Elevated serum creatinine as a marker of pancreatic necrosis in acute pancreatitis

Predicting in-hospital mortality in patients with acute pancreatitis in the ED: a direct, retrospective comparison of four clinical and radiological prognostic scores

BACKGROUND

Acute pancreatitis can be a severe disease that significantly impacts patients' quality of life and outcome. The clinical course is variable and predictive scoring systems have a debated role in early prognosis. This study aims to compare the prognostic accuracy of Balthazar, BISAP, HAPS and SOFA scores in the prediction of in-hospital mortality in patients with acute pancreatitis.

METHODS

This is a retrospective, single-center cohort study conducted in the Emergency Department of a third-level university hospital. Patients aged >18 years admitted from 1st January 2018 to 31st December 2021 for the first episode of acute pancreatitis were included.

RESULTS

A total of 385 patients (mean age of 65.4 years and 1.8% in-hospital mortality) were studied. Balthazar, BISAP and SOFA scores were significantly higher in patients with in-hospital mortality and AUROCs were equal to 0.95 (95% CI 0.91-0.99, P<0.001), 0.96 (95% CI 0.89-1, P=0.001), 0.91 (95% CI 0.81-1, P=0.001) with no differences among them and absence of in-hospital mortality in patients with HAPS=0.

CONCLUSIONS

Our data support the concept that clinical prediction scores can be useful for risk stratification in the Emergency Department. However, no single score has shown superiority in predicting acute pancreatitis-related in-hospital mortality among tested tools.

Predicting the severity of acute pancreatitis: Current approaches and future directions

Acute pancreatitis (AP) is a sudden-onset inflammatory disease of the pancreas. The severity of AP is classified into mild, moderate, and severe categories based on the presence and persistence of organ failure. Severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. It requires early recognition for appropriate timely management. Prognostic scores for predicting SAP incorporating many clinical, laboratory, and radiological parameters have been developed in the past. However, all of these prognostic scores have low positive predictive value for SAP and some of these scores require >24 h for assessment. There is a need to develop biomarkers that can accurately identify patients at risk for SAP early in the course of the presentation. In this review, we aim to provide a summary of the most commonly utilized prognostic scores for AP and discuss future directions.

Association between serum creatinine to albumin ratio and short- and long-term all-cause mortality in patients with acute pancreatitis admitted to the intensive care unit: a retrospective analysis based on the MIMIC-IV database

Background

Serum creatinine (Cr) and albumin (Alb) are important predictors of mortality in individuals with various diseases, including acute pancreatitis (AP). However, most previous studies have only examined the relationship between single Cr or Alb levels and the prognosis of patients with AP. To our knowledge, the association between short- and long-term all-cause mortality in patients with AP and the blood creatinine to albumin ratio (CAR) has not been investigated. Therefore, this study aimed to evaluate the short- and long-term relationships between CAR and all-cause mortality in patients with AP.

Methods

We conducted a retrospective study utilizing data from the Medical Information Market for Intensive Care (MIMIC-IV) database. The study involved analyzing various mortality variables and obtaining CAR values at the time of admission. The X-tile software was used to determine the optimal threshold for the CAR. Kaplan-Meier (K-M) survival curves and multivariate Cox proportional hazards regression models were used to assess the relationship between CAR and both short- and long-term all-cause mortality. The predictive power, sensitivity, specificity, and area under the curve (AUC) of CAR for short- and long-term mortality in patients with AP after hospital admission were investigated using Receiver Operating Characteristic analysis. Additionally, subgroup analyses were conducted.

Results

A total of 520 participants were included in this study. The CAR ideal threshold, determined by X-tile software, was 0.446. The Cox proportional hazards model revealed an independent association between CAR≥0.446 and all-cause mortality at 7-day (d), 14-d, 21-d, 28-d, 90-d, and 1-year (y) before and after adjustment for confounders. K-M survival curves showed that patients with CAR≥0.446 had lower survival rates at 7-d, 14-d, 21-d, 28-d, 90-d, and 1-y. Additionally, CAR demonstrated superior performance, with higher AUC values than Cr, Alb, serum total calcium, Glasgow Coma Scale, Systemic Inflammatory Response Syndrome score, and Sepsis-related Organ Failure Assessment score at 7-d, 14-d, 21-d, 28-d, 90-d, and 1-y intervals. Subgroup analyses showed that CAR did not interact with a majority of subgroups.

Conclusion

The CAR can serve as an independent predictor for short- and long-term all-cause mortality in patients with AP. This study enhances our understanding of the association between serum-based biomarkers and the prognosis of patients with AP.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

Course of Acute Pancreatitis Patients with Renal Failure According to Balthazar Classification

Background and Aim

There are criteria that include many organ systems to predict the prognosis in acute pancreatitis (AP) patients. In this study, we aimed to show how the course of the disease changes according to the Balthazar classification in AP patients presenting with renal failure.

Methods and Materials

Our study included 352 patients who were admitted to the Emergency Service of our hospital and were diagnosed and hospitalized with AP. According to the Balthazar score, patients with scores of 0-2, 4-6, and 8-10 were evaluated as mild, moderate, and severe AP, respectively. Demographic data (age, gender) of all patients were documented. The etiology of AP was determined in all patients. Biliary, drug/toxic, alcohol, infections, hyperlipidemia, post-endoscopic retrograde cholangiopancreatography (ERCP), genetics, hypercalcemia, structural anomalies, and malignancy were evaluated as the etiology. Those without any underlying pathology were evaluated as idiopathic AP. The patients were divided into two groups as those with and without renal insufficiency. All patients underwent helical computed tomography (section 64, Aquilion; Toshiba Medical Systems, Tokyo) within the first 12 hours and between days 3 and 7. Pancreas, peripancreatic and extrapancreatic findings, and complications were examined. "The Statistical Package for the Social Sciences 19.0 (SPSS Armonk, NY: IBM Corp.)" was used for all analyses. Kolmogorov-Smirnov test and histograms were used to determine whether there was a normal distribution. The non-parametric data of the groups were compared using the Mann-Whitney U test and the parametric data using the ındependent t test. Chi-square test was used to test categorical data. Cases with P < 0.05 were considered statistically significant.

Results

: While 22 (6.2%) patients had renal insufficiency, 332 (95.8%) patients did not have renal insufficiency. In the evaluation made in terms of AP severity; according to Balthazar classification at admission, there was no difference in mild and moderate pancreatitis for kidney insufficiency in both groups, but it was significantly higher in the group with severe pancreatitis [2 (9.1%) versus 1 (0.3%), P < 0.001]. In the evaluation made after 72 hours; renal failure was significantly lower in the group with mild pancreatitis [11 (50.0%) versus 245 (73.8%), P: 0.016] and severe renal failure was significantly higher in severe pancreatitis [7 (31.8%) versus 13 (%) 3.9), P < 0.001].

Conclusions

Early intensive care unit admission and close follow-up and early treatment in AP patients change the course of the disease. In our study, we showed that serum creatinine level is an important parameter in the course of AP and has a predictive value for the course of the disease.

EARLY PREDICTIVE VALUE OF PRESEPSIN FOR SECONDARY SEPSIS AND MORTALITY IN INTENSIVE CARE UNIT PATIENTS WITH SEVERE ACUTE PANCREATITIS

ABSTRACT

Purpose : Sepsis is the leading cause of death in patients with severe acute pancreatitis (SAP) in the intensive care unit (ICU). Early prediction of sepsis secondary to SAP developed in the late phase and of related mortality can enable appropriate treatment and improve outcomes. This study was conducted to evaluate the predictive value of presepsin in ICU patients with SAP at the early stage and compared it with established blood markers and scoring systems. Methods : This retrospective study enrolled 48 septic patients and 53 nonseptic patients admitted to ICU with SAP. Presepsin and other blood markers (procalcitonin, C-reactive protein, IL-6, white blood cell, and serum creatinine) on days 1, 3, and 7 after enrollment as well as scoring systems were assessed to predict secondary sepsis. Outcomes were evaluated at ICU discharge and on days 28 and 90. Results : Presepsin levels (on days 1, 3, and 7) were significantly higher in septic patients than in nonseptic patients. Presepsin levels showed an increasing trend over time in both sepsis and nonsepsis groups, but concentrations increased more rapidly in the sepsis group than in the nonsepsis group. Among the analyzed biomarkers, presepsin was the only blood marker independently associated with sepsis secondary to SAP on days 3 and 7, and presepsin on day 3 was independently associated with mortality at ICU discharge and on days 28 and 90. It showed similar or even better predictive accuracy for both secondary sepsis and mortality than procalcitonin and Sequential Organ Failure Assessment score. Conclusion : Presepsin could be a valuable early predictor of secondary sepsis and mortality in patients admitted to the ICU with SAP and may serve as an indicator for early risk stratification.

