Trends in incidence of acute pancreatitis in a Swedish population: is there really an increase?

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.

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.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Effect of ambient temperature on daily hospital admissions for acute pancreatitis in Nanchang, China: A time-series analysis

The aim of this study was to evaluate the short-term effect of temperature on the risk of acute pancreatitis (AP) in southern China. We performed a time-series study of 2822 patients admitted with a first episode of AP in Nanchang between May 2014 and June 2017. A generalized additive model combined with a distributed lag non-linear model was applied to assess the association of temperature and AP. In subgroup analysis, according to different etiologies of pancreatitis, significant associations were found between daily average temperature and non-biliary pancreatitis hospitalization at lags of 0-7 days, but not for biliary pancreatitis or total AP. Higher daily average temperature tended to increase the occurrence of non-biliary pancreatitis at lags of 0-7 days. These findings suggest that high temperature is associated with higher non-biliary pancreatitis risk in Nanchang, China. In the context of global warming, the morbidity of non-biliary pancreatitis may increase.

Evaluation of the Elasticity of the Pancreas Using Acoustic Radiation Force Impulse Elastography in Patients with Acute Pancreatitis: A Systematic Review and Meta-Analysis

Acoustic radiation force impulse (ARFI) elastography has been used to diagnose acute pancreatitis (AP). The present study aimed to assess the effectiveness of ARFI elastography in the diagnosis of AP. Studies examining the efficacy of ARFI elastography in AP were selected by searching MEDLINE, EMBASE, CENTRAL, ICTRP, and ClinicalTrial.gov. until September 2021. Meta-analyses were performed using random effects models. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the certainty of the evidence. Eight case-control studies (994 patients) were included in the meta-analysis. The ARFI-Virtual Touch Quantification value (or ARFI shear wave propagation velocity) of the AP patient group was 0.83 m/s higher (95% confidence interval [CI]: 0.36-1.3) than that in the control group (95% CI: 1.0-1.28). The sensitivity and specificity of ARFI elastography for diagnosing AP were 98.3% (95% CI: 92.6-96.6%) and 95.5% (95% CI: 87.5-98.5%), respectively. The results showed that physicians could use ARFI elastography to accurately diagnose patients with AP. Additional well-designed studies are necessary to validate the efficacy of ARFI elastography in patients with AP.

Predictive value of arterial blood lactic acid concentration on the risk of all-cause death within 28 days of admission in patients with severe acute pancreatitis

ObjectiveTo evaluate the ability of arterial blood lactic acid concentration to predict death within 28 days of admission of patients with severe acute pancreatitis (SAP) in the intensive care unit (ICU).MethodsClinical data of 523 SAP patients in the MIMIC-IV database were retrospectively analyzed. Patients were divided into those who survived (n=461) and those who died (n=62) within 28 days of admission. The association between lactic acid concentration and all-cause death in SAP patients was determined by Cox regression analysis, Kaplan-Meier survival analysis and subgroup analysis. The ability of lactic acid concentration to predict the risk of all-cause death in SAP patients was determined by time-dependent receiver operating curve (ROC) analysis.ResultsArterial blood lactic acid concentration was significantly higher in the 62 patients who died within 28 days than in the 461 patients who survived (P <0.05). Adjusted multivariate Cox regression analysis showed that lactic acid concentration was a significant independent predictor on all-cause mortality within 28 days of admission for SAP (hazard ratio=1.22, 95% confidence interval 1.09-1.36, P <0.001), as did time-dependent ROC analysis (area under the ROC curve=0.741). Kaplan-Meier analysis showed that the rate of all-cause mortality within 28 days of admission was significantly higher in patients with high than low lactic acid concentration (P <0.0001). Subgroup analysis showed that there was no significant interaction between lactic acid concentration and other factors with all-cause death within 28 days of admission (all P >0.05).ConclusionArterial blood lactic acid concentration is an important independent predictor of all-cause mortality within 28 days of admission of SAP patients in the ICU.

Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Acute pancreatitis is a common disease with significant associated morbidity and mortality. We performed a systematic review and meta-analysis of population-based studies to explore the changing temporal trends of acute pancreatitis incidence globally.

METHODS

We performed a systematic literature search to identify population-based studies reporting the annual incidence of acute pancreatitis. Abstracts were assessed independently to identify applicable articles for full-text review and data extraction. Joinpoint temporal trend analyses were performed to calculate the average annual percent change (AAPC) with 95% confidence intervals (CIs). The AAPCs were pooled in a meta-analysis to capture the overall and regional trends in acute pancreatitis incidence over time. Temporal data were summarized in a static map and an interactive, web-based map.

RESULTS

Forty-four studies reported the temporal incidence of acute pancreatitis (online interactive map: https://kaplan-acute-pancreatitis-ucalgary.hub.arcgis.com/). The incidence of acute pancreatitis has increased from 1961 to 2016 (AAPC, 3.07%; 95% CI, 2.30% to 3.84%; n = 34). Increasing incidence was observed in North America (AAPC, 3.67%; 95% CI, 2.76% to 4.57%; n = 4) and Europe (AAPC, 2.77%; 95% CI, 1.91% to 3.63%; n = 23). The incidence of acute pancreatitis was stable in Asia (AAPC, -0.28%; 95% CI, -5.03% to 4.47%; n = 4).

CONCLUSIONS

This meta-analysis provides a comprehensive overview of the global incidence of acute pancreatitis over the last 56 years and demonstrates a steadily rising incidence over time in most countries of the Western world. More studies are needed to better define the changing incidence of acute pancreatitis in Asia, Africa, and Latin America.

The role of the BISAP score in predicting acute pancreatitis severity according to the revised Atlanta classification: a single tertiary care unit experience from Turkey

BACKGROUND/AIMS

In this study, we examine the utility of Bedside Index of Severity in Acute Pancreatitis (BISAP), which is an increasingly more commonly used simple and practical novel scoring system for predicting the prognosis and severity of the disease at presentation.

MATERIALS AND METHODS

Consecutive patients diagnosed with AP between January 2013 and December 2020 were evaluated retrospectively. The AP severity was assessed using the revised Atlanta classification (RAC). BISAP score, demographic characteristics, pancreatitis etiology, pancreatitis history, duration of hospital stay, and mortality rates of the patients were recorded.

RESULTS

A total of 1000 adult patients were included, of whom 589 (58.9%) were female and 411 (41.1%) were male. The mean age in female and male patients was 62.15 ± 17.79 and 58.1 ± 16.33 years, respectively (p >0.05). The most common etiological factor was biliary AP (55.8%), followed by idiopathic AP (23%). Based on RAC, 389 (38.9%), 418 (41.8%), and 193 (19.3%) patients had mild, moderate, and severe AP. Of the 1000 patients, 42 (4.2%) died. Significant predictors of mortality included advanced age (>65 y) (p=0.003), hypertension (p=0.007), and ischemic heart disease (p=0.001). A BISAP score of ≥3 had a sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of 79.79%, 91.57%, 69.37%, and 94.99%, respectively, for determining SAP patients according to RAC.

CONCLUSION

BISAP is an effective scoring system with a high NPV in predicting the severity of AP in the early course of the disease in a Turkish population.

The global, regional, and national burden of acute pancreatitis in 204 countries and territories, 1990-2019

BACKGROUND

Acute pancreatitis is a common and potentially lethal gastrointestinal disease, but literatures for the disease burden are scarce for many countries. Understanding the current burden of acute pancreatitis and the different trends across various countries is essential for formulating effective preventive intervenes. We aimed to report the incidence, mortality, and disability-adjusted life-years (DALYs) caused by acute pancreatitis in 204 countries and territories between 1990 and 2019.

