Systemic inflammatory response syndrome between 24 and 48 h after ERCP predicts prolonged length of stay in patients with post-ERCP pancreatitis: a retrospective study

Predicting Hospitalization, Organ Dysfunction, and Mortality in Post-Endoscopic Retrograde Cholangiopancreatography Acute Pancreatitis: Are SIRS and qSOFA Reliable Tools?

Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has shown constant incidence throughout time, despite advances in endoscopic technology, devices, or personal skills of the operating endoscopists, with prevention and prediction of severity in PEP being constant concerns. Several prospective studies have investigated the role of systemic inflammatory response syndrome (SIRS) criteria or the quick Sequential Organ Failure Assessment (qSOFA) score in the PEP severity assessment. However, there are no clearly defined tools for the prediction of PEP severity. Methods: A total of 403 patients were prospectively monitored 60 days after ERCP for the detection of PEP development. Consequently, we evaluated the lengths of stay, incidence of organic dysfunction, and mortality rates of these patients. The predictive power of the univariate model was evaluated by using the receiver operating characteristic curve and analyzing the area under the curve (AUC). Results: Incidence of PEP was similar to that reported in the majority of trials. The 60-day survival rate of PEP patients reached 82.8%. A qSOFA score ≥ 1 is a very good predictor for organ dysfunction (AUC 0.993, p < 0.0001). SIRS can also be considered a significant predictor for organic dysfunctions in PEP patients (AUC 0.926, p < 0.0001). However, only qSOFA was found to significantly predict mortality in PEP patients (AUC 0.885, p = 0.003), with SIRS criteria showing a much lower predictive power. Neither SIRS nor qSOFA showed any predictive value for the length of stay of PEP patients. Conclusion: Our study offers novel information about severity prediction in PEP patients. Both SIRS criteria and qSOFA showed good predictive value for organic dysfunction, mortality, and hospitalization.

The Neutrophil-Lymphocyte Ratio as an Early Predictive Marker of the Severity of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Background and objectives: Factors predictive of severe non-iatrogenic acute pancreatitis have been investigated, but few studies have evaluated prognostic markers of severe post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The neutrophil–lymphocyte ratio (NLR) has been studied for predicting severe acute pancreatitis. We examined the predictive value of NLR in patients with PEP. Materials and Methods: From January 2012 to August 2021, 125 patients who developed PEP were retrospectively evaluated. The NLR was measured before, and on days 1 and 2 after, ERCP. PEP was categorized as mild, moderate, or severe according to consensus guidelines, based on the prolongation of planned hospitalization. Patients were divided into two groups, mild-to-moderate vs. severe PEP. Results: We analyzed 125 patients with PEP, 18 (14.4%) of whom developed severe PEP. The baseline NLR was similar between the two groups (2.26 vs. 3.34, p = 0.499). The severe PEP group had a higher NLR than the mild/moderate PEP group on days 1 (11.19 vs. 6.58, p = 0.001) and 2 (15.68 vs. 5.32, p < 0.001) post-ERCP. The area under the curve of the NLR on days 1 and 2 post-ERCP for severe PEP was 0.75 (95% confidence interval (CI), 0.64–0.86)) and 0.89 (95% CI, 0.81–0.97), respectively; NLR on day 2 had greater power to predict severe PEP. The optimal cutoff value of the NLR on days 1 and 2 after ERCP for prediction of severe PEP was 7.38 (sensitivity, 72%; specificity, 69%) and 8.17 (sensitivity, 83%; specificity, 83%), respectively. In a multivariate analysis, a Bedside Index of Severity in Acute Pancreatitis score ≥3 (odds ratio (OR) 9.07, p = 0.012) and NLR on day 2 > 8.17 (OR 18.29, p < 0.001) were significantly associated with severe PEP. Conclusions: The NLR on day 2 post-ERCP is a reliable prognostic marker of severe PEP.

Acute Pancreatitis

Acute pancreatitis is one of the most common reasons for gastroenterology-related hospitalization in the United States. With significant morbidity and subsequent mortality related to both the acute presentation and subsequent sequelae, prompt diagnosis and appropriate management are critical, especially in the first 24 hours of illness. It is also important to accurately recognize complications, such as pancreatic fluid collections and vascular events, and identify a definitive cause so that a strategy to prevent future attacks can be implemented.

Early immune response in post endoscopic retrograde cholangiopancreatography pancreatitis as a model for acute pancreatitis

This opinion review summarizes comparison of clinical presentation and immunology of post-endoscopic pancreatitis and acute pancreatitis (AP) of other etiology. The rationale for this topic was found in studies that mention differences in clinical presentation between these entities, stating that severe form of AP after endoscopic retrograde cholangiopancreatography was more severe than AP of other etiology. Found difference in clinical presentation may have a background in different immunology that needs to be further investigated.