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990).

Revisiting the Ranson score in acute pancreatitis: Is the drop in hematocrit a worrisome sign?

BACKGROUND

The Ranson score has 11 parameters that are complex and laborious to implement. In this study, we aimed to create a revised Ranson score by modifying the parameters in Ranson.

METHODS

A total of 938 patients diagnosed with acute pancreatitis (AP) between 2014 and 2021 were included in the study. The parameters of the Ranson score were included in the univariate and multivariate analyses. According to the results, some of these parameters were modified, and then the revised Ranson score was created.

RESULTS

The revised Ranson system was created with nine parameters by modifying the hematocrit parameter at 48 hours and excluding the aspartate aminotransferase parameter from the scoring system. For in-hospital mortality, the area under the curve value of the revised Ranson was 0.959 (95% CI: 0.931-0.986), and it was significantly higher compared to the three scoring systems evaluated. At a cut-off value of 3.5, the revised Ranson had a sensitivity and specificity of 91.7% and 89.1%, respectively, for mortality.

CONCLUSION

The revised Ranson scoring system had better predictive ability for all clinical outcomes compared to the original Ranson in our large sample of 938 patients. However, the revised version should be further validated by prospective and multicenter studies.

The role of high serum triglyceride levels on pancreatic necrosis development and related complications

BACKGROUND

The relevance of elevated serum triglyceride (TG) levels in the early stages of acute pancreatitis (AP) not induced by hypertriglyceridemia (HTG) remains unclear. Our study aims to determine the role of elevated serum TG levels at admission in developing pancreatic necrosis.

METHODS

We analyzed the clinical data collected prospectively from patients with AP. According to TG levels measured in the first 24 h after admission, we stratified patients into four groups: Normal TG (< 150 mg/dL), Borderline-high TG (150-199 mg/dL), High TG (200-499 mg/dL) and Very high TG (≥ 500 mg/dL). We analyzed the association of TG levels and other risk factors with the development of pancreatic necrosis.

RESULTS

A total of 211 patients were included. In the Normal TG group: 122, in Borderline-high TG group: 38, in High TG group: 44, and in Very high TG group: 7. Pancreatic necrosis developed in 29.5% of the patients in the Normal TG group, 26.3% in the Borderline-high TG group, 52.3% in the High TG group, and 85.7% in the Very high TG group. The trend analysis observed a significant association between higher TG levels and pancreatic necrosis (p = 0.001). A multivariable analysis using logistic regression showed that elevated TG levels ≥ 200 mg/dL (High TG and Very high TG groups) were independently associated with pancreatic necrosis (OR: 3.27, 95% CI - 6.27, p < 0.001).

CONCLUSIONS

An elevated TG level at admission ≥ 200 mg/dl is independently associated with the development of pancreatic necrosis. The incidence of pancreatic necrosis increases proportionally with the severity of HTG.

Deep Learning Models for Severity Prediction of Acute Pancreatitis in the Early Phase From Abdominal Nonenhanced Computed Tomography Images

OBJECTIVES

To develop and validate deep learning (DL) models for predicting the severity of acute pancreatitis (AP) by using abdominal nonenhanced computed tomography (CT) images.

METHODS

The study included 978 AP patients admitted within 72 hours after onset and performed abdominal CT on admission. The image DL model was built by the convolutional neural networks. The combined model was developed by integrating CT images and clinical markers. The performance of the models was evaluated by using the area under the receiver operating characteristic curve.

RESULTS

The clinical, Image DL, and the combined DL models were developed in 783 AP patients and validated in 195 AP patients. The combined models possessed the predictive accuracy of 90.0%, 32.4%, and 74.2% for mild, moderately severe, and severe AP. The combined DL model outperformed clinical and image DL models with 0.820 (95% confidence interval, 0.759-0.871), the sensitivity of 84.76% and the specificity of 66.67% for predicting mild AP and the area under the receiver operating characteristic curve of 0.920 (95% confidence interval, 0.873-0.954), the sensitivity of 90.32%, and the specificity of 82.93% for predicting severe AP.

CONCLUSIONS

The DL technology allows nonenhanced CT images as a novel tool for predicting the severity of AP.

Comparative Evaluation of Harmless Acute Pancreatitis Score (HAPS) and Bedside Index of Severity in Acute Pancreatitis (BISAP) Scoring System in the Stratification of Prognosis in Acute Pancreatitis

Acute pancreatitis is a common disease in patients presenting to the emergency room in any hospital. The most common causes are alcohol ingestion and gallstone disease. Diagnosis is usually based on clinical findings and elevated serum amylase and lipase levels. Imaging is often not necessary but may be used to confirm the diagnosis or rule out any other pathology or to evaluate for any complications. The majority of patients will have a mild, self-limiting disease but others may develop a severe fulminant course with organ failure. These patients are at high risk of developing complications, morbidity or mortality. Treatment of acute pancreatitis includes supportive treatment with antibiotics, fluids, analgesics and early enteral feeding. Several scores have been developed to predict the course of pancreatitis and help make informed decisions, monitoring and timely intervention. The majority of them are complicated, require extensive and expensive interventions or require time. Harmless acute pancreatitis score (HAPS) is one such score that is easy to calculate and is done at the time of admission, bedside index of severity in acute pancreatitis (BISAP) is another one requiring more parameters. The parameters used to calculate it are easily available and can be done at a majority of healthcare facilities in developing countries. HAPS thus seems to be a good option in aiding doctors in assessing acute pancreatitis. It may be considered as a standard scoring for acute pancreatitis for early and effective management. We have tried to study and compare the superiority of HAPS over BISAP in predicting prognosis in acute pancreatitis.

Machine learning model identifies aggressive acute pancreatitis within 48 h of admission: a large retrospective study

BACKGROUND

Acute pancreatitis (AP) with critical illness is linked to increased morbidity and mortality. Current risk scores to identify high-risk AP patients have certain limitations.

OBJECTIVE

To develop and validate a machine learning tool within 48 h after admission for predicting which patients with AP will develop critical illness based on ubiquitously available clinical, laboratory, and radiologic variables.

METHODS

5460 AP patients were enrolled. Clinical, laboratory, and imaging variables were collected within 48 h after hospital admission. Least Absolute Shrinkage Selection Operator with bootstrap method was employed to select the most informative variables. Five different machine learning models were constructed to predictive likelihood of critical illness, and the optimal model (APCU) was selected. External cohort was used to validate APCU. APCU and other risk scores were compared using multivariate analysis. Models were evaluated by area under the curve (AUC). The decision curve analysis was employed to evaluate the standardized net benefit.

RESULTS

Xgboost was constructed and selected as APCU, involving age, comorbid disease, mental status, pulmonary infiltrates, procalcitonin (PCT), neutrophil percentage (Neu%), ALT/AST, ratio of albumin and globulin, cholinesterase, Urea, Glu, AST and serum total cholesterol. The APCU performed excellently in discriminating AP risk in internal cohort (AUC = 0.95) and external cohort (AUC = 0.873). The APCU was significant for biliogenic AP (OR = 4.25 [2.08-8.72], P < 0.001), alcoholic AP (OR = 3.60 [1.67-7.72], P = 0.001), hyperlipidemic AP (OR = 2.63 [1.28-5.37], P = 0.008) and tumor AP (OR = 4.57 [2.14-9.72], P < 0.001). APCU yielded the highest clinical net benefit, comparatively.

CONCLUSION

Machine learning tool based on ubiquitously available clinical variables accurately predicts the development of AP, optimizing the management of AP.

Acute Changes in Serum Creatinine and Kinetic Glomerular Filtration Rate Estimation in Early Phase of Acute Pancreatitis

In patients with acutely changing kidney function, equations used to estimate glomerular filtration rate (eGFR) must be adjusted for dynamic changes in the concentrations of filtration markers (kinetic eGFR, KeGFR). The aim of our study was to evaluate serum creatinine-based KeGFR in patients in the early phase of acute pancreatitis (AP) as a marker of changing renal function and as a predictor of AP severity. We retrospectively calculated KeGFR on day 2 and 3 of the hospital stay in a group of 147 adult patients admitted within 24 h from the onset of AP symptoms and treated in two secondary-care hospitals. In 34 (23%) patients, changes in serum creatinine during days 1-3 of the hospital stay exceeded 26.5 µmol/L; KeGFR values almost completely differentiated those with increasing and decreasing serum creatinine (area under receiver operating characteristic curve, AUROC: 0.990 on day 3). In twelve (8%) patients, renal failure was diagnosed during the first three days of the hospital stay according to the modified Marshall scoring system, which was associated with significantly lower KeGFR values. KeGFR offered good diagnostic accuracy for renal failure (area under receiver operating characteristic-AUROC: 0.942 and 0.950 on days 2 and 3). Fourteen (10%) patients developed severe AP. KeGFR enabled prediction of severe AP with moderate diagnostic accuracy (AUROC: 0.788 and 0.769 on days 2 and 3), independently of age, sex, comorbidities and study center. Lower KeGFR values were significantly associated with mortality. Significant dynamic changes in renal function are common in the early phase of AP. KeGFR may be useful in the assessment of kidney function in AP and the prediction of AP severity.