METHODS

Estimates from the Global Burden of Disease Study 2019 (GBD 2019) were used to analyze the epidemiology of acute pancreatitis at the global, regional, and national levels. We also reported the correlation between development status and acute pancreatitis' age-standardized DALY rates, and calculated DALYs attributable to alcohol etiology that had evidence of causation with acute pancreatitis. All of the estimates were shown as counts and age-standardized rates per 100,000 person-years.

RESULTS

There were 2,814,972.3 (95% UI 2,414,361.3-3,293,591.8) incident cases of acute pancreatitis occurred in 2019 globally; 1,273,955.2 (1,098,304.6-1,478,594.1) in women and 1,541,017.1 (1,307,264.4-1,814,454.3) in men. The global age-standardized incidence rate declined from 37.9/100,000 to 34.8/100,000 during 1990-2019, an annual decrease of 8.4% (5.9-10.4%). In 2019, there were 115,053.2 (104,304.4-128,173.4) deaths and 3,641,105.7 (3,282,952.5-4,026,948.1) DALYs due to acute pancreatitis. The global age-standardized mortality rate decreased by 17.2% (6.6-27.1%) annually from 1.7/100,000 in 1990 to 1.4/100,000 in 2019; over the same period, the age-standardized DALY rate declined by 17.6% (7.8-27.0%) annually. There were substantial differences in the incidence, mortality and DALYs across regions. Alcohol etiology attributed to a sizable fraction of acute pancreatitis-related deaths, especially in the high and high-middle SDI regions.

CONCLUSION

Substantial variation existed in the burden of acute pancreatitis worldwide, and the overall burden remains high with aging population. Geographically targeted considerations are needed to tailor future intervenes to relieve the burden of acute pancreatitis in specific countries, especially for Eastern Europe.

Diabetes following acute pancreatitis

Diabetes represents a group of diseases involving persistent hyperglycaemia. Exocrine disorders of the pancreas are increasingly recognised to cause or precede the onset of diabetes, which in this context is referred to as pancreatogenic or type 3c diabetes. Diabetes, as a sequela of acute pancreatitis, is observed across the spectrum of severity in acute pancreatitis and can be associated with other clinical complications. The pathophysiology of acute pancreatitis-related diabetes is poorly understood, and observations suggest that it is probably multifactorial. In this Review, we discuss the epidemiology, pathophysiology, and management considerations of diabetes following acute pancreatitis, and highlight knowledge gaps in this topic.

Etiology, clinical characteristics, and outcomes of acute pancreatitis in patients at Assiut University Hospital

Background

Acute pancreatitis is one of the main causes of acute abdomen. It may cause multi-organ failure or even death. High morbidity and mortality are associated with it. The research study aimed at evaluating the clinical characteristics and results of acute pancreatitis in our community.

Results

Mean age of patients was 50.96 ± 9.71 years and 30 (60%) patients were males. Gallstone was the most frequent etiology (56%) followed by idiopathic pancreatitis (26%). The majority of patients improved and only four patients died. Old age, presence of comorbidities, and leucocytosis were risk factors for a severe attack while old ages, presence of comorbidities, severe pancreatitis, and presence of complications were associated with mortality.

Conclusion

Acute pancreatitis could have serious outcomes if not correctly and early managed. It is recommended to perform multicenter studies with a large sample of patients. A multi-disciplinary team is required to assess idiopathic pancreatitis.

Acute pancreatitis: 31-Year trends in incidence and mortality - A Danish population-based cohort study

BACKGROUND

Objectives: Increasing incidence rates and declining mortality rates have made acute pancreatitis a common cause of hospitalization. We aimed to examine 31-year trends in first-time hospitalization for acute pancreatitis, the subsequent short-term and long-term mortality, and the prognostic impacts of age, sex, and comorbidity.

METHODS

In this nationwide Danish population-based cohort study of 47,711 incident cases, we computed the annual sex-specific age-standardized incidence rates of acute pancreatitis for 1988-2018. Among patients with incident hospitalization for acute pancreatitis, we computed sex-specific 30-day and 31-365-day mortality rates, stratified them, and performed proportional-hazards regression to estimate mortality rate ratios adjusted for sex, age, and comorbidity, measured by Charlson Comorbidity Index categories.

RESULTS

From 1988 to 2018, the standardized incidence rate of acute pancreatitis per 100,000 person-years increased by 29% for men (28.8-37.0%) and by 148% for women (15.7-38.9%). Among patients with pancreatitis, the 30-day mortality declined from 10.0% in those diagnosed in 1988-1992 to 6.3% for those diagnosed in 2013-2017. The corresponding 31-365 day mortality increased from 5.5% to 6.0%. In comparing periods 1988-1992 and 2013-17, the adjusted 30-day mortality rate ratio was 0.36 (95% confidence interval: 0.32-0.41) and the adjusted 31-365 day mortality rate ratio was 0.64 (95% confidence interval: 0.56-0.74). Comorbidity was a strong predictor of mortality among patients with pancreatitis.

CONCLUSIONS

Over the 31 years of observations, annual rates of acute pancreatitis more than doubled among women, converging with those among men. The comorbidity burden was a strong prognostic factor for short and long-term mortality. Treatments for acute pancreatitis should focus on existing comorbidities.

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review

BACKGROUND

Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice.

METHODS

From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review.

RESULTS

The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period.

CONCLUSION

The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.

Pancreatic necrosis volume - A new imaging biomarker of acute pancreatitis severity

OBJECTIVE

Determine if the pancreatic necrosis volume (PNV) in computed tomography scan (CT) is a useful marker to predict the severity of acute pancreatitis (AP) comparing its predictive value with current clinical scoring systems.

METHODS

This retrospective study was conducted in a tertiary hospital, including patients hospitalized with AP during the period of 24 months. Demographic, clinical data, length of hospital stay and analytical parameters were collected from the hospital clinical information digital systems. Other information on the severity of the disease was also reviewed, including BISAP score, organ failure (OF) or admission to the ICU, as well as, complications during hospitalization as infected necrotic collections, surgical procedure or death. The quantification of the necrosis volume, CT severity index and Balthazar score were assessed in the CT studies. ROC curves were carried to compare the correlation between different scoring systems and the acute complications.

RESULTS

This study included 163 patients with AP. The calculated average value of PNV in the CT studies was 242 cc (0-1575 cc). PNV showed lineal correlation with hospital stay (Pearson 0.696) and statistically significant association with acute complications as OF, multiple organ failure, infection, need of treatment or hospitalization at ICU (P < 0.05). The optimal cut-off value for predicting complications of necrosis as infections or need of surgery treatments was 75 cc. Sensibility and specificity were 100 % and 78 %, respectively. ROC curves showed that PNV was the best radiological finding correlated with AP complications.

CONCLUSION

Necrosis volume is a radiological biomarker highly correlated with AP complications.

Evaluation of four scoring systems in prognostication of acute pancreatitis for elderly patients

BACKGROUND

To evaluate the ability of four scoring systems (Ranson, BISAP, Glasgow, and APACHE II) to predict outcomes of acute pancreatitis (AP) in elderly patients.

METHODS

This was a retrospective study of 918 patients presenting with AP at Zhongda Hospital Southeast University, from January 2015 to December 2018. We divided patients into two groups: 368 patients who were ≥ 60 years old, and 550 patients who were < 60 years old. Four scoring systems were used to analyze all patients.

RESULTS

The severity of the disease, and mortality were significantly different between the two groups (p < 0.05), while the difference between the two groups about pancreatic necrosis is statistically insignificant (p = 0.399). The differences of the AUCs (Area under curves) for prediction of outcome of SAP (severe acute pancreatitis) between the two groups were statistically significant for Ranson and APACHE II (p < 0.05), but not for the differences between BISAP and Glasgow. All the four scoring systems were similar in terms of prediction of pancreatic necrosis and death in both groups.

CONCLUSIONS

Prediction of severity, pancreatic necrosis, and death in AP for elderly patients can be performed very well by using BISAP. APACHE II is more suitable for younger patients when dealing with severity. Ranson and Glasgow can be used to evaluate all AP patients in most cases; however, Ranson is more effective for younger patients when used to assess severity.

