High early mortality rate from acute pancreatitis in Scotland, 1984-1995

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

AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Prognosis in acute pancreatitis associated with HIV infection

BACKGROUND

This prospective study compared scoring systems in predicting adverse outcomes in HIV associated acute pancreatitis (HIV+ve AP) METHODS: Systemic inflammatory response syndrome (SIRS), Glasgow criteria, C-reactive protein (CRP), bedside index of severity in acute pancreatitis (BISAP) and APACHE II scores using standard cut-off values were used to predict the endpoint of moderate and severe disease in HIV-ve and HIV+ve patients and in CD4 counts above and below 200 cells/mm³.

RESULTS

Ninety (38%) of 238 patients with AP were HIV+ve. Fifteen had organ failure, 33 local complications and 12 patients died. Advanced age was not associated with severe disease. The APACHE II was the best predictor of severe disease in HIV+ve (AUC 0.88) and HIV-ve patients (AUC 0.81) and CRP was the poorest predictor (AUC 0.59) in HIV+ve patients. In HIV+ve patients with CD4 counts greater and less than 200 cells/mm³ the Glasgow and APACHE II scores were the best prognosticators (AUC > 0.8) and BISAP in patients with CD4 > 200 cells/mm³ (AUC 0.90).

CONCLUSION

The APACHE II score was most effective irrespective of HIV status whereas the BISAP scores was better in CD4 > 200 cells/mm³.

65 yaş üstü hastalarda puanlama sistemlerinin şiddetli akut pankreatiti ve mortaliteyi erken öngörme açısından değerlendirilmesi

Purpose: The aim of this study is to investigate the power of disease severity scores to predict the development of Severe Acute Pancreatitis (SAP) and mortality in the early period over 65 years old diagnosed with acute pancreatitis in the emergency department. Materials and Methods: We calculated RANSON (on admission) and Computed Tomography Severity Index (CTSI) in addition to Bedside Index for Severity in Acute Pancreatitis (BISAP) score on admission to the emergency department. Results: One hundred and sixty patients (46.9% over 80 years of age) were included in the study. We observed statistically higher length of hospitalization, longer duration of stay in the intensive care unit, SAP and higher mortality in patients over 80 years of age. When we examined the ROC curve, we determined that the AUC values of the BISAP score were highest in both SAP and mortality estimation (AUC: 0.911, 95% CI 0.861-0.962; AUC: 0.918, 95% CI 0.864-0.9722, respectively). Binary logistic analysis indicated a 4.7-fold increased risk for SAP and a 12.3-fold increased mortality for each unit increase in BISAP score value. Conclusion: BISAP may be a good predictor for SAP and mortality estimation on admission to the emergency department in patients over 65 years of age with acute pancreatitis.

Progress in research of acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a rare and severe complication of pregnancy, which is characterized by rapid onset, rapid progression, many complications, and high mortality. According to previous studies, the incidence of APIP is about 1/10000-1/1000 and increases with gestational age. Due to the differences in genetic background and dietary habits between Asian and European populations, the incidence of APIP in China is as high as 1.14‰-2.27‰, significantly higher than that in Western countries. The lack of specific clinical symptoms of APIP often leads to misdiagnosis or missed diagnosis, which greatly increases the difficulty of diagnosis and treatment. Despite the deepening of the research on APIP, its pathogenesis is still unclear. This paper will give a systematical review of APIP.

Prevention and Management of Hypertriglyceridemia-Induced Acute Pancreatitis During Pregnancy: A Systematic Review

Severe gestational hypertriglyceridemia can lead to acute pancreatitis, with maternal mortality rate of approximately 20%. The recent National Lipid Association part 2 expert panel recommendations provide guidance on monitoring pregnant women at high risk for hyperlipidemia. We suggest that high-risk women have triglyceride levels checked once every trimester. Fasting triglycerides >250 mg/dL should prompt monthly triglyceride levels, screening for gestational diabetes, and implementing a strict low-carbohydrate, low-fat diet, exercise. Fasting triglycerides >500 mg/dL, despite a strict dietary and lifestyle modifications, should prompt treatment with omega-3-fatty acids and continue a fat-restricted diet (<20 g total fat/d or <15% total calories) under the guidance of a registered dietician. The use of fibrates should be considered as a second-line therapy due to their unclear risk versus benefit and potential teratogenic effects. Plasmapheresis should be considered early in asymptomatic pregnant women with fasting triglyceride levels >1000 mg/dL or in pregnant women with clinical signs and symptoms of pancreatitis and triglyceride levels >500 mg/dL despite maximal lifestyle changes and pharmacologic therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pancreatogenic Diabetes: Triggering Effects of Alcohol and HIV

Multiorgan failure may not be completely resolved among people living with HIV despite HAART use. Although the chances of organ dysfunction may be relatively low, alcohol may potentiate HIV-induced toxic effects in the organs of alcohol-abusing, HIV-infected individuals. The pancreas is one of the most implicated organs, which is manifested as diabetes mellitus or pancreatic cancer. Both alcohol and HIV may trigger pancreatitis, but the combined effects have not been explored. The aim of this review is to explore the literature for understanding the mechanisms of HIV and alcohol-induced pancreatotoxicity. We found that while premature alcohol-inducing zymogen activation is a known trigger of alcoholic pancreatitis, HIV entry through C-C chemokine receptor type 5(CCR5)into pancreatic acinar cells may also contribute to pancreatitis in people living with HIV (PLWH). HIV proteins induce oxidative and ER stresses, causing necrosis. Furthermore, infiltrative immune cells induce necrosis on HIV-containing acinar cells. When necrotic products interact with pancreatic stellate cells, they become activated, leading to the release of both inflammatory and profibrotic cytokines and resulting in pancreatitis. Effective therapeutic strategies should block CCR5 and ameliorate alcohol's effects on acinar cells.

Can Inflammatory Markers Foretell Aetiology and Prolonged Hospitalisation in Acute Pancreatitis?

Introduction

Acute pancreatitis (AP) causes a cascade of complex inflammatory responses following an initial insult. Hence, the scoring systems include white blood cell count (WBC) as a marker of severity of acute pancreatitis. C-reactive protein (CRP) was also shown to be useful in predicting the course of pancreatitis. This study analyses role of inflammatory markers in predicting gallstone aetiology of AP and length of hospital stay (LOS).

Materials and methods

A total of 143 patients with acute pancreatitis between October 2016 and 2017 were included in this study and relevant parameters were collected from the electronic patient database. The parameters were WBC, CRP, and LOS.

Results

Among 143 patients with AP, 50 patients had gallstone pancreatitis (GP) and remaining of 93 patients suffered nongallstone pancreatitis (NGP). The WBC count at admission, 24 hours and 72 hours in GP versus NGP were 11.6± 5 versus 13.7±17; P = 0.24; 12.6±20 versus 10.1±17; P = 0.21; and 13.2±22 versus 9.2±4.7; P = 0.15, respectively. Similarly, the serum CRP levels at admission, 24 hours and 72 hours were 30.4± 73 versus 47.6±79; P = 0.25; 71.9±20 versus 92.2±97; P = 0.35; and 89±106 versus 122.7±107; P = 0.05, respectively. More number of patients with elevated WBC in GP arm compared to NGP (12/50±7/93; P = 0.0008) was noted.