Identification of early predictors for infected necrosis in acute pancreatitis

Background

In acute pancreatitis, secondary infection of pancreatic necrosis is a complication that mostly necessitates interventional therapy. A reliable prediction of infected necrotizing pancreatitis would enable an early identification of patients at risk, which however, is not possible yet.

Methods

This study aims to identify parameters that are useful for the prediction of infected necrosis and to develop a prediction model for early detection. We conducted a retrospective analysis from the hospital information and reimbursement data system and screened 705 patients hospitalized with diagnosis of acute pancreatitis who underwent contrast-enhanced computed tomography and additional diagnostic puncture or drainage of necrotic collections. Both clinical and laboratory parameters were analyzed for an association with a microbiologically confirmed infected pancreatic necrosis. A prediction model was developed using a logistic regression analysis with stepwise inclusion of significant variables. The model quality was tested by receiver operating characteristics analysis and compared to single parameters and APACHE II score.

Results

We identified a total of 89 patients with necrotizing pancreatitis, diagnosed by computed tomography, who additionally received biopsy or drainage. Out of these, 59 individuals had an infected necrosis. Eleven parameters showed a significant association with an infection including C-reactive protein, albumin, creatinine, and alcoholic etiology, which were independent variables in a predictive model. This model showed an area under the curve of 0.819, a sensitivity of 0.692 (95%-CI [0.547–0.809]), and a specificity of 0.840 (95%-CI [0.631–0.947]), outperforming single laboratory markers and APACHE II score. Even in cases of missing values predictability was reliable.

Conclusion

A model consisting of a few single blood parameters and etiology of pancreatitis might help for differentiation between infected and non-infected pancreatic necrosis and assist medical therapy in acute necrotizing pancreatitis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02490-9.

Predicting Severity of Acute Pancreatitis

Acute pancreatitis has a diverse etiology and natural history, and some patients have severe complications with a high risk of mortality. The prediction of the severity of acute pancreatitis should be achieved by a careful ongoing clinical assessment coupled with the use of a multiple-factor scoring system and imaging studies. Over the past 40 years, various scoring systems have been suggested to predict the severity of acute pancreatitis. However, there is no definite and ideal scoring system with a high sensitivity and specificity. The interest in new biological markers and predictive models for identifying severe acute pancreatitis testifies to the continued clinical importance of early severity prediction. Although contrast-enhanced computed tomography (CT) is considered the gold standard for diagnosing pancreatic necrosis, early scanning for the prediction of severity is limited because the full extent of pancreatic necrosis may not develop within the first 48 h of presentation. This article provides an overview of the available scoring systems and biochemical markers for predicting severe acute pancreatitis, with a focus on their characteristics and limitations.

Application of nanotechnology in the diagnosis and treatment of acute pancreatitis

Acute pancreatitis (AP) is a common digestive system disease. The severity of AP ranges from mild edema in the pancreas to severe systemic inflammatory responses leading to peripancreatic/pancreatic necrosis, multi-organ failure and death. Improving the sensitivity of AP diagnosis and developing alternatives to traditional methods to treat AP have gained the attention of researchers. With the continuous rise of nanotechnology, it is being widely used in daily life, biomedicine, chemical energy and many other fields. Studies have demonstrated the effectiveness of nanotechnology in the diagnosis and treatment of AP. Nanotechnology has the advantages of simplicity, rapidity and sensitivity in detecting biomarkers of AP, as well as enhancing imaging, which helps in the early diagnosis of AP. On the other hand, nanoparticles (NPs) have oxidative stress inhibiting and anti-inflammatory effects, and can also be loaded with drugs as well as being used in anti-infection therapy, providing a new approach for the treatment of AP. In this article, we elaborate and summarize on the potential of nanoparticles for diagnostic and therapeutic applications in AP from the current reported literature and experimental results to provide useful guidelines for further research on the application of nanotechnology.

Effect of aggressive versus conservative hydration for early phase of acute pancreatitis in adult patients: A meta-analysis of 3,127 cases

BACKGROUND

The advantages of aggressive hydration compared to conservative hydration within 24 h for acute pancreatitis (AP) remain controversial in adult patients. A meta-analysis was undertaken to investigate whether aggressive strategies are more beneficial.

METHODS

We searched (on February 1, 2021) PubMed, Embase, and the Cochrane Library for eligible trials that assessed the two therapies and performed a meta-analysis. The primary endpoint was in-hospital mortality. Secondary outcomes were adverse events (e.g., renal failure and pancreatic necrosis) within 24 h of treatment.

RESULTS

Five randomized controlled trials and 8 observational trials involving 3127 patients were identified. Patients with severe pancreatitis showed significant difference of in-hospital mortality (OR 1.75; 95% CI 1.32-2.33) in aggressive hydration group, which were less susceptible to study type and age. Patients with severe pancreatitis were likely to develop respiratory failure (OR 5.08; 95% CI 2.31-11.15), persistent SIRS (OR 2.83; 95% CI 1.58-5.04), renal failure (OR 2.58; 95% CI 1.90-3.50) with significant difference. A longer hospital stay was observed in patients with severe pancreatitis (WMD 7.61; 95% CI 5.51-9.71; P < 0.05) in the aggressive hydration group. Higher incidence of pancreatic necrosis (OR 2.34; 95% CI 1.60-3.42; P < 0.05) was major susceptible to observational studies, old patients and mild pancreatitis.

CONCLUSIONS

Compared to conservative hydration, aggressive hydration increases in-hospital mortality and the incidence of renal failure, pancreatic necrosis with relatively strong evidence. Further investigation should be designed with a definitive follow-up period and therapeutic goals to address reverse causation bias.

Usefulness of Random Forest Algorithm in Predicting Severe Acute Pancreatitis

BACKGROUND AND AIMS

This study aimed to develop an interpretable random forest model for predicting severe acute pancreatitis (SAP).

METHODS

Clinical and laboratory data of 648 patients with acute pancreatitis were retrospectively reviewed and randomly assigned to the training set and test set in a 3:1 ratio. Univariate analysis was used to select candidate predictors for the SAP. Random forest (RF) and logistic regression (LR) models were developed on the training sample. The prediction models were then applied to the test sample. The performance of the risk models was measured by calculating the area under the receiver operating characteristic (ROC) curves (AUC) and area under precision recall curve. We provide visualized interpretation by using local interpretable model-agnostic explanations (LIME).

RESULTS

The LR model was developed to predict SAP as the following function: -1.10-0.13×albumin (g/L) + 0.016 × serum creatinine (μmol/L) + 0.14 × glucose (mmol/L) + 1.63 × pleural effusion (0/1)(No/Yes). The coefficients of this formula were utilized to build a nomogram. The RF model consists of 16 variables identified by univariate analysis. It was developed and validated by a tenfold cross-validation on the training sample. Variables importance analysis suggested that blood urea nitrogen, serum creatinine, albumin, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, calcium, and glucose were the most important seven predictors of SAP. The AUCs of RF model in tenfold cross-validation of the training set and the test set was 0.89 and 0.96, respectively. Both the area under precision recall curve and the diagnostic accuracy of the RF model were higher than that of both the LR model and the BISAP score. LIME plots were used to explain individualized prediction of the RF model.

CONCLUSIONS

An interpretable RF model exhibited the highest discriminatory performance in predicting SAP. Interpretation with LIME plots could be useful for individualized prediction in a clinical setting. A nomogram consisting of albumin, serum creatinine, glucose, and pleural effusion was useful for prediction of SAP.

Accurate prediction of acute pancreatitis severity based on genome-wide cell free DNA methylation profiles

Background

Patients with severe acute pancreatitis (SAP) have a high mortality, thus early diagnosis and interventions are critical for improving survival. However, conventional tests are limited in acute pancreatitis (AP) stratification. We aimed to assess AP severity by integrating the informative clinical measurements with cell free DNA (cfDNA) methylation markers.