Radiation dose from computed tomography in patients with acute pancreatitis: an audit from a tertiary care referral hospital

BACKGROUND

There is a limited data on the radiation dose from computed tomography (CT) in patients with acute pancreatitis (AP). The present study evaluated the radiation dose from CT scans in patients with AP.

MATERIAL

A retrospective review of CT reports of patients with AP was conducted. The type of CT scan (non-contrast vs. single-phase vs. biphasic CT) was recorded. The mean number of CT scans and cumulative radiation dose was calculated. The indications and abnormalities on biphasic CT scans were recorded. The radiation doses between different types of the scan were compared.

RESULTS

495 CT studies in 351 patients were evaluated. In patients (n = 78, 22.2%) undergoing multiple CT scans, mean number of CT scans per patient and mean radiation dose were 2.64 ± 1.18 (range 2-9) and 24 ± 15 mSv (range 8.3-79.8 mSv), respectively. The mean radiation dose was significantly greater in patients with modified CT severity index ≥ 8 (n = 63) [25.08 mSv vs. 18.96 mSv, (P = 0.048)]. 61 (12.32%) biphasic scans were performed. A definite indication for a biphasic CT scan was identified in 20 (32.7%) patients. Arterial abnormalities were detected in 6 (9.8%) patients undergoing CT for defined indication. Mean radiation dose in this group was 13.26 ± 7.64 mSv (range 3.42-38.27 mSv) which was significantly greater than the single venous phase scan (7.96 ± 3.48 mSv, P < 0.001).

CONCLUSION

There is a potential for substantial radiation exposure from CT scans to patients with AP. Patients with severe AP and those undergoing biphasic scans have significantly higher radiation exposure. Hence, routine arterial phase acquisition should be avoided.

Increase in the incidence of alcoholic pancreatitis and alcoholic liver disease in Iceland: impact of per capita alcohol consumption

Objective: To analyze the incidence of acute alcoholic pancreatitis and of severe alcoholic liver disease (ALD) and its association with per capita alcohol consumption with identification of both alcoholic cirrhosis (AC) and severe alcoholic hepatitis (AH), in a population-based setting.Methods: A search was undertaken in diagnoses database for diagnostic codes in order to find patients hospitalized with incident acute alcoholic pancreatitis (AP) and alcoholic liver disease in Iceland in 2001-2015. Diagnoses were verified in all patients who were retrospectively reviewed. Those with ALD had either AC or AH. Alcohol sales during the study period were obtained from Statistics Iceland.Results: Overall, 273 patients with acute AP, mean age at diagnosis 50 (14) years, 74% males and 159 patients with ALD, mean age 57 (11) years, 73% males, were identified. Mean per capita alcohol consumption was 6.95 (0.4) liters and increased by 21% over the study period. The annual incidence of AP increased from 4.2 per 100.000 to 9.5 and ALD from 1.6 to 6.1 per 100.000. Trend analysis showed a significant annual increase of 7% (RR 1.07, 95%CI 1.04-1.10) for AP and an annual increase of 10.5% (RR 1.10, 95%CI 1.06-1.15) for ALD. The increase was only significant in males.Conclusions: Increase per capita alcohol consumption over a 15 year study period was associated with an increase in the incidence of severe alcoholic liver disease and alcohol-related acute pancreatitis in males but not in females.

Nonaggressive Versus Aggressive Intravenous Fluid Therapy in Acute Pancreatitis With More Than 24 Hours From Disease Onset: A Randomized Controlled Trial

OBJECTIVE

This study aimed to compare a "nonaggressive" hydration versus an "aggressive" hydration using Hartmann's solution in patients with acute pancreatitis (AP) with more than 24 hours from disease onset.

METHODS

We included 88 patients with AP with more than 24 hours from disease onset, and were randomized into 2 groups. Group I (n = 45) received a nonaggressive hydration (Hartmann's solution at 1.5 mL kg h for the first 24 hours and 30 mL kg during the next 24 hours), and group II (n = 43) received an aggressive hydration (bolus of Hartmann's solution 20 mL kg, followed by an infusion of 3 mL kg h for the first 24 hours and then 30 mL kg for the next 24 hours).

RESULTS

The mean volume of fluid administered was greater in group II (P < 0.001). We did not find differences when comparing both groups in reference to persistent systemic inflammatory response syndrome (P = 0.528), pancreatic necrosis (P = 0.710), respiratory complications (P = 0.999), acute kidney injury (P = 0.714), or length of hospital stay (P = 0.892).

CONCLUSIONS

Our study suggests that the clinical evolution of patients with AP with more than 24 hours from disease onset is similar using an aggressive or nonaggressive hydration.

Rising incidence of acute pancreatitis in Sweden: National estimates and trends between 1990 and 2013

BACKGROUND

Recent reports from western countries have indicated an increased incidence and a decreased mortality in acute pancreatitis. However, the incidence assessment has often been hampered by the inclusion of both first-time and recurrent episodes of acute pancreatitis.

METHODS

In this retrospective cohort study, all Swedish residents hospitalized with a first-time episode of acute pancreatitis between 1990 and 2013 were identified using national registers. Sex- and age-standardized incidence rates per 100,000 individuals and year were calculated, as were annual percent changes (APC) from joinpoint regression models.

RESULTS

Overall, between 1990 and 2013, 66,131 individuals had a first-time episode of acute pancreatitis in Sweden. Comparing the first five years (1990-1994) to the last four years (2010-2013) of the study period, the overall incidence of acute pancreatitis increased from 25.2 (95% confidence interval (CI): 24.1, 26.3) to 38.3 (95% CI: 37.0, 39.5) cases per 100,000 individuals and year. An increase in incidence was observed irrespective of the subtypes of acute pancreatitis as well as the sex and age of the patients. Although the incidence of complicated acute pancreatitis declined in both men and women between 1990 and 2004, it started to increase in both sexes (APC 3.0; 95% CI: 0.5, 5.5 in men; APC 5.4; 95% CI: 2.6, 8.2 in women) from 2005 onwards.

CONCLUSION

Based on nationwide data, the incidence of first-time acute pancreatitis has increased in Sweden over a period of 24 years. The incidence of disease-related complications has also been on the rise during the past few years, after declining for more than 15 years before that.

Combination treatment with n-3 polyunsaturated fatty acids and ursodeoxycholic acid dissolves cholesterol gallstones in mice

The increasing prevalence of cholesterol gallstone disease places an economic burden on the healthcare system. To identify novel therapeutics, we assessed the effects of n-3 polyunsaturated fatty acids (PUFA) in combination with UDCA in a mouse model of cholesterol gallstones. Gallstone dissolution, gallbladder wall thickness, mucin gene expression in the gallbladder, and levels of phospholipids, cholesterol, and bile acids in bile and serum were analysed. RNA was extracted from the liver for mRNA sequencing and gene expression profiling. Combination treatment resulted in greater gallstone dissolution compared with the control group, and PUFA and combination treatments reduced the thickness of the gallbladder wall. Expression levels of mucin genes were significantly lower in the UDCA, PUFA, and combination groups. Transcriptome analyses revealed that combination treatment modulated hepatic lipid metabolism. The PUFA and combination groups showed elevated bile phospholipid and bile acid levels and a lower cholesterol saturation index. Combination treatment with PUFA and UDCA dissolves cholesterol gallstones in mice by decreasing mucin production, increasing levels of phospholipids and bile acids in bile, and decreasing cholesterol saturation. Further studies of the therapeutic effects of combination PUFA and UDCA treatment in patients with cholesterol gallstones are warranted.

Pancreatic necrosis: Complications and changing trend of treatment

Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.

