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Timmerhuis HC, van den Berg FF, Noorda PC, van Dijk SM, van Grinsven J, Sperna Weiland CJ, Umans DS, Mohamed YA, Curvers WL, Bouwense SAW, Hadithi M, Inderson A, Issa Y, Jansen JM, de Jonge PJF, Quispel R, Schwartz MP, Stommel MWJ, Tan ACITL, Venneman NG, Besselink MG, Bruno MJ, Bollen TL, Sieswerda E, Verdonk RC, Voermans RP, van Santvoort HC. Overuse and Misuse of Antibiotics and the Clinical Consequence in Necrotizing Pancreatitis: An Observational Multicenter Study. Ann Surg 2023; 278:e812-e819. [PMID: 36728517 DOI: 10.1097/sla.0000000000005790] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The use and impact of antibiotics and the impact of causative pathogens on clinical outcomes in a large real-world cohort covering the entire clinical spectrum of necrotizing pancreatitis remain unknown. SUMMARY BACKGROUND DATA International guidelines recommend broad-spectrum antibiotics in patients with suspected infected necrotizing pancreatitis. This recommendation is not based on high-level evidence and clinical effects are unknown. MATERIALS AND METHODS This study is a post-hoc analysis of a nationwide prospective cohort of 401 patients with necrotizing pancreatitis in 15 Dutch centers (2010-2019). Across the patient population from the time of admission to 6 months postadmission, multivariable regression analyses were used to analyze (1) microbiological cultures and (2) antibiotic use. RESULTS Antibiotics were started in 321/401 patients (80%) administered at a median of 5 days (P25-P75: 1-13) after admission. The median duration of antibiotics was 27 days (P25-P75: 15-48). In 221/321 patients (69%) infection was not proven by cultures at the time of initiation of antibiotics. Empirical antibiotics for infected necrosis provided insufficient coverage in 64/128 patients (50%) with a pancreatic culture. Prolonged antibiotic therapy was associated with Enterococcus infection (OR 1.08 [95% CI 1.03-1.16], P =0.01). Enterococcus infection was associated with new/persistent organ failure (OR 3.08 [95% CI 1.35-7.29], P <0.01) and mortality (OR 5.78 [95% CI 1.46-38.73], P =0.03). Yeast was found in 30/147 cultures (20%). DISCUSSION In this nationwide study of patients with necrotizing pancreatitis, the vast majority received antibiotics, typically administered early in the disease course and without a proven infection. Empirical antibiotics were inappropriate based on pancreatic cultures in half the patients. Future clinical research and practice must consider antibiotic selective pressure due to prolonged therapy and coverage of Enterococcus and yeast. Improved guidelines on antimicrobial diagnostics and therapy could reduce inappropriate antibiotic use and improve clinical outcomes.
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Affiliation(s)
| | - Fons F van den Berg
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism
| | | | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism
| | | | - Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam
| | | | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven
| | | | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden
| | - Yama Issa
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
- Department of Surgery, Gelre Hospital, Apeldoorn
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam
| | | | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort
| | | | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam
| | | | - Elske Sieswerda
- Department of Medical Microbiology
- Julius Center for Health Sciences and Primary Care, Utrecht University
| | - Robert C Verdonk
- Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein
| | - Rogier P Voermans
- Amsterdam Gastroenterology Endocrinology Metabolism
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam
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Siriviriyakul P, Sriko J, Somanawat K, Chayanupatkul M, Klaikeaw N, Werawatganon D. Genistein attenuated oxidative stress, inflammation, and apoptosis in L-arginine induced acute pancreatitis in mice. BMC Complement Med Ther 2022; 22:208. [PMID: 35927726 PMCID: PMC9351145 DOI: 10.1186/s12906-022-03689-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