Methods

One hundred and seventy-five blood samples were collected from 61 AP patients at multiple time points, plus 24 samples from healthy individuals. Genome-wide cfDNA methylation profiles of all samples were characterized with reduced representative bisulfite sequencing. Clinical blood tests covering 93 biomarkers were performed on AP patients within 24 h. SAP predication models were built based on cfDNA methylation and conventional blood biomarkers separately and in combination.

Results

We identified 565 and 59 cfDNA methylation markers informative for acute pancreatitis and its severity. These markers were used to develop prediction models for AP and SAP with area under the receiver operating characteristic of 0.92 and 0.81, respectively. Twelve blood biomarkers were systematically screened for a predictor of SAP with a sensitivity of 87.5% for SAP, and a specificity of 100% in mild acute pancreatitis, significantly higher than existing blood tests. An expanded model integrating 12 conventional blood biomarkers with 59 cfDNA methylation markers further improved the SAP prediction sensitivity to 92.2%.

Conclusions

These findings have demonstrated that accurate prediction of SAP by the integration of conventional and novel blood molecular markers, paving the way for early and effective SAP intervention through a non-invasive rapid diagnostic test.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-021-01217-z.

Association between high-density lipoprotein cholesterol and apolipoprotein A-I and severe acute pancreatitis: a case-control study

BACKGROUND

Evidence is limited concerning the association between serum concentrations of high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A-I (APO A-I) and severe acute pancreatitis (SAP). This study was designed to explore whether HDL-C and APO A-I were independently correlated to SAP after adjusting for covariates.

METHODS

There were 1127 patients with acute pancreatitis who were recruited from a tertiary teaching hospital in Wenzhou from 1 January 2018 to 30 April 2020. The independent variables were baseline levels of HDL-C, and APO A-I collected within 24 h after admission. The dependent variable was the occurrence of SAP during hospitalization. Univariate and multivariate binary logistic regression were conducted to analyze the relationship between HDL-C and APO A-I and SAP. The receiver operating characteristic curve was applied to analyze the prediction power of lipid parameters and C-reactive protein for SAP.

RESULTS

The incidence of SAP was 11.5% among the 678 patients included in the final analysis. The serum levels of APO A-I and HDL-C were negatively related to SAP after adjusting for confounders with an odds ratio of 0.24 [95% confidence interval (CI): 0.06-0.95] and 0.16 (95% CI, 0.04-0.56), respectively. APO A-I (area under the curve = 0.69; 95% CI, 0.63-0.76) and HDL-C (area under the curve = 0.72; 95% CI, 0.66-0.79) showed higher predictive value for SAP compared with other lipid parameters.

CONCLUSIONS

Decreased serum concentrations of HDL-C and APO A-I are associated with SAP after adjusting for covariates.

Factors Associated with Fluid Sequestration in Patients with Acute Pancreatitis: A Prospective Study in Tertiary Centre Hospital in Nepal

Background

Acute pancreatitis (AP) is associated with extensive fluid sequestration. The aim of this study was to determine association of fluid sequestration at 48 hours after hospital admission (FS⁴⁸) in AP patients with demographics, clinical parameters, and outcomes of AP.

Methods

A prospective observational study was carried out on all adult patients with AP admitted to Tribhuvan University Teaching Hospital, Nepal, from January to September 2017. FS⁴⁸ was calculated as the difference between fluid input and output in the first 48 hours of admission. The Kruskal-Wallis test with post hoc Dunn's test examined the difference in FS⁴⁸ between mild AP, moderately severe AP, and severe AP. Linear regression analysis was used to evaluate association between FS⁴⁸ with patients' characteristics and outcomes of AP. Outcomes of AP assessed included pancreatic necrosis, persistent organ failure, length of stay, and in-hospital mortality.

Results

Eighty patients (median age 44 years; 57% male) with a median FS⁴⁸ of 1610 mL were evaluated. The median FS⁴⁸ for mild AP, moderately severe AP, and severe AP were 1,180 mL, 2,380 mL, and 3,500 mL, respectively. There was a significant difference in pairwise comparisons between mild AP and moderately severe AP, along with mild AP and severe AP. Younger age, other etiology, and higher creatinine were independently associated with increased FS⁴⁸. Increased FS⁴⁸ was significantly associated with pancreatic necrosis, persistent organ failure, and in-hospital mortality.

Conclusions

In our study population, younger age and higher creatinine were predictors of increased FS⁴⁸. Increased FS⁴⁸ was associated with poorer outcomes of AP.

Serum phosphate is associated with mortality among patients admitted to ICU for acute pancreatitis

BACKGROUND AND AIMS

Routine laboratory tests can be useful predictors in the early assessment of the severity and mortality of acute pancreatitis (AP). The aim of this study was to evaluate the accuracy of clinical and laboratory parameters for the prediction of mortality among patients admitted to the intensive care unit (ICU) for AP.

METHODS

We conducted a retrospective analysis of prospectively collected data from Beth Israel Deaconess Hospital made publicly available to examine the relationship between routine clinical and laboratory parameters with respect to mortality for AP. Cox proportional hazard ratio was used to evaluate the impact of several routine laboratory markers on mortality. Receiver operation characteristic (ROC) curve was performed to determine the accuracy of diagnosis of laboratory tests by using area under curve (AUC) for the respective analysis.

RESULTS

In total, 499 patients were admitted to the ICU for AP. Several factors for predicting mortality in AP at admission were identified in the multivariate analysis: alkaline phosphatase hazard ratio (HR) = 1.00 (1.00-1.00, p = 0.024), anion gap HR = 1.09 (1.00-1.20, p = 0.047), bilirubin total HR = 1.11 (1.06-1.17, p < 0.001), calcium total HR = 0.59 (0.42-0.84, p = 0.004), phosphate HR = 1.51 (1.18-1.94, p = 0.001), potassium HR = 1.91 (1.03-3.55, p = 0.041), white blood cells HR = 1.04 (1.00-1.07, p = 0.028). The AUC of serum phosphate level for mortality was 0.7 in the ROC analysis. The optimal cut-off value of serum phosphate level for prediction of mortality was 3.78 mg/dl (sensitivity, 0.58; specificity, 0.78).

CONCLUSION

In this large cohort, we identified baseline serum phosphate as the most valuable single routine laboratory test for predicting mortality in AP. Future prospective studies are required to confirm these results.

The Relationship Between Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios With Hospital Stays and Mortality in the Emergency Department

Background Most acute pancreatitis scoring is made in the first 48-72 hours or later. Like many inflammatory processes, Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) can be useful in showing the severity and extent of inflammation in acute pancreatitis. Our study aimed to evaluate whether these rates affect mortality according to the NLR and PLR values ​​of patients diagnosed with acute pancreatitis by examining the blood samples taken within the first hour after admission to the emergency department rates are useful in predicting the length of stay. Methods In our retrospective study, 557 patients applied to our clinic for 4.5 years, whose amylase and lipase values ​​were higher than two times the cut-off value in blood tests and whose CT imaging was compatible with acute pancreatitis were included in the study. Results The median length of hospitalization of the patients was 4.0 (3.0-6.0) days. Gallstones were detected in 320 (57.5%) patients. Mortality of less than a year was observed in 45 (8.1%) of the study population. Eighteen of the patients (3.2%) showed the need for follow-up in the intensive care unit. A statistically significant relationship was found between mortality and variables hematocrit (HCT), red cell distribution width (RDW),c-reactive protein CRP), glucose, urea, potassium, albumin, PLR, and NLR (p <0.05). A statistically significant correlation was observed between RDW, NLR, glucose, and CRP levels in the two groups divided according to the median value of 4 days we found on hospitalization (p <0.05). According to the graphics and test results obtained by ROC analysis, the mortality status can be predicted at a statistically significant level with PLR and NLR diagnostic tests (p <0.05). Conclusion High levels of NLR, PLR, RDW, glucose, CRP, urea, potassium, low albumin and hematocrit values ​​at the first admission in the Emergency Service seem to be associated with increased 1-year mortality in acute pancreatitis.

Prognostic value of the creatinine-albumin ratio in acute pancreatitis debridement

Background

Increases in the levels of serum C-reactive protein (CRP) and creatinine (Cr) and decreases in those of albumin (Alb) are commonly observed in acute pancreatitis (AP). We aimed to evaluate the efficacy of the Cr/Alb and CRP/Alb ratios in the prediction of surgical treatment effect in AP patients.

Methods

This study retrospectively analyzed clinical data obtained from 140 AP patients who underwent debridement from January 2008 to November 2018 in Shanghai Ruijin Hospital. The Cr/Alb and CRP/Alb ratios at admission and before surgery were assessed in the analysis of clinical statistics, prediction of prognoses, and logistic regression analysis.