Temporal Trends in Incidence and Outcomes of Acute Pancreatitis in Hospitalized Patients in the United States From 2002 to 2013

OBJECTIVES

We sought to examine temporal trends in incidence and outcomes of acute pancreatitis (AP) in hospitalized adult patients in the United States.

METHODS

Subjects were obtained from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for the years 2002-2013. Incidence of AP, all-cause mortality, cost, and duration of hospitalization were assessed.

RESULTS

We identified 4,791,802 cases of AP. A significant increase in the incidence of AP was observed from 9.48 cases per 1000 hospitalizations in 2002 to 12.19 per 1000 hospitalizations in 2013 (P < 0.001). In-hospital mortality decreased from 2.99 cases per 100 cases in 2002 to 2.04 cases per 100 cases in 2013 (P < 0.001). Mean length of stay decreased from 6.99 (standard deviation [SD], 9.37) days in 2002 to 5.74 (SD, 7.94) days in 2013 (P < 0.001). Cost of hospitalization increased from $27,827 (SD, $54,556) in 2002 to $49,772 (SD, $106,205) in 2013 (P < 0.001).

CONCLUSIONS

Hospital admissions for AP in adults increased significantly in the United States from 2002 to 2013. In-hospital all-cause mortality and mean length of stay significantly decreased. In contrast, total cost of hospitalization rose.

Acute pancreatitis: Trends in outcomes and the role of acute kidney injury in mortality- A propensity-matched analysis

OBJECTIVES

To assess national trends of AP (acute pancreatitis) admissions, outcomes, prevalence of AKI (acute kidney injury) in AP, and impact of AKI on inpatient mortality.

METHODS

We queried the Nationwide Inpatient Sample database from 2003 to 2012 to identify AP admissions using ICD-9-CM codes. After excluding patients with missing information on age, gender, and inpatient mortality, we used ICD-9-CM codes to identify complications of AP, specifically AKI. We examined trends with survey-weighted multivariable regressions and analyzed predictors of AKI and inpatient mortality by multivariate logistic regression. Additionally, both AKI and non-AKI groups were propensity-matched and regressed against mortality.

RESULTS

A total of 3,466,493 patients (1.13% of all discharges) were hospitalized with AP, of which 7.9% had AKI. AP admissions increased (1.02%→1.26%) with rise in concomitant AKI cases (4.1%→11.7%) from year 2003-2012. Mortality rate decreased (1.8%→1.1%) in the AP patients with a substantial decline noted in AKI subgroup (17.4%→6.4%) during study period. Length of stay (LOS) and cost of hospitalization decreased (6.1→5.2 days and $13,654 to $10,895, respectively) in AKI subgroup. Complications such as AKI (OR: 6.08, p < 0.001), septic shock (OR: 46.52, p < 0.001), and acute respiratory failure (OR: 22.72, p < 0.001) were associated with higher mortality. AKI, after propensity matching, was linked to 3-fold increased mortality (propensity-matched OR: 3.20, P < 0.001).

CONCLUSION

Mortality, LOS, and cost of hospitalization in AP has decreased during the study period, although hospitalization and AKI prevalence has increased. AKI is independently associated with higher mortality.

Association of circulating inflammation proteins and gallstone disease

BACKGROUND AND AIM

Inflammation plays a role in the development of both gallstones and gallbladder cancer; however, few studies have investigated the association of circulating inflammation proteins with risk of gallstones.

METHODS

This study measured 13 cytokines (including 10 interleukins [ILs]) that have been associated with cancer in serum samples collected from 150 gallstone patients and 149 population-based controls from Shanghai, China, in 1997-2001. This study estimated the associations of each cytokine, categorized into quartiles and coded as a trend, with risk of gallstones using logistic regression models adjusted for potential confounders.

RESULTS

Higher levels of IL-6, IL-10, IL-12 (p70), and IL-13 were associated with increased risk of gallstones (i.e. P_trend  < 0.003, Bonferroni corrected), with odds ratios (ORs) that ranged from OR_{highest quartile [Q4] versus lowest quartile [Q1]}  = 3.2 (95% confidence interval: 1.4, 7.5) for IL-13 to OR_{Q4 versus Q1}  = 5.7 (95% confidence interval: 2.5, 13.5) for IL-12 (p70). In a regression model including all four ILs, only IL-12 retained statistical significance (P < 0.05).

CONCLUSION

This study found four circulating ILs that were associated with gallstones. Future studies are needed to validate the findings and evaluate the common pathway or mechanism in the development of gallbladder diseases associated with these cytokine signatures.

The Use of International Classification of Diseases Codes to Identify Patients with Pancreatitis: A Systematic Review and Meta-analysis of Diagnostic Accuracy Studies

Background

Hospital discharge codes are increasingly used in gastroenterology research, but their accuracy in the setting of acute pancreatitis (AP) and chronic pancreatitis (CP), one of the most frequent digestive diseases, has never been assessed systematically. The aim was to conduct a systematic literature review and determine accuracy of diagnostic codes for AP and CP, as well as the effect of covariates.

Methods

Three databases (Pubmed, EMBASE and Scopus) were searched by two independent reviewers for relevant studies that used International Classification of Disease (ICD) codes. Summary estimates of sensitivity, specificity and positive predictive value were obtained from bivariate random-effects regression models. Sensitivity and subgroup analyses according to recurrence of AP and age of the study population were performed.

Results

A total of 24 cohorts encompassing 18,106 patients were included. The pooled estimates of sensitivity and specificity of ICD codes for AP were 0.85 and 0.96, respectively. The pooled estimates of sensitivity and specificity of ICD codes for CP were 0.75 and 0.94, respectively. The positive predictive value of ICD codes was 0.71 for either AP or CP. It increased to 0.78 when applied to incident episode of AP only. The positive predictive value decreased to 0.68 when the ICD codes were applied to paediatric patients.

Conclusion

Nearly three out of ten patients are misidentified as having either AP or CP with the indiscriminate use of ICD codes. Limiting the use of ICD codes to adult patients with incident episode of AP may improve identification of patients with pancreatitis in administrative databases.

TLR4 Asp299Gly and Thr399Ile and TLR2 intron 2 microsatellite gene polymorphism in patients with acute biliary pancreatitis: Does it cause the disease?

OBJECTIVES

There has been coverage of Toll-like receptor 4 and Toll-like receptor 2 gene polymorphisms in inflammatory episodes in a number of studies. In view of the inflammatory nature of acute pancreatitis, we aimed to determine the predictive value of mutations in Asp299Gly and Thr399Ile of the Toll-like receptor 4 gene, and the intron 2 microsatellite polymorphism of the Toll-like receptor 2 gene on the occurrence of acute biliary pancreatitis.

MATERIAL AND METHODS

The study included 86 patients for the Toll-like receptor 4 Thr399Ile polymorphism, 100 patients for the Toll-like receptor 4 Asp299Gly polymorphism with acute biliary pancreatitis, and 101 healthy volunteers. At the same time, 93 patients and 92 healthy volunteers were included in the study to research the Toll-like receptor 2 intron 2 microsatellite polymorphism. Genotypes were determined using the restriction fragment length polymorphism analysis of PCR products and by an allele-specific PCR.

RESULTS

The Toll-like receptor 4 Thr399Ile homozygotes mutant variants (p=0.005) and Toll-like receptor 2 MM genotype (p<0.001) were detected with a significantly higher frequency in patients with acute biliary pancreatitis than in the healthy blood donors.

CONCLUSION

The Toll-like receptor 4 Asp299Gly and Thr399Ile polymorphisms and the Toll-like receptor 2 intron 2 microsatellite polymorphism are statistically associated with ABP.

Interleukin-6 significantly improves predictive value of systemic inflammatory response syndrome for predicting severe acute pancreatitis

BACKGROUND

Predicting severe acute pancreatitis (AP) is important for triage, prognosis, and designing therapeutic trials. Persistent systemic inflammatory response syndrome (SIRS) predicts severe AP but its diagnostic accuracy is suboptimal. Our objective was to study if cytokine levels could improve the predictive value of clinical variables for the development of severe AP.