Aim Acute pancreatitis is a common and potentially serious condition. However, a specific treatment for this condition is still lacking. Genistein, with its anti-oxidant and anti-inflammatory effects, could possibly be used to tackle the underlying pathophysiology of acute pancreatitis. Therefore, the aim of this study was to investigate the effects of genistein on oxidative stress, inflammation, and apoptosis in acute pancreatitis induced by L-arginine in mice. Methods Twenty-four male ICR mice were equally divided into 4 groups: Control (Con); Acute pancreatitis (AP) group: Two doses of i.p. 350 mg/100 g body weight (BW) of L-arginine were administered 1 h apart; AP and low-dose genistein (LG) group: mice were given i.p. injection of 10 mg/kg genistein 2 h prior to L-arginine injection followed by once-daily dosing for 3 days; and AP and high-dose genistein (HG) group: mice were given 100 mg/kg genistein with the similar protocol as the LG group. Pancreatic tissue was evaluated for histopathological changes and acinar cell apoptosis, malondialdehyde (MDA) levels, immunohistochemical staining for myeloperoxidase (MPO), nuclear factor-kappa beta (NF-kB), and 4-hydroxynonenal (4-HNE). Serum levels of amylase (AMY), c-reactive protein (CRP), and interleukin (IL)-6 were measured. Results Significant increases in the degree of acinar cell apoptosis, pancreatic MDA, serum IL-6 and amylase, MPO, NF-kB and 4-HNE positivity were observed in the AP group. All these parameters declined after low- and high-dose genistein treatment. Severe pancreatic inflammation, edema, and acinar cell necrosis were observed in the AP group. Significant improvement of histopathological changes was seen in both low- and high-dose genistein groups. There were no significant differences in any parameters between low and high doses of genistein. Conclusion Genistein could attenuate the severity of histopathological changes in acute pancreatitis through its anti-oxidant, anti-inflammatory, and anti-apoptotic properties. Supplementary Information The online version contains supplementary material available at 10.1186/s12906-022-03689-9.
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Niu DG, Li WQ, Huang Q, Yang F, Tian WL, Li C, Ding LA, Fang HC, Zhao YZ. Open necrosectomy combined with continuous positive drainage and prophylactic diverting loop ileostomy for late infected pancreatic necrosis: a retrospective cohort study. BMC Gastroenterol 2020; 20:212. [PMID: 32640995 PMCID: PMC7341608 DOI: 10.1186/s12876-020-01343-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 06/09/2020] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate an innovative open necrosectomy strategy with continuous positive drainage and prophylactic diverting loop ileostomy for the management of late infected pancreatic necrosis (LIPN). Methods Consecutive patients were divided into open necrosectomy (ON) group (n = 23), open necrosectomy with colonic segment resection (ON+CSR) group (n = 8) and open necrosectomy with prophylactic diverting loop ileostomy (ON+PDLI) group (n = 11). Continuous positive drainage (CPD) via double-lumen irrigation–suction tube (DLIST) was performed in ON+PDLI group. The primary endpoints were duration of organ failure after surgery, postoperative complication, the rate of re-surgery and mortality. The secondary endpoints were duration of hospitalization, cost, time interval between open surgery and total enteral nutrition (TEN). Results The recovery time of organ function in ON+PDLI group was shorter than that in other two groups. Colonic complications occurred in 13 patients (56.5%) in the ON group and 3 patients (27.3%) in the ON+PDLI group (p = 0.11). The length of stay in the ON+PDLI group was shorter than the ON group (p = 0.001). The hospitalization cost in the ON+PDLI group was less than the ON group (p = 0.0052). Conclusion ON+PDLI can avoid the intestinal dysfunction, re-ileostomy, the resection of innocent colon and reduce the intraoperative trauma. Despite being of colonic complications before or during operation, CPD + PDLI may show superior effectiveness, safety, and convenience in LIPN.
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Affiliation(s)
- Dong-Guang Niu
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Wei-Qin Li
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Qian Huang
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Fan Yang
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Wei-Liang Tian
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China
| | - Chen Li
- Oncology Department, Xintai people's Hospital, Tai'an, 271200, Shandong, China
| | - Lian-An Ding
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Hong-Chun Fang
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yun-Zhao Zhao
- Department of General Surgery, Jinling clinical college of Nanjing Medical University, Nanjing, 210002, Jiangsu, China. .,Department of General Surgery, Jinling clinical college of Nanjing Medical University, 305 East Zhongshan Road, Nanjing, 210000, Jiangsu, China.
