The incidence and aetiology of acute pancreatitis across Europe

Genetic Variability in the CPA1 Gene and Its Impact on Acute Pancreatitis Risk: New Insights from a Large-Scale Study

Acute pancreatitis (AP) is a common and potentially lethal disease. Over the last 10 years, AP has become one of the most important healthcare problems. On a global scale, the incidence has increased by 63% over the last 20 years. AP is usually caused by gallstones and excessive alcohol consumption and genetic factors play an important role in the development of inflammation. Recent studies involving the CPA1 mutations are ambiguous and dependent on the population studied. In this study, the variability of the CPA1 gene in patients with AP was analyzed. Genetic material was isolated from the blood of 301 patients with AP and 184 healthy individuals. Identification of the variants in exons 5, 6, 8, and 9 with introns was performed using molecular biology methods. Mutations were identified by comparison to the reference sequence (NM_001868.4). Statistical analysis included the identification of mutations correlating with the risk of AP, the etiology of inflammation, and family history. Several novel mutations in the CPA1 gene have been identified, along with a high degree of variability within the coding region of the carboxypeptidase gene. A correlation between mutations CPA1:c.1072 + 84del; c.987 + 57G>A and increased risk of developing AP was found. Two protective mutations, CPA1:c.625A>T, c.1072 + 94del, were identified. The CPA1 gene is characterized by high sequence variability and regions in which mutations lead to an increased risk of developing AP. Single or co-occurring mutations of the CPA1 gene can significantly affect the risk of developing AP.

Predictive value of thrombin-antithrombin III complex and tissue plasminogen activator-inhibitor complex biomarkers in assessing the severity of early-stage acute pancreatitis

BACKGROUND AND AIM

The development of acute pancreatitis (AP) is strongly linked to blood clotting and fibrinolysis issues. Modern clinical practices now utilize advanced blood markers like thrombin-antithrombin III complex (TAT), plasmin-α2-plasmin inhibitor complex, thrombomodulin (TM), and tissue plasminogen activator-inhibitor complex (t-PAIC) to assess thrombosis risk. Our study used a highly sensitive chemiluminescence technique to measure these markers in AP patients, aiming to determine their early predictive value for AP severity.

METHODS

There were 173 patients with AP, all of whom developed symptoms within 72 h; 102 individuals had onset symptoms within 48 h. The biomarkers were measured upon admission before determining the severity of AP.

RESULTS

The levels of TAT, plasmin-α2-plasmin inhibitor complex, TM, and t-PAIC were significantly higher in the severe acute pancreatitis (SAP) group compared with the mild acute pancreatitis and moderate severe acute pancreatitis groups. For the patients within 72 h of onset, TAT, TM, and t-PAIC predicted the occurrence of SAP. For the patients within 48 h of onset, TAT and t-PAIC predicted the occurrence of SAP. The area under the curve (AUC) of prediction models is similar to Bedside Index for Severity in Acute Pancreatitis (BISAP) but significantly higher than C-reactive protein (P < 0.05). Notably, t-PAIC had a larger AUC than TAT, BISAP, and C-reactive protein.

CONCLUSION

In the initial 48 h, plasma TAT and t-PAIC levels may predict the development of SAP. Within 72 h, plasma levels of TAT, TM, and t-PAIC may predict the development of SAP, and the TAT + TM + t-PAIC prediction model achieved a maximum AUC of 0.915, comparable to BISAP.

DGA ameliorates severe acute pancreatitis through modulating macrophage pyroptosis

Severe acute pancreatitis (SAP) is an inflammatory disease with varying severity, ranging from mild local inflammation to severe systemic disease, with a high incidence rate and mortality. Current drug treatments are not ideal. Therefore, safer and more effective therapeutic drugs are urgently needed. 7α,14β-dihydroxy-ent-kaur-17-dimethylamino-3,15-dione DGA, a diterpenoid compound derivatized from glaucocalyxin A, exhibits anti-inflammatory activity. In this study, we demonstrated the therapeutic potential of DGA against SAP and elucidated the underlying mechanisms. Treatment with DGA markedly (1) inhibited death of RAW264.7 and J774a.1 cells induced by Nigericin and lipopolysaccharide, (2) alleviated edema, acinar cell vacuolation, necrosis, and inflammatory cell infiltration of pancreatic tissue in mice, and (3) inhibited the activity of serum lipase and the secretion of inflammatory factor IL-1β. DGA significantly reduced the protein expression of IL-1β and NLRP3 and inhibited the phosphorylation of NF-κB. However, DGA exhibited no inhibitory effect on the expression of caspase-1, gasdermin D (GSDMD), NF-κB, TNF-α, or apoptosis-associated speck-like protein (ASC) and on the cleavage of caspase-1 or GSDMD. Molecular docking simulation confirmed that DGA can bind to TLR4 and IL-1 receptor. In conclusion, DGA may effectively alleviate the symptoms of SAP in mice and macrophages by inhibiting the binding of TLR4 and IL-1 receptor to their ligands; therefore, DGA is a promising drug candidate for the treatment of patients with SAP.

A meta-analysis of Lactate Ringer's solution versus Normal Saline in the treatment of acute pancreatitis

Fluid resuscitation is an important way in the treatment of acute pancreatitis (AP). This meta-analysis aimed to compare the safety and efficacy of Lactate Ringer's solution (LR) and Normal Saline (NS) in the treatment of patients with acute pancreatitis. Searched in PubMed, Web of Science Core Collection (Clarivate), Embase, Cochrane Library, CNKI, China Wanfang, and China VIP database. All randomized controlled clinical trials (RCTs) were identified. Six studies with 431 patients were included. Compared with NS, LR can significantly reduce the incidence of SIRS at 24h, reduce the length of hospitalization, moderate-severe AP, ICU admission and local complications, especially pancreatic necrosis. It is safe and effective to choose LR for fluid resuscitation in AP, but due to the small number of included studies, multi-center and large-sample RCTs are still needed for further verification. PROSPERO registration number: CRD42022322788.

When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies

Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.

Establishment of trypsinogen-2 Amplification Luminescent Proximity Homogeneous Assay and its Application in Acute Pancreatitis

We aim to develop an amplified luminescence proximity homogeneous assay (AlphaLISA) for quantification of trypsinogen-2 levels in human serum for the diagnosis of acute pancreatitis. Based on new amplified luminescence proximity homogeneity assay (AlphaLISA) method, carboxyl-modified donor and acceptor beads were coupled to capture and detection antibodies. A double antibody sandwich immunoassay was used to detect the concentration of trypsinogen-2 in serum. The method had good linearity (> 0.998). The intra - analysis precision was between 1.54% and 2.20% (< 10%), the inter-analysis precision was between 3.17% and 6.94% (< 15%), and the recovery was between 96.23% and 103.45%. The cross-reactivity of carbohydrate antigen 242 (CA242) and T-cell immunoglobulin mucin-3 (Tim-3) were 0.09% and 0.93%, respectively. The detection time only needed 15 min. The results of trypsinogen-2-AlphaLISA and time-resolved fluorescence immunoassay were consistent (ρ = 0.9019). In addition, serum trypsinogen-2 concentration in patients with acute pancreatitis [239.23 (17.83-807.58) ng/mL] was significantly higher than that in healthy controls [20.54 (12.10-39.73) ng/mL]. When the cut-off value was 35.38ng/mL, the sensitivity and specificity were 91.8% and 96.67%, and the positive detection rate was 91.80%. We have successfully established a trypsinogen-2-AlphaLISA method, which can promote the timely diagnosis of acute pancreatitis.

The Role of Hematocrit Levels in Diagnosing the Severity of Acute Pancreatitis: A Cross-Sectional Study at a Tertiary Care Center in Nepal

Background and objective Acute pancreatitis (AP) is a frequent cause of hospitalization for gastrointestinal issues, with a significant proportion of cases requiring intensive care. Although various scoring systems are available to predict AP severity, they often involve inconvenience and can be time-consuming and expensive. Hematocrit, a simple, cost-effective, readily available hematological test, has been used to predict AP severity. However, its effectiveness has been inconsistent across different studies. In light of this, we aimed to analyze the role of hematocrit levels in determining AP severity. Methods We conducted a prospective study at Patan Hospital in Lalitpur, Nepal, from June 8, 2022, to June 27, 2023. Sixty-five AP patients were evaluated to determine the prognostic value of hematocrit at admission. The severity of AP was classified per the Revised Atlanta Classification. Results Among the patients, 52 (80%) had mild AP (MAP), five (7.69%) had moderately severe AP (MSAP), and eight (12.31%) had severe AP (SAP). The receiver operating characteristic (ROC) curve for admission hematocrit levels yielded an area under the curve (AUC) of 0.551 (95% CI: 0.423-0.675). A hematocrit cutoff value of 42% resulted in a sensitivity of 69.23% and a specificity of 46.15% for predicting severe AP (MSAP + SAP). Conclusions Based on our findings, hematocrit at admission is not a strong predictor of the severity of AP.