In GP arm, patients with elevated CRP at admission (10.5±8.67 versus 5.4±5.8 days; P = 0.02) and 24 hours (9.8±8.3 versus 4.2±4.7 days; P = 0.001) had long LOS. However, patients with elevated CRP at 72 hours (89±106 versus 122.7±107; P = 0.05) had longer LOS in NGP.

Conclusion

Significantly high CRP level at 72 hours was associated with NGP and longer length of hospital stay. In GP, patients with elevated CRP level at admission and 24 hours predicts long LOS.

High Body Mass Index and Central Adiposity Is Associated with Increased Risk of Acute Pancreatitis: A Meta-Analysis

BACKGROUND

Higher body mass index and waist circumference have been associated with increased risk of pancreatitis in several prospective studies; however, the results have not been entirely consistent.

AIMS

We conducted a systematic review and dose-response meta-analysis of prospective studies on adiposity and risk of pancreatitis to clarify this association.

METHODS

PubMed and Embase databases were searched for studies on adiposity and pancreatitis up to January 27, 2020. Prospective studies reporting adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) for the association between adiposity and risk of pancreatitis were included, and summary RRs (95% CIs) were calculated using a random effects model.

RESULTS

Ten prospective studies with 5129 cases and 1,693,657 participants were included. The summary RR (95% CI) of acute pancreatitis was 1.18 (95% CI: 1.03-1.35, I² = 91%, n = 10 studies) per 5 kg/m² increase in BMI and 1.36 (95% CI: 1.29-1.43, I² = 0%, n = 3) per 10 cm increase in waist circumference. There was evidence of a nonlinear association between BMI and acute pancreatitis, p_nonlinearity < 0.0001, with a steeper association at higher levels of BMI, but not for waist circumference, p_nonlinearity = 0.19. Comparing a BMI of 35 with a BMI of 22, there was a 58% increase in the RR and there was a fourfold increase in the RR comparing a waist circumference of 110 cm with 69 cm. There was no evidence of publication bias.

CONCLUSIONS

This meta-analysis suggests that both increasing BMI and waist circumference are associated with a dose-response-related increase in the risk of acute pancreatitis.

Predictivity of Biochemical Markers on Aetiology and Length of Hospitalisation in Acute Pancreatitis

Background Acute pancreatitis (AP) is a common cause of emergency hospital admission. Predictive value of biochemical markers including alanine aminotransferase (ALT), alkaline phosphatase (ALP), bilirubin and lipase on pancreatitis has not been fully established. This study aimed to assess the role of ALT, ALP, bilirubin and lipase levels at admission on predicting the aetiology and length of hospital stay in AP. This study also assesses quantitative high lipase as a predictor of gallstone pancreatitis (GP). Methods All patients above the age of 18 with a diagnosis of AP between October 2016 - 2017 were included in our study. The exclusion criteria were patients with a known history of pancreatitis or biliary disease/bile duct stones and pregnancy. This is a retrospective study performed from a prospectively collected electronic patient database at our hospital. Results Among the 143 patients with AP, 50 patients were diagnosed with gallstone pancreatitis (GP) and the remaining of 93 patients suffered non-gallstone pancreatitis (NGP). Mean ALT level was significantly higher in gallstone pancreatitis (237 ± 351 IU) compared to non-gallstone pancreatitis (107 ± 162 IU; P = 0.005). ALP level was numerically high in GP (151.5 ± 186) compared to NGP (138 ± 105 IU; P = 0.64). Similar results in bilirubin level also noted in GP (35.5 ± 24.5) comparing to NGP (20.7 ± 79.6 µmol/L; P = 0.09). Raised ALT (9.3 ± 8.2 versus 3 ± 2.19 days), bilirubin (8.5 ± 2.5 versus 6.9 ± 1.19 days) and ALP levels (6.26 ± 6.1 versus 3.5 ± 10 days respectively; P = 0.05) were associated with longer hospitalisation in GP comparing to NGP. The lipase level more than 10 times the upper reference level (10-URL) was found to be associated with GP (39/50) than NGP (54/93; P = 0.027). Conclusion Raised ALT, high lipase of 10 URL levels were associated with gallstone pancreatitis. In gallstone pancreatitis, patients with high ALT, bilirubin and ALP levels had longer hospital stay.

Study protocol for resolution of organ injury in acute pancreatitis (RESORP): an observational prospective cohort study

INTRODUCTION

Survivors of acute pancreatitis (AP) have shorter overall survival and increased incidence of new-onset cardiovascular, respiratory, liver and renal disease, diabetes mellitus and cancer compared with the general population, but the mechanisms that explain this are yet to be elucidated. Our aim is to characterise the precise nature and extent of organ dysfunction following an episode of AP.

METHODS AND ANALYSIS

This is an observational prospective cohort study in a single centre comprising a University hospital with an acute and emergency receiving unit and clinical research facility. Participants will be adult patient admitted with AP. Participants will undergo assessment at recruitment, 3 months and 3 years. At each time point, multiple biochemical and/or physiological assessments to measure cardiovascular, respiratory, liver, renal and cognitive function, diabetes mellitus and quality of life. Recruitment was from 30 November 2017 to 31 May 2020; last follow-up measurements is due on 31 May 2023. The primary outcome measure is the incidence of new-onset type 3c diabetes mellitus during follow-up. Secondary outcome measures include: quality of life analyses (SF-36, Gastrointestinal Quality of Life Index); montreal cognitive assessment; organ system physiological performance; multiomics predictors of AP severity, detection of premature cellular senescence. In a nested cohort within the main cohort, individuals may also consent to multiparameter MRI scan, echocardiography, pulmonary function testing, cardiopulmonary exercise testing and pulse-wave analysis.

ETHICS AND DISSEMINATION

This study has received the following approvals: UK IRAS Number 178615; South-east Scotland Research Ethics Committee number 16/SS/0065. Results will be made available to AP survivors, caregivers, funders and other researchers. Publications will be open-access.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov Registry (NCT03342716) and ISRCTN50581876; Pre-results.

Clinical outcomes of acute pancreatitis in elderly patients: An experience of single tertiary center

BACKGROUND

Although well understanding the course of diseases in geriatric population is of paramount importance in order to provide the optimal treatment, there is only a few studies with controversial results that have been conducted about the course and outcomes of acute pancreatitis (AP) in elderly. We aimed to compare clinical outcomes of AP disease in geriatric age group and to evaluate the risk factors affecting outcomes.

METHODS

A total of 336 patients diagnosed with AP, hospitalized and followed-up in our hospital between July/2013-February/2019 were included in this study. Patients aged 65 years and over were assessed as elderly population. Patients' demographic data, comorbidities, duration of hospitalization, local systemic complications, and mortality rates were documented.

RESULTS

196(58.3%) of the patients were female with a mean age of 54.1 ± 17.9 years. The number of patients was 114(33.9%) in the elderly group and 222(66.1%) in the non-elderly group. Although there was no significant difference between both groups in terms of abscess, pseudocyst and necrosis, pancreatic necrosis and systemic complications were higher in the elderly group (p < 0.05). The durations of oral intake and hospitalization were longer, the mortality rate and severity of AP according to the Ranson and Atlanta criteria were significantly higher in the geriatric population (p < 0.05). In addition, age and severity of AP were found to be independent predictive factors of developing complications.