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Sun J, Fu J, Zhong Y, Li L, Chen C, Wang X, Wang L, Hou Y, Wang H, Zhao R, Zhang X, Yamamoto M, Xu Y, Pi J. NRF2 mitigates acute alcohol-induced hepatic and pancreatic injury in mice. Food Chem Toxicol 2018; 121:495-503. [PMID: 30248482 DOI: 10.1016/j.fct.2018.09.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/20/2022]
Abstract
Binge alcohol drinking is an important health concern and well-known risk factor for the development of numerous disorders. Oxidative stress plays a critical role in the pathogenesis of acute alcoholism. Nuclear factor erythroid 2 like 2 (NRF2) is a master regulator of cellular adaptive response to oxidative insults. However, the role of NRF2 in acute alcoholism and associated pathologies remains unclear. We found that Nrf2-knockout (Nrf2-KO) mice had exaggerated hypoglycemia and hypothermia and increased mortality compared to wildtype mice after binge ethanol exposure. This phenotype was partially rescued by providing warm environment and/or glucose administration. Acute high dose of alcohol exposure resulted in substantially worsened liver and pancreatic injuries in Nrf2-KO mice. Importantly, deficiency of Nrf2 allowed severe pancreatitis and pancreatic β-cell injury with increased insulin secretion and/or leaking during binge ethanol exposure, which contributed to hypoglycemia. In contrast, a clinically used NRF2 activator dimethyl fumarate (DMF) protected against hypoglycemia and lethality induced by acute ethanol exposure. Furthermore, Nrf2-KO mice likely had defective hepatic acetaldehyde metabolism. Taken together, NRF2 plays an important protective role against acute binge alcohol-induced hepatic and pancreatic damage, which may be partially attributable to its primary regulating role in antioxidant response and impact on ethanol metabolism.
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Affiliation(s)
- Jing Sun
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Jingqi Fu
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China.
| | - Yang Zhong
- Department of Chemistry, School of Fundamental Sciences, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Lu Li
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Chengjie Chen
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Xiaolei Wang
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Linlin Wang
- School of Forensic Medicine, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Yongyong Hou
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Huihui Wang
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Rui Zhao
- School of Forensic Medicine, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Xixuan Zhang
- Department of Chemistry, School of Fundamental Sciences, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Masayuki Yamamoto
- Department of Medical Biochemistry, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8575, Japan
| | - Yuanyuan Xu
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China
| | - Jingbo Pi
- Program of Environmental Toxicology, School of Public Health, China Medical University, No. 77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, PR China.
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Ren Z, Wang X, Xu M, Yang F, Frank JA, Ke ZJ, Luo J. Binge ethanol exposure causes endoplasmic reticulum stress, oxidative stress and tissue injury in the pancreas. Oncotarget 2018; 7:54303-54316. [PMID: 27527870 PMCID: PMC5342343 DOI: 10.18632/oncotarget.11103] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/19/2016] [Indexed: 12/19/2022] Open
Abstract
Alcohol abuse is associated with both acute and chronic pancreatitis. Repeated episodes of acute pancreatitis or pancreatic injury may result in chronic pancreatitis. We investigated ethanol-induced pancreatic injury using a mouse model of binge ethanol exposure. Male C57BL/6 mice were exposed to ethanol intragastrically (5 g/kg, 25% ethanol w/v) daily for 10 days. Binge ethanol exposure caused pathological changes in pancreas demonstrated by tissue edema, acinar atrophy and moderate fibrosis. Ethanol caused both apoptotic and necrotic cell death which was demonstrated by the increase in active caspase-3, caspase-8, cleaved PARP, cleaved CK-18 and the secretion of high mobility group protein B1 (HMGB1). Ethanol altered the function of the pancreas which was indicated by altered levels of alpha-amylase, glucose and insulin. Ethanol exposure stimulated cell proliferation in the acini, suggesting an acinar regeneration. Ethanol caused pancreatic inflammation which was indicated by the induction of TNF-alpha, IL-1beta, IL-6, MCP-1 and CCR2, and the increase of CD68 positive macrophages in the pancreas. Ethanol-induced endoplasmic reticulum stress was demonstrated by a significant increase in ATF6, CHOP, and the phosphorylation of PERK and eiF-2alpha. In addition, ethanol increased protein oxidation, lipid peroxidation and the expression of iNOS, indicating oxidative stress. Therefore, this paradigm of binge ethanol exposure caused a spectrum of tissue injury and cellular stress to the pancreas, offering a good model to study alcoholic pancreatitis.