Association between diabetic status and risk of acute pancreatitis: A nationwide population-based study

OBJECTIVE

There have been several epidemiologic studies on the association between diabetes mellitus and acute pancreatitis. However, there is no solid evidence, and the effect of diabetes mellitus severity on acute pancreatitis incidence is not well known. This study aimed to evaluate the association between diabetic status and the risk of acute pancreatitis in a nationwide population-based cohort.

METHODS

Among the participants who underwent national health examinations between 2009 and 2012, patients with diabetes mellitus were included. Patients diagnosed with acute pancreatitis before the health examination or diagnosed with pancreatitis within 1 year following the examination were excluded. The association between the number of oral hypoglycemic agents (<3 or ≥3) or insulin use during examination and acute pancreatitis occurrence was analyzed after follow-up until December 31, 2018.

RESULTS

Overall, 2,444,254 patients were included in the final analysis. During the follow-up period, acute pancreatitis occurred in 10,360 patients with an incidence ratio of 0.585 per 1,000 person-years, and it was observed that the risk of acute pancreatitis sequentially increased between patients taking oral hypoglycemic agents <3 (incidence ratio = 0.546), those taking ≥3 (incidence ratio = 0.665), and those using insulin (incidence ratio = 0.872). The adjusted hazard ratios of patients taking three or more hypoglycemic agents and those using insulin were 1.196 (95% confidence interval (CI) 1.123-1.273) and 1.493 (95% CI 1.398-1.594), respectively.

CONCLUSIONS

As diabetes mellitus severity increases, the risk of acute pancreatitis increases.

Predictive Value of C-Reactive Protein/Albumin Ratio for Acute Kidney Injury in Patients with Acute Pancreatitis

Purpose

This study aims to evaluate the predictive efficacy of the C-reactive protein/albumin ratio (CAR), a cost-effective, easily accessible, and reproducible biomarker obtained from standard blood tests, in forecasting acute kidney injury (AKI) among patients undergoing acute pancreatitis (AP). Considering that changes in the CAR are associated with AKI incidence in AP cases, this work aims to explore whether CAR can be used as the innovative, inflammation-based diagnostic marker for AKI in AP patients.

Methods

The current retrospective cohort study consecutively enrolled AP patients admitted to First College of Clinical Medical Science of China Three Gorges University during the period from January 2019 to October 2023. Data were extracted systematically in electronic medical records from these hospitalized individuals, including baseline demographic and clinical characteristics. To ascertain the association of the CAR level with the development of AKI, we carried out multivariate logistic regression, adjusting for potential confounders. These confounders were initially identified through univariate regression. Furthermore, the potential effect modifiers in the relationship between CAR and AKI occurrence were explored by stratified logistic regression.

Results

Totally, 1514 AP were recruited, including 257 (16.9%) with AKI. CAR was positively correlated with AKI. When adjusting for potential confounders, the AKI risk in patients in the upper CAR tertile (2.628-22.994) increased by 83% relative to those in lower tertile (0.05-0.289) (OR 1.83, 95% CI 1.13-2.96, P = 0.013). The AKI risk tended to increase according to the increasing CAR tertile (P for trend = 0.013). No significant interactions were observed among subgroups based on age, sex, BMI, admission to ICU, hypertension, DM, chronic obstructive pulmonary disease, severity of AP, etiology of AP, demand for CRRT, mechanical ventilation, and blood transfusion (all P > 0.05).

Conclusion

A higher CAR is significantly related to the higher AKI incidence in AP patients in the Chinese population.

Retinal microvascular changes in patients with pancreatitis and their clinical significance

Acute pancreatitis, a common exocrine inflammatory disease affecting the pancreas, is characterized by intense abdominal pain and multiple organ dysfunction. However, the alterations in retinal blood vessels among individuals with acute pancreatitis remain poorly understood. This study employed optical coherence tomography angiography (OCTA) to examine the superficial and deep retinal blood vessels in patients with pancreatitis. Sixteen patients diagnosed with pancreatitis (32 eyes) and 16 healthy controls (32 eyes) were recruited from the First Affiliated Hospital of Nanchang University for participation in the study. Various ophthalmic parameters, such as visual acuity, intraocular pressure, and OCTA image for retina consisting of the superficial retinal layer (SRL) and the deep retinal layer (DRL), were recorded for each eye. The study observed the superficial and deep retinal microvascular ring (MIR), macrovascular ring (MAR), and total microvessels (TMI) were observed. Changes in retinal vascular density in the macula through annular partitioning (C1-C6), hemispheric quadrant partitioning (SR, SL, IL, and IR), and early diabetic retinopathy treatment studies (ETDRS) partitioning methods (R, S, L, and I). Correlation analysis was employed to investigate the relationship between retinal capillary density and clinical indicators. Our study revealed that in the superficial retinal layer, the vascular density of TMI, MIR, MAR, SR, IR, S, C2, C3 regions were significantly decreased in patients group compared with the normal group. For the deep retinal layer, the vascular density of MIR, SR, S, C1, C2 regions also reduced in patient group. The ROC analysis demonstrated that OCTA possesses significant diagnostic performance for pancreatitis. In conclusion, patients with pancreatitis may have retinal microvascular dysfunction, and OCTA can be a valuable tool for detecting alterations in ocular microcirculation in pancreatitis patients in clinical practice.

Acute Pancreatitis in Individuals with Sickle Cell Disease: A Systematic Review

Background/Objectives: Sickle cell disease (SCD) impacts about 100,000 people in the US. SCD increases the risk of cholelithiasis and microvascular ischemia, which could increase the risk of acute pancreatitis (AP). Abdominal pain is a common presenting symptom of AP and sickle cell vaso-occlusive crisis. The purpose of our systematic review is to estimate the prevalence and determine the severity of AP in individuals with SCD compared to the general population. Methods: Multiple electronic databases were searched. We included studies that included children and adults (population) and addressed the association of SCD (exposure) with AP (outcome) compared to the same population without SCD (control). Two authors screened titles and abstracts independently, and data were abstracted in duplication from included studies. We registered this protocol in PROSPERO-CRD42023422397. Results: Out of 296 studies screened from multiple electronic databases, we identified 33 studies. These studies included 17 case reports, one case series, and 15 retrospective cohort studies, and 18 studies included children. Eight of the AP case reports were in patients with HbSS genotype, two with sickle beta thalassemia, and one with HbSoArab, and in six case reports, a genotype was not specified. Complications were reported in 11 cases-respiratory complication (in at least four cases), splenic complications (three cases), pancreatic pseudocyst (two cases) and death from AP (one case). Of the four AP cases in the case series, three had HbSS genotype, and two cases had complications and severe pancreatitis. AP prevalence in SCD was estimated to be 2% and 7% in two retrospective studies, but they lacked a comparison group. In retrospective studies that evaluated the etiology of AP in children, biliary disease caused mostly by SCD was present in approximately 12% and 34%, respectively. Conclusions: Data on the prevalence of AP in individuals with SCD are limited. Prospectively designed studies aiming to proactively evaluate AP in individuals with SCD who present with abdominal pain are needed to improve timely diagnosis of AP in SCD and outcomes.

Pancreatic Cancer: A Review of Risk Factors

Pancreatic adenocarcinoma is one of the most lethal types of gastrointestinal cancer despite the latest medical advances. Its incidence has continuously increased in recent years in developed countries. The location of the pancreas can result in the initial symptoms of neoplasia being overlooked, which can lead to a delayed diagnosis and a subsequent reduction in the spectrum of available therapeutic options. The role of modifiable risk factors in pancreatic cancer has been extensively studied in recent years, with smoking and alcohol consumption identified as key contributors. However, the few screening programs that have been developed focus exclusively on genetic factors, without considering the potential impact of modifiable factors on disease occurrence. Thus, fully understanding and detecting the risk factors for pancreatic cancer represents an important step in the prevention and early diagnosis of this type of neoplasia. This review reports the available evidence on different risk factors and identifies the areas that could benefit the most from additional studies.

Incidence and impact of venous thromboembolism in hospitalized patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) and venous thromboembolism (VTE) remain common and potentially lethal disease entities. AP might be an important trigger of systemic inflammtion and may activate the coagulation system with increased VTE risk.

