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Ali H, Inayat F, Jahagirdar V, Jaber F, Afzal A, Patel P, Tahir H, Anwar MS, Rehman AU, Sarfraz M, Chaudhry A, Nawaz G, Dahiya DS, Sohail AH, Aziz M. Early versus delayed necrosectomy in pancreatic necrosis: A population-based cohort study on readmission, healthcare utilization, and in-hospital mortality. World J Methodol 2024; 14:91810. [DOI: 10.5662/wjm.v14.i3.91810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND Acute necrotizing pancreatitis is a severe and life-threatening condition. It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications. Several minimally invasive and open necrosectomy procedures have been developed. Despite advancements in treatment modalities, the optimal timing to perform necrosectomy lacks consensus.
AIM To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States.
METHODS A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database. Patients with non-elective admissions for pancreatic necrosis were identified. The participants were divided into two groups based on the necrosectomy timing: The early group received intervention within 48 hours, whereas the delayed group underwent the procedure after 48 hours. The various intervention techniques included endoscopic, percutaneous, or surgical necrosectomy. The major outcomes of interest were 30-day readmission rates, healthcare utilization, and inpatient mortality.
RESULTS A total of 1309 patients with pancreatic necrosis were included. After propensity score matching, 349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention. The early cohort had a 30-day readmission rate of 8.6% compared to 4.8% in the delayed cohort (P = 0.040). Early necrosectomy had lower rates of mechanical ventilation (2.9% vs 10.9%, P < 0.001), septic shock (8% vs 19.5%, P < 0.001), and in-hospital mortality (1.1% vs 4.3%, P = 0.01). Patients in the early intervention group incurred lower healthcare costs, with median total charges of $52202 compared to $147418 in the delayed group. Participants in the early cohort also had a relatively shorter median length of stay (6 vs 16 days, P < 0.001). The timing of necrosectomy did not significantly influence the risk of 30-day readmission, with a hazard ratio of 0.56 (95% confidence interval: 0.31-1.02, P = 0.06).
CONCLUSION Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs. Delayed intervention does not significantly alter the risk of 30-day readmission.
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Affiliation(s)
- Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Faisal Inayat
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, United States
| | - Arslan Afzal
- Division of Gastroenterology and Hepatology, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Pratik Patel
- Division of Gastroenterology, Mather Hospital and Zucker School of Medicine at Hofstra University, Port Jefferson, NY 11777, United States
| | - Hamza Tahir
- Department of Internal Medicine, Jefferson Einstein Hospital, Philadelphia, PA 19141, United States
| | - Muhammad Sajeel Anwar
- Department of Internal Medicine, UHS Wilson Medical Center, Johnson City, NY 13790, United States
| | - Attiq Ur Rehman
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Muhammad Sarfraz
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA 18711, United States
| | - Ahtshamullah Chaudhry
- Department of Internal Medicine, St. Dominic's Hospital, Jackson, MS 39216, United States
| | - Gul Nawaz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Punjab 54550, Pakistan
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology, and Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, United States
| | - Amir H Sohail
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, United States
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, The University of Toledo, Toledo, OH 43606, United States
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Saxena J, Das S, Kumar A, Sharma A, Sharma L, Kaushik S, Kumar Srivastava V, Jamal Siddiqui A, Jyoti A. Biomarkers in sepsis. Clin Chim Acta 2024; 562:119891. [PMID: 39067500 DOI: 10.1016/j.cca.2024.119891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/20/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
Sepsis is a life-threatening condition characterized by dysregulated host response to infection leading to organ dysfunction. Despite advances in understanding its pathology, sepsis remains a global health concern and remains a major contributor to mortality. Timely identification is crucial for improving clinical outcomes, as delayed treatment significantly impacts survival. Accordingly, biomarkers play a pivotal role in diagnosis, risk stratification, and management. This review comprehensively discusses various biomarkers in sepsis and their potential application in antimicrobial stewardship and risk assessment. Biomarkers such as white blood cell count, neutrophil to lymphocyte ratio, erythrocyte sedimentation rate, C-reactive protein, interleukin-6, presepsin, and procalcitonin have been extensively studied for their diagnostic and prognostic value as well as in guiding antimicrobial therapy. Furthermore, this review explores the role of biomarkers in risk stratification, emphasizing the importance of identifying high-risk patients who may benefit from specific therapeutic interventions. Moreover, the review discusses the emerging field of transcriptional diagnostics and metagenomic sequencing. Advances in sequencing have enabled the identification of host response signatures and microbial genomes, offering insight into disease pathology and aiding species identification. In conclusion, this review provides a comprehensive overview of the current understanding and future directions of biomarker-based approaches in sepsis diagnosis, management, and personalized therapy.
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Affiliation(s)
- Juhi Saxena
- Department of Biotechnology, Parul Institute of Technology, Parul University, Vadodara, Gujarat, India
| | - Sarvjeet Das
- Department of Life Science, Parul Institute of Applied Science, Parul University, Vadodara, Gujarat, India
| | - Anshu Kumar
- Department of Life Science, Parul Institute of Applied Science, Parul University, Vadodara, Gujarat, India
| | - Aditi Sharma
- Department of Pharmacology, School of Pharmaceutical Sciences, Shoolini University of Biotechnology,and Management Sciences, Solan 173229, Himachal Pradesh, India
| | - Lalit Sharma
- Department of Pharmacology, School of Pharmaceutical Sciences, Shoolini University of Biotechnology,and Management Sciences, Solan 173229, Himachal Pradesh, India
| | - Sanket Kaushik
- Amity Institute of Biotechnology, Amity University Rajasthan, Jaipur, India
| | | | - Arif Jamal Siddiqui
- Department of Biology, College of Science, University of Ha'il, P.O. Box 2440, Ha'il, Saudi Arabia
| | - Anupam Jyoti
- Department of Life Science, Parul Institute of Applied Science, Parul University, Vadodara, Gujarat, India.
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Chan KS, Tan LYC, Balasubramaniam S, Shelat VG. Should Empiric Anti-Fungals Be Administered Routinely for All Patients with Perforated Peptic Ulcers? A Critical Review of the Existing Literature. Pathogens 2024; 13:547. [PMID: 39057774 PMCID: PMC11279535 DOI: 10.3390/pathogens13070547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 07/27/2024] Open
Abstract
A perforated peptic ulcer (PPU) is a surgical emergency with a high mortality rate. PPUs cause secondary peritonitis due to bacterial and fungal peritoneal contamination. Surgery is the main treatment modality and patient's comorbidites impacts perioperative morbidity and surgical outcomes. Even after surgery, resuscitation efforts should continue. While empiric antibiotics are recommended, the role of empiric anti-fungal treatment is unclear due to a lack of scientific evidence. This literature review demonstrated a paucity of studies evaluating the role of empiric anti-fungals in PPUs, and with conflicting results. Studies were heterogeneous in terms of patient demographics and underlying surgical pathology (PPUs vs. any gastrointestinal perforation), type of anti-fungal agent, timing of administration and duration of use. Other considerations include the need to differentiate between fungal colonization vs. invasive fungal infection. Despite positive fungal isolates from fluid culture, it is important for clinical judgement to identify the right group of patients for anti-fungal administration. Biochemistry investigations including new fungal biomarkers may help to guide management. Multidisciplinary discussions may help in decision making for this conundrum. Moving forward, further research may be conducted to select the right group of patients who may benefit from empiric anti-fungal use.