METHODS

Consecutive patients with AP were included in a prospective cohort study at a tertiary care center. Serum levels of IL-6, TNF-α, IL-10, MCP-1, GM-CSF and IL-1β were measured at day 3 of onset of AP. Variables such as age, co-morbidity, etiology, SIRS, and cytokines were modeled to predict severe AP by multivariable regression analysis. Genotyping was done to correlate IL-6, TNF-α and MCP-1 gene polymorphisms with cytokine levels.

RESULTS

Of 236 patients with AP, 115 patients admitted within 7 days of onset formed the study group. 37 of the 115 (32%) patients developed organ failure. Independent predictors of organ failure were persistent SIRS (OR 34; 95% CI: 7.2-159) and day 3 serum IL-6 of >160 pg/ml (OR 16.1; 95% CI:1.8-142). IL-6 gene (-174 G/C) GG genotype was associated with significantly higher levels of IL-6 compared to CC/CG genotype. Serum IL-6 >160 pg/ml increased the positive predictive value of persistent SIRS from 56% to 85% and specificity from 64% to 95% for predicting OF without compromising its sensitivity and negative predictive value.

CONCLUSION

Serum IL-6 of >160 ng/ml added significantly to the predictive value of SIRS for severe AP.

Short article: Presence, extent and location of pancreatic necrosis are independent of aetiology in acute pancreatitis

OBJECTIVE

The most common aetiologies of acute pancreatitis (AP) are gallstones, alcohol and idiopathic. The impact of the aetiology of AP on the extent and morphology of pancreatic and extrapancreatic necrosis (EXPN) has not been clearly established. The aim of the present study was to assess the influence of aetiology on the presence and location of pancreatic necrosis in patients with AP.

PATIENTS AND METHODS

We carried out a post-hoc analysis of a previously established multicentre cohort of patients with AP in whom a computed tomography was available for review. Clinical data were obtained from the medical records. All computed tomographies were revised by the same expert radiologist. The impact of aetiology on pancreatic and EXPN was calculated.

RESULTS

In total, 159 patients with necrotizing pancreatitis were identified from a cohort of 285 patients. The most frequent aetiologies were biliary (105 patients, 37%), followed by alcohol (102 patients, 36%) and other aetiologies including idiopathic (78 patients, 27%). No relationship was found between the aetiology and the presence of pancreatic necrosis, EXPN, location of pancreatic necrosis or presence of collections.

CONCLUSION

We found no association between the aetiology of AP and the presence, extent and anatomical location of pancreatic necrosis.

Impact of Seasons and Festivals on the Onset of Acute Pancreatitis in Shanghai, China

OBJECTIVES

Seasonal variation on acute pancreatitis (AP) has not been investigated in Eastern Asia. The aims of the study were to assess the association of the onset of AP with the occurrence of seasons and Chinese festivals and to investigate trends in AP incidence in Shanghai, China.

METHODS

From January 2009 to December 2014, a total of 1780 patients with AP were considered. The incidence was assessed by different etiology and severity. Monthly disease prevalence was investigated to explore the seasonal variation. The prevalence on weekdays, weekends, and festivals was evaluated to establish any weekly or festival influences in AP.

RESULTS

Acute pancreatitis increased from 30.5 per 100,000 in 2009 to 39.2 in 2014 (5.1% annual increase), with greatest increases in alcoholic (19.8% annually) and severe AP (13.7% annually). Time series analysis indicated that prevalence was significantly higher form February to May (spring) and from September to October (autumn). Acute pancreatitis increased during Chinese festivals, 17% and 28% greater than that observed on weekdays and weekends, respectively. Prevalence was greatest in Chinese Spring Festival week.

CONCLUSIONS

Acute pancreatitis increased in Shanghai and had a seasonal variation, with a higher frequency of events in the spring and autumn. Chinese festivals are associated with a high prevalence of AP.

Angiotensin II receptor blockers and risk of acute pancreatitis - a population based case-control study in Sweden

Background

Acute pancreatitis is a potentially lethal disease, with a rising incidence in the Western world. Yet, no pharmacological prevention or specific treatment for acute pancreatitis exists. Also, the connection with severity of acute pancreatitis is unknown. Experimental and epidemiological research suggests a protective effect of angiotensin II receptor blockers.

Methods

During 2006 to 2008, we performed a nationwide case–control study on Swedish residents aged 40–84 years. First-time cases with acute pancreatitis were identified in the National Patient Register and data on dispensed prescriptions was retrieved from the Prescribed Drug Register. Controls were randomly selected from the general population in Sweden frequency-matched on sex, age, and calendar year. To estimate relative risk of acute pancreatitis, by degree of severity, among users of angiotensin II receptor blockers, as compared to non-users, we used multivariable logistic regression analysis to calculate odds ratios (OR) with 95% confidence interval (CI).

Results

Among 6,161 cases of acute pancreatitis and 61,637 controls, current use of angiotensin II receptor blockers was followed by a decreased risk of acute pancreatitis, compared to non-users, adjusted OR 0 · 77 (95% CI 0 · 69–0 · 86). No protective association, but an increased risk was found for users of angiotensin-converting enzyme inhibitors (adjusted OR 1 · 11, 95% CI: 1 · 01–1 · 21), analysed for comparison reasons. There was a significant decreased risk associated with both severe acute pancreatitis, (OR 0 · 71 (0 · 59–0 · 85), and mild acute pancreatitis; adjusted OR 0 · 81 (0 · 70–0 · 94).

Conclusion

This population-based case–control study indicates that use of angiotensin II receptor blockers might be associated with a lesser risk of acute pancreatitis, and that the protective association was significant among cases of both severe and mild acute pancreatitis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-017-0595-8) contains supplementary material, which is available to authorized users.

Acute biliary pancreatitis: focus on recurrence rate and costs when current guidelines are not complied

BACKGROUND

International guidelines recommend cholecystectomy within 2-4 weeks after mild to moderate acute biliary pancreatitis (ABP) to prevent recurrence. We aimed to investigate the compliance to guidelines concerning early cholecystectomy and the associated costs.

METHODS

Admissions for ABP 2011-2013 were retrospectively reviewed. Classification was made according to the revised Atlanta classification. Treatment, time to surgery and recurrence, as well as cost analysis for both in-hospital costs and loss of production (LOP) were performed.

RESULTS

In total, 254 patients were included. Some 202 of the ABP patients (80%) underwent definitive treatment during their first attack of ABP (68% cholecystectomy, 17% endoscopic retrograde cholangiopancreatography (ERCP), 15% both interventions) and 186 (73%) were treated within 1 month of discharge. Patients with ERCP alone were significantly older than cholecystectomy cases (p < .001), but no significant difference was observed between those who underwent ERCP or no treatment (p = .071). Mild ABP had intervention earlier (p < .001). In all, 52 patients (20%) had no intervention, out of which 15 were readmitted due to pancreatitis, compared to 3 patients of those treated at the initial admission (p < .001). The mean cost for hospital care and LOP in mild ABP was €6882 ± 3010 and €9580 ± 7047 for moderate ABP (p = .001). The cost for a recurrent episode was €16,412 ± 22,367.

CONCLUSION

By improved compliance to current guidelines concerning the management of ABP, recurrence rate and associated costs can potentially be reduced.

The incidence and aetiology of acute pancreatitis across Europe

BACKGROUND

Acute pancreatitis is increasingly one of the most important acute gastrointestinal conditions throughout much of the world, although incidence and aetiology varies across countries and regions. This study investigated regional and national patterns in the incidence and aetiology of acute pancreatitis, demographic patterns in incidence and trends over time in incidence across Europe.