CONCLUSIONS

Early recognition of AP is important in the geriatric population. Clinical and laboratory investigations, and early diagnosis in severe patients will be largely helpful in providing close follow-up and the optimal treatment.

Diabetes mellitus and the risk of pancreatitis: A systematic review and meta-analysis of cohort studies

BACKGROUND

Diabetes mellitus has been associated with increased risk of pancreatitis in several studies, however, not all studies have found an association. We conducted a systematic review and meta-analysis of prospective studies on diabetes mellitus and pancreatitis to clarify the association.

METHODS

PubMed and Embase databases were searched for studies on diabetes mellitus and pancreatitis up to 8^th of January 2020. Cohort studies that reported adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) for the association between diabetes diagnosis and pancreatitis were included and summary RRs (95% CIs) were calculated using a random effects model.

RESULTS

Eight cohort studies were included in the meta-analysis, and seven of these were included in the analysis of diabetes mellitus and acute pancreatitis (14124 cases, 5.7 million participants). Comparing diabetes patients with persons without diabetes the summary RRs (95% CIs) were 1.74 (95% CI: 1.33-2.29, I² = 95%) for acute pancreatitis, 1.40 (95% CI: 0.88-2.22, I² = 0%, n = 2) for chronic pancreatitis, and 1.39 (95% CI: 1.07-1.80, I² = 54%, n = 3) for pancreatitis overall. Although there was some indication of publication bias in the analysis of acute pancreatitis this appeared to be explained by one outlying study which when excluded did not substantially alter the association. The results persisted in several subgroup and sensitivity analyses.

CONCLUSIONS

These results suggest that diabetes patients are at an increased risk of acute pancreatitis. Further studies are needed on diabetes and risk of chronic pancreatitis, pancreatitis overall and on gallstone-related and non-gallstone-related pancreatitis.

Tobacco smoking and the risk of pancreatitis: A systematic review and meta-analysis of prospective studies

BACKGROUND

Tobacco smoking has been associated with increased risk of pancreatitis in several studies, however, not all studies have found an association and it is unclear whether there is a dose-response relationship between increasing amount of tobacco smoked and pancreatitis risk. We conducted a systematic review and meta-analysis of prospective studies on tobacco smoking and pancreatitis to clarify the association.

METHODS

PubMed and Embase databases were searched for relevant studies up to April 13th^, 2019. Prospective studies that reported adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) for the association between tobacco smoking and pancreatitis were included and summary RRs were calculated using a random effects model.

RESULTS

Ten prospective studies were included. The summary RR for acute pancreatitis was 1.49 (95% CI: 1.29-1.72, I² = 68%, n = 7) for current smokers, 1.24 (95% CI: 1.15-1.34, I² = 0%, n = 7) for former smokers, and 1.39 (95% CI: 1.25-1.54, I² = 69%, n = 7) for ever smokers compared to never smokers. Similar results were observed for chronic pancreatitis and acute/chronic pancreatitis combined. The summary RR per 10 cigarettes per day was 1.30 (95% CI: 1.18-1.42, I² = 42%, n = 3) and per 10 pack-years in current smokers was 1.13 (95% CI: 1.08-1.17, I² = 14%, n = 4) for acute pancreatitis and results were similar for chronic pancreatitis and acute/chronic pancreatitis combined.

CONCLUSIONS

These results suggest that tobacco smoking increases the risk of acute and chronic pancreatitis and acute and chronic pancreatitis combined and that there is a dose-response relationship between increasing number of cigarettes and pack-years and pancreatitis risk.

An enigmatic triad of acute pancreatitis, diabetic ketoacidosis and hypertriglyceridaemia: who is the culprit?

Acute pancreatitis(AP) is one of the common causes of acute abdomen and known to be associated with high morbidity and mortality in severe cases. Though most common causes of AP are cholelithiasis and alcoholism, it has also been reported in association with diabetic ketoacidosis (DKA). Triad of AP, hypertriglyceridaemia (HTG) and DKA is rare co-association and here the causal factor of AP is still not fully established. We report a case of AP in a DKA patient with recent diagnosis of hyperlipidaemia and diabetes. Usually AP has been associated with severe HTG; interestingly, our patient showed only moderate raise in triglycerides but still suffered AP during DKA. Hence, it raises question about the real culprit in this enigmatic triad.

Short- and long-term survival after severe acute pancreatitis: A retrospective 17 years' cohort study from a single center

PURPOSE

To study mortality in severe acute pancreatitis (SAP) and to identify risk factors for mortality.

MATERIALS AND METHODS

A retrospective 17-years' cohort study of 435 consecutive adult patients with SAP treated at intensive care unit of a university hospital.

RESULTS

Overall, 357 (82.1%) patients survived at 90 days follow-up. Three-hundred six (89.5%) patients under 60 years, 38 (60.3%) patients between 60 and 69 years, and 13 (43.3%) patients over 69 years of age survived at 90 days follow-up. Independent risk factors for death within 90-days were: 60 to 69 years of age (odds ratio [OR] 5.1), >69 years of age (OR 10.4), female sex (OR 2.0), heart disease (OR 2.9), chronic liver failure (OR 12.3), open abdomen treatment (OR 4.4) and sterile necrosectomy within 4 weeks (OR 14.7). The 10-year survival estimate was <70% in patients under 60 years and <30% in patients over 60 years. Underlying cause of death after the initial 90-day follow-up period was alcohol-related in 48 (57.1%) patients, and all of them had suffered from alcoholic SAP.

CONCLUSIONS

Although younger patients have excellent short-term survival after SAP, the long-term survival estimate is disappointing mostly due to alcohol abuse.

Low molecular weight heparin treatment of acute moderate and severe pancreatitis: A randomized, controlled,open-label study

BACKGROUND/AIMS

Acute pancreatitis (AP) runs a moderately severe and severe course in 20%-30% of cases. The purpose of the present study was to determine the effect of low molecular weight heparin (LMWH) for the prevention of pancreatic necrosis (PN) in moderately severe and severe AP (MSAP).

MATERIALS AND METHODS

A total of 100 patients with MSAP were randomized to receive either standard care (SC) or SC plus LMWH. LMWH was administered at 1 mg/kg via subcutaneous injection twice a day between days 1 and 7. The revised Atlanta criteria were used in the diagnosis of MSAP. Patients with a Harmless AP Score of >1 and a Balthazar computed tomography (CT) score of D and E were included in the study.

RESULTS

The mean age±SD of the patients (46 male and 54 female) was 52±19 years (range, 17-100). There were 50 patients in each group. On admission, clinical and laboratory parameters and Balthazar CT scores were similar between the groups. Initially, PN was present in one patient in the LMWH group and two in the SC group. Over the course, PN developed in 3 (6.1%) patients in the LMWH group and 11 (22.9%) in the SC group (p<0.05). Local and systemic complications were significantly lower in the LMWH group (p<0.05). No hemorrhagic complication occurred. Mortality was not significantly different between the groups (p=0.056).

CONCLUSION

Low molecular weight heparin treatment is safe and provides better prognosis in MSAP.

Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes

Introduction: Acute pancreatitis (AP) incidence in the elderly population has increased in the last years. However, the role of age as influencing factor on the AP clinical course is still debated. Methods: We reviewed clinical records of consecutive patients admitted with diagnosis of AP. Patients were divided in elderly (≥65 years) and non-elderly  (<65 years). Primary endpoint was comparison of overall mortality. Secondary endpoint included ICU admission, in-hospital length of stay (LOS) and surgical procedures. Results: We enrolled 352 elderly and 532 non-elderly patients. A higher mortality rate (7.4% vs 1.9%; p < .001), ICU admission rate (18.9% vs 6.3%; p < .001) and prolonged length of hospital stay (9 (6-14) vs 7 (5-11.7) days; p = .01) were registered in the ≥65 years group. Multivariate analysis identified age (OR: 3.5; 95% CI:1.645-7.555; p = .001), a higher Ranson score at admission (OR: 5.52; 95% CI:1.11-27.41; p<.001) and necrotic pancreatitis (OR: 8.6; 95% CI:2.46-30.27; p = .001) as independent predictors of mortality. Conversely age and necrotic pancreatitis were independent risk factors for higher LOS and ICU admission. Conclusions: Patients with AP and age ≥65 years have a higher mortality, ICU admission and prolonged LOS. Early recognition and prompt treatment are key elements to improve outcomes in this population.

Validation of Modified Determinant-Based Classification of severity for acute pancreatitis in a tertiary teaching hospital

BACKGROUND

The relative merits of two recent classifications of acute pancreatitis severity, the Determinant-Based Classification (DBC) and the Revised Atlanta Classification (RAC), have been debated. A Modified DBC (MDBC) was recently proposed in intensive care unit (ICU) patients. By dividing the DBC 'severe' category into two groups, the MDBC classified non-mild acute pancreatitis into 4 groups rather than 2 in RAC and 3 in DBC. In this study we aim to validate MDBC in both ICU and non-ICU patients and evaluate infected necrosis as a determinant of severity.

METHODS

Prospective data collected on consecutive patients admitted to a tertiary teaching hospital were retrospectively analyzed. Patients were assigned to the categories of severity defined by the DBC, RAC and MDBC. Clinical interventions and outcomes were compared between categories.

RESULTS

A total of 1102 patients were enrolled and the overall mortality was 5.7%. When MDBC was applied, the four Groups were significantly different in regard to ICU admission rates (30%, 40%, 69% and 87%) and mortality (2%, 15%, 40% and 57%). Groups 2 and 3 were different in intervention rates and morbidity, providing evidence that IN is an important determinant of severity.

CONCLUSIONS

This study validates the MDBC proposal to subdivide the DBC 'severe' category into two groups for ICU and non-ICU patients in a tertiary hospital.

The product value of serum albumin and prothrombin time activity could be a useful biomarker for severity prediction in AP: An ordinal retrospective study

AIM

To appraise the predictive function of 'the product value of serum albumin and prothrombin time activity' (PAA) on admission for the organ failure related events of acute pancreatitis (AP).

BACKGROUND

789 patients with AP were included in this retrospective study. 468 patients generated transient organ failure (TOF). 242 were diagnosed with persistent organ failure (POF), of which 63 patients died.

STUDY

All the values of laboratory parameters were measured upon admission to hospital. Dunnett'T3 test, Uni- and multi-variate ordinal logistic regression were used. ROC curve was utilized to evaluate the ultimate predictive values.

RESULTS

Among the patients with 4 different levels of severity of acute pancreatitis, PAA observably reduced as the disease aggravated (32.20 vs 29.56 vs 23.54 vs 17.89). PAA was also an independent risk factor for the aggravation of AP (OR: 0.873, 95% CI: 0.848, 0.899; p < 0.01). The Area Under the Curve (AUC) of PAA for OF was 0.828 (0.783, 0.872), 0.828 for POF (0.790, 0.865) and 0.905 for death cases (0.862, 0.948).

CONCLUSION

The product value of serum albumin and prothrombin time activity is a good predictor of the severity, especially the events related to organ failure of acute pancreatitis.

Therapeutic effect of ultrasound interventional perirenal catheter-assisted early peripancreatic lavage of protease inhibitor on severe acute pancreatitis in miniature pigs

OBJECTIVES

To study the therapeutic effect of early peripancreatic lavage of ulinastatin on severe acute pancreatitis(SAP).

METHODS

Sixteen pigs were divided into 4 groups: model(SAP), saline lavage(SL), ulinastatin lavage(UL), intravenous ulinastatin(IU). UL and SL group were given peripancreatic lavage of ulinastatin by ultrasound-guided perirenal catheterization and IU group was intravenously instilled with ulinastatin. The multi-organ functions and the inflammatory factors were observed.

RESULTS

UL group has the best therapeutic effect. The changes of multi-organ functions and the inflammatory factors were compared with SAP group as follows. In time window of treatment: amylase (p < 0.01), lipase (p < 0.01), ALT (p > 0.05), AST (p < 0.05), CR (p < 0.01), UR (p < 0.01), IL-6 (p < 0.01), IL-10 (p < 0.01). In post-treatment phase: amylase (p < 0.01), lipase (p < 0.01), ALT (p < 0.01), AST (p < 0.01), CR (p < 0.05), UR (p > 0.05), IL-6 (p < 0.01), IL-10 (p < 0.01).

CONCLUSIONS

Early peripancreatic lavage of ulinastatin in SAP could effectively improve the multi-organ functions and inflammatory response.

Survival and new-onset morbidity after critical care admission for acute pancreatitis in Scotland: a national electronic healthcare record linkage cohort study

INTRODUCTION

Severe acute pancreatitis (AP) requiring critical care admission (ccAP) impacts negatively on long-term survival.

OBJECTIVE

To document organ-specific new morbidity and identify risk factors associated with premature mortality after an episode of ccAP.

DESIGN

Cohort study.

SETTING

Electronic healthcare registries in Scotland.

PARTICIPANTS

The ccAP cohort included 1471 patients admitted to critical care with AP between 1 January 2008 and 31 December 2010 followed up until 31 December 2014. The population cohort included 3450 individuals from the general population of Scotland frequency-matched for age, sex and social deprivation.

METHODS

Record linkage of routinely collected electronic health data with population matching.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient demographics, comorbidity (Charlson Comorbidity Index), acute physiology, organ support and other critical care data were linked to records of mortality (death certificate data) and new-onset morbidity. Kaplan-Meier and Cox regression analyses were used to identify risk factors associated with mortality.

RESULTS

310 patients with AP died during the index admission. Outcomes were not ascertained for five patients, and the deprivation quintile was not known for six patients. 340 of 1150 patients in the resulting postdischarge ccAP cohort died during the follow-up period. Greater comorbidity measured by the Charlson score, prior to ccAP, negatively influenced survival in the hospital and after discharge. The odds of developing new-onset diabetes mellitus after ccAP compared with the general population were 10.70 (95% CI 5.74 to 19.94). A new diagnosis of myocardial infarction, stroke, heart failure, liver disease, peptic ulcer, renal failure, cancer, peripheral vascular disease and lung disease was more frequent in the ccAP cohort than in the general population.

CONCLUSIONS

The persistent deleterious impact of severe AP on long-term outcome and survival is multifactorial in origin, influenced by pre-existing patient characteristics and acute episode features. Further mechanistic and epidemiological investigation is warranted.