Results

The admission Cr/Alb had the best predictive value of the four ratios. This value was significantly higher in patients with re-operation and those who died (P < 0.05) and was correlated with the Acute Physiology and Chronic Health Evaluation (APACHE II) score, admission CRP/Alb, preoperative Cr/Alb, and post-operative complications. The admission Cr/Alb could predict the risk of AP-related re-operation and mortality with sensitivities, specificities and areas under the curve of 86.3%, 61.7% and 0.824, and 73.4%, 81.3% and 0.794, respectively. At a cut-off value of 3.43, admission Cr/Alb values were indicative of a worse clinical state, including impaired laboratory test values, APACHE II scores, rates of post-operative complications and re-operation, and mortality (P < 0.05). In the logistic regression analysis, admission Cr/Alb values were independently related to the APACHE II score, post-operative renal failure, and mortality.

Conclusion

Cr/Alb is a novel but promising, easy-to-measure, reproducible, non-invasive prognostic score for the prediction of the effect of debridement in AP patients.

Association between Acute Pancreatitis and COVID-19: Could Pancreatitis Be the Missing Piece of the Puzzle about Increased Mortality Rates?

BACKGROUND

The COVID-19 pandemic caused by SARS-CoV-2 commenced in Wuhan China in 2019 and soon spread worldwide. SARS-CoV-2 enters the cell by binding to the ACE II receptor and begins viral replication. The effects and clinical findings of SARS-CoV-2 on the liver, kidney, heart, gastrointestinal (GI) system and especially lungs have been widely discussed. However, the effects on the pancreas-another organ that also expresses ACE II-have not been studied.

METHODS

This work prospectively evaluated data from 316 patients who were admitted with a diagnosis of COVID-19 pneumonia. The patients were categorized into three according to the severity of pneumonia (mild, severe, critical). Demographic data, rate of pancreatitis, biochemical parameters, and radiological images from each group were analyzed. The patients were divided into two groups and outcomes were compared: COVID-19 patients with acute pancreatitis (Group P) and without acute pancreatitis (Group C).

RESULTS

The median age was 54 (18-87), and the median age for patients with acute pancreatitis was 55 (26-84). As an expected finding, we found a positive correlation between advanced age and mortality (p = 0.0003). 12.6% of the patients had acute pancreatitis. While pancreatitis was not seen in patients on mild status, the rate of pancreatitis was 32.5% in critical patients. Hospitalization and mortality rates were higher in patients with COVID-19 accompanied by acute pancreatitis (p = 0.0038 and p < 0.0001, respectively). C-Reactive Protein (CRP) and ferritin were significantly higher in those who had pancreatitis (p < 0.0001). D-Dimer and procalcitonin levels had only a small difference (p = 0.1127 and p = 0.3403, respectively).

CONCLUSION

Acute pancreatitis alone is a clinical condition that can lead to mortality and may be one of the reasons for the exaggerated immune response developing in the progression of COVID-19. Our results point out that the presence of pancreatic damage triggered by SARS-CoV-2 can deteriorate the clinical condition of patients and the mortality rate may increase in these patients.

Severe acute pancreatitis: capillary permeability model linking systemic inflammation to multiorgan failure

Severe acute pancreatitis (SAP) includes persistent systemic inflammation (SIRS) and multiorgan failure (MOF). The mechanism of transition from SIRS to MOF is unclear. We developed a fluid compartment model and used clinical data to test predictions. The model includes vascular, interstitial and "third-space" compartments with variable permeability of plasma proteins at the capillaries. Consented patients from University of Pittsburgh Medical Center Presbyterian Hospital were studied. Preadmission and daily hematocrit (HCT), blood urea nitrogen (BUN), creatine (Cr), albumin (Alb), and total protein (TP) were collected, and nonalbumin plasma protein (NAPP = TP minus the Alb) was calculated. Subjects served as their own controls for trajectory analysis. Of 57 SAP subjects, 18 developed MOF (5 died), and 39 were non-MOF (0 died). Compared with preadmission levels, admission HCT increased in MOF +5.00 [25%-75% interquartile range, IQR] versus non-MOF -0.10 [-1.55, 1.40] (P < 0.002) with HCT > +3 distinguishing MOF from non-MOF (odds ratio 17.7, P = 0.014). Preadmission Alb fell faster in MOF than non-MOF (P < 0.01). By day 2, TP and NAPP dropped in MOF but not non-MOF (P < 0.001). BUN and Cr levels increased in MOF (P = 0.001), but BUN-to-Cr ratios remained constant. Pancreatic necrosis was more common in MOF (56%) than non-MOF (23%). Changing capillary permeability to allow loss of NAPP in this model predicts loss of plasma oncotic pressure and reduced vascular volume, hypotension with prerenal azotemia and acute kidney dysfunction, pancreas necrosis, and pulmonary edema from capillary leak in the lung with acute respiratory distress syndrome. Sequential biomarker analysis in humans with or without MOF is consistent with this model. This study is registered on https://clinicaltrials.gov at NCT03075605.NEW & NOTEWORTHY Acute pancreatitis is a sudden inflammatory response to pancreatic injury that may spread to systemic inflammation, multiorgan failure, and death in some patients. With the use of the predictions of a new mechanistic model, we compared patients with severe acute pancreatitis with or without multiorgan failure. All biomarkers of capillary leak and clinical features of multiorgan failure were accurately predicted. This provides a new paradigm for understanding and developing new treatments for patients with severe acute pancreatitis.

Recent Advances in Diagnosis and Severity Assessment of Acute Pancreatitis

The incidence and prevalence of acute pancreatitis (AP) is increasing over time. The diagnosis of acute pancreatitis is established by revised Atlanta criteria (2012). Multiple criteria and scoring systems have been used for assessment of severity of AP. Majority of acute pancreatitis cases (80%) are mild, the challenge remains in early diagnosis, severity assessment and treatment of severe AP and its complications. Assessment of severity of AP is important part of management because line of treatment depends on aetiology and severity of acute pancreatitis. In this article a comprehensive review of recent advances in diagnosis and severity assessment of acute pancreatitis has been described.

Initially elevated arterial lactate as an independent predictor of poor outcomes in severe acute pancreatitis

BACKGROUND

The present study aimed to investigate the relationships between arterial lactate levels and outcomes in severe acute pancreatitis.

METHODS

The study retrospectively analyzed the medical data of 329 patients with severe acute pancreatitis from January 2014 to February 2019. We compared baseline characteristics, laboratory data, severity scores, types of persistent organ failure, and primary and secondary outcomes of patients with and without elevated arterial lactate levels at admission. A multivariate logistic regression analysis model and receiver operating characteristic curve were adopted to evaluate the value of arterial lactate ≥4 mmol/L for identifying high-risk patients. Trends in arterial lactate levels were compared between patients in the survivor and nonsurvivor groups over a period of 7 days.

RESULTS

Compared to normal arterial lactate levels, patients with elevated arterial lactate levels show significantly higher incidences of multiple persistent organ failure (3% vs 30%, P < 0.01), death (2% vs 11%, P < 0.01), septic shock (4% vs 24%, P < 0.01), pancreatic infection (12% vs 37%, P < 0.01), abdominal compartment syndrome (3% vs 20%, P < 0.01), pancreatic necrosis (41% vs 63%, P < 0.01), and a need for ventilator support (26% vs 54%, P < 0.01). For predicting mortality, arterial lactate levels ≥4 mmol/L had a high hazard ratio (10, 95% CI; 3.7-27; P < 0.01) and the highest area under the curve (0.78).

CONCLUSIONS

Our results indicate that initially elevated arterial lactate is independently associated with poor outcomes and death in patients with severe acute pancreatitis and may serve as an early high-risk stratification indicator.

Aggressive hydration compared to standard hydration with lactated ringer's solution for prevention of post endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND AND AIMS

Previous studies have suggested that aggressive hydration with lactated ringer solution are one of the protective factors in preventing post endoscopic retrograde cholangiopancreatography (post-ERCP). We conducted a systematic review and meta-analysis to examine the efficacy aggressive hydration with lactated Ringer solution in preventing PEP.

METHODS

All published and unpublished articles on aggressive hydration with lactated ringer solution in those underwent ERCP procedure for any reasons were screened for eligibility. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. This paper doesn't need the IRB approval.

RESULTS

Seven RCTs met the inclusion criteria. Meta-analysis indicates that aggressive hydration with lactated Ringer solution were associated with lower PEP rate.[odds ratio (OR) 0.29; 95% confidence interval (CI) 0.18-0.48]; lower incidence of hyperamylasemia (OR 0.49; 95% CI 0.35, 0.69) and lower risk of pain (OR 0.28; 95% CI 0.10-0.81). The association between aggressive hydration with lactated Ringer solution and incidence of moderate severity PEP were unclear (OR 0.57; 95% CI 0.22, 1.45). Sensitivity analyses also showed that omitting 1 study from analysis of PEP rate could reduce the heterogeneity but did not change the conclusion of this meta-analysis. A cumulating meta-analysis was performed statistically which showed a stable result of overall incidence of PEP.