METHODS

A structured review of acute pancreatitis incidence and aetiology from studies of hospitalised patient case series, cohort studies or other population based studies from 1989 to 2015 and a review of trends in incidence from 1970 to 2015 across all 51 European states.

RESULTS

The incidence of acute pancreatitis was reported from 17 countries across Europe and ranged from 4.6 to 100 per 100 000 population. Incidence was usually highest in eastern or northern Europe, although reported rates often varied according to case ascertainment criteria. Of 20 studies that reported on trends in incidence, all but three show percentage increases over time (overall median increase = 3.4% per annum; range = -0.4%-73%). The highest ratios of gallstone to alcohol aetiologies were identified in southern Europe (Greece, Turkey, Italy and Croatia) with lowest ratios mainly in eastern Europe (Latvia, Finland, Romania, Hungary, Russia and Lithuania).

CONCLUSIONS

The incidence of acute pancreatitis varies across Europe. Gallstone is the dominant aetiology in southern Europe and alcohol in eastern Europe with intermediate ratios in northern and western Europe. Acute pancreatitis continues to increase throughout most of Europe.

Global incidence and mortality of pancreatic diseases: a systematic review, meta-analysis, and meta-regression of population-based cohort studies

BACKGROUND

There is a lack of robust estimates of the worldwide incidence and mortality of acute pancreatitis, chronic pancreatitis, pancreatic cysts, and pancreatic cancer in the general population. Our aim was to quantitate and compare the incidence and mortality of major pancreatic diseases in high-quality population-based cohort studies.

METHODS

Three databases (PubMed, Embase, and Scopus) were searched independently by two reviewers. Data from eligible studies were subject to meta-analysis to obtain global estimates. A number of prespecified subgroup analyses and meta-regression analyses were also done.

FINDINGS

48 population-based cohort studies (35 on pancreatic cancer, ten on acute pancreatitis, three on chronic pancreatitis, and none on pancreatic cysts) were identified, with a total study population of 296 million individuals and 119 000 patients with pancreatic diseases. Global estimates of incidence and mortality were 8·14 cases (95% CI 6·63-9·98) per 100 000 person-years and 6·92 deaths (95% CI 3·72-12·89) per 100 000 person-years for pancreatic cancer, 33·74 cases (95% CI 23·33-48·81) per 100 000 person-years and 1·60 deaths (95% CI 0·85-1·58) per 100 000 person-years for acute pancreatitis, and 9·62 cases (95% CI 7·86-11·78) per 100 000 person-years and 0·09 deaths (95% CI 0·02-0·47) per 100 000 person-years for chronic pancreatitis. Subgroup analysis based on the WHO regions showed that the incidences of both pancreatic cancer and acute pancreatitis, and mortality from pancreatic cancer, were significantly higher in the American region than in the European and Western Pacific regions, while the incidence of chronic pancreatitis was significantly higher in the European region than in the American region. Mortality from pancreatic cancer was lowest in the Southeast Asian region. The incidence of chronic pancreatitis was twice as high in men as in women, although there was no difference between sexes for pancreatic cancer or acute pancreatitis.

INTERPRETATION

Globally, acute pancreatitis is the most common pancreatic disease whilst pancreatic cancer is the most lethal. However, their burden is not equal across the globe. The epidemiological estimates reported in this study could inform future high-quality studies.

FUNDING

None.

Impact of a clinical pathway on treatment outcome in patients with acute pancreatitis

AIM: To determine the impact of a clinical pathway (CP) on acute pancreatitis (AP) treatment outcome.

METHODS: A retrospective analysis of medical records was performed. We compared the results of AP treatment outcome over two time periods in our centre, before (2006-2007) and after (2010-2012) the implementation of a CP. The CP comprised the following indicators of quality: performance of all laboratory tests on admission (including lipids and carbohydrate deficient transferrin), determination of AP aetiology, abdomen ultrasound (US) within the first 24 h after admission, contrast-enhanced computed tomography of the abdomen in all cases of suspected pancreatic necrosis, appropriately selected and sufficiently used antibiotic therapy (if necessary), pain control, adequate hydration, control of haemodynamic parameters and transfer to the Intensive Care Unit (ICU) (if necessary), endoscopic retrograde cholangiopancreatography (ERCP) in biliary AP, surgical treatment (if necessary), and advice on outpatient follow-up after discharge. A comparison of the length of stay with that in other Slovenian hospitals was also performed.

RESULTS: There were 139 patients treated in the three-year period after the introduction of a CP, of which 81 (58.3%) were male and 58 (41.7%) female. The patients’ mean age was 59.6 ± 17.3 years. The most common aetiologies were alcoholism and gallstones (38.8% each), followed by unexplained (11.5%), drug-induced, hypertriglyceridemia, post ERCP (2.9% each) and tumours (2.2%). Antibiotic therapy was prescribed in 72 (51.8%) patients. Abdominal US was performed in all patients within the first 24 h after admission. Thirty-two (23.0%) patients were treated in the ICU. Four patients died (2.9%). In comparison to 2006-2007, we found an increased number of alcoholic and biliary AP and an associated decrease in the number of unexplained aetiology cases. The use of antibiotics also significantly decreased after the implementation of a CP (from 70.3% to 51.8%; P = 0.003). There was no statistically significant difference in mortality (1.8% vs 2.9%). The length of stay was significantly shorter when compared to the Slovenian average (P = 0.018).

CONCLUSION: The introduction of a CP has improved the treatment of patients with AP, as assessed by all of the observed parameters.

Change of Both Endocrine and Exocrine Insufficiencies After Acute Pancreatitis in Non-Diabetic Patients: A Nationwide Population-Based Study

Acute pancreatitis (AP) is the most common pancreatic disease and consists of an acute inflammation of the pancreas. AP can contribute to endocrine and exocrine insufficiencies in survivors as a result of the key role of the pancreas in both glucose metabolism and nutritional digestion. The aim of this population-based study was to determine the endocrine or exocrine insufficiencies in patients after initial AP with biliary or alcohol-associated causes.We conducted a nationwide cohort study using data from Taiwan's National Health Insurance Research Database collected between 2001 and 2010. A total of 12,284 patients with AP were identified.Alcohol-associated AP (odds ratio, 1.894; 95% CI, 1.520-2.268; P < 0.001) and ≥2 admissions for AP (odds ratio, 1.937; 95% CI, 1.483-2.391; P < 0.001) were significantly associated with newly diagnosed diabetes mellitus after AP. Further, only alcohol-associated AP (odds ratio, 1.215; 95% CI, 1.133-1.297; P < 0.001) was significantly associated with pancreatic exocrine insufficiency after AP. Additionally, alcohol-associated AP (odds ratio, 1.804; 95% CI, 1.345-2.263; P < 0.001) and ≥2 readmissions for AP (odds ratio, 3.190; 95% CI, 2.317-4.063; P < 0.001) were significantly associated with both exocrine and endocrine insufficiencies after AP.Our data showed that alcohol-associated AP, rather than a biliary cause, contributed to a higher extent to exocrine or endocrine insufficiencies. Furthermore, recurrent AP also led to endocrine insufficiency.

Enteral nutrition formulations for acute pancreatitis

BACKGROUND

Acute pancreatitis is a common and potentially lethal disease with increasing incidence. Severe cases are characterised by high mortality, and despite improvements in intensive care management, no specific treatment relevantly improves clinical outcomes of the disease. Meta-analyses suggest that enteral nutrition is more effective than conventional treatment consisting of discontinuation of oral intake with use of total parenteral nutrition. However, no systematic review has compared different enteral nutrition formulations for the treatment of patients with acute pancreatitis.

OBJECTIVES

To assess the beneficial and harmful effects of different enteral nutrition formulations in patients with acute pancreatitis.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Specialised Register of Clinical Trials, the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 7), MEDLINE (from inception to 20 August 2013), EMBASE (from inception to 2013, week 33) and Science Citation Index-Expanded (from 1990 to August 2013); we conducted full-text searches and applied no restrictions by language or publication status.