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Affiliation(s)
- Kai Siang Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore; (L.Y.C.T.); (V.G.S.)
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore;
| | - Lee Yee Calista Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore; (L.Y.C.T.); (V.G.S.)
| | | | - Vishal G. Shelat
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore; (L.Y.C.T.); (V.G.S.)
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore;
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Padula D, Mauro A, Maggioni P, Kurihara H, Di Sabatino A, Anderloni A. Practical approach to acute pancreatitis: from diagnosis to the management of complications. Intern Emerg Med 2024:10.1007/s11739-024-03666-9. [PMID: 38850357 DOI: 10.1007/s11739-024-03666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
The purpose of this review is to provide a practical guide for the clinical care of patients with acute pancreatitis (AP) from the management of the early phases of disease to the treatment of local complications. AP is one of the most frequent causes of gastroenterological admission in emergency departments. It is characterized by a dynamic and unpredictable course and in its most severe forms, is associated with organ dysfunction and/or local complications, requiring intensive care with significant morbidity and mortality. Initial therapy includes adequate fluid resuscitation, nutrition, analgesia, and when necessary critical care support. In recent years, the development of minimally invasive tailored treatments for local complications, such as endoscopic drainage, has improved patients' acceptance and outcomes. Despite this, the management of AP remains a challenge for clinicians. The present review was conducted by the authors, who formulated specific questions addressing the most critical and current aspects of the clinical course of AP with the aim of providing key messages.
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Affiliation(s)
- Donatella Padula
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy.
| | - Paolo Maggioni
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
- Scuola di Specializzazione in Medicina di Emergenza-Urgenza, Università Degli Studi Di Milano, Milan, Italy
| | - Hayato Kurihara
- Emergency Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, Milan, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy
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Shah J, Fernandez Y Viesca M, Jagodzinski R, Arvanitakis M. Infected pancreatic necrosis-Current trends in management. Indian J Gastroenterol 2024; 43:578-591. [PMID: 38625518 DOI: 10.1007/s12664-023-01506-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/11/2023] [Indexed: 04/17/2024]
Abstract
Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.
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Affiliation(s)
- Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, HUB, Université Libre de Bruxelles, Brussels, Belgium.
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Wang D, Lin Z, Su M, Zhou Y, Ma M, Li M. Revealing the role of Peg13: A promising therapeutic target for mitigating inflammation in sepsis. Genet Mol Biol 2024; 47:e20230205. [PMID: 38856110 PMCID: PMC11151158 DOI: 10.1590/1678-4685-gmb-2023-0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 04/22/2024] [Indexed: 06/11/2024] Open
Abstract
To investigate the role of Peg13 in modulating the inflammatory response in sepsis, we established Lipopolysaccharide (LPS)-induced 293T cells and mouse models. Peg13 expression was assessed at various time points after infection using RT-qPCR. The levels of high mobility group box 1 (HMGB1) and interleukin-6 (IL-6) were quantified through ELISA. A total of 44 septic patients and 36 healthy participants were recruited to measure Peg13 and HMGB1 levels in the blood. Peg13 demonstrated significant down-regulation in the supernatant of LPS-induced 293T cells and in the blood of LPS-induced mice. Moreover, the levels of proinflammatory cytokines HMGB1 and IL-6 were elevated in both the supernatant of LPS-induced cell models and blood specimens from LPS-induced murine models, and this elevation could be notably reduced by Peg13 suppression. In a clinical context, Peg13 and HMGB1 levels were higher in septic patients compared to healthy subjects. Peg13 exhibited a negative correlation with HMGB1, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) among septic patients. Peg13 mitigates the inflammatory response by reducing the release of proinflammatory cytokines HMGB1 and IL-6 in sepsis, presenting a potential therapeutic target for alleviating inflammation in sepsis treatment.
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Affiliation(s)
- dan Wang
- Shaoxing People’s Hospital, Department of Infectious Diseases, Shaoxing, Zhejiang, People’s Republic of China
| | - Zhiqiang Lin
- Shaoxing People’s Hospital, Department of general surgery, Shaoxing, Zhejiang, People’s Republic of China
| | - Meixia Su
- Shaoxing People’s Hospital, Department of Infectious Diseases, Shaoxing, Zhejiang, People’s Republic of China
| | - Yiqing Zhou
- Shaoxing People’s Hospital, Department of Infectious Diseases, Shaoxing, Zhejiang, People’s Republic of China
| | - Mengjie Ma
- Shaoxing People’s Hospital, Department of Infectious Diseases, Shaoxing, Zhejiang, People’s Republic of China
| | - Minghui Li
- Shaoxing People’s Hospital, Department of Infectious Diseases, Shaoxing, Zhejiang, People’s Republic of China
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Trikudanathan G, Yazici C, Evans Phillips A, Forsmark CE. Diagnosis and Management of Acute Pancreatitis. Gastroenterology 2024:S0016-5085(24)04916-3. [PMID: 38759844 DOI: 10.1053/j.gastro.2024.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 01/03/2024] [Accepted: 02/18/2024] [Indexed: 05/19/2024]
Abstract
Acute pancreatitis (AP) is increasing in incidence across the world, and in all age groups. Major changes in management have occurred in the last decade. Avoiding total parenteral nutrition and prophylactic antibiotics, avoiding overly aggressive fluid resuscitation, initiating early feeding, avoiding endoscopic retrograde cholangiopancreatography in the absence of concomitant cholangitis, same-admission cholecystectomy, and minimally invasive approaches to infected necrosis should now be standard of care. Increasing recognition of the risk of recurrence of AP, and progression to chronic pancreatitis, along with the unexpectedly high risk of diabetes and exocrine insufficiency after AP is the subject of large ongoing studies. In this review, we provide an update on important changes in management for this increasingly common disease.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Cemal Yazici
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, Illinois
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida.