METHODS

The German nationwide inpatient sample was screened for patients admitted due to AP (ICD-code K85) 2005-2019. AP hospitalizations were stratified for VTE as well as risk-factors and the impact of VTE on in-hospital case-fatality rate were investigated.

RESULTS

Overall, 797,364 hospitalizations of patients due to AP (aged in median 56.0 [IQR 44.0-71.0] years), 39.2 % females) were detected in Germany 2005-2019. Incidence of VTE in hospitalized AP patients was 1764.8 per 100,000 hospitalizations (1.8 %) with highest VTE rate between 5th and 6th decade. Cancer (OR 1.656 [95 %CI 1.513-1.812], P < 0.001), any surgery (OR 4.063 [95 %CI 3.854-4.284], P < 0.001), and heart failure (OR 1.723 [95 %CI 1.619-1.833], P < 0.001) were independently associated with VTE occurrence. Case-fatality (8.8 % vs. 2.7 %, P < 0.001) was more than 3-fold higher in AP patients with than without VTE. VTE was associated with increased case-fatality in AP patients (OR 3.925 [95 %CI 3.684-4.181], P < 0.001).

CONCLUSIONS

VTE is a life-threatening event in hospitalized AP patients associated with an almost 4-fold increased case-fatality rate. Cancer, any surgery, thrombophilia and heart failure were important risk factors for occurrence of VTE in AP.

Association between monocyte-to-high-density lipoprotein-cholesterol ratio and gallstones in U.S. adults: findings from the National Health and Nutrition Examination Survey 2017-2020

BACKGROUND

Studies have indicated that monocyte-to-high-density lipoprotein cholesterol ratio (MHR) can be a reliable indicator of various diseases. However, the association between MHR and gallstone prevalence remains unclear. Therefore, this study aimed to explore any potential association between MHR and gallstone prevalence.

METHODS

This study used data from the National Health and Nutrition Examination Survey (NHANES) 2017-March 2020. MHR was calculated as the monocyte count ratio to high-density lipoprotein cholesterol levels. Multiple logistic regression models, Cochran-Armitage trend test, and subgroup analyses were used to examine the association between MHR and gallstones.

RESULTS

This study included 5907 participants, of whom 636 (10.77%) were gallstone formers. The study participants had a mean age of 50.78 ± 17.33 years. After accounting for multiple covariables, the multiple logistic regression model showed a positive linear association between MHR and gallstone odds. The subgroup analyses and interaction testing results revealed that the association between MHR and gallstones was statistically different across strata, including sex, smoking, asthma, and hypertension.

CONCLUSIONS

Gallstone prevalence positively associated with elevated MHR, indicating that MHR can be employed as a clinical indicator to assess gallstone prevalence.

Gallstones as a cause in presumed acute alcoholic pancreatitis: observational multicentre study

BACKGROUND

Data on the incidence and clinical relevance of gallstones in patients with suspected acute alcoholic pancreatitis are lacking and are essential to minimize the risk of recurrent acute pancreatitis. The aim of this study was to assess the incidence of gallstones and the associated rate of recurrent acute pancreatitis in patients with presumed acute alcoholic pancreatitis.

METHODS

Between 2008 and 2019, 23 hospitals prospectively enrolled patients with acute pancreatitis. Those diagnosed with their first episode of presumed acute alcoholic pancreatitis were included in this study. The term gallstones was used to describe the presence of cholelithiasis or biliary sludge found during imaging. The primary outcome was pancreatitis recurrence during 3 years of follow-up.

RESULTS

A total of 334 patients were eligible for inclusion, of whom 316 were included in the follow-up analysis. Gallstone evaluation, either during the index admission or during follow-up, was performed for 306 of 334 patients (91.6%). Gallstones were detected in 54 patients (17.6%), with a median time to detection of 6 (interquartile range 0-42) weeks. During follow-up, recurrent acute pancreatitis occurred in 121 of 316 patients (38.3%), with a significantly higher incidence rate for patients with gallstones compared with patients without gallstones (59% versus 34.2% respectively; P < 0.001), while more patients with gallstones had stopped drinking alcohol at the time of their first recurrence (41% versus 24% respectively; P = 0.020). Cholecystectomy was performed for 19 patients with gallstones (36%). The recurrence rate was lower for patients in the cholecystectomy group compared with patients who did receive inadequate treatment or no treatment (5/19 versus 19/34 respectively; P = 0.038).

CONCLUSION

Gallstones were found in almost one in every five patients diagnosed with acute alcoholic pancreatitis. Gallstones were associated with a higher rate of recurrent pancreatitis, while undergoing cholecystectomy was associated with a reduction in this rate.

Nomogram for the prediction of infected pancreatic necrosis in moderately severe and severe acute pancreatitis

OBJECTIVES

As a serious complication of moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN) can lead to a prolonged course of interventional therapy. Most predictive models designed to identify such patients are complex or lack validation. The aim of this study was to develop a predictive model for the early detection of IPN in MSAP and SAP.

METHODS

A total of 594 patients with MSAP or SAP were included in the study. To reduce dimensionality, least absolute shrinkage and selection operator regression analysis was used to screen potential predictive variables, a nomogram was then constructed using logistic regression analysis. The receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the discrimination, accuracy, and clinical efficacy of the model. External data were also obtained to further validate the constructed model.

RESULTS

There were 476, 118, and 82 patients in the training, internal validation, and external validation cohorts, respectively. Platelet count, hematocrit, albumin/globulin, severity of acute pancreatitis, and modified computed tomography severity index score were independent factors for predicting IPN in MSAP and SAP. The area under the ROC curves were 0.923, 0.940, and 0.817, respectively, in the three groups. There was a good consistency between the actual probabilities and the predicted probabilities. DCA revealed excellent clinical utility.

CONCLUSION

The constructed nomogram is a simple and feasible model that has good clinical predictive value and efficacy in clinical decision-making for IPN in MSAP and SAP.

A retrospective study of pregnant patients with acute pancreatitis

OBJECTIVE

Acute pancreatitis is a rare disease in pregnant patients. Although it may have serious maternal and fetal consequences, morbidity and mortality rates have decreased recently due to appropriate and rapid treatment with earlier diagnosis. The aim of this study was to evaluate pregnant patients diagnosed with acute pancreatitis.

METHODS

The study included pregnant patients diagnosed with acute pancreatitis who were admitted to Adana City Training and Research Hospital in Adana, Turkey, between January 2014 and January 2022. Patients' files were screened. Patients' demographics, acute pancreatitis etiology, severity, complications, and applied treatment, as well as maternal and fetal outcomes were evaluated.

RESULTS

The study included 65 pregnant patients with acute pancreatitis. The mean age was 26.6±5 (19-41) years. Acute pancreatitis was observed in the third trimester. The most common cause of acute pancreatitis was gallstones, and its severity was often mild. Only two patients required endoscopic retrograde cholangiopancreatography, and the remaining patients were treated medically. Maternal and infant death developed in a patient with necrotizing acute pancreatitis secondary to hyperlipidemia.

CONCLUSION

The most common etiology of acute pancreatitis in pregnancy was gallstones. Acute pancreatitis occurred in the third trimester. Most of the patients had mild acute pancreatitis. Maternal and fetal complications were rare. We think that the reasons for the low mortality rate were mild disease severity and biliary etiology, and most patients were in the third trimester, as well as early diagnosis and no delay in the intervention.

The red cell distribution width-to-albumin ratio: A simple index has high predictive accuracy for clinical outcomes in patients with acute pancreatitis

BACKGROUND/OBJECTIVES

Ongoing research is seeking to identify the best prognostic marker for acute pancreatitis (AP). The purpose of this study was to investigate the role of the red blood cell distribution width-to-albumin ratio (RAR) in the prognosis of AP.

METHODS

This 18-month prospective cohort study was conducted between June 2021 and December 2022 with patients diagnosed with AP. The patients were divided into two groups: severe AP (SAP) and non-severe AP. Factors associated with SAP within the first 48 h of admission were determined. In addition, RAR values at admission and at 48 h (RAR-48th) were calculated, and their ability to predict clinical outcomes was assessed. The primary outcomes were severe disease and in-hospital mortality.