Comparison of Various Scoring Systems and Biochemical Markers in Predicting the Outcome in Acute Pancreatitis

OBJECTIVE

Early risk assessment is important in acute pancreatitis (AP). The primary objective of this study was to compare various scores and biochemical markers done on the day of admission in predicting the outcome.

METHODS

Demographic, clinical, and laboratory data of patients presenting within 2 weeks of onset were collected. Various scores were calculated and biochemical markers were measured on the day of admission. Optimum cutoffs were identified through receiver operating curve analysis. Multivariate analysis was used to identify predictors of outcome.

RESULTS

Of 343 patients included, 202 (59%) were male; mean (SD) age was 38.7 (15.5) years. Acute pancreatitis was severe in 170 (49.6%) patients. Twenty-eight percent of the patients developed infected pancreatic necrosis and 18% died. An Acute Physiology and Chronic Health Evaluation (APACHE II) score of at least 7, bedside index for severity of AP (BISAP) of at least 2, systemic inflammatory response syndrome score of at least 3, and C-reactive protein of at least 82 ng/mL predicted severity. Predictors of infected pancreatic necrosis were as follows: PANC 3 score of at least 1, BISAP score of at least 2, and Marshall score of at least 2, whereas C-reactive protein of greater than 98, BISAP score of at least 2, APACHE score of at least 10, and a blood urea nitrogen of at least 17 predicted mortality.

CONCLUSIONS

Both BISAP and APACHE II are comparable in predicting outcome, but BISAP predicted all 3 outcomes with the same cutoff and hence is a robust scoring system.

The incidence and aetiology of acute pancreatitis across Europe

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Report of 320 Cases of Childhood Pancreatitis: Increasing Incidence, Etiologic Categorization, Dynamics, Severity Assessment, and Outcome

OBJECTIVES

Because there is paucity of data on natural history of pediatric pancreatitis, we studied prevalence, etiology, severity, and outcome of pancreatitis.

METHODS

Over 12 years consecutive children with pancreatitis were included. Pancreatitis was classified as acute (AP), acute recurrent (ARP), and chronic pancreatitis (CP) as per standard definitions.

RESULTS

The study group comprised of 320 children (age, 11.4 ± 3.5 years, 201 males); AP, 160 (50%); ARP, 67 (21%); and CP, 93 (29%). The number of cases increased progressively from 28 to 157 between first and last quarter, and there was a significant increase (r = 0.92, P < 0.001) in AP-related hospitalizations over the years. Half of AP were idiopathic, 69% had severe pancreatitis (6 died) and on follow-up (21.1 ± 20.9 months) 21.5% progressed to either ARP (n = 8) or CP (n = 24). Progression was significantly associated with idiopathic etiology. The majority of ARP (70%) and CP (88%) were idiopathic and on follow-up (23.2 ± 28.9 months) 22% of ARP developed CP.

CONCLUSIONS

There was 7-fold increase in number of hospitalization due to pancreatitis over the years. Progression of AP to ARP/CP was noted in 21.5% and ARP to CP in 22%. Thus, a subset of pancreatitis seems to be a continuum of acute to ARP and CP.

Clinical Value of Severity Markers in Acute Pancreatitis

Acute pancreatitis is a common digestive disease of which the severity may vary from mild, edematous to severe, necrotizing disease. An improved outcome in the severe form of the disease is based on early identification of disease severity and subsequent focused management of these high-risk patients. However, the ability of clinicians to predict, upon presentation, which patient will have mild or severe acute pancreatitis is not accurate. Prospective systems using clinical criteria have been used to determine severity in patients with acute pancreatitis, such as the Ranson's prognostic signs, Glasgow score, and the acute physiology and chronic health evaluation II score (APACHE II). Their application in clinical practise has been limited by the time delay of at least 48 h to judge all parameters in the former two and by being cumbersome and time-consuming in the latter. Contrast-enhanced computed tomography is presently the most accurate non-invasive single method to evaluate the severity of acute pancreatitis. It cannot, however, be performed to all patients with acute pancreatitis. Therefore, considerable interest has grown in the development of reliable biochemical markers that reflect the severity of acute pancreatitis. In this article we critically appraise current and new severity markers of acute pancreatitis in their ability to distinguish between mild and severe disease and their clinical utility.

Prospective, Multicentre, Nationwide Clinical Data from 600 Cases of Acute Pancreatitis

Objective

The aim of this study was to analyse the clinical characteristics of acute pancreatitis (AP) in a prospectively collected, large, multicentre cohort and to validate the major recommendations in the IAP/APA evidence-based guidelines for the management of AP.

Design

Eighty-six different clinical parameters were collected using an electronic clinical research form designed by the Hungarian Pancreatic Study Group.

Patients

600 adult patients diagnosed with AP were prospectively enrolled from 17 Hungarian centres over a two-year period from 1 January 2013.

Main Results

With respect to aetiology, biliary and alcoholic pancreatitis represented the two most common forms of AP. The prevalence of biliary AP was higher in women, whereas alcoholic AP was more common in men. Hyperlipidaemia was a risk factor for severity, lack of serum enzyme elevation posed a risk for severe AP, and lack of abdominal pain at admission demonstrated a risk for mortality. Abdominal tenderness developed in all the patients with severe AP, while lack of abdominal tenderness was a favourable sign for mortality. Importantly, lung injury at admission was associated with mortality. With regard to laboratory parameters, white blood cell count and CRP were the two most sensitive indicators for severe AP. The most common local complication was peripancreatic fluid, whereas the most common distant organ failure in severe AP was lung injury. Deviation from the recommendations in the IAP/APA evidence-based guidelines on fluid replacement, enteral nutrition and timing of interventions increased severity and mortality.

Conclusions

Analysis of a large, nationwide, prospective cohort of AP cases allowed for the identification of important determinants of severity and mortality. Evidence-based guidelines should be observed rigorously to improve outcomes in AP.

Analysis of Research Activity in Gastroenterology: Pancreatitis Is in Real Danger

OBJECTIVE

Biomedical investment trends in 2015 show a huge decrease of investment in gastroenterology. Since academic research usually provides the basis for industrial research and development (R&D), our aim was to understand research trends in the field of gastroenterology over the last 50 years and identify the most endangered areas.

METHODS

We searched for PubMed hits for gastrointestinal (GI) diseases for the 1965-2015 period. Overall, 1,554,325 articles were analyzed. Since pancreatology was identified as the most endangered field of research within gastroenterology, we carried out a detailed evaluation of research activity in pancreatology.

RESULTS

In 1965, among the major benign GI disorders, 51.9% of the research was performed on hepatitis, 25.7% on pancreatitis, 21.7% on upper GI diseases and only 0.7% on the lower GI disorders. Half a century later, in 2015, research on hepatitis and upper GI diseases had not changed significantly; however, studies on pancreatitis had dropped to 10.7%, while work on the lower GI disorders had risen to 23.4%. With regard to the malignant disorders (including liver, gastric, colon, pancreatic and oesophageal cancer), no such large-scale changes were observed in the last 50 years. Detailed analyses revealed that besides the drop in research activity in pancreatitis, there are serious problems with the quality of the studies as well. Only 6.8% of clinical trials on pancreatitis were registered and only 5.5% of these registered trials were multicentre and multinational (more than five centres and nations), i.e., the kind that provides the highest level of impact and evidence level.