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Affiliation(s)
- Zhenhua Ren
- Department of Anatomy, School of Basic Medicine, Anhui Medical University, Hefei, China.,Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Xin Wang
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Mei Xu
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Fanmuyi Yang
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Jacqueline A Frank
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Zun-Ji Ke
- Department of Biochemistry, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jia Luo
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, Kentucky, USA.,Department of Biochemistry, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Kovacic S, Roginic S, Nemrava J, Gospocic K, Seferovic Saric M, Luetic K. Acute pancreatitis in two patients with Parkinson’s disease. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1312802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Sanja Kovacic
- Department of Neurology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
- Faculty of Medicine, University of Osijek, Josip Juraj Strosmayer, 31000 Osijek, Croatia
| | - Sinisa Roginic
- Department of Internal Medicine, General Hospital Zabok and Hospital of Croatian, Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Johann Nemrava
- Department of Surgery, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Ksenija Gospocic
- Department of Radiology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Maida Seferovic Saric
- Department of Neurology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Kresimir Luetic
- Clinic for Internal Medicine, University Hospital Sv. Duh, Sv. Duh 64, 10000 Zagreb, Croatia
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Ren Z, Yang F, Wang X, Wang Y, Xu M, Frank JA, Ke ZJ, Zhang Z, Shi X, Luo J. Chronic plus binge ethanol exposure causes more severe pancreatic injury and inflammation. Toxicol Appl Pharmacol 2016; 308:11-19. [PMID: 27538709 DOI: 10.1016/j.taap.2016.08.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/12/2016] [Accepted: 08/13/2016] [Indexed: 02/06/2023]
Abstract
Alcohol abuse increases the risk for pancreatitis. The pattern of alcohol drinking may impact its effect. We tested a hypothesis that chronic ethanol consumption in combination with binge exposure imposes more severe damage to the pancreas. C57BL/6 mice were divided into four groups: control, chronic ethanol exposure, binge ethanol exposure and chronic plus binge ethanol exposure. For the control group, mice were fed with a liquid diet for two weeks. For the chronic ethanol exposure group, mice were fed with a liquid diet containing 5% ethanol for two weeks. In the binge ethanol exposure group, mice were treated with ethanol by gavage (5g/kg, 25% ethanol w/v) daily for 3days. For the chronic plus binge exposure group, mice were fed with a liquid diet containing 5% ethanol for two weeks and exposed to ethanol by gavage during the last 3days. Chronic and binge exposure alone caused minimal pancreatic injury. However, chronic plus binge ethanol exposure induced significant apoptotic cell death. Chronic plus binge ethanol exposure altered the levels of alpha-amylase, glucose and insulin. Chronic plus binge ethanol exposure caused pancreatic inflammation which was shown by the macrophages infiltration and the increase of cytokines and chemokines. Chronic plus binge ethanol exposure increased the expression of ADH1 and CYP2E1. It also induced endoplasmic reticulum stress which was demonstrated by the unfolded protein response. In addition, chronic plus binge ethanol exposure increased protein oxidation and lipid peroxidation, indicating oxidative stress. Therefore, chronic plus binge ethanol exposure is more detrimental to the pancreas.
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Affiliation(s)
- Zhenhua Ren
- Department of Anatomy, School of Basic Medicine, Anhui Medical University, Hefei, Anhui, China 230032; Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Fanmuyi Yang
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Xin Wang
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Yongchao Wang
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Mei Xu
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Jacqueline A Frank
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Zun-Ji Ke
- Department of Biochemistry, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Zhuo Zhang
- Department of Toxicology and Cancer Biology, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Xianglin Shi
- Department of Toxicology and Cancer Biology, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Jia Luo
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY 40536, United States.