RESULTS

Fifty (13.7 %) of 365 patients had SAP. Systemic inflammatory response syndrome, blood urea nitrogen, calcium, and RAR at 48 h after admission were independent predictors of SAP. When RAR-48th was >4.35, the risk of SAP increased approximately 18-fold (OR: 18.59; 95 % CI: 8.58-40.27), whereas no patients with a RAR-48th value of <4.6 died. For in-hospital mortality, the area under the curve (AUC) value of RAR-48th was 0.960 (95 % CI: 0.931-0.989), significantly higher than the AUC values of existing scoring systems. The results of RAR-48th were comparable to those of the other scoring systems with regard to the remaining clinical outcomes.

CONCLUSIONS

RAR-48th successfully predicted clinical outcomes, particularly in-hospital mortality. Being simple and readily calculable, RAR-48th is a promising alternative to burdensome and complex scoring systems for the prediction of clinical outcomes in AP.

The 2023 MANCTRA Acute Biliary Pancreatitis Care Bundle: A Joint Effort Between Human Knowledge and Artificial Intelligence (ChatGPT) to Optimize the Care of Patients With Acute Biliary Pancreatitis in Western Countries

OBJECTIVE

To generate an up-to-date bundle to manage acute biliary pancreatitis using an evidence-based, artificial intelligence (AI)-assisted GRADE method.

BACKGROUND

A care bundle is a set of core elements of care that are distilled from the most solid evidence-based practice guidelines and recommendations.

METHODS

The research questions were addressed in this bundle following the PICO criteria. The working group summarized the effects of interventions with the strength of recommendation and quality of evidence applying the GRADE methodology. ChatGPT AI system was used to independently assess the quality of evidence of each element in the bundle, together with the strength of the recommendations.

RESULTS

The 7 elements of the bundle discourage antibiotic prophylaxis in patients with acute biliary pancreatitis, support the use of a full-solid diet in patients with mild to moderately severe acute biliary pancreatitis, and recommend early enteral nutrition in patients unable to feed by mouth. The bundle states that endoscopic retrograde cholangiopancreatography should be performed within the first 48 to 72 hours of hospital admission in patients with cholangitis. Early laparoscopic cholecystectomy should be performed in patients with mild acute biliary pancreatitis. When operative intervention is needed for necrotizing pancreatitis, this should start with the endoscopic step-up approach.

CONCLUSIONS

We have developed a new care bundle with 7 key elements for managing patients with acute biliary pancreatitis. This new bundle, whose scientific strength has been increased thanks to the alliance between human knowledge and AI from the new ChatGPT software, should be introduced to emergency departments, wards, and intensive care units.

Etiological Changes and Prognosis of Hospitalized Patients with Acute Pancreatitis Over a 15-Year Period

BACKGROUND

The worldwide incidence of acute pancreatitis (AP) is increasing, but the dominant etiology of AP may vary by country. Mixed etiologies are involved in the increase in the number of AP patients.

AIMS

This study was to analyze the etiological changes and prognosis of AP patients and explore the prognosis of AP patients with mixed etiologies.

METHODS

Using a retrospective analysis method, AP patients hospitalized from January 2007 to December 2021 were selected from a pancreatic center in Nanchang, China. Trends in the main etiologies were analyzed, and the severity and prognosis of different etiologies were compared.

RESULTS

A total of 10,071 patients were included. Cholelithiasis (56.0%), hyperlipidemia (25.3%), and alcohol (6.5%) were the top three etiologies. The proportion of acute biliary pancreatitis (ABP) showed a decreasing trend, while the proportion of hypertriglyceridemic pancreatitis (HTGP) and alcoholic AP showed an increasing trend (all ptrend < 0.001). The incidence of organ failure and necrotizing pancreatitis was higher in patients with HTGP than in those with AP induced by other etiologies (all p < 0.05). There was no statistically significant difference in mortality among patients with different etiologies. Patients with AP due to a mixed hypertriglyceridemia-alcoholic etiology had higher ICU admission rates and were more severe than those with AP induced by other mixed etiologies.

CONCLUSION

In the past 15 years, the proportion of ABP has trended downward, while those of HTGP and alcoholic AP have risen. Among patients with mixed etiologies, those with a mixed hypertriglyceridemia-alcoholic etiology had a worse prognosis.

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

Structured alcohol cessation support program versus current practice in acute alcoholic pancreatitis (PANDA): Study protocol for a multicentre cluster randomised controlled trial

BACKGROUND/OBJECTIVES

The most important risk factor for recurrent pancreatitis after an episode of acute alcoholic pancreatitis is continuation of alcohol use. Current guidelines do not recommend any specific treatment strategy regarding alcohol cessation. The PANDA trial investigates whether implementation of a structured alcohol cessation support program prevents pancreatitis recurrence after a first episode of acute alcoholic pancreatitis.

METHODS

PANDA is a nationwide cluster randomised superiority trial. Participating hospitals are randomised for the investigational management, consisting of a structured alcohol cessation support program, or current practice. Patients with a first episode of acute pancreatitis caused by harmful drinking (AUDIT score >7 and < 16 for men and >6 and < 14 for women) will be included. The primary endpoint is recurrence of acute pancreatitis. Secondary endpoints include cessation or reduction of alcohol use, other alcohol-related diseases, mortality, quality of life, quality-adjusted life years (QALYs) and costs. The follow-up period comprises one year after inclusion.

DISCUSSION

This is the first multicentre trial with a cluster randomised trial design to investigate whether a structured alcohol cessation support program reduces recurrent acute pancreatitis in patients after a first episode of acute alcoholic pancreatitis, as compared with current practice.

TRIAL REGISTRATION

Netherlands Trial Registry (NL8852). Prospectively registered.

Identification of optimal reference genes in golden Syrian hamster with ethanol- and palmitoleic acid-induced acute pancreatitis using quantitative real-time polymerase chain reaction

BACKGROUND

Acute pancreatitis (AP) is a severe disorder that leads to high morbidity and mortality. Appropriate reference genes are important for gene analysis in AP. This study sought to study the expression stability of several reference genes in the golden Syrian hamster, a model of AP.

METHODS

AP was induced in golden Syrian hamster by intraperitoneal injection of ethanol (1.35 g/kg) and palmitoleic acid (2 mg/kg). The expression of candidate genes, including Actb, Gapdh, Eef2, Ywhaz, Rps18, Hprt1, Tubb, Rpl13a, Nono, and B2m, in hamster pancreas at different time points (1, 3, 6, 9, and 24 h) posttreatment was analyzed using quantitative polymerase chain reaction. The expression stability of these genes was calculated using BestKeeper, Comprehensive Delta CT, NormFinder, and geNorm algorithms and RefFinder software.

RESULTS

Our results show that the expression of these reference genes fluctuated during AP, of which Ywhaz and Gapdh were the most stable genes, whereas Tubb, Eef2, and Actb were the least stable genes. Furthermore, these genes were used to normalize the expression of TNF-α messenger ribonucleic acid in inflamed pancreas.

CONCLUSIONS

In conclusion, Ywhaz and Gapdh were suitable reference genes for gene expression analysis in AP induced in Syrian hamster.

Predictors of Pancreatitis Among Patients with Inflammatory Bowel Disease Treated with Vedolizumab: Observation from a Large Global Safety Database

BACKGROUND

Patients with inflammatory bowel diseases (IBDs) are at increased risk of pancreatitis. Data from a global safety database (GSD) were queried to identify risk factors for pancreatitis in vedolizumab-treated patients with IBD.

METHODS

Takeda's GSD was retrospectively queried for case reports (CRs) of adverse events (AEs) following vedolizumab treatment, from licensure (May 20, 2014) through March 31, 2021. Unsolicited and solicited CRs of pancreatitis were coded using the Medical Dictionary for Regulatory Activities (MedDRA) High-Level Term "Acute and chronic pancreatitis." To examine factors associated with severe pancreatitis, serious CRs (serious AEs [SAEs]) were compared with SAEs from a comparator group of 600 random non-pancreatitis AEs. Comparisons were performed using t, χ2, and Fisher's exact tests. Logistic regression was performed to adjust for covariates allowing backward selection.

RESULTS

In total, 196 patients reported pancreatitis in > 700,000 patient-years of vedolizumab exposure. Pancreatitis was serious in 195 patients (99.5%), and non-pancreatitis AEs were serious in 195 of 600 (32.5%) in the random comparator group. In the pancreatitis group, 17 patients (8.7%) had a known history of pancreatitis versus none in the random comparator group. Younger age, vedolizumab indication of ulcerative colitis, concomitant medications (with a risk for pancreatitis), pancreatitis history, and comorbid conditions (especially ongoing pancreatitis) were associated with development of severe pancreatitis.

CONCLUSIONS

These analyses identified factors associated with pancreatitis SAEs in patients with IBD treated with vedolizumab, but do not suggest an increased risk of pancreatitis with vedolizumab. These findings will help inform which patients treated for IBD might have an elevated risk, regardless of treatment.