CONCLUSIONS

There has been a clear drop in research activity in pancreatitis. New international networks and far more academic R&D activities should be established in order to find the first therapy specifically for acute pancreatitis.

Identifying risk factors for progression to critical care admission and death among individuals with acute pancreatitis: a record linkage analysis of Scottish healthcare databases

OBJECTIVES

Acute pancreatitis (AP) can initiate systemic complications that require support in critical care (CC). Our objective was to use the unified national health record to define the epidemiology of AP in Scotland, with a specific focus on deterministic and prognostic factors for CC admission in AP.

SETTING

Health boards in Scotland (n=4).

PARTICIPANTS

We included all individuals in a retrospective observational cohort with at least one episode of AP (ICD10 code K85) occurring in Scotland from 1 April 2009 to 31 March 2012. 3340 individuals were coded as AP.

METHODS

Data from 16 sources, spanning general practice, community prescribing, Accident and Emergency attendances, hospital in-patient, CC and mortality registries, were linked by a unique patient identifier in a national safe haven. Logistic regression and gamma models were used to define independent predictive factors for severe AP (sAP) requiring CC admission or leading to death.

RESULTS

2053 individuals (61.5% (95% CI 59.8% to 63.2%)) met the definition for true AP (tAP). 368 patients (17.9% of tAP (95% CI 16.2% to 19.6%)) were admitted to CC. Predictors of sAP were pre-existing angina or hypertension, hypocalcaemia and age 30-39 years, if type 2 diabetes mellitus was present. The risk of sAP was lower in patients with multiple previous episodes of AP. In-hospital mortality in tAP was 5.0% (95% CI 4.1% to 5.9%) overall and 21.7% (95% CI 19.9% to 23.5%) in those with tAP necessitating CC admission.

CONCLUSIONS

National record-linkage analysis of routinely collected data constitutes a powerful resource to model CC admission and prognosticate death during AP. Mortality in patients with AP who require CC admission remains high.

INCIDENCE OF ACUTE PANCREATITIS IN ALBANIAN POPULATION

Background:

Acute Pancreatitis (AP) is an inflammatory pathology with large regional variations in incidence and etiology

Aim:

The aim of the study was to provide a description of the epidemiologic situation of AP in Albanian population, regarding incidence, etiology and severity of the disease

Methods:

We have studied all the files of all patients with acute pancreatitis admitted at the UHC ‘Mother Theresa” during an eight year period (2005-2012).

The results:

We had 964 admissions with the diagnosis acute pancreatitis, making an incidence of 5.64 per 100 000 inhabitants per year. Mean age of patients was 54.5 ± 16.93 years old. Among risk factors, alcohol consumption was found in 382 patients (39.6%), gallstone in 362 patients (37.6%), and others in 220 patients (22.8%).

Conclusion:

The incidence of acute pancreatitis in Albania ranges from 3.6 – 5.64 new cases per 100 000 inhabitants per year, with an increasing trend during the last years. The incidence of AP among females almost doubles during 2005-2012. Alcohol consumption is the predominating etiologic factor among young males.

Lung ultrasonography as a direct measure of evolving respiratory dysfunction and disease severity in patients with acute pancreatitis

BACKGROUND

The value of lung ultrasonography in the diagnosis of respiratory dysfunction and severity stratification in patients with acute pancreatitis (AP) was investigated.

METHODS

Over a 3-month period, 41 patients (median age: 59.1 years; 21 males) presenting with a diagnosis of potential AP were prospectively recruited. Each participant underwent lung ultrasonography and the number of comet tails was linked with contemporaneous clinical data. Group comparisons, areas under the curve (AUC) and respective measures of diagnostic accuracy were investigated.

RESULTS

A greater number of comet tails were evident in patients with respiratory dysfunction (P = 0.021), those with severe disease (P < 0.001) and when contemporaneous and maximum CRP exceeded 100 mg/L (P = 0.048 and P = 0.003 respectively). Receiver-operator characteristic plot area under the curve (AUC) was greater when examining upper lung quadrants, using respiratory dysfunction and AP severity as variables of interest (AUC = 0.783, 95% C.I.: 0.544-0.962, and AUC = 0.996, 95% C.I.: 0.982-1.000, respectively). Examining all lung quadrants except for the lower lateral resulted in greater AUCs for contemporaneous and maximum CRP (AUC = 0.708, 95% C.I.: 0.510-0.883, and AUC = 0.800, 95% C.I.: 0.640-0.929).

DISCUSSION

Ultrasonography of non-dependent lung parenchyma can reliably detect evolving respiratory dysfunction in AP. This simple bedside technique shows promise as an adjunct to severity stratification.

P38 pathway regulates iNOS and PGE2 expression in hippocampal neurons in rats with severe acute pancreatitis

AIM: To investigate the effect of P38 mitogen-activated protein kinase (P38MAPK) pathway on the expression of inducible nitric oxide synthase (iNOS) and prostaglandin E2 (PGE2) in hippocampal neurons of rats with severe acute pancreatitis (SAP).

METHODS: Healthy male Sprague-Dawley rats were randomly divided into three groups: a control group, a model group, and an SB203580 (an inhibitor of P38MAPK pathway) group. The pathological changes in brain tissue were observed. By immunohistochemistry and Western blot, expression of iNOS and PGE2 and phosphorylation of P38MAPK were detected to observe the changes of positive cell numbers and the expression levels in the hippocampus.

RESULTS: Compared with the control group, the numbers of p-P38 (20.4 ± 2.2 vs 2.1 ± 1.3), iNOS (33.6 ± 4.4 vs 3.7 ± 0.4), and PGE2 (34.7 ± 4.0 vs 2.4 ± 1.0) immunoreactive cells increased markedly in the hippocampal CA1 region (P < 0.05). After treatment with SB203580, the numbers of p-P38 (12.8 ± 0.7), iNOS (14.4 ± 4.9), and PGE2 (18.3 ± 0.5) immunoreactive cells were reduced significantly as compared with the model group (P < 0.05). The inhibitor group had significantly improved pancreatic cell pathology compared to the SAP group, which had ultrastructural changes such as rough endoplasmic network degranulation and mitochondrial swelling expansion.

CONCLUSION: P38MAPK pathway regulates the expression of iNOS and PGE2 in the hippocampus, and inhibition of the pathway has a neuroprotective effect in rats with SAP.

The Acute Physiology and Chronic Health Evaluation IV, a New Scoring System for Predicting Mortality and Complications of Severe Acute Pancreatitis

OBJECTIVES

Severe acute pancreatitis is associated with significant morbidity/mortality; thus, the ability to predict hospital course is imperative. An updated version of the Acute Physiology and Chronic Health Evaluation II (APACHE), APACHE IV, has recently been validated. Unlike other versions, APACHE IV uses hepatobiliary parameters and accounts for multiple comorbid conditions and sedation. The intention of this study was to examine APACHE IV for predicting mortality and secondary outcomes for pancreatitis in a prospective cohort. In addition, we compared APACHE IV to APACHE II, Bedside Index for Severity in Acute Pancreatitis, and Ranson criterion.