SELECTION CRITERIA

We considered randomised clinical trials assessing enteral nutrition in patients with acute pancreatitis. We allowed concomitant interventions if they were received equally by all treatment groups within a trial.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and extracted data. We performed the analysis using Review Manager 5 (Review Manager 2013) and both fixed-effect and random-effects models. We expressed results as risk ratios (RRs) for dichotomous data, and as mean differences (MDs) for continuous data, both with 95% confidence intervals (CIs). Analysis was based on an intention-to-treat principle.

MAIN RESULTS

We included 15 trials (1376 participants) in this review. We downgraded the quality of evidence for many of our outcomes on the basis of high risk of bias. Low-quality evidence suggests that immunonutrition decreases all-cause mortality (RR 0.49, 95% CI 0.29 to 0.80). The effect of immunonutrition on other outcomes from a subset of the included trials was uncertain. Subgrouping trials by type of enteral nutrition did not explain any variation in effect. We found mainly very low-quality evidence for the effects of probiotics on the main outcomes. One eligible trial in this comparison reported a higher rate of serious adverse events leading to increased organ failure and mortality due to low numbers of events and low risk of bias. When we excluded this study as a post hoc sensitivity analysis, risks of mortality (RR 0.30, 95% CI 0.10 to 0.84), organ failure (RR 0.74, 95% CI 0.59 to 0.92) and local septic complications (RR 0.40, 95% CI 0.22 to 0.72) were lower with probiotics. In one trial assessing immunonutrition with probiotics and fibres, no deaths occurred, but hospital stay was shorter with immunonutrition (MD -5.20 days, 95% CI -8.73 to -1.67). No deaths were reported following semi-elemental enteral nutrition (EN), and the effect on length of hospital stay was small (MD 0.30 days, 95% CI -0.82 to 1.42). Fibre-enriched formulations reduced the number of other local complications (RR 0.52, 95% CI 0.32 to 0.87) and length of hospital stay (MD -9.28 days, 95% CI -13.21 to -5.35) but did not significantly affect all-cause mortality (RR 0.23, 95% CI 0.03 to 1.84) and other outcomes. Very low-quality evidence from the subgroup of trials comparing EN versus no intervention showed a decrease in all-cause mortality with EN (RR 0.50, 95% CI 0.29 to 0.86).

AUTHORS' CONCLUSIONS

We found evidence of low or very low quality for the effects of immunonutrition on efficacy and safety outcomes. The role of supplementation of enteral nutrition with potential immunomodulatory agents remains in question, and further research is required in this area. Studies assessing probiotics yielded inconsistent and almost contrary results, especially regarding safety and adverse events, and their findings do not support the routine use of EN enriched with probiotics in routine clinical practice. However, further research should be carried out to try to determine the potential efficacy or harms of probiotics. Lack of trials reporting on other types of EN assessed and lack of firm evidence regarding their effects suggest that additional randomised clinical trials are needed. The quality of evidence for the effects of any kind of EN on mortality was low, and further studies are likely to have an impact on the finding of improved survival with EN versus no nutritional support. Evidence remains insufficient to support the use of a specific EN formulation.

Resistin is not an appropriate biochemical marker to predict severity of acute pancreatitis: A case-controlled study

AIM: To assess levels of serum resistin upon hospital admission as a predictor of acute pancreatitis (AP) severity.

METHODS: AP is both a common and serious disease, with severe cases resulting in a high mortality rate. Several predictive inflammatory markers have been used clinically to assess severity. This prospective study collected data from 102 patients who were diagnosed with an initial acute biliary pancreatitis between March 2010 and February 2013. Measurements of body mass index (BMI) and waist circumference (WC) were obtained and serum resistin levels were analyzed at the time of hospital admission using enzyme-linked immunosorbent assay. Additionally, resistin levels were measured from a control group after matching gender, BMI and age.

RESULTS: A total of 102 patients (60 females and 42 males) were diagnosed with acute gallstone-induced pancreatitis. The mean age was 45 years, and mean BMI value was 30.5 kg/m² (Obese, class I). Twenty-two patients (21.6%) had severe AP, while eighty-eight patients had mild pancreatitis (78.4%). Our results showed that BMI significantly correlated with pancreatitis severity (P = 0.007). Serum resistin did not correlate with BMI, weight or WC. Furthermore, serum resistin was significantly higher in patients with AP compared to control subjects (P < 0.0001). The mean resistin values upon admission were 17.5 ng/mL in the severe acute biliary pancreatitis group and 16.82 ng/mL in the mild AP group (P = 0.188), indicating that resistin is not an appropriate predictive marker of clinical severity.

CONCLUSION: We demonstrate that obesity is a risk factor for developing severe AP. Further, although there is a correlation between serum resistin levels and AP at the time of hospital admission, resistin does not adequately serve as a predictive marker of clinical severity.

Nutrition, inflammation, and acute pancreatitis

Acute pancreatitis is acute inflammatory disease of the pancreas. Nutrition has a number of anti-inflammatory effects that could affect outcomes of patients with pancreatitis. Further, it is the most promising nonspecific treatment modality in acute pancreatitis to date. This paper summarizes the best available evidence regarding the use of nutrition with a view of optimising clinical management of patients with acute pancreatitis.

The incidence of acute pancreatitis: impact of social deprivation, alcohol consumption, seasonal and demographic factors

BACKGROUND

The incidence of acute pancreatitis has increased sharply in many European countries and the USA in recent years.

AIM

To establish trends in incidence and mortality for acute pancreatitis in Wales, UK, and to assess how incidence may be linked to factors including social deprivation, seasonal effects and alcohol consumption.

METHODS

Use of record linked inpatient, mortality and primary care data for 10,589 hospitalised cases of acute pancreatitis between 1999 and 2010.

RESULTS

The incidence of acute pancreatitis was 30.0 per 100,000 population overall, mortality was 6.4% at 60 days. Incidence increased significantly from 27.6 per 100,000 in 1999 to 36.4 in 2010 (average annual increase = 2.7% per year), there was little trend in mortality (0.2% average annual reduction). The largest increases in incidence were among women aged <35 years (7.9% per year) and men aged 35-44 (5.7%) and 45-54 (5.3%). Incidence was 1.9 times higher among the most deprived quintile of patients compared with the most affluent (3.9 times higher for alcoholic acute pancreatitis and 1.5 for gallstone acute pancreatitis). Acute pancreatitis was increased significantly during the Christmas and New Year weeks by 48% (95% CI = 24-77%) for alcoholic aetiology, but not for gallstone aetiology (9%). Alcoholic admissions were increased with higher consumption of spirits and beer, but not wine.

CONCLUSIONS

The study shows an elevated rate of alcoholic acute pancreatitis during the Christmas and New Year period. Acute pancreatitis continues to rise, most rapidly for young women, while alcoholic acute pancreatitis is linked strongly with social deprivation.

Incidence and mortality of acute and chronic pancreatitis in the Netherlands: A nationwide record-linked cohort study for the years 1995-2005

AIM: To analyze trends in incidence and mortality of acute pancreatitis (AP) and chronic pancreatitis (CP) in the Netherlands and for international standard populations.

METHODS: A nationwide cohort is identified through record linkage of hospital data for AP and CP, accumulated from three nationwide Dutch registries: the hospital discharge register, the population register, and the death certificate register. Sex- and age-group specific incidence rates of AP and CP are defined for the period 2000-2005 and mortality rates of AP and CP for the period 1995-2005. Additionally, incidence and mortality rates over time are reported for Dutch and international (European and World Health Organization) standard populations.