Cause or Coincidence: A Case of Necrotizing Pancreatitis in the Setting of Herpes Simplex Virus Infection

This study explores a rare occurrence of acute pancreatitis induced by herpes simplex virus (HSV) in an immunocompetent adult. The patient, initially diagnosed with pancreatitis presumed to be gallstone-related, exhibited persistent symptoms and elevated lipase levels. Endoscopic ultrasound revealed necrotizing pancreatitis without stones, prompting suspicion of an atypical cause. Subsequent serology confirmed acute HSV infection. This case underscores the importance of considering viral etiologies in atypical pancreatitis cases, especially when hepatitis coexists. The study contributes to the limited literature on HSV-induced pancreatitis in immunocompetent individuals, emphasizing the significance of early recognition and appropriate management in the absence of typical risk factors.

Incidence and prognostic role of pleural effusion in patients with acute pancreatitis: a meta-analysis

BACKGROUND

Pleural effusion (PE) is reported as a common complication in acute pancreatitis (AP), while the incidence of PE in AP varies widely among studies, and the association between PE and mortality is not clear. This study aimed to comprehensively analyze the pooled incidence of PE in patients with AP and to evaluate the influence of PE on mortality through a meta-analysis.

METHOD

Six databases (PubMed, Web of Science, EMBASE, Cochrane, Scopus, and OVID) were searched thoroughly for relevant studies. Data were extracted, and Stata SE 16.0 software was applied to compute the pooled incidence of PE and assess the association between PE and mortality, taking the risk ratio (RR) as the effect size.

RESULTS

Thirty-five articles involving 7,675 patients with AP were eventually included in this meta-analysis. The pooled incidence of PE was 34% (95% CI: 28%-39%), with significant heterogeneity among studies (I2=96.7%). Further analysis revealed that the pooled incidence of unilateral and small PE occupied 49% (95% CI: 21%-77%) and 59% (95% CI: 38%-81%) of AP patients complicated by PE, respectively. The subgroup analysis revealed that "region" and "examination method" may contribute to heterogeneity. PE may be associated with increased mortality in AP patients (RR 3.99, 95% CI: 1.73-9.2).

CONCLUSION

This study suggested that PE is a common complication with high pooled incidence and that PE may be associated with increased mortality in AP patients. More studies should be performed to validate our findings.

Microenvironment of pancreatic inflammation: calling for nanotechnology for diagnosis and treatment

Acute pancreatitis (AP) is a common and life-threatening digestive disorder. However, its diagnosis and treatment are still impeded by our limited understanding of its etiology, pathogenesis, and clinical manifestations, as well as by the available detection methods. Fortunately, the progress of microenvironment-targeted nanoplatforms has shown their remarkable potential to change the status quo. The pancreatic inflammatory microenvironment is typically characterized by low pH, abundant reactive oxygen species (ROS) and enzymes, overproduction of inflammatory cells, and hypoxia, which exacerbate the pathological development of AP but also provide potential targeting sites for nanoagents to achieve early diagnosis and treatment. This review elaborates the various potential targets of the inflammatory microenvironment of AP and summarizes in detail the prospects for the development and application of functional nanomaterials for specific targets. Additionally, it presents the challenges and future trends to develop multifunctional targeted nanomaterials for the early diagnosis and effective treatment of AP, providing a valuable reference for future research.

Prospective multicentre study of indications for surgery in patients with idiopathic acute pancreatitis following endoscopic ultrasonography (PICUS)

BACKGROUND

Cholecystectomy in patients with idiopathic acute pancreatitis (IAP) is controversial. A randomized trial found cholecystectomy to reduce the recurrence rate of IAP but did not include preoperative endoscopic ultrasonography (EUS). As EUS is effective in detecting gallstone disease, cholecystectomy may be indicated only in patients with gallstone disease. This study aimed to determine the diagnostic value of EUS in patients with IAP, and the rate of recurrent pancreatitis in patients in whom EUS could not determine the aetiology (EUS-negative IAP).

METHODS

This prospective multicentre cohort study included patients with a first episode of IAP who underwent outpatient EUS. The primary outcome was detection of aetiology by EUS. Secondary outcomes included adverse events after EUS, recurrence of pancreatitis, and quality of life during 1-year follow-up.

RESULTS

After screening 957 consecutive patients with acute pancreatitis from 24 centres, 105 patients with IAP were included and underwent EUS. In 34 patients (32 per cent), EUS detected an aetiology: (micro)lithiasis and biliary sludge (23.8 per cent), chronic pancreatitis (6.7 per cent), and neoplasms (2.9 per cent); 2 of the latter patients underwent pancreatoduodenectomy. During 1-year follow-up, the pancreatitis recurrence rate was 17 per cent (12 of 71) among patients with EUS-negative IAP versus 6 per cent (2 of 34) among those with positive EUS. Recurrent pancreatitis was associated with poorer quality of life.

CONCLUSION

EUS detected an aetiology in a one-third of patients with a first episode of IAP, requiring mostly cholecystectomy or pancreatoduodenectomy. The role of cholecystectomy in patients with EUS-negative IAP remains uncertain and warrants further study.

Natural Course of Common Bile Duct Microlithiasis

BACKGROUND

Common bile duct microlithiasis (CBDM) with a diameter of ≤ 3 mm can pass spontaneously without causing any symptoms, but in some cases, it can also cause severe cholangitis and pancreatitis. The optimal strategy for managing CBDM is yet to be determined.

METHODS

Data of 154 patients with CBDM were collected and divided into two groups: with endoscopic retrograde cholangiopancreatography (with ERCP, n = 82) and without ERCP (n = 72). Clinical outcomes, including the incidence of unfavorable outcomes (UOs), such as cholangitis and pancreatitis, were observed and compared between the two groups.

RESULTS

The incidence of UOs was significantly lower in the ERCP group than in the without ERCP group (3.7% vs. 23.6%, respectively, p < 0.001). Moreover, the total number of readmissions was also lower in the ERCP group than in the without ERCP group (p < 0.001). A multivariate analysis adjusted for age, sex, and the American Society of Anesthesiologists (ASA) class revealed that endoscopic sphincterotomy (EST) and cholecystectomy were associated with a lower risk of UOs.

CONCLUSION

The high rate of UOs in CBDM patients without ERCP suggests that its natural clinical course may not be as favorable as previously suggested. This finding implies that efforts should be made to clear the bile ducts.

Genotype 4 HEV infection triggers the initiation and development of acute pancreatitis

The role of HEV infection in AP remains unclear. 1000 patients with AP and 1000 HCs were enrolled, and pancreatitis was evaluated in HEV-infected rhesus macaques. The positive rates of anti-HEV IgG, IgM, and HEV RNA in the AP patients were significantly higher than HCs. With the increase in the severity of AP, the percentage of HEV infection increased. AP patients were divided into AP- and AP + AHE groups. The percentage of severe AP in the AP + AHE group was significantly higher than in the AP- group. HEV infection was one of the main independent risk factors and had high predictive power for AP outcomes. A high level of HEV titer would prolong the recovery time and increase the risk of recurrent AP. Moreover, AP + AHE patients receiving conservative treatment showed a better prognosis. Furthermore, HEV can replicate in the pancreas of rhesus macaques. The pancreatic islet structure was damaged, the tissue was loose after 272 dpi, and a large amount of hyperemia appeared after 770 dpi. HEV infection also caused a large number of inflammatory cells in the pancreas. The pancreas and liver had a comparable viral load. HEV infection affects AP's occurrence, development, and prognosis.

Low molecular weight heparin decreases mortality and major complication rates in moderately severe and severe acute pancreatitis-a systematic review and meta-analysis

Background

Routine anticoagulation therapy in acute pancreatitis (AP) is not recommended by the guidelines in the field, although it is frequently used in clinical practice.

Objectives

We aimed to analyze the efficacy and safety of adding anticoagulants therapy to AP management.

Methods

The systematic search was performed in three databases on the 14th of October 2022 without restrictions. Randomized controlled trials (RCTs) and observational studies that reported the differences in the outcomes of AP for patients receiving anticoagulants (intervention group) in addition to the standard of care (SOC), compared to patients managed by SOC alone (control group), were eligible. A random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding 95%-confidence intervals (CI). We performed subgroup analysis for study design and disease severity, among other criteria.