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Lin C, Li J, Liu B, Hong X, Luo T, Ye J, Yu Y, Peng X, Gou S, Tang H, Yuan T, Luo J, Yang M, Feng B, Zhao Z, Ning C, Sun Z, Zhu S, Chen L, Shen D, Huang G. Metagenomic next-generation sequencing, instead of procalcitonin, could guide antibiotic usage in patients with febrile acute necrotizing pancreatitis: a multicenter, prospective cohort study. Int J Surg 2024; 110:2721-2729. [PMID: 38348834 PMCID: PMC11093443 DOI: 10.1097/js9.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/26/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUNDS The effectiveness of procalcitonin-based algorithms in guiding antibiotic usage for febrile acute necrotizing pancreatitis (ANP) remains controversial. Metagenomic next-generation sequencing (mNGS) has been applied to diagnose infectious diseases. The authors aimed to evaluate the effectiveness of blood mNGS in guiding antibiotic stewardship for febrile ANP. MATERIALS AND METHODS The prospective multicenter clinical trial was conducted at seven hospitals in China. Blood samples were collected during fever (T ≥38.5°C) from ANP patients. The effectiveness of blood mNGS, procalcitonin, and blood culture in diagnosing pancreatic infection was evaluated and compared. Additionally, the real-world utilization of antibiotics and the potential mNGS-guided antimicrobial strategy in febrile ANP were also analyzed. RESULTS From May 2023 to October 2023, a total of 78 patients with febrile ANP were enrolled and 30 patients (38.5%) were confirmed infected pancreatic necrosis (IPN). Compared with procalcitonin and blood culture, mNGS showed a significantly higher sensitivity rate (86.7% vs. 56.7% vs. 26.7%, P <0.001). Moreover, mNGS outperformed procalcitonin (89.5 vs. 61.4%, P <0.01) and blood culture (89.5 vs. 69.0%, P <0.01) in terms of negative predictive value. Blood mNGS exhibited the highest accuracy (85.7%) in diagnosing IPN and sterile pancreatic necrosis, significantly superior to both procalcitonin (65.7%) and blood culture (61.4%). In the multivariate analysis, positive blood mNGS (OR=60.2, P <0.001) and lower fibrinogen level (OR=2.0, P <0.05) were identified as independent predictors associated with IPN, whereas procalcitonin was not associated with IPN, but with increased mortality (Odds ratio=11.7, P =0.006). Overall, the rate of correct use of antibiotics in the cohort was only 18.6% (13/70) and would be improved to 81.4% (57/70) if adjusted according to the mNGS results. CONCLUSION Blood mNGS represents important progress in the early diagnosis of IPN, with particular importance in guiding antibiotic usage for patients with febrile ANP.
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Affiliation(s)
- Chiayen Lin
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Jiarong Li
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Baiqi Liu
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Xiaoyue Hong
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Tao Luo
- Department of General Surgery, Changde Hospital, Xiangya School of Medicine, Central South University, Changde
| | - Jinsong Ye
- Department of General Surgery, Changde Hospital, Xiangya School of Medicine, Central South University, Changde
| | - Yi Yu
- Department of Hepatobiliary Surgery, General Surgery, The First People’s Hospital of Chenzhou City, Chenzhou
| | - Xinran Peng
- Department of Hepatobiliary Surgery, General Surgery, The First People’s Hospital of Chenzhou City, Chenzhou
| | - Shanmiao Gou
- Department of Pancreatic Surgery, General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Huayong Tang
- Department of General Surgery, The First Affiliated Hospital of Hunan Traditional Chinese Medical College
| | - Tongli Yuan
- Department of General Surgery, The First Affiliated Hospital of Hunan Traditional Chinese Medical College
| | - Jianguan Luo
- Department of Hepatobiliary Surgery, General Surgery, Liuyang People’s Hospital, Changsha
| | - Ming Yang
- Department of Hepatobiliary Surgery, General Surgery, Liuyang People’s Hospital, Changsha
| | - Bin Feng
- Center of Hepatobiliary and Pancreatic Surgery, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou, Hunan Province, People’s Republic of China
| | - Zhijian Zhao
- Center of Hepatobiliary and Pancreatic Surgery, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou, Hunan Province, People’s Republic of China
| | - Caihong Ning
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Zefang Sun
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Shuai Zhu
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Lu Chen
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Dingcheng Shen
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Gengwen Huang
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
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9
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Seok H, Park DW. Role of biomarkers in antimicrobial stewardship: physicians' perspectives. Korean J Intern Med 2024; 39:413-429. [PMID: 38715231 PMCID: PMC11076897 DOI: 10.3904/kjim.2023.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/05/2024] [Accepted: 03/15/2024] [Indexed: 05/12/2024] Open
Abstract
Biomarkers are playing an increasingly important role in antimicrobial stewardship. Their applications have included use in algorithms that evaluate suspected bacterial infections or provide guidance on when to start or stop antibiotic therapy, or when therapy should be repeated over a short period (6-12 h). Diseases in which biomarkers are used as complementary tools to determine the initiation of antibiotics include sepsis, lower respiratory tract infection (LRTI), COVID-19, acute heart failure, infectious endocarditis, acute coronary syndrome, and acute pancreatitis. In addition, cut-off values of biomarkers have been used to inform the decision to discontinue antibiotics for diseases such as sepsis, LRTI, and febrile neutropenia. The biomarkers used in antimicrobial stewardship include procalcitonin (PCT), C-reactive protein (CRP), presepsin, and interleukin (IL)-1β/IL-8. The cut-off values vary depending on the disease and study, with a range of 0.25-1.0 ng/mL for PCT and 8-50 mg/L for CRP. Biomarkers can complement clinical diagnosis, but further studies of microbiological biomarkers are needed to ensure appropriate antibiotic selection.
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Affiliation(s)
- Hyeri Seok
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Dae Won Park
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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10
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Chan KS, Shelat VG. The Ongoing Debate on the Use of Prophylactic Antibiotics in Acute Pancreatitis-Is There a Conclusion? A Comprehensive Narrative Review. Antibiotics (Basel) 2024; 13:411. [PMID: 38786140 PMCID: PMC11117274 DOI: 10.3390/antibiotics13050411] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/28/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024] Open
Abstract
Acute pancreatitis (AP) is a common but often self-limiting disease in the majority of patients. However, in the minority, who may progress to moderately severe or severe AP, high mortality risk has been reported. Infected pancreatitis necrosis (IPN) in necrotising pancreatitis has been shown to result in more than twice the mortality rate compared with in sterile pancreatic necrosis. This raises the question on whether prophylactic antibiotics (PABs) should be given in subgroups of AP to prevent superimposed infection to improve survival outcomes. Despite numerous randomised controlled trials (RCTs), meta-analyses, and guidelines on the management of AP, there is a lack of strong evidence to suggest the use of PABs in AP. Additionally, use of PABs is associated with antimicrobial resistance. Considerable heterogeneity exists and limits the interpretation of results-subgroup of AP benefitting from PAB use, choice/class of PAB, and timing of administration from symptom onset and duration of PAB use. Only a minority of existing meta-analyses suggest mortality benefits and reduction in IPN. The majority of existing guidelines do not recommend the use of PABs in AP. More research is required to make more definitive conclusions. Currently, PAB should only be administered after multidisciplinary discussions led by pancreatology experts.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore;
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore;
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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11
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Dong J, Shen Y, Wang Z, Zhang J, Qin X, Zhu C, Gao Y, Yu Q. Prediction of severe hypertriglyceridemia-associated acute pancreatitis using a nomogram based on CT findings and blood biomarkers. Medicine (Baltimore) 2024; 103:e37911. [PMID: 38669422 PMCID: PMC11049775 DOI: 10.1097/md.0000000000037911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Hypertriglyceridemia is a common cause of acute pancreatitis (AP). Fatty liver, a manifestation of metabolic syndrome, is related to the severity of AP. The present study aimed to construct an accurate predictive model for severe AP (SAP) by combining the fatty liver infiltration on a computerized tomography (CT) scan with a series of blood biomarkers in patients with hypertriglyceridemia-associated AP (HTG-AP). A total of 213 patients diagnosed with HTG-AP were included in the present retrospective study. Clinical information and imageological findings were retrospectively analyzed. The model was constructed from independent risk factors using univariate analysis, the least absolute shrinkage and selection operator method. Subsequently, the data from the training group of 111 patients with HTG-AP was analyzed using logistic regression analysis. The efficacy of the model was verified using an external validation group of 102 patients through the receiver operating characteristic curve (ROC). Independent predictors, including serum calcium, C-reactive protein, lactate dehydrogenase and liver-to-spleen CT attenuation ratio (L/S ratio), were incorporated into the nomogram model for SAP in HTG-AP. The model achieved a sensitivity of 91.3% and a specificity of 88.6% in the training group. Compared with the Ranson model, the established nomogram model exhibited a better discriminative ability in the training group [area under the curve (AUC): 0.957] and external validation group (AUC: 0.930), as well as better calibration and clinical benefits. The present study demonstrates that the constructed nomogram based on CT findings and blood biomarkers is useful for the accurate prediction of SAP in HTG-AP.