CONCLUSIONS

Aggressive hydration with lactated Ringer solution was a protective factor in reducing the overall incidence of PEP, hyperamylasemia and risk of abdominal pain.

Multifactorial Scores and Biomarkers of Prognosis of Acute Pancreatitis: Applications to Research and Practice

Acute pancreatitis (AP) is a severe inflammation of the pancreas presented with sudden onset and severe abdominal pain with a high morbidity and mortality rate, if accompanied by severe local and systemic complications. Numerous studies have been published about the pathogenesis of AP; however, the precise mechanism behind this pathology remains unclear. Extensive research conducted over the last decades has demonstrated that the first 24 h after symptom onset are critical for the identification of patients who are at risk of developing complications or death. The identification of these subgroups of patients is crucial in order to start an aggressive approach to prevent mortality. In this sense and to avoid unnecessary overtreatment, thereby reducing the financial implications, the proper identification of mild disease is also important and necessary. A large number of multifactorial scoring systems and biochemical markers are described to predict the severity. Despite recent progress in understanding the pathophysiology of AP, more research is needed to enable a faster and more accurate prediction of severe AP. This review provides an overview of the available multifactorial scoring systems and biochemical markers for predicting severe AP with a special focus on their advantages and limitations.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment

BACKGROUND

Post endoscopic retrograde cholangiopancreatography (ERCP) is comparatively complex application. Researchers has been investigated prevention of post-ERCP pancreatitis (PEP), since it has been considered to be the most common complication of ERCP. Although ERCP can lead various complications, it can also be avoided.

AIM

To study the published evidence and systematically review the literature on the prevention and treatment for PEP.

METHODS

A systematic literature review on the prevention of PEP was conducted using the electronic databases of ISI Web of Science, PubMed and Cochrane Library for relevant articles. The electronic search for the review was performed by using the search terms “Post endoscopic retrograde cholangiopancreatography pancreatitis” AND “prevention” through different criteria. The search was restricted to randomized controlled trials (RCTs) performed between January 2009 and February 2019. Duplicate studies were detected by using EndNote and deleted by the author. PRISMA checklist and flow diagram were adopted for evaluation and reporting. The reference lists of the selected papers were also scanned to find other relevant studies.

RESULTS

726 studies meeting the search criteria and 4 relevant articles found in the edited books about ERCP were identified. Duplicates and irrelevant studies were excluded by screening titles and abstracts and assessing full texts. 54 studies were evaluated for full text review. Prevention methods were categorized into three groups as (1) assessment of patient related factors; (2) pharmacoprevention; and (3) procedural techniques for prevention. Most of studies in the literature showed that young age, female gender, absence of chronic pancreatitis, suspected Sphincter of Oddi dysfunction, recurrent pancreatitis and history of previous PEP played a crucial role in posing high risks for PEP. 37 studies designed to assess the impact of 24 different pharmacologic agents to reduce the development of PEP delivered through various administration methods were reviewed. Nonsteroidal anti-inflammatory drugs are widely used to reduce risks for PEP. Rectal administration of indomethacin immediately prior to or after ERCP in all patients is recommended by European Society for Gastrointestinal Endoscopy guidelines to prevent the development of PEP. The majority of the studies reviewed revealed that rectally administered indomethacin had efficacy to prevent PEP. Results of the other studies on the other pharmacological interventions had both controversial and promising results. Thirteen studies conducted to evaluate the efficacy of 4 distinct procedural techniques to prevent the development of PEP were reviewed. Pancreatic Stent Placement has been frequently used in this sense and has potent and promising benefits in the prevention of PEP. Studies on the other procedural techniques have had inconsistent results.

CONCLUSION

Prevention of PEP involves multifactorial aspects, including assessment of patients with high risk factors for alternative therapeutic and diagnostic techniques, administration of pharmacological agents and procedural techniques with highly precise results in the literature.

Prediction of Self-Limited Acute Pancreatitis Cases at Admission to Emergency Unit

Background

While acute pancreatitis (AP) resolves spontaneously with supportive treatment in most patients, it may be life-threatening. Predicting the disease severity at onset dictates the management strategy. We aimed to define the patients with mild pancreatitis who may be considered for outpatient management with significant cost-savings.

Materials and Methods

This prospective observational study included 180 patients with mild AP according to the harmless acute pancreatitis score (HAPS) and Imrie score. The relationships of biochemical parameters with the changes in the Balthazar score and clinical course were examined.

Results

The study included 180 patients (111 females, 69 males; mean age: 53.9 ± 17.2 years; range: 17-92 years). The etiology was biliary in 118 (65%) patients and remained undetermined in 38 (21.1%) patients. Computed tomography (CT) performed within the first 12 h revealed mild and moderate AP in 159 (88.3%) and 21 (11.7%) patients, respectively. CT repeated at 72 h revealed mild, moderate, and severe AP in 155 (86.1%), 24 (13.3%), and 1 (0.6%) patients, respectively. Comparisons between stages A + B + C and D + E showed significant differences in the amylase levels on day 1 and 3, and in C-reactive protein on day 3. Also, in stage D and E disease, narcotic analgesic intake, oral intake onset time, and pain were significantly higher.

Conclusion

There were no significant changes in the CT findings of patients with mild AP at 12 and 72 h. Most patients (n = 179; 99.4%) recovered uneventfully. Patients with mild pancreatitis according to the HAPS and Imrie scores can be considered for outpatient management. The recovery is longer in stage D and E disease.

Development and validation of three machine-learning models for predicting multiple organ failure in moderately severe and severe acute pancreatitis

BACKGROUND

Multiple organ failure (MOF) is a serious complication of moderately severe (MASP) and severe acute pancreatitis (SAP). This study aimed to develop and assess three machine-learning models to predict MOF.

METHODS

Patients with MSAP and SAP who were admitted from July 2014 to June 2017 were included. Firstly, parameters with significant differences between patients with MOF and without MOF were screened out by univariate analysis. Then, support vector machine (SVM), logistic regression analysis (LRA) and artificial neural networks (ANN) models were constructed based on these factors, and five-fold cross-validation was used to train each model.

RESULTS

A total of 263 patients were enrolled. Univariate analysis screened out sixteen parameters referring to blood volume, inflammatory, coagulation and renal function to construct machine-learning models. The predictive efficiency of the optimal combinations of features by SVM, LRA, and ANN was almost equal (AUC = 0.840, 0.832, and 0.834, respectively), as well as the Acute Physiology and Chronic Health Evaluation II score (AUC = 0.814, P > 0.05). The common important predictive factors were HCT, K-time, IL-6 and creatinine in three models.

CONCLUSIONS

Three machine-learning models can be efficient prognostic tools for predicting MOF in MSAP and SAP. ANN is recommended, which only needs four common parameters.

Development and validation of a risk prediction score for severe acute pancreatitis

INTRODUCTION

The available prognostic scoring systems for severe acute pancreatitis (SAP) have limitations that restrict their clinical value. The aim of this study was to develop a simple model (score) that could rapidly identify those at risk for SAP.

METHODS

We derived a risk model using a retrospective cohort of 700 patients by logistic regression and bootstrapping methods. The discriminative power of the risk model was assessed by calculating the area under the receiver operating characteristic curves (AUC). The classification and regression tree (CART) analysis was used to create risk categories. The model was internally validated by a tenfold cross-validation and externally validated in a separate prospective cohort of 194 patients.

RESULTS

The incidence of SAP was 9.7% in the derivation cohort and 9.3% in the validation cohort. A prognostic score (We denoted it as the SABP score), ranging from 0 to 10, consisting of systemic inflammatory response syndrome, serum albumin, blood urea nitrogen and pleural effusion, was developed by logistic regression and bootstrapping analysis. Patients could be divided into three risk categories according to total SABP score based on CART analysis. The mean probability of developing SAP was 1.9%, 12.8% and 41.6% in patients with low (0-3), moderate (4-6) and high (7-10) SABP score, respectively. The AUCs of prognostic score in tenfold cross-validation was 0.873 and 0.872 in the external validation.

CONCLUSION

Our risk prediction score may assist physicians in predicting the development of SAP.