METHODS

We prospectively collected physiologic parameters for each scoring system in 266 patients with severe acute pancreatitis from August 2011 to April 2014. Prognostic value of each score was determined using the area under the receiver operating characteristic curve.

RESULTS

Among 266 patients, 59% were men, 52% were white, and 36.5% had alcohol-induced pancreatitis. Mortality occurred in 15 (5.6%), and an APACHE IV of 44 or greater predicted mortality in 100% of cases. The receiver operating characteristic curve for APACHE IV was 0.93 (confidence interval [CI], 0.88-0.97); APACHE II, 0.87 (CI, 0.80-0.94); Bedside Index for Severity in Acute Pancreatitis, 0.86 (CI, 0.78-0.94); and Ranson criterion, 0.90 (CI, 0.94-0.96).

CONCLUSION

The APACHE IV is a valid means for predicting mortality and disease-related complications in acute pancreatitis.

Minimally Invasive Necrosectomy Techniques in Severe Acute Pancreatitis: Role of Percutaneous Necrosectomy and Video-Assisted Retroperitoneal Debridement

Consensus advocating a principle of early organ support, nutritional optimisation, followed ideally by delayed minimally invasive intervention within a “step-up” framework where possible has radically changed the surgical approach to complications of acute pancreatitis in the last 20 years. The 2012 revision of the Atlanta Classification incorporates these changes, and provides a background which underpins the complexities of individual patient management decisions. This paper discusses the place for delayed minimally invasive surgical intervention (percutaneous necrosectomy, video-assisted retroperitoneal debridement (VARD)), and the rationale for opting to adopt a percutaneous approach over endoscopic or laparoscopic approaches in different clinical situations.

Lung ultrasonography as a direct measure of evolving respiratory dysfunction and disease severity in patients with acute pancreatitis

BACKGROUND

The value of lung ultrasonography in the diagnosis of respiratory dysfunction and severity stratification in patients with acute pancreatitis (AP) was investigated.

METHODS

Over a 3-month period, 41 patients (median age: 59.1 years; 21 males) presenting with a diagnosis of potential AP were prospectively recruited. Each participant underwent lung ultrasonography, and the number of comet tails present on scans was linked with contemporaneous clinical data. Group comparisons, areas under the curve (AUC) and respective measures of diagnostic accuracy were investigated.

RESULTS

A greater number of comet tails were evident in patients with respiratory dysfunction (P = 0.013), those with severe disease (P = 0.001) and when contemporaneous and maximum in-patient C-reactive protein (CRP) exceeded 150 mg/l (P = 0.018 and P = 0.049, respectively). Receiver-operator characteristic plot area under the curve (AUC) was greater when examining upper lung quadrants, using respiratory dysfunction and AP severity as variables of interest (AUC = 0.803, 95% CI: 0.583-1.000, and AUC = 0.996, 95% CI: 0.983-1.000, respectively). Examining all lung quadrants resulted in greater AUCs for contemporaneous and maximum CRP (AUC = 0.764, 95% CI: 0.555-0.972, and AUC = 0.704, 95% CI: 0.510-0.898).

DISCUSSION

Ultrasonography of non-dependent lung parenchyma can reliably detect evolving respiratory dysfunction in AP. This simple bedside technique shows promise as an adjunct to severity stratification.

A 23-year, single-center, retrospective analysis of 36 cases of acute pancreatitis in pregnancy

OBJECTIVE

To assess the incidence, causes, clinical characteristics, and outcomes of cases of acute pancreatitis in pregnancy (APIP).

METHODS

A retrospective review was conducted of the medical records of pregnant women who were diagnosed with APIP at any point during pregnancy, labor, or the puerperium and attended Beijing Chaoyang Hospital, China, between January 1, 1991, and March 31, 2014.

RESULTS

Among 34 292 pregnant women admitted to the center during the study period, 36 patients were diagnosed with APIP. The condition developed during the second (9 [25%] cases) and third (22 [61%]) trimesters. The underlying cause was hypertriglyceridemia for 14 (39%) patients and biliary diseases for 7 (19%). Severe acute pancreatitis was significantly more common among patients with hypertriglyceridemia (11/14 [79%]) than among those without hypertriglyceridemia (6/22 [27%]; P=0.006). Additionally, complications were recorded for more patients with hypertriglyceridemia (11 [79%]) than those without hypertriglyceridemia (4 [18%]; P<0.001). Delayed diagnosis was more common among patients with severe acute pancreatitis (8/17 [47%]) than among those with mild acute pancreatitis (3/19 [16%]; P=0.039). No maternal deaths and only two perinatal deaths were recorded.

CONCLUSION

The overall incidence of APIP was low; however, hypertriglyceridemia was associated with poor outcomes. Early diagnosis and prompt treatment should be implemented to improve maternal and fetal prognosis and decrease mortality.

Implementation of a novel emergency surgical unit significantly improves the management of gallstone pancreatitis

INTRODUCTION

Emergency surgery is changing rapidly with a greater workload, early subspecialisation and centralisation of emergency care. We describe the impact of a novel emergency surgical unit (ESU) on the definitive management of patients with gallstone pancreatitis (GSP).

METHODS

A comparative audit was undertaken for all admissions with GSP before and after the introduction of the ESU over a six-month period. The impact on compliance with British Society of Gastroenterology (BSG) guidelines was assessed.

RESULTS

Thirty-five patients were treated for GSP between December 2013 and May 2014, after the introduction of the ESU. This was twice the nationally reported average for a UK trust over a six-month period. All patients received definitive management for their GSP and 100% of all suitable patients received treatment during the index admission or within two weeks of discharge. This was a significantly greater proportion than that prior to the introduction of the ESU (57%, p=0.0001) as well as the recently reported national average (34%). The mean length of total inpatient stay was reduced significantly after the ESU was introduced from 13.7 ± 4.7 days to 7.8 ± 2.1 days (p=0.03). The mean length of postoperative stay also fell significantly from 6.7 ± 2.6 days to 1.8 ± 0.8 days (p=0.001).

CONCLUSIONS

A dedicated ESU following national recommendations for emergency surgery care by way of using dedicated emergency surgeons and a streamlined protocol for common presentations has been shown by audit of current practice to significantly improve the management of patients presenting to a busy district general hospital with GSP.

Comparison of scoring systems in predicting the severity of acute pancreatitis

AIM: To investigate the prognostic usefulness of several existing scoring systems in predicting the severity of acute pancreatitis (AP).

METHODS: We retrospectively analyzed the prospectively collected clinical database from consecutive patients with AP in our institution between January 2011 and December 2012. Ranson, Acute Physiology and Chronic Health Evaluation (APACHE)-II, and bedside index for severity in acute pancreatitis (BISAP) scores, and computed tomography severity index (CTSI) of all patients were calculated. Serum C-reactive protein (CRP) levels were measured at admission (CRPi) and after 24 h (CRP₂₄). Severe AP was defined as persistent organ failure for more than 48 h. The predictive accuracy of each scoring system was measured by the area under the receiver-operating curve (AUC).