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Affiliation(s)
- Jun Dong
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Yuhang Shen
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Zhihuai Wang
- The Institute of Hepatobiliary and Pancreatic Diseases, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Jiankang Zhang
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Xihu Qin
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Chunfu Zhu
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Yuan Gao
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
- The Institute of Hepatobiliary and Pancreatic Diseases, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
| | - Qiang Yu
- Department of Hepato-biliary-pancreatic Surgery, The Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University, Changzhou, China
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12
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Van Veldhuisen CL, Sissingh NJ, Boxhoorn L, van Dijk SM, van Grinsven J, Verdonk RC, Boermeester MA, Bouwense SA, Bruno MJ, Cappendijk VC, van Duijvendijk P, van Eijck CHJ, Fockens P, van Goor H, Hadithi M, Haveman JW, Jacobs MA, Jansen JM, Kop MP, Manusama ER, Mieog JSD, Molenaar IQ, Nieuwenhuijs VB, Poen AC, Poley JW, Quispel R, Römkens TE, Schwartz MP, Seerden TC, Dijkgraaf MG, Stommel MW, Straathof JWA, Venneman NG, Voermans RP, van Hooft JE, van Santvoort HC, Besselink MG. Long-Term Outcome of Immediate Versus Postponed Intervention in Patients With Infected Necrotizing Pancreatitis (POINTER): Multicenter Randomized Trial. Ann Surg 2024; 279:671-678. [PMID: 37450701 PMCID: PMC10922655 DOI: 10.1097/sla.0000000000006001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To compare the long-term outcomes of immediate drainage versus the postponed-drainage approach in patients with infected necrotizing pancreatitis. BACKGROUND In the randomized POINTER trial, patients assigned to the postponed-drainage approach using antibiotic treatment required fewer interventions, as compared with immediate drainage, and over a third were treated without any intervention. METHODS Clinical data of those patients alive after the initial 6-month follow-up were re-evaluated. The primary outcome was a composite of death and major complications. RESULTS Out of 104 patients, 88 were re-evaluated with a median follow-up of 51 months. After the initial 6-month follow-up, the primary outcome occurred in 7 of 47 patients (15%) in the immediate-drainage group and 7 of 41 patients (17%) in the postponed-drainage group (RR 0.87, 95% CI 0.33-2.28; P =0.78). Additional drainage procedures were performed in 7 patients (15%) versus 3 patients (7%) (RR 2.03; 95% CI 0.56-7.37; P =0.34). The median number of additional interventions was 0 (IQR 0-0) in both groups ( P =0.028). In the total follow-up, the median number of interventions was higher in the immediate-drainage group than in the postponed-drainage group (4 vs. 1, P =0.001). Eventually, 14 of 15 patients (93%) in the postponed-drainage group who were successfully treated in the initial 6-month follow-up with antibiotics and without any intervention remained without intervention. At the end of follow-up, pancreatic function and quality of life were similar. CONCLUSIONS Also, during long-term follow-up, a postponed-drainage approach using antibiotics in patients with infected necrotizing pancreatitis results in fewer interventions as compared with immediate drainage and should therefore be the preferred approach. TRIAL REGISTRATION ISRCTN33682933.
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Affiliation(s)
- Charlotte L. Van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Noor J. Sissingh
- Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Lotte Boxhoorn
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Sven M. van Dijk
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
| | - Stefan A.W. Bouwense
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | | | - Paul Fockens
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten A.J.M. Jacobs
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jeroen M. Jansen
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, The Netherlands
| | - Marnix P.M. Kop
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Radiology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Eric R. Manusama
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Alexander C. Poen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Group, Delft, The Netherlands
| | - Tessa E.H. Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Matthijs P. Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Tom C. Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Marcel G.W. Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, location University of Amsterdam, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Martijn W.J. Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jan Willem A. Straathof
- Department of Gastroenterology and Hepatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Niels G. Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Rogier P. Voermans
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, The Netherlands
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Cahyadi O, Dhir V, Leeds J, de-Madaria E, Tehami N. The DESTIN trial: to step up or not? Lancet Gastroenterol Hepatol 2024; 9:289. [PMID: 38460533 DOI: 10.1016/s2468-1253(24)00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 03/11/2024]
Affiliation(s)
- Oscar Cahyadi
- Department of Gastroenterology, St. Josef-Hospital, Ruhr-University Bochum, Bochum D-44791, Germany.