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Abstract
OBJECTIVES Severe necrotizing pancreatitis (SNP) is a disease with relevant morbidity and mortality until today. No specific therapy is in sight. Central α2 agonists such as clonidine and dexmedetomidine are known to have anti-inflammatory effects though the cholinergic anti-inflammatory pathway and are implemented in the clinical routine as adjunct sedative drugs. Their potential effect on SNP has not yet been tested. METHODS Severe necrotizing pancreatitis was induced in male Wistar rats. Four treatment groups received either clonidine or dexmedetomidine before (prophylactic) or after induction of SNP (therapeutic). After 12 hours, pancreatic morphologic injury, systemic proinflammatory high-mobility group box 1 protein, and pancreatic and pulmonary myeloperoxidase levels were evaluated. RESULTS Severe necrotizing pancreatitis was fully established 12 hours after induction. "Prophylactic" and "therapeutic" administration of clonidine and dexmedetomidine reduced pancreatic morphologic injury (P < 0.05 vs SNP), serum proinflammatory high-mobility group box 1 protein (P < 0.0001 vs SNP), as well as pancreatic and pulmonary myeloperoxidase levels (P < 0.01 vs SNP). CONCLUSIONS Prophylactic and therapeutic applications of the central α2 agonists clonidine and dexmedetomidine are effective to attenuate local and systemic injury in experimental SNP and should be evaluated in the clinical setting.
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Abstract
Acute pancreatitis is an acute inflammation of the pancreas. Several classification systems have been used in the past but were considered unsatisfactory. A revised Atlanta classification of acute pancreatitis was published that assessed the clinical course and severity of disease; divided acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis; discerned an early phase (first week) from a late phase (after the first week); and focused on systemic inflammatory response syndrome and organ failure. This article focuses on the revised classification of acute pancreatitis, with emphasis on imaging features, particularly on newly-termed fluid collections and implications for the radiologist.
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Affiliation(s)
- Ruedi F Thoeni
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, Medical School, PO Box 2829, San Francisco, CA 94126-2829, USA.
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Barauskas G, Ignatavičius P, Vitkauskienė A, Pundzius J, Dambrauskas Ž. Impact of etiology on course and outcomes of severe acute pancreatitis. MEDICINA-LITHUANIA 2015; 51:167-172. [PMID: 28705479 DOI: 10.1016/j.medici.2015.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 04/24/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Since the influence of etiological factors on the course and outcomes of acute pancreatitis (AP) is not fully understood yet, the aim of the study was to compare the outcomes of alcoholic and biliary severe acute pancreatitis (SAP). MATERIALS AND METHODS We investigated 81 patients with alcoholic and biliary SAP. Demographic data, etiologic factors, severity scores, intra-abdominal pressure, imaging studies, interventions, and treatment outcomes were prospectively entered into specially maintained database and subsequently analyzed. RESULTS No statistically significant difference was observed in the prevalence of SAP in biliary and alcoholic AP groups (P=0.429). Although, in the biliary SAP group patients were predominantly elderly women (P=0.003), the total in-hospital stay was longer in alcoholic SAP patients (P=0.021). The abdominal compartment syndrome developed more frequently (P=0.041) and necrosectomy was more frequently performed in alcoholic SAP group (not statistically significant). Although not statistically significant, a lower mortality rate among biliary SAP patients (25.0% vs. 13.5%) was observed. CONCLUSIONS We defined a trend toward decreased incidence of infected necrosis in larger volume (≥30%) pancreatic necrosis, absence of abdominal compartment syndrome, lower rate of necrosectomies, shorter in-hospital stay, and an insignificantly reduced mortality rate in biliary SAP patients, indicating more favorable course of biliary SAP.