RESULTS: Incidence of AP per 100000 persons per year increased between 2000 and 2005 from 13.2 (95%CI: 12.6-13.8) to 14.7 (95%CI: 14.1-15.3). Incidence of AP for males increased from 13.8 (95%CI: 12.9-14.7) to 15.2 (95%CI: 14.3-16.1), for females from 12.7 (95%CI: 11.9-13.5) to 14.2 (95%CI: 13.4-15.1). Irregular patterns over time emerged for CP. Overall mean incidence per 100000 persons per year was 1.77, for males 2.16, and for females 1.4. Mortality for AP fluctuated during 1995-2005 between 6.9 and 11.7 per million persons per year and was almost similar for males and females. Concerning CP, mortality for males fluctuated between 1.1 (95%CI: 0.6-2.3) and 4.0 (95%CI: 2.8-5.8), for females between 0.7 (95%CI: 0.3-1.6) and 2.0 (95%CI: 1.2-3.2). Incidence and mortality of AP and CP increased markedly with age. Standardized rates were lowest for World Health Organization standard population.

CONCLUSION: Incidence of AP steadily increased while incidence of CP fluctuated. Mortality for both AP and CP remained fairly stable. Patient burden and health care costs probably will increase because of an ageing Dutch population.

Abdominal and total adiposity and the risk of acute pancreatitis: a population-based prospective cohort study

OBJECTIVES

Previous research has indicated that obesity may be linked to the severity of acute pancreatitis. However, the association between abdominal and total adiposity as risk factors in the development of acute pancreatitis in a general population has not been studied.

METHODS

A follow-up study was conducted, using the Swedish Mammography Cohort and the Cohort of Swedish Men, to examine the association between waist circumference and body mass index (BMI) and the risk of first-time acute pancreatitis. Severe acute pancreatitis was defined as hospital stay of >14 days, in-hospital death, or mortality within 30 days of discharge. Cox proportional hazards models were used to estimate rate ratios (RRs) with 95% confidence intervals (CIs), adjusted for confounders.

RESULTS

In total, 68,158 individuals, aged 46-84 years, were studied for a median of 12 years. During this time, 424 persons developed first-time acute pancreatitis. The risk of acute pancreatitis among those with a waist circumference of >105 cm was twofold increased (RR=2.37; 95% CI: 1.50-3.74) compared with individuals with a waist circumference of 75.1-85.0 cm, when adjusted for confounders. This association was seen in patients with non-gallstone-related and gallstone-related acute pancreatitis. The results remained unchanged when stratifying the analyses with regards to sex or the severity of acute pancreatitis. There was no association between BMI and the risk of acute pancreatitis.

CONCLUSIONS

Abdominal adiposity, but not total adiposity, is an independent risk factor for the development of acute pancreatitis.

Age-dependent vulnerability to experimental acute pancreatitis is associated with increased systemic inflammation and thrombosis

The severity and mortality rates of acute pancreatitis (AP) are significantly elevated in the elderly population. However, due to a lack of appropriate animal models, the underlying mechanisms for this age-dependent vulnerability remain largely unknown. The purpose of this study was to characterize a murine model of AP, which displays age-associated severity, and to use this model to identify pathophysiologies that are distinctive of the aged with AP. AP was induced in young (4-5 months), middle-aged (12-13 months), and aged (23-25 months) C57BL/6 mice by repeated injection of caerulein, a homologue of the gastrointestinal hormone cholecystokinin. Approximately 10% of aged mice died during AP, while young and middle-aged mice showed no mortality. Although both young and aged mice exhibited early signs of edema and inflammation in the pancreas, kidney, and lung, young mice showed signs of recovery within 24 h, while aged mice exhibited increasingly severe tissue damage and cell death. There was a significant age-dependent increase in pancreatic neutrophil activation and systemic inflammation as assessed by pancreatic myeloperoxidase and plasma interleukin-6 (IL-6) concentration, respectively. Importantly, aged but not young mice with AP showed significantly elevated thrombosis in the lung and kidney as well as a marked increase in plasma concentration of plasminogen activator inhibitor-1 (PAI-1), a primary inhibitor of the fibrinolytic system. These results demonstrate that aging is associated with increased severity of AP characterized by augmented and prolonged pancreatic inflammation and the presence of multiple extra-pancreatic sequelae including thrombosis.

Analyses of hospital administrative data that use diagnosis codes overestimate the cases of acute pancreatitis

BACKGROUND & AIMS

Although widely used, little information exists on the validity of using hospital administrative data to code acute pancreatitis (AP). We sought to determine if discharge diagnosis codes accurately identify patients whose clinical course met the standard for AP diagnosis.

METHODS

We analyzed data from 401 unique patients admitted through the emergency department who received a primary inpatient discharge diagnosis of AP at 2 University of Pittsburgh Medical Center hospitals in the years 2000, 2002, and 2005. Each patient was matched with a control patient who was admitted with abdominal pain and then discharged without a diagnosis of AP. Patients were matched based on demographics, testing for serum levels of pancreatic enzymes, year of visit to the emergency department, admission to the intensive care unit, and performance of abdominal computed tomography scan. The standard used to diagnose AP was the presence of 2 of 3 features (abdominal pain, ≥ 3-fold increase in serum levels of pancreatic enzymes, and positive results from imaging analysis).

RESULTS

The median age of AP cases was 53 years (interquartile range, 41.5-67 years); 47.1% were male, 85% were white. The most common etiologies were biliary (33.4%), alcohol-associated (16.2%), and idiopathic (24.2%). Serum levels of pancreatic enzymes were increased by any amount, and by ≥ 3-fold, in 95.3% and 68.6% of patients diagnosed with AP and in 16.2% and 2.2% of controls, respectively. The standard for diagnosis of AP was met in 80% of cases diagnosed with this disorder; they had no history of pancreatitis. The sensitivity, specificity, and positive and negative predictive values of the AP diagnosis code were 96%, 85%, 80%, and 98%, respectively.

CONCLUSIONS

Approximately 1 of 5 patients diagnosed with AP upon discharge from the hospital do not meet the guidelines for diagnosis of this disorder. Efforts should be made to more consistently use guidelines for AP diagnosis.

A prospective cohort study on risk of acute pancreatitis related to serum triglycerides, cholesterol and fasting glucose

BACKGROUND/OBJECTIVES

To investigate risk for acute pancreatitis related to moderately elevated triglycerides, cholesterol and fasting glucose.

METHODS

This was a prospective cohort study in Malmö, Sweden of 33,346 subjects investigated 1974-1992 and followed until December 31, 2006. Baseline investigation included a self-administered questionnaire and analysis of serum triglycerides, cholesterol and fasting glucose. Cases of acute pancreatitis (n = 277, median time since baseline investigation 15.6 years) were identified in diagnosis registries and validated retrospectively. Attacks were classified as obstructive or non obstructive (alcohol or non alcohol related). Cox proportional hazards analysis was used to calculate hazard ratios (HR) for acute pancreatitis related to relevant risk factors, adjusting for age, sex, smoking habits and alcohol consumption.

RESULTS

Triglycerides were associated with overall, non obstructive and non obstructive non alcohol related acute pancreatitis with adjusted HRs of 1.21 (95% confidence interval (CI), 1.07-1.36), 1.23 (95% CI, 1.06-2.43) and 1.34 (95% CI, 1.11-1.62) per 1 mmol/l increment, respectively. Corresponding HRs for forth versus first quartile of triglycerides were 1.55 (95% CI, 1.09-2.21), 1.60 (95% CI, 1.60-1.01-1.35) and 2.07 (95% CI, 1.13-3.79). Triglycerides were not associated with obstructive acute pancreatitis and there were no associations between glucose or cholesterol and the risk of acute pancreatitis.

CONCLUSIONS

We found an association between prediagnostic levels of triglycerides and risk for acute pancreatitis. This association was most pronounced in the non obstructive non alcohol related group. Our findings suggest that triglycerides may be a more important risk factor for acute pancreatitis than what has previously been estimated.

Epidemiology of gallbladder disease: cholelithiasis and cancer

Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.