospective cohort study, men and women randomly selected from the area of Copenhagen were invited to complete a questionnaire, undergo a physical examination, and provide blood samples for biochemical and genetic analyses, from 2003 through 2015. We obtained triglyceride measurements from 117,427 participants. We examined for 15 genetic variants that are associated with lipoprotein lipase function in DNA samples from 102,888 participants and analyzed data from 117,427 participants in observational analyses. Diagnoses of acute pancreatitis (970 diagnoses among participants in the genetic analysis and 527 among participants in the observational study) were obtained from Danish registries. We performed a 1-sample Mendelian randomization analysis in which specific variants were used as markers of the plasma level of triglycerides to determine the association between the plasma level of triglyceride and acute pancreatitis. We calculated unweighted, internally weighted, and externally weighted allele scores for each participant by adding numbers of triglyceride-increasing alleles.

RESULTS

The highest genetic allele score correlated with a higher plasma level of triglycerides of 0.54 mmol/L (48 mg/dL). Among participants with the highest vs the lowest genetic allele score, the odds ratio for acute pancreatitis was 1.55 (95% CI, 1.08-2.23). Using instrumental variable analysis, integrating the effect of genotype on both triglycerides levels and risk of acute pancreatitis, we associated higher unweighted allele scores with an increased risk of acute pancreatitis (odds ratio [OR], 1.76; 95% CI, 1.16-2.65), as well as internally weighted higher allele scores (OR, 1.41; 95% CI, 1.01-1.97) and externally weighted higher allele scores (OR, 1.44; 95% CI, 1.01-2.04). Every 1 mmol/L (89 mg/dL) increase in triglycerides was observationally associated with an increase in OR of 1.09 (95% CI, 1.05-1.14) after multivariable adjustment.

CONCLUSIONS

Based on an analysis of individuals with genetic variants associated with an increased level of triglycerides, via their effects on the lipoprotein lipase pathway, we associated an increased plasma levels of triglycerides with an increased risk of acute pancreatitis. Strategies to reduce plasma levels of triglycerides, by increasing lipoprotein lipase function, might be developed for prevention of acute pancreatitis.

Hypertriglyceridemic pancreatitis

Hypertriglyceridemic acute pancreatitis is an emerging issue in gastroenterology, frequently underdiagnosed in clinical practice. Despite the rarity of the disease, hypertriglyceridemia should be considered as a leading cause of acute pancreatitis, especially in defined subsets of patients. Primary and secondary forms of hypertriglyceridemia need to be considered and excluded during the diagnostic work-up of all patients with acute pancreatitis. An accurate diagnosis is crucial to establish an appropriate treatment and to reduce the risk of recurrences. The aim of the present article is to briefly review epidemiology, etiology, diagnosis and therapy of hypertriglyceridemic acute pancreatitis, based on a clinical and practical point of view.

Domino effect of pituitary growth hormone tumor complicated by diabetic ketoacidosis and pituitary apoplexy: a case report

BACKGROUND

Patients with growth hormone (GH)-secreting adenoma usually develop glucose intolerance. GH increases metabolic rate and, when secreted aberrantly, may result in metabolic syndrome. Herein, we examine the associations of pituitary tumor-induced secretion of hormone with insulin resistance and metabolic syndrome, and determine the relation of pituitary tumor apoplexy-induced diabetic ketoacidosis (DKA) and acute pancreatitis.

CASE PRESENTATION

A 44-year-old male with a history of hypertension presented to the emergency department of our hospital on February 14, 2019 with symptoms of headache, dizziness, and vomiting. Computed tomography of the head revealed pituitary tumor with bleeding. An ultrasound scan of the abdomen revealed fatty liver and acute pancreatitis. Further examination revealed the presence of DKA, hypertriglyceridemia, cortical hypofunction crisis and acute kidney injury. Surgical endoscopic resection of the pituitary tumor resection via the transsphenoidal approach was performed. The patient's postoperative recovery was remarkable.

CONCLUSIONS

Long-term growth hormone abnormality may trigger insulin resistance, leading to metabolic syndrome and impaired glucose and lipid metabolism. The pituitary adenoma apoplexy may also directly induce DKA, creating a domino effect, which further deteriorate the aberrant metabolism of glucose and lipids.

Identification of a Risk Profile for New-Onset Diabetes After Acute Pancreatitis

OBJECTIVES

There is a paucity of studies evaluating predictors of new-onset diabetes mellitus (DM) after acute pancreatitis (AP-related DM). We used a population-based database to evaluate predictors of AP-related DM.

METHODS

The Nationwide Readmissions Database (2010-2014) was used to identify all nondiabetic adults with an index primary diagnosis of AP. Multiple exclusions were applied to identify cohorts with and without AP-related DM. A case-control study was conducted to identify risk factors for developing AP-related DM within the calendar year.

RESULTS

We identified 2510 subjects with AP-related DM and 40,308 controls with AP who did not develop DM. Multivariable analysis revealed that increasing age (50-64 years; adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.14-1.60), male sex (aOR, 1.2; 95% CI, 1.03-1.40), lowest income quartile (aOR, 1.48; 95% CI, 1.18-1.84), Elixhauser comorbidity index of 3 or higher (aOR, 1.47; 95% CI, 1.23-1.75), components of metabolic syndrome (aOR, 2.12; 95% CI, 1.21-3.70), severe AP (aOR, 1.60; 95% CI, 1.34-1.90), and recurrent AP (aOR, 1.46; 95% CI, 1.24-1.72) were independently associated with increased risk of AP-related DM.

CONCLUSIONS

These population-level variables predictive of developing AP-related DM can potentially identify patients who may benefit from closer follow-up, intensive education, and implementation of preventative strategies.

Familial hypertriglyceridemia/polygenic hypertrigliceridemia

For decades, familial hypertriglyceridemia (HTG) has been considered a specific entity characterized by an increase in VLDL particles and an autosomal dominant inheritance pattern. In the genomics era, it has been proven that familial HTG, although it could be grouped in families, had a polygenic inheritance in which the phenotype would be determined by concomitant environmental factors. Hence its inclusion in the group of polygenic HTGs. Clinically, they are characterized by moderate HTG, with the consequent increase in cardiovascular risk, and in rare cases, by severe HTG with risk of acute pancreatitis. Treatment will be based on controlling environmental factors, implementing hygienic-dietetic measures and sometimes drugs, to reduce cardiovascular risk in moderate HTGs and acute pancreatitis risk in severe HTGs.

PPAR-Alpha Agonist Fenofibrate Combined with Octreotide Acetate in the Treatment of Acute Hyperlipidemia Pancreatitis

At present, there are more and more patients with acute hypertriglyceridemia pancreatitis in clinical practice. Common treatment measures include fasting and water withdrawal, fluid resuscitation, and somatostatin. In recent years, studies have pointed out that the PPARa agonist fenofibrate may help improve the condition of such patients. Therefore, through clinical research and analysis, we reported for the first time that fenofibrate combined with octreotide acetate has a more excellent effect in the treatment of patients with acute hypertriglyceridemia pancreatitis, and from the perspective of signal pathways, we revealed that the combination of the two drugs has an effect on NF-κB P65. The synergistic inhibitory effect proves that the combined treatment is beneficial to control inflammation, protect liver function, and improve the prognosis of patients. It is worthy of clinical promotion.