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Affiliation(s)
- Giedrius Barauskas
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Povilas Ignatavičius
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Laboratory of Surgical Gastroenterology, Institute for Digestive System Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Astra Vitkauskienė
- Department of Laboratory Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Juozas Pundzius
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Žilvinas Dambrauskas
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Laboratory of Surgical Gastroenterology, Institute for Digestive System Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
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11
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Inflammatory profiling of early experimental necrotizing pancreatitis. Life Sci 2015; 126:76-80. [PMID: 25711429 DOI: 10.1016/j.lfs.2015.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/30/2014] [Accepted: 01/20/2015] [Indexed: 01/26/2023]
Abstract
AIMS Inflammatory mediators play a pivotal role in severe necrotizing pancreatitis (SNP). Therapeutic approaches aim at the early inflammatory liberation of cytokines to avoid systemic complications. The present study evaluates the kinetics of inflammatory mediator release in SNP. MAIN METHODS Experimental SNP was induced in male Wistar rats using the GDOC model. The animals were allocated into seven groups (n = 6/group). In group 1, sample harvesting was performed after sham operation while in groups 2-7 this was performed 1 h, 2 h, 4 h, 6 h, 9 h, and 12 h after initiation of SNP, respectively. Inflammatory mediator release,morphologic injury, and tissue MPO concentrations were evaluated between 1 and 12 h after induction. KEY FINDINGS Pancreatic injury showed a continuous increase over the observation period (p b 0.05, respectively). MPO levels in the pancreas and lungs increased until 12 h after induction (p b 0.05, respectively). Antiinflammatory IL-10 showed an early peak and the pro-inflammatory mediators TNFα and IL-1β peaked after 6 and 9 h, respectively (p b 0.05, respectively). HMGB1 levels constantly increased over time (p b 0.05, respectively). SIGNIFICANCE The present study shows the release of relevant pro- and anti-inflammatory mediators in SNP for the first time in one single experimental setup. Inflammatory mediators peak within the first few hours after SNP induction. Consequently, the effect of therapeutic approaches on early changes in cytokine release should be evaluated later than 2 h after initiation.
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Barauskas G, Ignatavičius P, Vitkauskienė A, Pundzius J, Dambrauskas Ž. Impact of etiology on course and outcomes of severe acute pancreatitis. Medicina (B Aires) 2015; 51:167-172. [DOI: 10.1016/j.medici.2015.04.002 free article] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
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Aranda-Narváez JM, González-Sánchez AJ, Montiel-Casado MC, Titos-García A, Santoyo-Santoyo J. Acute necrotizing pancreatitis: Surgical indications and technical procedures. World J Clin Cases 2014; 2:840-845. [PMID: 25516858 PMCID: PMC4266831 DOI: 10.12998/wjcc.v2.i12.840] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 10/07/2014] [Accepted: 10/27/2014] [Indexed: 02/05/2023] Open
Abstract
Necrosis of pancreatic parenchyma or extrapancreatic tissues is present in 10%-20% of patients with acute pancreatitis, defining the necrotizing presentation frequently associated with high morbidity and mortality rates. During the initial phase of acute necrotizing pancreatitis the most important pillars of medical treatment are fluid resuscitation, early enteral nutrition, endoscopic retrograde colangiopancreatography if associated cholangitis and intensive care unit support. When infection of pancreatic or extrapancreatic necrosis occurs, surgical approach constitutes the most accepted therapeutic option. In this context, we have recently assited to changes in time for surgery (delaying the indication if possible to around 4 wk to deal with “walled-off” necrosis) and type of access for necrosectomy: from a classical open approach (with closure over large-bore drains for continued postoperative lavage or semiopen techniques with scheduled relaparotomies), trends have changed to a “step-up” philosophy with initial percutaneous drainage and posterior minimally invasive or endoscopic access to the retroperitoneal cavity for necrosectomy if no improvement has been previously achieved. These approaches are progressively gaining popularity and morbidity and mortality rates have decreased significantly. Therefore, a staged, multidisciplinary, step-up approach with minimally invasive or endoscopic access for necrosectomy is widely accepted nowadays for management of pancreatic necrosis.