| | - Vinay Dhir
- Institute of Digestive and Liver Care, SL Raheja Hospital, Mumbai, India
| | - John Leeds
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK; Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Enrique de-Madaria
- Department of Gastroenterology, Dr Balmis General University Hospital and Department of Clinical Medicine, Miguel Herna´ndez University, Alicante, Spain; Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Nadeem Tehami
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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14
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Liu W, Wang X, Zhao S, Yang S, Zheng X, Gong F, Pei L, Xu D, Li R, Yang Z, Mao E, Chen E, Chen Y. Unraveling the immunological landscape in acute pancreatitis progression to sepsis: insights from a Mendelian randomization study on immune cell traits. Front Immunol 2024; 15:1374787. [PMID: 38601150 PMCID: PMC11004341 DOI: 10.3389/fimmu.2024.1374787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/15/2024] [Indexed: 04/12/2024] Open
Abstract
Background Acute pancreatitis (AP) is a severe digestive system disorder with a significant risk of progressing to sepsis, a major cause of mortality. Unraveling the immunological pathways in AP is essential for developing effective treatments, particularly understanding the role of specific immune cell traits in this progression. Methods Employing a bidirectional two-sample Mendelian Randomization (MR) approach, this study first examined the causal relationship between AP and 731 immune cell traits to identify those significantly associated with AP. Subsequently, we explored the causal associations between 731 immune cell traits and sepsis. The analysis utilized extensive genome-wide association studies (GWAS) summary datasets, with a focus on identifying common immune cell traits with statistically significant causal associations between AP and sepsis. Results Our investigation identified 44 immune cell traits unidirectionally associated with AP and 36 traits unidirectionally associated with sepsis. Among these, CD127 on CD28+ CD45RA- CD8+ T cells emerged as a common mediator, accounting for 5.296% of the increased risk of sepsis in AP patients. This finding highlights the significant role of specific memory CD8+ T cells in the pathophysiology of AP and its progression to sepsis. Conclusion This study elucidates the critical role of specific immune cell traits, particularly CD127hi memory CD8+ T cells, in the progression of AP to sepsis. Our findings provide a foundation for future research into targeted immune-modulatory therapies, potentially improving patient outcomes in AP-related sepsis and offering new insights into the complex immunological dynamics of this condition.
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Affiliation(s)
- Wenbin Liu
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaofeng Wang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shanzhi Zhao
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Song Yang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiangtao Zheng
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fangchen Gong
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Pei
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dan Xu
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ranran Li
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhitao Yang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Enqiang Mao
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Erzhen Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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15
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Mann BK, Bhandohal JS, Kalha I, Fox K, Jean B. Relevance of Procalcitonin Levels as a Marker of Severity and Predictor of Mortality, Initiation and Duration of Antibiotics in Patients Admitted with Acute Pancreatitis: A Retrospective Cohort Study. Clin Exp Gastroenterol 2024; 17:31-39. [PMID: 38352170 PMCID: PMC10863456 DOI: 10.2147/ceg.s453345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
Introduction Procalcitonin levels have been studied to predict the benefit of adding antibiotics in a patient with acute pancreatitis. Through this study, we are searching for any possible correlation between serum procalcitonin levels and the severity of acute pancreatitis (included acute on chronic cases) to determine whether procalcitonin levels can predict a benefit from antibiotic therapy in acute pancreatitis. Methods This is a retrospective cohort study involving patients with acute pancreatitis and acute on chronic pancreatitis. We included all hospitalized patients admitted to Kern Medical from January 2020 to October 2022 with a diagnosis of acute pancreatitis in a consecutive manner. The primary outcome studied was mortality related to the pancreatitis episode. Logistic regression was used to control numerous confounders. Results Based on univariate analysis of procalcitonin, we found starting antibiotics on the day of admission statistically significant. We also found the median differences in mortality to be mildly significant (difference = 0.79, p = 0.0640) based on procalcitonin values. In a multivariate analysis of ln(procalcitonin), we found lipase (p = 0.0249), duration of antibiotics (p = 0.0009), multi-organ failure (p = 0.0045) to be statistically significant, and lactate being mildly significant in the multivariate model (p = 0.0643). Conclusion The procalcitonin level can predict the initiation of antibiotics, duration of antibiotics, multi-organ failure, and mortality in patients with acute pancreatitis.
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Affiliation(s)
- Baldeep Kaur Mann
- Division of Hospital Medicine, Department of Medicine, Kern Medical Center, Bakersfield, CA, USA
| | - Janpreet Singh Bhandohal
- Division of Hospital Medicine, Department of Medicine, Kern Medical Center, Bakersfield, CA, USA
| | - Ishaan Kalha
- Division of Gastroenterology, Department of Medicine, Kern Medical Center, Bakersfield, CA, USA
| | - Kasey Fox
- Division of Hospital Medicine, Department of Medicine, Kern Medical Center, Bakersfield, CA, USA
| | - Brian Jean
- Biostatistician, Professor Emeritus, Kern Medical Center, Bakersfield, CA, USA
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16
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Song Y, Lee SH. Recent Treatment Strategies for Acute Pancreatitis. J Clin Med 2024; 13:978. [PMID: 38398290 PMCID: PMC10889262 DOI: 10.3390/jcm13040978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/26/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Acute pancreatitis (AP) is a leading gastrointestinal disease that causes hospitalization. Initial management in the first 72 h after the diagnosis of AP is pivotal, which can influence the clinical outcomes of the disease. Initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis, plays a fundamental role in AP treatment. Recent updates for fluid resuscitation, including treatment goals, the type, rate, volume, and duration, have triggered a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution. Evidence of the clinical benefit of early enteral feeding is becoming definitive. The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has recently been investigated to distinguish between inflammation and infection in patients with AP. Although urgent ERCP (within 24 h) should be performed for patients with gallstone pancreatitis and cholangitis, urgent ERCP is not indicated in patients without cholangitis. The management approach for patients with local complications of AP, particularly those with infected necrotizing pancreatitis, is discussed in detail, including indications, timing, anatomical considerations, and selection of intervention methods. Furthermore, convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is also important for improving the prognosis and preventing recurrence in patients with AP. This review focuses on recent updates on the initial and convalescent management strategies for AP.
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Affiliation(s)
| | - Sang-Hoon Lee
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul 05030, Republic of Korea;
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17
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Tarján D, Szalai E, Lipp M, Verbói M, Kói T, Erőss B, Teutsch B, Faluhelyi N, Hegyi P, Mikó A. Persistently High Procalcitonin and C-Reactive Protein Are Good Predictors of Infection in Acute Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis. Int J Mol Sci 2024; 25:1273. [PMID: 38279274 PMCID: PMC10816999 DOI: 10.3390/ijms25021273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/09/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024] Open
Abstract
Infected necrotizing pancreatitis (INP) is associated with an increased risk of organ failure and mortality. Its early recognition and timely initiation of antibiotic therapy can save patients' lives. We systematically searched three databases on 27 October 2022. In the eligible studies, the presence of infection in necrotizing pancreatitis was confirmed via a reference test, which involved either the identification of gas within the necrotic collection through computed tomography imaging or the examination of collected samples, which yielded positive results in Gram staining or culture. Laboratory biomarkers compared between sterile necrotizing pancreatitis and INP were used as the index test, and our outcome measures included sensitivity, specificity, the receiver operating characteristic (ROC) curve and area under the ROC curve (AUC). Within the first 72 hours (h) after admission, the AUC of C-reactive protein (CRP) was 0.69 (confidence interval (CI): 0.62-0.76), for procalcitonin (PCT), it was 0.69 (CI: 0.60-0.78), and for white blood cell count, it was 0.61 (CI: 0.47-0.75). After the first 72 h, the pooled AUC of CRP showed an elevated level of 0.88 (CI: 0.75-1.00), and for PCT, it was 0.86 (CI: 0.60-1.11). The predictive value of CRP and PCT for infection is poor within 72 h after hospital admission but seems good after the first 72 h. Based on these results, infection is likely in case of persistently high CRP and PCT, and antibiotic initiation may be recommended.