Results

Of the 8,223 screened records, we included eight in the meta-analysis. Except one, all studies reported on low-molecular-weight heparin (LMWH). Both RCTs and observational studies reported results in favor of the LMWH group. Subgroup RCTs' analysis revealed significantly decreased odds of mortality [OR 0.24; 95%CI 0.17-0.34] and multiple organ failure [OR 0.32; 95%CI 0.17-0.62] in the intervention group. Moreover, the need for endoscopic or surgical interventions [OR 0.41; 95%CI 0.28-0.61] were significantly reduced by LMWH. The subgroup analyzes for moderate and severe cases, respectively, yielded similar results. Due to limited data, we could no perform subgroup analysis for mild cases.

Conclusion

LMWH therapy reduces major complication rates in moderate and severe AP. Across all identified RCTs, LMWH were initiated early after AP diagnosis and improved its prognosis.

Endoscopic Ultrasound to Identify the Actual Cause of Idiopathic Acute Pancreatitis: A Systematic Review

Idiopathic acute pancreatitis (IAP) presents a diagnostic challenge and refers to cases where the cause of acute pancreatitis remains uncertain despite a comprehensive diagnostic evaluation. Endoscopic ultrasound (EUS) has emerged as a valuable tool in the diagnostic workup of IAP. This review explores the pivotal role of EUS in detecting the actual cause of IAP and assessing its accuracy, timing, safety, and future technological improvement. In this review, we investigate the role of EUS in identifying the actual cause of IAP by examining the available literature. We aim to assess possible existing evidence regarding EUS accuracy, timing, and safety and explore potential trends of future technological improvements in EUS for diagnostic purposes. Following PRISMA guidelines, 60 pertinent studies were selected and analysed. EUS emerges as a crucial diagnostic tool, particularly when conventional imaging fails. It can offer intricate visualization of the pancreas, biliary system, and adjacent structures. Microlithiasis, biliary sludge, chronic pancreatitis, and small pancreatic tumors seem to be much more accurately identified with EUS in the setting of IAP. The optimal timing for EUS is post-resolution of the acute phase of the disease. With a low rate of complications, EUS poses minimal safety concerns. EUS-guided interventions, including fine-needle aspiration, collection drainage, and biopsies, aid in the cytological analysis. With high diagnostic accuracy, safety, and therapeutic potential, EUS is able to improve patient outcomes when managing IAP. Further refinement of EUS techniques and cost-effectiveness assessment of EUS-guided approaches need to be explored in multicentre prospective studies. This review underscores EUS as a transformative tool in unraveling IAP's enigma and advancing diagnostic and therapeutic strategies.

The anti-inflammatory effect of dimethyl trisulfide in experimental acute pancreatitis

Various organosulfur compounds, such as dimethyl trisulfide (DMTS), display anti-inflammatory properties. We aimed to examine the effects of DMTS on acute pancreatitis (AP) and its mechanism of action in both in vivo and in vitro studies. AP was induced in FVB/n mice or Wistar rats by caerulein, ethanol-palmitoleic acid, or L-ornithine-HCl. DMTS treatments were administered subcutaneously. AP severity was assessed by pancreatic histological scoring, pancreatic water content, and myeloperoxidase activity measurements. The behaviour of animals was followed. Pancreatic heat shock protein 72 (HSP72) expression, sulfide, and protein persulfidation were measured. In vitro acinar viability, intracellular Ca2+ concentration, and reactive oxygen species production were determined. DMTS dose-dependently decreased the severity of AP. It declined the pancreatic infiltration of leukocytes and cellular damage in mice. DMTS upregulated the HSP72 expression during AP and elevated serum sulfide and low molecular weight persulfide levels. DMTS exhibited cytoprotection against hydrogen peroxide and AP-inducing agents. It has antioxidant properties and modulates physiological but not pathophysiological Ca2+ signalling. Generally, DMTS ameliorated AP severity and protected pancreatic acinar cells. Our findings indicate that DMTS is a sulfur donor with anti-inflammatory and antioxidant effects, and organosulfur compounds require further investigation into this potentially lethal disease.

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

Importance

Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this issue.

Objective

To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP.

Design, Settings, and Participants

This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023.

Main Outcomes

Mortality and morbidity after EC.

Results

Of the 3696 patients (mean [SD] age, 58.5 [17.8] years; 1907 [51.5%] female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P < .001) and morbidity (7.7% vs 3.7%, P < .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio [OR], 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 [15.6%] vs 0 [0%], P < .001), morbidity (30 [30.3%] vs 57 [5.5%], P < .001), bile leakage (2 [2.4%] vs 4 [0.4%], P = .02), and infections (12 [14.6%] vs 4 [0.4%], P < .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 [15.6%] vs 2 [1.2%], P < .001), morbidity (30 [30.3%] vs 17 [10.3%], P < .001), and infections (12 [14.6%] vs 2 [1.3%], P < .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient's age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003).

Conclusions and Relevance

This cohort study's findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC.

Evaluating approaches to diagnosis and management of idiopathic acute pancreatitis

INTRODUCTION

Idiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence.

METHODS

Patients diagnosed with IAP from 2015-21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines.

RESULTS

A total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence.

CONCLUSION

Complete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.

Invalidity of Tokyo guidelines in acute biliary pancreatitis: A multicenter cohort analysis of 944 pancreatitis cases

BACKGROUND

There is a noteworthy overlap between the clinical picture of biliary acute pancreatitis (AP) and the 2018 Tokyo guidelines currently used for the diagnosis of cholangitis (AC) and cholecystitis (CC). This can lead to significant antibiotic and endoscopic retrograde cholangiopancreatography (ERCP) overuse.

OBJECTIVES

We aimed to assess the on-admission prevalence of AC/CC according to the 2018 Tokyo guidelines (TG18) in a cohort of biliary AP patients, and its association with antibiotic use, ERCP and clinically relevant endpoints.

METHODS

We conducted a secondary analysis of the Hungarian Pancreatic Study Group's prospective multicenter registry of 2195 AP cases. We grouped and compared biliary cases (n = 944) based on the on-admission fulfillment of definite AC/CC according to TG18. Aside from antibiotic use, we evaluated mortality, AC/CC/AP severity, ERCP performance and length of hospitalization. We also conducted a literature review discussing each criteria of the TG18 in the context of AP.

RESULTS

27.8% of biliary AP cases fulfilled TG18 for both AC and CC, 22.5% for CC only and 20.8% for AC only. Antibiotic use was high (77.4%). About 2/3 of the AC/CC cases were mild, around 10% severe. Mortality was below 1% in mild and moderate AC/CC patients, but considerably higher in severe cases (12.8% and 21.2% in AC and CC). ERCP was performed in 89.3% of AC cases, common bile duct stones were found in 41.1%.

CONCLUSION

Around 70% of biliary AP patients fulfilled the TG18 for AC/CC, associated with a high rate of antibiotic use. Mortality in presumed mild or moderate AC/CC is low. Each of the laboratory and clinical criteria are commonly fulfilled in biliary AP, single imaging findings are also unspecific-AP specific diagnostic criteria are needed, as the prevalence of AC/CC are likely greatly overestimated. Randomized trials testing antibiotic use are also warranted.

Endoscopy in Gallstone Pancreatitis

The root cause for biliary pancreatitis is a transient impediment of the outflow of secretion from the pancreatic duct due to gallstones and sludge obstructing the ampulla of Vater. Based on meta-analyses and recent studies, clear recommendations can be formulated when and when not to perform an ERC in patients with biliary pancreatitis. ERC is indicated urgently in patients with biliary pancreatitis and concomitant cholangitis. Urgent ERC is not indicated in patients with predicted mild or severe biliary pancreatitis without cholangitis, even when stones or sludge are proven on EUS imaging.

Machine learning-based decision tool for selecting patients with idiopathic acute pancreatitis for endosonography to exclude a biliary aetiology

BACKGROUND

Biliary microlithiasis/sludge is detected in approximately 30% of patients with idiopathic acute pancreatitis (IAP). As recurrent biliary pancreatitis can be prevented, the underlying aetiology of IAP should be established.

AIM

To develop a machine learning (ML) based decision tool for the use of endosonography (EUS) in pancreatitis patients to detect sludge and microlithiasis.

METHODS

We retrospectively used routinely recorded clinical and laboratory parameters of 218 consecutive patients with confirmed AP admitted to our tertiary care hospital between 2015 and 2020. Patients who did not receive EUS as part of the diagnostic work-up and whose pancreatitis episode could be adequately explained by other causes than biliary sludge and microlithiasis were excluded. We trained supervised ML classifiers using H2O.ai automatically selecting the best suitable predictor model to predict microlithiasis/sludge. The predictor model was further validated in two independent retrospective cohorts from two tertiary care centers (117 patients).