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Nunes QM, Mournetas V, Lane B, Sutton R, Fernig DG, Vasieva O. The heparin-binding protein interactome in pancreatic diseases. Pancreatology 2013; 13:598-604. [PMID: 24280576 DOI: 10.1016/j.pan.2013.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 07/23/2013] [Accepted: 08/14/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The cellular microenvironment plays an important role in the regulation of homoeostasis and is a source of potential biomarkers and drug targets. In a genome-wide analysis the extracellular proteins that bind to heparin (HBPs) have been shown to form highly modular and interconnected extracellular protein regulatory networks. Using a systems biology approach, we have investigated the role of HBP networks in the normal pancreas and pancreatic digestive diseases. METHODS Lists of mRNAs encoding for HBPs associated with the normal pancreas (NP), acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) were obtained using public databases and publications. Networks of the putative protein interactomes derived from mRNA expression data of HBPs were built and analysed using cluster analysis, gene ontology term enrichment and canonical pathways analysis. RESULTS The extracellular heparin-binding putative protein interactomes in the pancreas were better connected than their non heparin-binding counterparts, having higher clustering coefficients in the normal pancreas (0.273), acute pancreatitis (0.457), chronic pancreatitis (0.329) and pancreatic ductal adenocarcinoma (0.269). 'Hepatic Fibrosis/Hepatic Stellate Cell Activation' appears to be a significant canonical pathway in pancreatic homoeostasis in health and disease with a large number of important HBPs. CONCLUSIONS Our analyses clearly demonstrate that HBPs form disease-specific and highly connected networks that can be explored for potential biomarkers and as collective drug targets via the modification of heparin binding properties.
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Affiliation(s)
- Q M Nunes
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Daulby Street, Liverpool L69 3GA, United Kingdom.
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Wang JH, Sun GF, Zhang J, Shao CW, Zuo CJ, Hao J, Zheng JM, Feng XY. Infective severe acute pancreatitis: A comparison of 99mTc-ciprofloxacin scintigraphy and computed tomography. World J Gastroenterol 2013; 19:4897-4906. [PMID: 23946594 PMCID: PMC3740419 DOI: 10.3748/wjg.v19.i30.4897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 04/12/2013] [Accepted: 05/17/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate 99mTc-ciprofloxacin scintigraphy compared with computed tomography (CT) for detecting secondary infections associated with severe acute pancreatitis (SAP) in swine.
METHODS: Six healthy swine were assigned to a normal control group (group A, n = 6). SAP was induced in group B (n = 9) and C (n = 18), followed by inoculation of the resulting pancreatic necroses with inactive Escherichia coli (E. coli) (group B) and active E. coli (group C), respectively. At 7 d after inoculation, a CT scan and a series of analyses using infecton imaging (at 0.5, 1, 2, 3, 4 and 6 h after the administration of 370 MBq of intravenous infecton) were performed. The scintigrams were visually evaluated and semi-quantitatively analyzed using region of interest assignments. The differences in infecton uptake and changes in the lesion-background radioactive count ratios (L/B) in the 3 groups were recorded and compared. After imaging detection, histopathology and bacterial examinations were performed, and infected SAP was regarded as positive. The imaging findings were compared with histopathological and bacteriological results.
RESULTS: In group A, 6 animals survived without infection in the pancreas. In group B, 7/9 swine survived and one suffered from infection. In group C, 15/18 animals survived with infection. Hence, the number of normal, non-infected and infected SAP swine was 6, 6 and 16, respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the infecton method were 93.8% (15/16), 91.7% (11/12), 92.9% (26/28), 93.8% (15/16) and 91.7% (11/12), whereas these values for CT were 12.5% (2/16), 100.0% (12/12), 50.0% (14/28), 100.0% (2/2) and 46.2% (12/26), respectively. The changes in L/B for the infected SAP were significantly different from those of the non-infected and normal swine (P < 0.001). The mean L/B of the infectious foci at 0.5, 1, 2, 3, 4 and 6 h was 1.17 ± 0.10, 1.71 ± 0.30, 2.46 ± 0.45, 3.36 ± 0.33, 2.04 ± 0.37 and 1.1988 ± 0.09, respectively. At 3 h, the radioactive counts (2350.25 ± 602.35 k) and the mean L/B of the infectious foci were significantly higher than that at 0.5 h (P = 0.000), 1 h (P = 0.000), 2 h (P = 0.04), 4 h (P = 0.000) and 6 h (P = 0.000).
CONCLUSION: 99mTc-ciprofloxacin scintigraphy may be an effective procedure for detecting SAP secondary infections with higher sensitivity and accuracy than CT.