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Affiliation(s)
- Dorottya Tarján
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Institute of Pancreatic Diseases, Semmelweis University, 1083 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
| | - Eszter Szalai
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Department of Restorative Dentistry and Endodontics, Semmelweis University, 1088 Budapest, Hungary
| | - Mónika Lipp
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Institute of Pancreatic Diseases, Semmelweis University, 1083 Budapest, Hungary
| | - Máté Verbói
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
| | - Tamás Kói
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Department of Stochastics, Institute of Mathematics, Budapest University of Technology and Economics, 1111 Budapest, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Institute of Pancreatic Diseases, Semmelweis University, 1083 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
- Department of Radiology, Medical Imaging Centre, Semmelweis University, 1085 Budapest, Hungary
| | - Nándor Faluhelyi
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Division of Medical Imaging, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Institute of Pancreatic Diseases, Semmelweis University, 1083 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, 6725 Szeged, Hungary
| | - Alexandra Mikó
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (D.T.); (E.S.); (M.L.); (T.K.); (B.E.); (B.T.); (N.F.); (A.M.)
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary;
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, 6725 Szeged, Hungary
- Department for Medical Genetics, Medical School, University of Pécs, 7624 Pécs, Hungary
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18
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Wen Y, Xu L, Zhang D, Sun W, Che Z, Zhao B, Chen Y, Yang Z, Chen E, Ni T, Mao E. Effect of early antibiotic treatment strategy on prognosis of acute pancreatitis. BMC Gastroenterol 2023; 23:431. [PMID: 38066411 PMCID: PMC10709887 DOI: 10.1186/s12876-023-03070-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Antibiotic use in the early stages of acute pancreatitis is controversial. The purpose of this study was to investigate the effect of early antibiotic application on the prognosis of acute pancreatitis (AP). MATERIALS AND METHODS Clinical data of patients with primary AP admitted to our emergency ward within 72 hours of onset were retrospectively collected from January 2016 to December 2020. We classified patients with acute pancreatitis according to etiology and disease severity, and compared the differences in hospital stay, laparotomy rate, and in-hospital mortality among AP patients who received different antibiotic treatment strategies within 72 hours of onset. RESULTS A total of 1134 cases were included, with 681 (60.1%) receiving early antibiotic treatment and 453 (39.9%) not receiving it. There were no significant differences in baseline values and outcomes between the two groups. In subgroup analysis, patients with biliary severe acute pancreatitis (SAP) who received early antibiotics had lower rates of laparotomy and invasive mechanical ventilation, as well as shorter hospital stays compared to those who did not receive antibiotics. In logistic regression analysis, the early administration of carbapenem antibiotics in biliary SAP patients was associated with a lower in-hospital mortality rate. Early antibiotic use in biliary moderate-severe acute pancreatitis (MSAP) reduced hospital stays and in-hospital mortality. Quinolone combined with metronidazole treatment in biliary mild acute pancreatitis (MAP) shortened hospital stays. Early antibiotic use does not benefit patients with non-biliary AP. CONCLUSION Strategies for antibiotic use in the early stages of AP need to be stratified according to cause and disease severity.
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Affiliation(s)
- Yi Wen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lili Xu
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dayi Zhang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenwu Sun
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zaiqian Che
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Zhao
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhitao Yang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Erzhen Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tongtian Ni
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Enqiang Mao
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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19
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Xia H, Guo J, Shen J, Jiang S, Han S, Li L. Butyrate ameliorated the intestinal barrier dysfunction and attenuated acute pancreatitis in mice fed with ketogenic diet. Life Sci 2023; 334:122188. [PMID: 37866809 DOI: 10.1016/j.lfs.2023.122188] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/07/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Abstract
Butyrate, a short-chain fatty acid (SCFA), has demonstrated significant efficacy in preventing colitis-associated inflammation. Acute pancreatitis is an acute gastrointestinal disorder characterized by increased systemic inflammation, bacterial translocation, and disrupted intestinal barrier. However, the effects and mechanisms of butyrate in attenuating acute pancreatitis remain unclear. In this study, we established two mouse models of acute pancreatitis induced by cerulein (Cer) and taurocholate (TA), which were further exacerbated by a ketogenic diet (KD). The results suggested that butyrate supplementation effectively reduced mortality rates, systemic inflammation, and intestinal barrier disruption caused by Cer- and TA-induced acute pancreatitis in mice fed a KD. Furthermore, we observed a significant reduction in gut microbiota diversity as well as overgrowth of Lachnospirales and Erysipelotrichales along with depletion of SCFAs in mice fed a KD, and these alterations were reversed by butyrate supplement. To evaluate the role of microbiota and butyrate supplement, we conducted germ-depletion trials by antibiotics. The results showed that while systemic inflammation was attenuated in mice with TA-induced pancreatitis following antibiotic treatment, the reduction in mortality remained inconclusive (p = 0.055). Importantly, the key differential change between antibiotic treatment and butyrate supplementation was found to be related to intestinal barrier dysfunction and repairment. These results suggest that butyrate plays a central role in mitigating acute pancreatitis through amelioration of intestinal barrier dysfunction.
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Affiliation(s)
- He Xia
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine,79 Qingchun Rd., Hangzhou City 310003, China
| | - Jing Guo
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine,79 Qingchun Rd., Hangzhou City 310003, China
| | - Jian Shen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine,79 Qingchun Rd., Hangzhou City 310003, China
| | - Shiman Jiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine,79 Qingchun Rd., Hangzhou City 310003, China
| | - Shengyi Han
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine,79 Qingchun Rd., Hangzhou City 310003, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine,79 Qingchun Rd., Hangzhou City 310003, China.
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20
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de-Madaria E, Buxbaum JL. Advances in the management of acute pancreatitis. Nat Rev Gastroenterol Hepatol 2023; 20:691-692. [PMID: 37344583 DOI: 10.1038/s41575-023-00808-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Affiliation(s)
- Enrique de-Madaria
- Department of Gastroenterology, Dr. Balmis General University Hospital-ISABIAL, Alicante, Spain.