Effect of Aggressive Fluid Therapy on Outcomes after Endoscopic Retrograde Cholangiopancreatography: A Randomized Controlled Clinical Trial

BACKGROUND Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP), which may lead to death. The purpose of this study was to evaluate the preventive effect of aggressive fluid therapy on the incidence of post-ERCP pancreatitis. METHODS In double-blind controlled condition, 240 patients were selected and divided into two groups. The treatment of the intervention group (n = 120) included a dose of 20 mL/kg of ringer lactate infusion within 90 minutes before ERCP and 3 mL/kg/h during ERCP followed by 3 mL/kg/h up to 8 hours. The treatment of the control group (n = 120) included a dose of 1.5 mL/kg of ringer lactate infusion during ERCP up to 8 hours later. Firstly, the patients were evaluated in terms of excessive fluid and serum amylase and pain level, and then they were re-evaluated 2, 8, and 24 hours after ERCP. RESULTS The mean age of the patients was 51.57 ± 13.5 years. Most of the patients were female (54.5%). Pancreatitis was developed in 26 patients including 5.83% of the patients in the intervention group and 15.83% of the patients in the control group (p = 0.013). Pancreatic pain was seen in 7.5% of the patients in the intervention group and in 27.5% of the control group (p < 0.005). Hyperamylasemia was seen in 20.83% of the patients in the intervention group and in 35% of the control group (p = 0.014). The mean days of hospital admission was 1.308 ± 0.807 in the intervention group and 1.425 ± 0.876 in the control group (p = 0.275). CONCLUSION Aggressive fluid therapy with ringer lactate solution before ERCP can effectively prevent postERCP pancreatitis, pancreatic pain, and hyperamylasemia.

Serum Creatinine Level and APACHE-II Score within 24 h of Admission Are Effective for Predicting Persistent Organ Failure in Acute Pancreatitis

Aim

The present study was aimed at comparing serum markers and APACHE-II score to predict persistent organ failure (POF) in early acute pancreatitis (AP).

Methods

In this retrospective study, data from 6024 patients with AP were included within 24 h of their admission. Serum levels of urea nitrogen (BUN), creatinine, glucose, and hematocrit and APACHE-II score were analyzed for patients with AP. We employed the area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, and specificity analyses to evaluate the accuracy of the studied laboratory parameters and APACHE-II score.

Results

Our study included 2090 (35%) patients out of 6024 patients who were evaluated within 24 h of hospital admission. For predicting POF, serum creatinine level ≥ 1.8 mg/dl had the highest specificity (98%). The second classification tree has shown that when the serum creatinine level > 1.8 and APACHE − II ≥ 8 within 24 h were combined, the rates of predicted persistent organ failure achieved 66.7%.

Conclusions

In this large, hospital-based retrospective study, we demonstrated that an APACHE-II score ≥ 8 and a serum creatinine level ≥ 1.8 mg/dl within 24 h of admission can positively predict POF in AP and that serum creatinine levels < 1.8 mg/dl within 24 h of admission can be useful for negatively predicting POF in AP.

Serum Serine Peptidase Inhibitor Kazal-Type 1, Trypsinogens 1 to 3, and Complex of Trypsin 2 and α1-Antitrypsin in the Diagnosis of Severe Acute Pancreatitis

OBJECTIVES

We explored prediction of severe acute pancreatitis (AP) and development of organ dysfunction (OD).

METHODS

Serum concentrations of serine peptidase inhibitor Kazal type 1 (SPINK1), trypsinogen 1, trypsinogen 2, and trypsinogen 3, complex between trypsin 2 and α1-antitrypsin, serum C-reactive protein, creatinine, and pancreatic amylase were measured in 239 AP patients with disease onset within 72 hours.

RESULTS

SPINK1 distinguished most accurately patients who later developed severe AP. The area under the receiver operating characteristic curve for SPINK1 was 0.742, followed by trypsinogen 2 (0.726), complex between trypsin 2 and α1-antitrypsin (0.657), creatinine (0.656), trypsinogen 1 (0.652), trypsinogen 3 (0.557), and C-reactive protein (0.499). With a cutoff of 166 μg/L, SPINK1 had a specificity of 93%, a sensitivity of 48%, and diagnostic odds ratio of 11.52. In multivariate logistic regression analysis, only SPINK1 was an independent predictor of severe AP among patients presenting without OD on admission (P < 0.001).

CONCLUSIONS

Plasma levels of the biomarkers and creatinine correlated with the severity of AP and development of OD. In patients presenting without OD at admission, SPINK1 was an independent marker for later development of severe AP.

Predicative values of C-reactive protein for the therapeutic effects of ulinastatin combined with somatostatin in severe acute pancreatitis and for the severity of gastrointestinal failure

Severe acute pancreatitis (SAP) is a serious systemic disease with high mortality. Ulinastatin is a drug widely used for patients with SAP and multiple organ failure syndrome. The present study aimed to investigate the capacity of the serum C-reactive protein (CRP) levels to predict the therapeutic effects of ulinastatin combined with somatostatin as well as determine the severity of SAP. SAP patients were treated with ulinastatin combined with somatostatin and serum CRP levels were measured. The computed tomography severity index (CTSI), acute physiology and chronic health evaluation II (APACHE II) and gastrointestinal failure scores were used to determine the therapeutic effects. All patients were assigned to the effective group and the ineffective group. Receiver operating characteristic curve analysis was performed to determine the sensitivity and specificity of CRP levels in predicting the severity of SAP and patient prognosis. Logistic regression analysis was adopted to investigate the factors influencing the therapeutic effects. Prior to and after treatment, serum CRP levels in patients of the effective and ineffective groups were significantly different. After treatment, serum CRP levels in patients of the effective group exhibited a more obvious reduction. The sensitivity and specificity of serum CRP levels in predicting the therapeutic effects of ulinastatin combined with somatostatin in SAP patients upon hospital admission were 0.813 and 0.934, respectively. Serum CRP levels were positively correlated with APACHE II, CTSI and gastrointestinal failure scores of SAP patients. The logistic regression demonstrated that serum albumin, creatinine and CRP levels on admission were factors influencing the therapeutic effects of ulinastatin combined with somatostatin in SAP patients. These results indicate that serum CRP levels may have a predictive value regarding the therapeutic effects of ulinastatin combined with somatostatin and are an indicator of the severity of gastrointestinal failure in SAP.

Are traditional scoring systems for severity stratification of acute pancreatitis sufficient?

BACKGROUNDS/AIMS

Ranson's score (RS) and Glasgow score (GS) have been utilized to stratify the severity of acute pancreatitis (AP). The aim of this study was to validate RS and GS for stratifying the severity of acute pancreatitis and audit our experience of managing AP.

METHODS

We conducted a retrospective review of patients treated for AP from July 2009 to September 2016. Final severity was determined using the revised Atlanta classification. Mortality and complications were analyzed.

RESULTS

From July 2009 to September 2016, a total of 675 patients with a diagnosis of AP were admitted at the hospital. Of them, 669 patients who had sufficient data were analyzed. Their average age±SD was 58.7±17.4 years (range, 21-98 years). There was a male preponderance (n=393, 53.8%). A total of 82 (12.3%) patients had eventual severe pancreatitis. RS demonstrated a sensitivity of 92.7% and a specificity of 52.8% with a positive predictive value (PPV) of 21.5% and a negative predictive value (NPV) of 98.1%. GS demonstrated a sensitivity of 76.8% and a specificity of 69.2% with a PPV of 25.8% and a NPV of 95.5%. For severity prediction, areas under the curve (AUCs) for RS and GS were 0.848 (95% CI: 0.819-0.875) and 0.784 (95% CI: 0.750-0.814), respectively (p=0.003). Twelve (1.6%) patients died in the hospital.

CONCLUSIONS

RS has higher sensitivity, NPV and AUC for predicting severity of AP than GS.

The Pancreatitis Activity Scoring System predicts clinical outcomes in acute pancreatitis: findings from a prospective cohort study

OBJECTIVES

The Pancreatitis Activity Scoring System (PASS) has been derived by an international group of experts via a modified Delphi process. Our aim was to perform an external validation study to assess for concordance of the PASS score with high face validity clinical outcomes and determine specific meaningful thresholds to assist in application of this scoring system in a large prospectively ascertained cohort.

METHODS

We analyzed data from a prospective cohort study of consecutive patients admitted to the Los Angeles County Hospital between March 2015 and March 2017. Patients were identified using an emergency department paging system and electronic alert system. Comprehensive characterization included substance use history, pancreatitis etiology, biochemical profile, and detailed clinical course. We calculated the PASS score at admission, discharge, and at 12 h increments during the hospitalization. We performed several analyses to assess the relationship between the PASS score and outcomes at various points during hospitalization as well as following discharge. Using multivariable logistic regression analysis, we assessed the relationship between admission PASS score and risk of severe pancreatitis. PASS score performance was compared to established systems used to predict severe pancreatitis. Additional inpatient outcomes assessed included local complications, length of stay, development of systemic inflammatory response syndrome (SIRS), and intensive care unit (ICU) admission. We also assessed whether the PASS score at discharge was associated with early readmission (re-hospitalization for pancreatitis symptoms and complications within 30 days of discharge).