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17
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Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology 2012; 262:751-64. [PMID: 22357880 DOI: 10.1148/radiol.11110947] [Citation(s) in RCA: 244] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.
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Affiliation(s)
- Ruedi F Thoeni
- University of California San Francisco Medical School, Department of Radiology and Biomedical Imaging, PO Box 1325, San Francisco, CA 94143-1325, USA.
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Abstract
The initial injury in acute pancreatitis is characteristically sterile and results in acinar cells necrosis. Intracellular contents released from damaged cells into the extracellular space serve as damage-associated molecular patterns (DAMPs) that trigger inflammation. There is increasing evidence that this sterile inflammatory response mediated through DAMPs released from necrotic acinar cells is a key determinant of further pancreatic injury, remote organ injury, and disease resolution in experimental models. A number of DAMPS, including high-mobility group box protein 1, DNA, adenosine triphosphate and heat shock protein 70, have been shown to have a role in experimental pancreatitis. Many of these DAMPs are also detectable in the human pancreatitis. Genetic deletion and pharmacologic antagonism demonstrate that specific DAMP receptors, including Toll-like receptor (TLR) 4, TLR9, and P2X7, are also required for inflammation in experimental acute pancreatitis. Downstream DAMP-sensing components include nod-like receptor protein 3, caspase 1, interleukin-1β (IL-1), IL-18, and IL-1 receptor, and also are required for full experimental pancreatitis. These DAMP-mediated pathways provide novel therapeutic targets using antagonists of TLRs and other receptors.
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Affiliation(s)
- Rafaz Hoque
- Section of Digestive Diseases, Yale University, New Haven, CT, USA
| | - Ahsan Malik
- Section of Digestive Diseases, Yale University, New Haven, CT, USA
| | - Fred Gorelick
- Section of Digestive Diseases, Yale University, New Haven, CT, USA
| | - Wajahat Mehal
- Section of Digestive Diseases, Yale University, New Haven, CT, USA
- Department of Immunobiology, Yale University, New Haven, CT, USA
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Abstract
Currently, patients with severe necrotizing pancreatitis rarely need interventional or surgical treatment. However, in case of pancreatic infection and septic complications they should be treated with the step up approach, primarily with an interventional or endoscopic drainage. If further clinical deterioration occurs necrosectomy is indicated. This should ideally be postponed until the third or fourth week after onset of pancreatitis to optimize surgical conditions including demarcation of the necrosis. Open necrosectomy with postoperative continuous lavage is a valid treatment option with low mortality, low morbidity and good long-term outcome. In recent years, several minimally invasive techniques for necrosectomy have been developed and are alternative approaches in about 70% of cases. In most cases, the retroperitoneoscopic approach is used, although the endoscopic transgastric route is also being used more and more frequently. While the reduced operative trauma should theoretically also reduce the onset of postoperative organ failure, no study has actually proven this.
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Affiliation(s)
- J Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universität Heidelberg, Heidelberg, Deutschland.
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Petrov MS, Chong V, Windsor JA. Infected pancreatic necrosis: Not necessarily a late event in acute pancreatitis. World J Gastroenterol 2011; 17:3173-6. [PMID: 21912463 PMCID: PMC3158390 DOI: 10.3748/wjg.v17.i27.3173] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 01/24/2011] [Accepted: 01/31/2011] [Indexed: 02/06/2023] Open
Abstract
It is widely believed that infection of pancreatic necrosis is a late event in the natural course of acute pancreatitis. This paper discusses the available data on the timing of pancreatic infection. It appears that infected pancreatic necrosis occurs early in almost a quarter of patients. This has practical implications for the type, timing and duration of preventive strategies used in these patients. There are also implications for the classification of severity in patients with acute pancreatitis. Given that the main determinants of severity are both local and systemic complications and that they can occur both early and late in the course of acute pancreatitis, the classification of severity should be based on their presence or absence rather than on when they occur. To do otherwise, and in particular overlook early infected pancreatic necrosis, may lead to a misclassification error and fallacies of clinical studies in patients with acute pancreatitis.
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