| | - James L Buxbaum
- Division of Gastroenterology, University of Southern California, Los Angeles, CA, USA
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21
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Xiao H, Huang Y, Zhang P, Zhou H, Liu D, Luo J. Prognostic value of post-operative serum procalcitonin in gastric adenocarcinoma patients undergoing radical gastrectomy: propensity score matching analysis of extended cohort from a prospective bi-center study. Gastric Cancer 2023; 26:1051-1062. [PMID: 37578602 PMCID: PMC10640415 DOI: 10.1007/s10120-023-01422-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/03/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The aim of this study was to investigate the predictive value of procalcitonin (PCT) on post-operative day (POD) 3 and 5 for the prognosis of gastric adenocarcinoma (GA) patients who underwent radical gastrectomy surgery in extended cohort from a prospective bi-center study. METHODS Consecutive GA patients who received surgery in the Hunan Cancer Hospital were enrolled as the training cohort, and those from Wuhan Union Hospital were included as external validation cohort. The optimal cutoff concentration of PCT for overall survival (OS) in the training cohort was determined by X-tile. The independent predictive factors for OS were identified using univariate and multivariate Cox regression analyses. Furthermore, the predictive value of elevated PCT was clarified in the validation cohort and propensity score matched cohort, respectively. RESULTS The optimal cutoff concentrations of PCT for OS were 0.67 ng/mL at POD 3 and 0.39 ng/mL at POD 5 in the training cohort (n = 906). Patients with higher PCT concentrations (≥ 0.39 ng/mL) at POD 5 had a significantly worse prognosis whether developing post-operative infections or not. Moreover, a synergistic influence was confirmed in those with elevated PCT concentration and infections. Multivariate analyses confirmed that PCT concentration ≥ 0.39 ng/mL at POD 5 was significantly associated with poorer survival in training cohort (HR: 1.422, 95% CI 1.041-1.943, P = 0.027), validation cohort (n = 297, HR: 2.136, 95% CI 1.073-4.252, P = 0.031) and matched cohort (n = 901, HR: 1.454, 95% CI 1.104-1.914, P = 0.008), separately. CONCLUSIONS PCT concentration ≥ 0.39 ng/mL at POD 5 was a reliable predictor for poorer prognosis in GA patients undergoing radical gastrectomy.
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Affiliation(s)
- Hua Xiao
- Department of Hepatobiliary and Intestinal Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, 283 Tongzipo Road, Changsha, 410013, Hunan, China
- Department of Gastroduodenal and Pancreatic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Yongzhou Huang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of General Surgery, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi, 832008, China
| | - Peng Zhang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Huijun Zhou
- Department of Gastroenterology and Urology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Dian Liu
- Department of Lamphoma and Abdominal Radiotherapy, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Jia Luo
- Department of Hepatobiliary and Intestinal Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, 283 Tongzipo Road, Changsha, 410013, Hunan, China.
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22
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Li Q, Zhao SJ, Zhou JC. Editorial: Antimicrobial resistance and therapy in critically ill patients. Front Med (Lausanne) 2023; 10:1283865. [PMID: 37780570 PMCID: PMC10541214 DOI: 10.3389/fmed.2023.1283865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023] Open
Affiliation(s)
- Qi Li
- Department of Emergency Medicine, Lanxi People's Hospital, Lanxi, China
| | - Shun-Jin Zhao
- Department of Respiratory and Critical Care Medicine, Lanxi People's Hospital, Lanxi, China
| | - Jian-Cang Zhou
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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23
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Nakai Y, Hamada T, Saito T, Shiomi H, Maruta A, Iwashita T, Iwata K, Takenaka M, Masuda A, Matsubara S, Sato T, Mukai T, Yasuda I, Isayama H. Time to think prime times for treatment of necrotizing pancreatitis: Pendulum conundrum. Dig Endosc 2023; 35:700-710. [PMID: 37209365 DOI: 10.1111/den.14598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/16/2023] [Indexed: 05/22/2023]
Abstract
Pancreatic fluid collections (PFCs) typically develop as local complications of acute pancreatitis and complicate the clinical course of patients with acute pancreatitis and potentially fatal clinical outcomes. Interventions are required in cases of symptomatic walled-off necrosis (WON) (matured PFCs with necrosis) and pancreatic pseudocysts (matured PFCs without necrosis). In the management of necrotizing pancreatitis and WON, endoscopic ultrasound-guided transluminal drainage combined with on-demand endoscopic necrosectomy (i.e. the step-up approach) is increasingly used as a less invasive treatment modality compared with a surgical or percutaneous approach. Through the substantial research efforts and development of specific devices and stents (e.g. lumen-apposing metal stents), endoscopic techniques of PFC management have been standardized to some extent. However, there has been no consensus about timing of carrying out each treatment step; for instance, it is uncertain when direct endoscopic necrosectomy should be initiated and finished and when a plastic or metal stent should be removed following clinical treatment success. Despite emerging evidence for the effectiveness of noninterventional supportive treatment (e.g. antibiotics, nutritional support, irrigation of the cavity), there has been only limited data on the timing of starting and stopping the treatment. Large studies are required to optimize the timing of those treatment options and improve clinical outcomes of patients with PFCs. In this review, we summarize the current available evidence on the indications and timing of interventional and supportive treatment modalities for this patient population and discussed clinical unmet needs that should be addressed in future research.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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24
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Severino A, Varca S, Airola C, Mezza T, Gasbarrini A, Franceschi F, Candelli M, Nista EC. Antibiotic Utilization in Acute Pancreatitis: A Narrative Review. Antibiotics (Basel) 2023; 12:1120. [PMID: 37508216 PMCID: PMC10376815 DOI: 10.3390/antibiotics12071120] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
Acute pancreatitis is a complex inflammatory disease with significant morbidity and mortality. Despite advances in its management, the role of antibiotics in the prophylaxis and treatment of acute pancreatitis remains controversial. The aim of this comprehensive review is to analyze current evidence on the use of antibiotics in acute pancreatitis, focusing on prophylactic and therapeutic strategies. Prophylactic use aims to prevent local and systemic infections. However, recent studies have questioned the routine use of antibiotics for prophylaxis and highlighted the potential risks of antibiotic resistance and adverse effects. In selected high-risk cases, such as infected necrotizing pancreatitis, prophylactic antibiotic therapy may still be beneficial. As for therapeutic use, antibiotics are usually used to treat infected pancreatic necrosis and extrapancreatic infections. When selecting an antibiotic, the microbiologic profile and local resistance patterns should be considered. Combination therapy with broad-spectrum antibiotics is often recommended to cover both Gram-positive and Gram-negative pathogens. Recent research has highlighted the importance of individualized approaches to antibiotic use in acute pancreatitis and underscored the need for a tailored approach based on patient-specific factors. This review also highlights the potential role of new antimicrobial agents and alternative strategies, such as probiotics, in the management of acute pancreatitis.
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Affiliation(s)
- Andrea Severino
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Simone Varca
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carlo Airola
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Teresa Mezza
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesco Franceschi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Marcello Candelli
- Department of Emergency, Anesthesiological and Reanimation Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Enrico Celestino Nista
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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25
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Di Vincenzo F, Nicoletti A, Negri M, Vitale F, Zileri Dal Verme L, Gasbarrini A, Ponziani FR, Cerrito L. Gut Microbiota and Antibiotic Treatments for the Main Non-Oncologic Hepato-Biliary-Pancreatic Disorders. Antibiotics (Basel) 2023; 12:1068. [PMID: 37370387 DOI: 10.3390/antibiotics12061068] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/10/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
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.