RESULTS

Twenty-eight categorized patients' variables recorded at admission were identified to compute the predictor model with an accuracy of 0.84 [95% confidence interval (CI): 0.791-0.9185], positive predictive value of 0.84, and negative predictive value of 0.80 in the identification cohort (218 patients). In the validation cohort, the robustness of the prediction model was confirmed with an accuracy of 0.76 (95%CI: 0.673-0.8347), positive predictive value of 0.76, and negative predictive value of 0.78 (117 patients).

CONCLUSION

We present a robust and validated ML-based predictor model consisting of routinely recorded parameters at admission that can predict biliary sludge and microlithiasis as the cause of AP.

Endoscopic changes in patients diagnosed with acute pancreatitis

BACKGROUND

There have been long debates on the introduction of proton pump inhibitors into acute pancreatitis therapy as standard treatment. The aim of the study was to assess endoscopic lesions of the upper gastrointestinal tract in patients hospitalized for acute pancreatitis.

METHODS

We carried out a prospective analysis of patients hospitalized in one surgical center who had an upper gastrointestinal tract endoscopic examination performed during the first 48 hours of hospitalization. We performed analysis of basic descriptive statistics along with the Shapiro-Wilk Test, logistic order regression analysis, One-Way Analysis of Variance, and Student's t-test for independent trials.

RESULTS

From January 2016 to December 2019, 476 patients were hospitalized because of acute pancreatitis. The upper gastrointestinal tract endoscopic examination was performed in 85 patients (N.) in the first 48 hours. From the examined group 45 patients (52.94%) developed mild acute pancreatitis, 28 (32.94%) moderate pancreatitis, and 12 (14.12%) severe pancreatitis. Lesions in the endoscopic imaging were observed in 80 patients (94.12%).

CONCLUSIONS

A very high percentage of patients hospitalized for acute pancreatitis present lesions in the endoscopic imaging of the upper gastrointestinal tract. The standard treatment of AP is the administration of non-steroidal anti-inflammatory drugs, which themselves can cause gastric and duodenal mucosal defects. All these factors indicate the need for standard use of proton pump inhibitors in patients hospitalized for acute pancreatitis.

Post-healing perceptions and experiences of alcohol withdrawal and life management in men with alcoholic pancreatitis: a qualitative study

Introduction

The aim of this study was to examine the perceptions and experiences of male patients with alcoholic pancreatitis after healing regarding alcohol withdrawal and life management.

Methods

This study used a qualitative descriptive design, and participants were selected by purposive sampling from two tertiary care hospitals in Shandong Province, China. Semi-structured in-depth interviews were conducted with 18 male patients discharged from the gastroenterology department who had recovered from alcoholic pancreatitis. Colaizzi's method was used to analyze the interview data, and the findings were reported using COREQ criteria.

Results

By analyzing the interview data, we summarized five themes, (1) the dilemma of sobriety, (2) role change, (3) illness status, (4) family influence, and (5) life management.

Conclusion

By profiling the perceptions and experiences of post-healing alcoholic pancreatitis patients' alcohol cessation and life management in men, it helps to grasp the details of alcohol cessation and health direction of patients' home management, which provides more directional guidance to help patients maintain positive and good lifestyle habits and active management awareness, followed by targeted personalized interventions to provide patients with knowledge of disease care and health management.

[Sex-specific differences in gastroenterological diseases]

Diseases of the gastrointestinal tract present with substantial sex differences that have a potential impact on patient outcome. This fact is not sufficiently addressed either in basic research or in clinical studies. For example, most animal studies utilize male animals. Despite differences in incidence, sex may affect complication rates, prognosis, or therapeutic response. The incidence of gastrointestinal cancers is frequently higher in males, but this observation cannot solely rely on a distinct risk behaviour. Here, differences in immune response and p53 signalling may be factors responsible for this finding. Nevertheless, taking sex differences into account and improving our understanding of relevant mechanisms is crucial and will most likely have a substantial impact on disease outcome. This overview aims to highlight sex differences in the context of various gastroenterological diseases, primarily to enhance awareness. Attention to sex-specific differences is essential to improve individualized treatment.

The Impact of the COVID-19 Pandemic on Outcomes in Acute Pancreatitis: A Propensity Score Matched Study Comparing before and during the Pandemic

We aimed to evaluate the outcomes and survival of patients with acute pancreatitis who shared the same clinical form, age, and sex before the pandemic, during the pandemic, and among those with confirmed COVID-19 infection upon hospital admission. This consideration used the sparse data in the existing literature on the influence of the pandemic and COVID-19 infection on patients with acute pancreatitis. To accomplish this, we conducted a multicentric, retrospective case-control study using propensity score matching with a 2:1 match of 28 patients with SARS-CoV-2 infection and acute pancreatitis, with 56 patients with acute pancreatitis pre-pandemic, and 56 patients with acute pancreatitis during the pandemic. The study outcome demonstrated a six-fold relative risk of death in patients with acute pancreatitis and SARS-CoV-2 infection compared to those with acute pancreatitis before the pandemic. Furthermore, restrictive measures implemented during the pandemic period led to a partial delay in the care of patients with acute pancreatitis, which likely resulted in an impairment of their immune state. This, in certain circumstances, resulted in a restriction of surgical treatment indications, leading to a three-fold relative risk of death in patients with acute pancreatitis during the pandemic compared to those with acute pancreatitis before the pandemic.

Physical activity, sedentary behavior and pancreatitis risk: Mendelian randomization study

BACKGROUND

Although observational studies have shown that physical activity is a protective factor for acute pancreatitis, the causal associations between PA/ sedentary behavior and acute pancreatitis (AP) and chronic pancreatitis (CP) remain unclear.

METHODS

We used Mendelian randomization as a strategy to assess the causalities between exposures and outcomes by simulating randomized experiments with genetic variation. The collected genetic variants data of physical activity were from UK Biobank, the data on sedentary behavior were also from UK Biobank, and both of them could be found in the GWAS catalog, and the data on AP and CP were from FinnGen. There were three physical activity related activity patterns (moderate to vigorous physical activity [MVPA], accelerometer-based physical activity with average acceleration, [AccAve] and accelerometer-based physical activity with accelerations >425 milli-gravities, [Acc425]) and three sedentary behavior-related lifestyle patterns (Leisure screen time [LST], Sedentary commuting, Sedentary behavior at work). We used inverse variance weighted (IVW), weighted median and MR-Egger for the analysis of Mendelian randomization, followed by sensitivity tests with the Cochran Q test, MR-Egger intercepts analysis and MR-PRESSO.

RESULTS

A causal relationship was found between LST and acute pancreatitis based on IVW analysis (odds ratios [OR] = 1.38, corresponding 95% confidence intervals [CI] = 1.16-1.64, p = 0.0002) and there were no causal relationships between physical activity/sedentary behavior and chronic pancreatitis. Sensitivity analysis showed no pleiotropy and heterogeneity of the results.

CONCLUSIONS

Results show that reducing LST contributes to the prevention of acute pancreatitis, thereby reducing the health burden associated with it.

Comparison of Interleukin-6, C-Reactive Protein, Procalcitonin, and the Computed Tomography Severity Index for Early Prediction of Severity of Acute Pancreatitis

Background/Aims

Acute pancreatitis (AP) is a common gastrointestinal disease associated with hospitalization. With the increase in its incidence, AP has become a greater burden on healthcare resources. Early identification of patients with mild AP can facilitate the appropriate use of resources. We aimed to investigate the ability of inflammatory markers, including interleukin-6 (IL-6), procalcitonin, and C-reactive protein (CRP), as well as various scoring systems to differentiate mild AP from more severe diseases.

Methods

We retrospectively investigated patients hospitalized with AP, for whom severity assessment and clinical course confirmation were possible. Inflammatory markers were measured at admission, and CRP levels were measured 24 hours after admission (CRP2). Predictive values were calculated using the area under the receiver operating characteristic curve (AUROC) and logistic regression model analysis.

Results

Of 103 patients with AP, 42 (40.8%) were diagnosed with mild AP according to the revised Atlanta classification. Based on the AUROC, IL-6 (0.755, p<0.001), CRP2 (0.787, p<0.001), and computed tomography severity index (CTSI) (0.851, p<0.001) were useful predictors of mild AP. With standard cutoff values, the diagnostic sensitivity, specificity, and accuracy were 83.3%, 62.3%, and 70.9% for IL-6 (<50 pg/mL), and 78.6%, 63.9%, and 69.9% for CRP2 (<50 mg/L), respectively. The AUROC of IL-6 and CRP2 were significantly higher than those of other inflammatory markers and were not significantly different from that of CTSI.