RESULTS

A total of 439 patients were enrolled, their mean age was 42 (±15) years, and 53% were male. Admission PASS score >140 was associated with moderately severe and severe pancreatitis (OR 3.5 [95% CI 2.0, 6.3]), ICU admission (OR 4.9 [2.5, 9.4]), local complications (3.0 [1.6, 5.7]), and development of SIRS (OR 2.9 [1.8, 4.5]) as well as prolongation of hospitalization by a mean of 1.5 (1.3-1.7) days. For the prediction of moderately severe/severe pancreatitis, the PASS score (AUC = 0.71) was comparable to the more established Ranson's (AUC = 0.63), Glasgow (AUC = 0.72), Panc3 (AUC = 0.57), and HAPS (AUC = 0.54) scoring systems. Discharge PASS score >60 was associated with early readmission (OR 5.0 [2.4, 10.7]).

CONCLUSIONS

The PASS score is associated with important clinical outcomes in acute pancreatitis. The ability of the score to forecast important clinical events at different points in the disease course suggests that it is a valid measure of activity in patients with acute pancreatitis.

Acute pancreatitis: current perspectives on diagnosis and management

The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved. In this article, we revisit and review the methods in diagnosing acute pancreatitis. We present the evidence for the supportive management of the condition, and then discuss the management of acute gallstone pancreatitis. Based on the evidence, our local institutional pathways, and clinical experience, we have produced an outline to guide clinicians in the management of acute gallstone pancreatitis.

Evaluation of Early Prognostic Factors of Mortality in Patients with Acute Pancreatitis: A Retrospective Study

Early and accurate assessment of severity in acute pancreatitis (AP) is of great importance to provide effective disease management and prevent mortality. In this study, we aim to evaluate early indicators that predict the mortality of AP. We retrospectively analyzed 24-hour clinical characteristics and laboratory data in 166 AP patients recruited between January 2014 and November 2015 in Baotou Central Hospital. In total, 18 patients did not survive the disease. Multivariate logistic regression showed that red cell distribution (RDW) (OR = 2.965, P = 0.001) and creatinine (OR = 1.025, P = 0.005) were early independent risk factors of AP mortality while albumin (OR = 0.920, P = 0.032) levels reduced AP mortality. The corresponding optimal cut-off values were 14.45, 125.5, and 34.95, respectively. The positive predictive values of the AP mortality were 80.1%, 54.5%, and 69.5%. In combined measurement, the area under the curve of RDW, creatinine, and albumin was 0.964 (95% CI: 0.924 to 1.000, P < 0.001). RDW ≥ 14.45%, creatinine ≥ 125.5 μmol/l, and albumin ≤ 34.95 g/l indicated a good predictive value for mortality in AP patients with a sensitivity of 100% and specificity of 64.2%. RDW, creatinine, and albumin may serve as early indicators for AP mortality which warrants further clinical investigation.

Which Patients with Mild Acute Pancreatitis Require Prolonged Hospitalization?

Objectives:

In our experience, a subset of mild acute pancreatitis (AP) patients, as defined by the Revised Atlanta Classification, has longer than expected hospitalization. Our aims are to report the prevalence of patients with mild AP who have a prolonged length of stay (LOS), evaluate the etiology, thoroughly phenotype, and finally compare this subset to those with expected LOS.

Methods:

Patients admitted with AP from 2003 to 2015 were prospectively enrolled into this cohort study. LOS ≥8 days was considered as prolonged LOS. Data on demographics, clinical and laboratory variables, management, and outcomes was both prospectively and retrospectively collected. Continuous variables were compared using the nonparametric t-test (Wilcoxon's test) and categorical variables using the Pearson’s χ² test.

Results:

Among 231 enrolled mild AP patients, 46 (20%) had a prolonged LOS (≥8 days). The main determinants of prolonged LOS included ongoing pancreatitis-related symptoms (n=31, 67.4%) and performance of cholecystectomy (n=11, 23.9%). When compared to patients with expected LOS (<8 days, n=185), patients with prolonged LOS due to ongoing symptoms (n=31) were more likely to have systemic inflammatory response syndrome at 48 h from admission (37% vs. 13.4%, P<0.001), a prolonged fasting period (6.6 vs. 2.8 days, P<0.001), and need for nutritional support (30% vs. 1.6%, P<0.001).

Conclusions:

About 20% of patients with mild AP have a longer than expected hospital stay, mostly attributed to ongoing pancreatitis-related symptoms. An early decision (at 72 h) for enteral nutrition support in these patients needs to be explored so as to shorten hospitalization and reduce cost of care.

Comparison of multifactor scoring systems and single serum markers for the early prediction of the severity of acute pancreatitis

BACKGROUND

The purpose of this study was to clarify whether the current scoring systems and single serum markers used in pancreatitis remain applicable for the early prediction of infected pancreatic necrosis (IPN) and the severity and mortality of acute pancreatitis (AP) in accordance with the revised Atlanta and determinant-based classifications.

METHODS

Demographic, clinical, and laboratory data from 708 consecutive patients with AP were prospectively collected between January 2011 and December 2012. The severity was classified using the revised Atlanta and determinant-based classification systems. The predictive accuracies for moderately severe AP (MSAP), severe AP (SAP), critically severe AP (CAP), IPN, and mortality were measured using area under the receiver operating characteristic curves.

RESULTS

The receiver operating characteristic analysis showed that the multifactor scoring systems and single serum markers had a low predictive accuracy regarding moderately severe AP. The Acute Physiology and Chronic Health Evaluation (APACHE) II score had the highest accuracy in predicting SAP with area under the curve (AUC) values of 0.75 (95% CI = 0.71-0.79) and 0.77 (95% CI = 0.73-0.81) at 24 and 48 h after admission, respectively. Procalcitonin was the most accurate predictor for CAP and IPN, with respective AUCs of 0.86 (95% CI = 0.82-0.89) and 0.83 (95% CI = 0.78-0.87) at 48 h after admission. In predicting mortality, both the APACHE II score and blood urea nitrogen had the highest accuracy.

CONCLUSIONS

The APACHE II score had the highest predictive accuracy for SAP and mortality as defined by the revised Atlanta classification, whereas procalcitonin was the most accurate predictor for CAP and IPN.

BISAP, RANSON, lactate and others biomarkers in prediction of severe acute pancreatitis in a European cohort

BACKGROUND AND AIM

The study aims to assess and compare the predicting ability of some scores and biomarkers in acute pancreatitis.

METHODS

We prospectively collected data from 269 patients diagnosed of acute pancreatitis, admitted to Virgen de las Nieves University Hospital between June 2010 and June 2012. Blood urea nitrogen (BUN), C-reactive protein, and creatinine were measured on admission and after 48 h, lactate and bedside index for severity acute pancreatitis (BISAP) only on admission and RANSON within the first 48 h. Definitions from 2012 Atlanta Classification were used. Area under the curve (AUC) was calculated for each scoring system for predicting severe acute pancreatitis (SAP), mortality, and intensive care unit (ICU) admission, obtaining optimal cut-off values from the receiver operating characteristic curves.

RESULTS

Eight (3%) patients died, 17 (6.3%) were classified as SAP, and 10 (3.7%) were admitted in ICU. BISAP was the best predictor on admission for SAP, mortality, and ICU admission with an AUC of 0.9 (95% CI 0.83-0.97); 0.97 (95% CI 0.95-0.99); and 0.89 (95% CI 0.79-0.99), respectively. After 48 h, BUN 48 h was the best predictor of SAP (AUC = 0.96 CI: 0.92-0.99); BUN 48 h and BISAP were the best predictors for mortality (AUC = 0.97 CI: 0.95-0.99) and creatinine 48 h for ICU admission (AUC = 0.96 CI: 0.92-0.99). Lactate showed an AUC of 0.79 (CI: 0.71-0.88), 0.87 (CI: 0.78-0.96), and 0.77 (CI: 0.67-0.87) for SAP, mortality, and ICU admission, respectively. All parameters were predictors for SAP, mortality, and ICU admission, but C-reactive protein on admission was only a significant predictor of SAP.

CONCLUSION

Bedside index for severity acute pancreatitis is a good predictive system for SAP, mortality, and ICU admission, being useful for triaging patients for ICU management. Lactate could be useful for developing new scores.