The Efficiency of Aggressive Hydration With Lactated Ringer Solution for the Prevention of Post-ERCP Pancreatitis: A Systematic Review and Meta-analysis

BACKGROUND

As shown in studies, aggressive hydration during the perioperative period of endoscopic retrograde cholangiopancreatography (ERCP) effectively prevents post-ERCP pancreatitis (PEP). We conducted a systematic review and meta-analysis to evaluate the clinical effectiveness and safety of aggressive hydration with lactated Ringer solution at preventing PEP.

MATERIALS AND METHODS

We searched all relevant research from PubMed, the Cochrane Library, Embase, the Web of Science, ClinicalTrial.gov, and Scopus database for randomized controlled trials (RCTs) published before March 2017. Reference lists from reviews or relevant articles were screened for RCTs. The primary outcomes were the incidence of PEP and the incidence of moderate to severe pancreatitis. The secondary outcomes were the incidence of hyperamylasemia and pain and the length of hospital stay. The meta-analysis was conducted using the Cochrane Program Review Manager.

RESULTS

Three RCTs were included in our study. On the basis of the results of the meta-analysis, the aggressive hydration group had a lower incidence of pancreatitis after ERCP [odds ratio (OR)=0.29; 95% confidence interval (CI), 0.16-0.53]; a lower incidence of moderate to severe PEP (OR=0.16; 95% CI, 0.03-0.96); lower incidence of hyperamylasemia (OR=0.38; 95% CI, 0.25-0.59); lower risk of pain (OR=0.17; 95% CI, 0.08-0.38); and a shorter duration of hospital stay (standardized mean difference=-0.41; 95% CI, -0.69 to -0.14).

CONCLUSIONS

Aggressive hydration with lactated Ringer solution can reduce the overall incidence of PEP, moderate to severe pancreatitis and hyperamylasemia, shorten the length of hospitalization and reduce pain.

Immature granulocytes predict severe acute pancreatitis independently of systemic inflammatory response syndrome

Introduction

Early prediction of severity of acute pancreatitis (AP) by a simple parameter that positively correlates with the activation stage of the immune system would be very helpful because it could influence the management and improve the outcome. Tumor necrosis factor α (TNF-α) and interleukin-1 (IL-1) play a critical role in the pathogenesis systemic inflammatory response syndrome (SIRS) and severity of AP. One of the effects of IL-1 and TNF-α is an increase in the number of immature granulocytes (IGs) in the peripheral blood.

Aim

To assess whether the IGs% in plasma could be an independent marker of AP severity.

Material and methods

A cohort of 77 patients with AP were prospectively enrolled in the study. The IGs were measured from whole blood samples obtained from the first day of hospitalization using an automated analyser.

Results

We observed 44 (57%) patients with mild AP, 21 (27%) patients with moderate severe AP (SAP) and 12 (16%) patients with SAP. The cut-off value of IGs was 0.6%. The IGs > 0.6% had a sensitivity, specificity, and positive and negative predictive value of 100%, 96%, 85.7%, and 100%, respectively (area under the curve (AUC) = 0.98). On admission, SIRS was present in 25 (32%) patients. We found that in patients who fulfilled at least two criteria for SIRS, SAP could be predicted with 75% sensitivity and 75.4% specificity, positive predictive value 36%, negative predictive value 94.2%.

Conclusions

The IGs% as a routinely obtained marker appears to be a promising, independent biomarker and a better predictor of early prognosis in SAP than SIRS and white blood cell.

Soluble urokinase-type plasminogen activator receptor (suPAR) in patients with acute pancreatitis (AP) - Progress in prediction of AP severity

BACKGROUND

Soluble urokinase-type plasminogen activator receptor (suPAR) is a glycoprotein secreted during inflammation and infections. Moreover, increased levels of suPAR are observed after hypoxia and ischaemia. The aim of the study was to assess whether suPAR could represent a useful marker of acute pancreatitis (AP) severity.

PATIENTS AND METHODS

We have observed a cohort of 126 prospectively enrolled patients. Based on the presence of persistent organ failure (more than 48 h) and local complications (diagnosis of moderate AP [MSAP]), patients were classified into three groups: mild AP (MAP), moderate and severe AP (SAP). The blood samples were taken on admission for detecting suPAR concentrations.

RESULTS

AP was considered severe in 33 patients (26.2%), MSAP was found in 37 patients (29.4%), and MAP was found in 56 patients (44,4%). The AUC for SAP predicted by suPAR was 0.993. The calculated cut-off point for prognosis SAP is 4.75 ng/mL. The BISAP score of ≥3 for detection of SAP had sensitivity and specificity of 94.6% and 63.6%, respectively. The AUC for severity predicted by BISAP amounted to 0.916. Additionally, suPAR turned out to be a good predictor of fatal AP: for the cut-off point 7.05 ng/mL, the AUC was 0.917. The AUC for death prediction in AP patients based on the BISAP score ≥3 was 0.894.

CONCLUSIONS

suPAR concentration is a promising new diagnostic and prognostic indicator in SAP obtainable in the early stage of disease. Larger studies are recommended to evaluate this role further.