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Affiliation(s)
- Federica Di Vincenzo
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Alberto Nicoletti
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Marcantonio Negri
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Federica Vitale
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Lorenzo Zileri Dal Verme
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesca Romana Ponziani
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Lucia Cerrito
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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26
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Manrai M, Dawra S, Singh AK, Jha DK, Kochhar R. Controversies in the management of acute pancreatitis: An update. World J Clin Cases 2023; 11:2582-2603. [PMID: 37214572 PMCID: PMC10198120 DOI: 10.12998/wjcc.v11.i12.2582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/22/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam K Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Army Hospital (Research and Referral), New Delhi 11010, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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27
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Abstract
PURPOSE OF REVIEW This review provides insight into the recent advancements in the management of acute pancreatitis. RECENT FINDINGS Moderate fluid resuscitation and Ringer's lactate has advantages above aggressive fluid resuscitation and normal saline, respectively. A normal "on-demand" diet has a positive effect on recovery from acute pancreatitis and length of hospital stay. A multimodal pain management approach including epidural analgesia might reduce unwarranted effects of opiate use. A more targeted use of antibiotics is starting to emerge. Markers such as procalcitonin may be used to limit unwarranted antibiotic use. Conversely, many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear. Delay of drainage as much as is possible is advised since it is associated with less procedures. If drainage is required, clinicians have an expanding arsenal of interventional options to their disposal such as the lumen-apposing metal stent for transgastric drainage and (repeated) necrosectomy. Immunomodulation using removal of systemic cytokines or anti-inflammatory drugs is an attractive idea, but up to now the results of clinical trials are disappointing. No additional preventive measures beside non-steroidal anti-inflammatory drugs (NSAIDs) can be recommended for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. SUMMARY More treatment modalities that are less invasive became available and a trend towards less aggressive treatments (fluids, starvation, interventions, opiates) of acute pancreatitis is again emerging. Despite recent advancements, the pathophysiology of specific subgroup phenotypes is still poorly understood which reflects the disappointing results of pharmacological and immunomodulatory trials.
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Affiliation(s)
- Fons F. van den Berg
- Amsterdam UMC location University of Amsterdam, Medical Microbiology & Infection prevention
| | - Marja A. Boermeester
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9
- Amsterdam institute for Infection and Immunity
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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28
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Lu J, Ding Y, Qu Y, Mei W, Guo Y, Fang Z, Qu C, Gao C, Cao F, Li F, Feng Y. Risk Factors and Outcomes of Multidrug-Resistant Bacteria Infection in Infected Pancreatic Necrosis Patients. Infect Drug Resist 2022; 15:7095-7106. [PMID: 36483142 PMCID: PMC9725918 DOI: 10.2147/idr.s387384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/18/2022] [Indexed: 08/30/2023] Open
Abstract
OBJECTIVE The incidence of acute pancreatitis (AP) is increasing. Twenty percent of AP patients with developing necrotizing pancreatitis (NP), while ~40-70% of NP patients develop potentially fatal infectious complications. When patients are suspected or confirmed infected pancreatic necrosis (IPN), antibiotics should be administered timeously to control the infection, but long-term use of antibiotics can lead to multidrug-resistant bacteria (MDRB) infection and eventually to increased mortality. Our study aimed to determine the incidence of MDRB infection and evaluate the risk factors for MDRB infection in IPN patients. METHODS Clinical data of IPN patients admitted to the general surgery department of Xuanwu Hospital of Capital Medical University between January 1, 2014, and December 31, 2021, were retrospectively analyzed. RESULTS IPN patients (n = 267) were assigned to MDRB infection (n = 124) and non-MDRB infection (n = 143) groups. On admission, patients in the MDRB group had a higher modified computer tomography severity index (CTSI) score (P < 0.05), pancreatic necrosis degree, and PCT level (P < 0.05) than those in the non-MDRB group, and the prognosis of patients in MDRB group was poor. The most common gram-negative bacteria were Acinetobacter baumannii (n = 117), the most common gram-positive bacteria were Enterococcus faecium (n = 98), and the most common fungal infection was Candida albicans (n = 47). Multivariable analysis showed that complications of EPI (OR: 4.116, 95% CI: 1.381-12.271, P = 0.011), procalcitonin (PCT) level at admission (OR: 2.728, 95% CI: 1.502-4.954, P = 0.001), and degree of pancreatic necrosis (OR: 2.741, 95% CI: 1.109-6.775, P = 0.029) were independent risk factors for MDRB infection in IPN patients. CONCLUSION We identified common infectious strains and risk factors for MDRB infection in IPN patients.
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Affiliation(s)
- Jiongdi Lu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yixuan Ding
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yuanxu Qu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wentong Mei
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yulin Guo
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhen Fang
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chang Qu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chongchong Gao
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Feng Cao
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fei Li
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yulu Feng
- Department of Pediatric, Chui Yang Liu Hospital Affiliated Tsinghua University, Beijing, People’s Republic of China
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Mir BA, Majeed T, Chauhan A. Procalcitonin-guided use of antibiotics in acute pancreatitis. Lancet Gastroenterol Hepatol 2022; 7:1073. [PMID: 36370735 DOI: 10.1016/s2468-1253(22)00271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 07/28/2022] [Accepted: 08/02/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Bilal Ahmad Mir
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla 171001, India
| | - Tahir Majeed
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla 171001, India
| | - Ashish Chauhan
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla 171001, India.
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Samanta J, Dhar J. Procalcitonin-guided use of antibiotics in acute pancreatitis. Lancet Gastroenterol Hepatol 2022; 7:1073-1074. [DOI: 10.1016/s2468-1253(22)00272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 11/11/2022]
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Siriwardena AK, Jegatheeswaran S, Mason JM. Procalcitonin-guided use of antibiotics in acute pancreatitis - Authors' reply. Lancet Gastroenterol Hepatol 2022; 7:1074. [PMID: 36370736 DOI: 10.1016/s2468-1253(22)00332-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
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Nakai Y. Management of severe acute pancreatitis: all hands to the pump. Hepatobiliary Surg Nutr 2022; 11:903-905. [PMID: 36523937 PMCID: PMC9745630 DOI: 10.21037/hbsn-22-529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/14/2022] [Indexed: 08/30/2023]
Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan
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Chan KS, Shelat VG. Diagnosis, severity stratification and management of adult acute pancreatitis–current evidence and controversies. World J Gastrointest Surg 2022; 14:1179-1197. [PMID: 36504520 PMCID: PMC9727576 DOI: 10.4240/wjgs.v14.i11.1179] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/08/2022] [Accepted: 10/25/2022] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Capurso G, de-Madaria E. Procalcitonin-guided reduction of antibiotic use in acute pancreatitis. Lancet Gastroenterol Hepatol 2022; 7:896-897. [PMID: 35863359 DOI: 10.1016/s2468-1253(22)00231-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan 20132, Italy.
| | - Enrique de-Madaria
- Gastroenterology Department, Dr Balmis General University Hospital, Alicante, Spain; Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain; Alicante Institute for Health and Biomedical Research, Alicante, Spain
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