Conclusions

IL-6, CRP2, and CTSI are helpful for early differentiation of AP severity. Among inflammatory markers, IL-6 has the advantage of early prediction of mild pancreatitis at the time of admission.

Increased incidence and reduced mortality after first attack of acute pancreatitis over an 18-year period

AIMS

To determine time trends in the incidence and etiology of acute pancreatitis and identify predictors for in-hospital mortality.

PATIENTS AND METHODS

Retrospective study of 1722 patients with acute pancreatitis admitted to Akershus University Hospital between January 2000 and December 2017. Data were obtained from electronic patient files and computed tomography scans. We estimated a logistic regression model to assess differences in associations between patient characteristics and in-hospital mortality in two time periods, 2000-2009 (first period) and 2010-2018 (second period).

RESULTS

First attack of acute pancreatitis (FAAP) was identified in 1579 patients (91.7%). The incidence of FAAP increased from 20.1/100,000 during the first period to 27.7/100,000 in the second period (p = .011). Etiology showed no differences between the two time periods. Gallstone was the most frequent etiology (47.2%). In total, 187 patients (11.8%) had necrotizing pancreatitis; more in the second period compared to the first (14.2 vs. 7.7%; p < .001). The overall mortality rate was 3.9%. Mortality rates decreased for both inflammatory and necrotizing pancreatitis during the study period. Age and comorbidity according to Charlson Comorbidity Index (CCI) were predictors of in-hospital mortality (OR 1.07, 95% CI 0.07; 0.40 and 13.58, 95% CI 3.88; 47.52), as were alcohol and organ failure (OR 7.20, 95% CI 2.02; 25.67 and OR 34.15, 95% CI 8.94; 130.53, respectively).

CONCLUSIONS

The incidence of FAAP is increasing in southeast Norway. The etiology has remained unchanged over an 18-year period, with gallstones being the most frequent cause. The outcomes for both inflammatory and necrotic pancreatitis are improving.

Acute peripancreatic fluid collection in acute pancreatitis: Incidence, outcome, and association with inflammatory markers

Background

The hospital outcomes and predictors of acute peripancreatic fluid collection (APFC) have not been well-characterized. In this study, we aimed to investigate the clinical outcomes of APFC in patients with acute pancreatitis (AP) and the role of the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and C-reactive protein (CRP) level in predicting the occurrence of APFC.

Methods

In this retrospective study, the complicated group (patients with APFC) and the uncomplicated group (patients without APFC) were compared for their clinical characteristics, hospital outcomes (mortality rate, intensive care unit admission rate, and length of hospital stay), pseudocyst formation, CRP levels, SII, and SIRI on admission and at 48 hours.

Results

Of 132 patients with AP, 51 (38.6%) had APFC and eight (6.1%) had pancreatic pseudocysts. Of 51 patients with APFC, 15.7% had pancreatic pseudocysts. Pseudocyst did not develop in the uncomplicated group. SII value at 48 h [median 859 (541-1740) x 109/L vs. 610 (343-1259) x 109/L, P = 0.01] and CRP level at 48 h [89 (40-237) mg/L vs. 38 (12-122) mg/L, P = 0.01] were higher in the complicated group than in the uncomplicated group. The length of hospital stay was longer in the complicated group, compared with the uncomplicated group [median 8 days (5-15), vs. 4 days (3-7), P < 0.001, respectively]. No significant difference was detected between the two study groups' mortality rates and intensive care unit admission rates.

Conclusions

While 38.6% of the AP patients had APFC, 6.1% of all patients and 15.7% of the patients with APFC had pancreatic pseudocysts. APFC was found to lengthen the hospital stay and to be associated with the SII value and CRP level measured at 48 h.

Epidemiological trends in acute pancreatitis: A retrospective cohort in a tertiary center over a seven year period

BACKGROUND

Acute pancreatitis (AP) remains a major cause of hospitalization and mortality with important health-related costs worldwide. Using an electronic database of a large tertiary center, we estimated the incidence, etiology, severity and costs of hospitalized AP cases in southern Romania.

AIM

To estimate the incidence, cost and tobacco usage of hospitalized AP cases in southern Romania and to update and upgrade the knowledge we have on the etiology, severity (in regard to Revised Atlanta Classification), outcome, morphology and local complications of AP.

METHODS

We performed an electronic health care records search on AP patients treated at Emergency University Hospital of Bucharest (Spitalul Universitar de Urgență București) between 2015 and 2022. The incidence, etiology, and severity were calculated; potential risk factors were evaluated, and the hospitalization costs of AP were documented and analyzed. The cohort of this study is part of the BUCharest - Acute Pancreatitis Index registry.

RESULTS

A total of 947 consecutive episodes of AP where the patients were hospitalized in the gastroenterology department were analyzed, with 79.45% as 1^st episode and the rest recurrent. The majority of the patients were males (68.9%). Alcoholic (45.7%), idiopathic (16.4%) and biliary (15.2%) were the main causes. The incidence was estimated at 29.2 episodes/100000 people. The median length of stay was 7 d. The median daily cost was 747.96 RON (165 EUR). There was a high prevalence of active tobacco smokers (68.5%). The prevalence of severe disease was 11.1%. The admission rate to the intensive care unit was 4.6%, with a mortality rate of 38.6%. The overall mortality was 5.5%.

CONCLUSION

We estimated the incidence of AP at 29.2 episodes that required hospitalization per 100000 people. The majority of our cases were found in males (68.9%) and were related to alcohol abuse (45.7%). Out of the cases we were able to find data regarding tobacco usage, the majority were active smokers (68.5%). Most patients had a mild course (54.4%), with a mortality rate of 5.5%. Interstitial AP prevailed (45.3%). The median daily cost of hospitalization was 747.96 RON (165 EUR).

Gut Microbiota and Antibiotic Treatments for the Main Non-Oncologic Hepato-Biliary-Pancreatic Disorders

The gut microbiota is a pivotal actor in the maintenance of the balance in the complex interconnections of hepato-biliary-pancreatic system. It has both metabolic and immunologic functions, with an influence on the homeostasis of the whole organism and on the pathogenesis of a wide range of diseases, from non-neoplastic ones to tumorigenesis. The continuous bidirectional metabolic communication between gut and hepato-pancreatic district, through bile ducts and portal vein, leads to a continuous interaction with translocated bacteria and their products. Chronic liver disease and pancreatic disorders can lead to reduced intestinal motility, decreased bile acid synthesis and intestinal immune dysfunction, determining a compositional and functional imbalance in gut microbiota (dysbiosis), with potentially harmful consequences on the host's health. The modulation of the gut microbiota by antibiotics represents a pioneering challenge with striking future therapeutic opportunities, even in non-infectious diseases. In this setting, antibiotics are aimed at harmonizing gut microbial function and, sometimes, composition. A more targeted and specific approach should be the goal to pursue in the future, tailoring the treatment according to the type of microbiota modulation to be achieved and using combined strategies.

Age-period-cohort analysis of pancreatitis epidemiological trends from 1990 to 2019 and forecasts for 2044: a systematic analysis from the Global Burden of Disease Study 2019

Objective

Pancreatitis poses a serious medical problem worldwide. This study aims to explore the epidemiological trends of pancreatitis from 1990 to 2019, analyze the association between disease burden and age, period and birth cohort, and subsequently present a forecast of pancreatitis incidence and deaths.

Methods

Epidemiologic data were gathered from the Global Health Data Exchange query tool. Joinpoint regression model was used to calculate the average annual percentage changes (AAPCs). Age-period-cohort analysis was utilized to estimate the independent effects of age, period and birth cohort. We also predicted the global epidemiological trends to 2044.

Results

Globally, the incident cases and deaths of pancreatitis increased 1.63-and 1.65-fold from 1990 to 2019, respectively. Joinpoint regression analysis showed that the age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) decreased over the past three decades. The age effect indicates that older people have higher age-specific incidence and death rates. The period effect on incidence and deaths showed downward trends from 1990 to 2019. The cohort effect demonstrated that incidence and death risk peaked in the earlier birth cohort and were lower in the latest birth cohort. Incident cases and deaths of pancreatitis may significantly increase in the next 25 years. The ASIRs were predicted to slightly increase, while the ASDRs were predicted to decrease.

Conclusion

Epidemiologic patterns and trends of pancreatitis across age, period and birth cohort may provide novel insight into public health. Limitations of alcohol use and prevention strategies for pancreatitis are necessary to reduce future burden.