RESULTS: Of 161 patients, 21 (13%) were classified as severe AP, and 3 (1.9%) died. Statistically significant cutoff values for prediction of severe AP were Ranson ≥ 3, BISAP ≥ 2, APACHE-II ≥ 8, CTSI ≥ 3, and CRP₂₄≥ 21.4. AUCs for Ranson, BISAP, APACHE-II, CTSI, and CRP₂₄ in predicting severe AP were 0.69 (95%CI: 0.62-0.76), 0.74 (95%CI: 0.66-0.80), 0.78 (95%CI: 0.70-0.84), 0.69 (95%CI: 0.61-0.76), and 0.68 (95%CI: 0.57-0.78), respectively. APACHE-II demonstrated the highest accuracy for prediction of severe AP, however, no statistically significant pairwise differences were observed between APACHE-II and the other scoring systems, including CRP₂₄.

CONCLUSION: Various scoring systems showed similar predictive accuracy for severity of AP. Unique models are needed in order to achieve further improvement of prognostic accuracy.

Improving the management of acute pancreatitis in a district general hospital

Acute pancreatitis is a common problem seen in the United Kingdom, with an incidence of 56.6 per 100,000 population.[1,2,3] Optimising management has been shown to reduce mortality and morbidity, and the British Society of Gastroenterology (BSG) published revised guidelines in 2005 to standardise treatment for this potentially life threatening condition.[4]

The aim of this quality improvement project was to investigate and improve the initial management of acute pancreatitis in patients presenting to the Great Western Hospital (GWH) in Swindon between November 2012 and July 2013.

Patients presenting to the surgical team during this time with a diagnosis of acute pancreatitis were identified for the initial data collection. Notes were prospectively reviewed and data collected allowing a comparison between management in GWH against BSG guidelines. Following this stage, a pro forma based on the 2005 guidelines was created and implemented, with the aim of raising awareness and standardising care among surgical staff. Following implementation of the pro forma, data collection was repeated between May and June 2013 to assess the impact of the intervention.

Results revealed an improvement from 93% to 100% of patients receiving the correct diagnosis within 24 hours of presentation. Severity stratification within 48 hours of diagnosis improved from 75% to 88% and identification of aetiology also improved from 64% to 74%.

The implementation of an acute pancreatitis management protocol and education of junior surgical staff has been shown to improve compliance with BSG guidelines at the GWH, and ultimately aims to improves patient care and outcomes.

Early peritoneal lavage with ulinastatin improves outcome and enhances multi-organ protection in a model of severe acute pancreatitis

The aim of this study was to investigate the effect of early peritoneal lavage with ulinastatin on the outcome of a rat model of severe acute pancreatitis (SAP). A total of 80 male Wistar rats were randomly divided into the following groups: Sham-operated (C), SAP model (M), saline lavage (SL), intravenous ulinastatin (IU), early ulinastatin lavage (EUL) and late ulinastatin lavage (LUL). Intraperitoneal lavage or injection were performed immediately subsequent to the establishment of the SAP model in groups SL, IU and EUL and 3 h later in group LUL. Intraperitoneal lavage with or without ulinastatin was performed for 3 h. The survival time of the rats in groups C, M, EUL and LUL was recorded over a 12-h period and the median survival time was calculated. At 3 h after the induction of SAP, histopathological analyses were performed and the biochemical parameters of groups C, M, SL, IU and EUL were assessed. Groups EUL and LUL exhibited an increased median survival time compared with Group M, with the survival time of the rats in group EUL markedly longer than that in the group LUL rats. Group SL, IU and EUL rats were found to have reduced plasma activities of amylase, lipase, aspartate transaminase and alanine transaminase, with the biggest change observed in the group EUL rats. Furthermore, the intervention in groups SL and EUL was more effective at reducing creatinine and urea levels than that in group IU. Rats in group EUL exhibited a greater inhibition of the SAP-induced increase in troponin T levels than rats in groups SL and IU. The pathological severity scores of the pancreas, liver, kidney and lung in group EUL were significantly lower than those in groups M and better than those in groups SL and IU. In conclusion, early intraperitoneal lavage with ulinastatin significantly improves the median survival time and protects multi-organ function in an SAP model.

Can the time course of systemic inflammatory response syndrome score predict future organ failure in acute pancreatitis?

OBJECTIVES

In patients with acute pancreatitis (AP), we aimed to precisely quantify the association between systemic inflammatory response syndrome score (SIRSS), an easily measured bedside tool, and various adverse outcomes of AP.

METHODS

We prospectively identified patients admitted to Mayo Clinic on day 1 of AP. Patients with positive SIRSS (≥2) on day 1 were further followed up with daily measurement of SIRSS and organ failure status for 14 days or until discharge. Positive SIRSS on day 1, persistent SIRSS on day 3, and time course of SIRSS were correlated with development of organ failure.

RESULTS

SIRSS and persistent SIRSS were associated with all the complications of AP with a high sensitivity and negative predictive value, ranging from 73.1% to 100.0%. Persistent SIRSS at day 3 added significantly higher specificity to this association (71.7%-80.0%). All patients who developed late-onset organ failure had the highest possible value of cumulative SIRSS.

CONCLUSIONS

SIRSS of less than 2 on day 1 has a high negative predictive value for complications of AP. Eighty percent of the patients with persistent SIRSS on day 3 will develop at least 1 adverse outcome. A new variable "cumulative SIRSS" has the potential to reliably predict late-onset persistent organ failure.

Early organ dysfunction affects long-term survival in acute pancreatitis patients

BACKGROUND

The effect of early organ dysfunction on long-term survival in acute pancreatitis (AP) patients is unknown.

OBJECTIVE

The aim of this study was to ascertain whether early organ dysfunction impacts on long-term survival after an episode of AP.

METHODS

A retrospective analysis was performed using survival data sourced from a prospectively maintained database of patients with AP admitted to the Royal Infirmary of Edinburgh during a 5-year period commencing January 2000. A multiple organ dysfunction syndrome (MODS) score of ≥ 2 during the first week of admission was used to define early organ dysfunction. After accounting for in-hospital deaths, long-term survival probabilities were estimated using the Kaplan-Meier test. The prognostic significance of patient characteristics was assessed by univariate and multivariate analyses using Cox's proportional hazards methods.

RESULTS

A total of 694 patients were studied (median follow-up: 8.8 years). Patients with early organ dysfunction (MODS group) were found to have died prematurely [mean survival: 10.0 years, 95% confidence interval (CI) 9.4-10.6 years] in comparison with the non-MODS group (mean survival: 11.6 years, 95% CI 11.2-11.9 years) (log-rank test, P = 0.001) after the exclusion of in-hospital deaths. Multivariate analysis confirmed MODS as an independent predictor of long-term survival [hazard ratio (HR): 1.528, 95% CI 1.72-2.176; P = 0.019] along with age (HR: 1.062; P < 0.001), alcohol-related aetiology (HR: 2.027; P = 0.001) and idiopathic aetiology (HR: 1.548; P = 0.048).

CONCLUSIONS

Early organ dysfunction in AP is an independent predictor of long-term survival even when in-hospital deaths are accounted for. Negative predictors also include age, and idiopathic and alcohol-related aetiologies.

Complex role for the immune system in initiation and progression of pancreatic cancer

The immune system plays a complex role in the development and progression of pancreatic cancer. Inflammation can promote the formation of premalignant lesions and accelerate pancreatic cancer development. Conversely, pancreatic cancer is characterized by an immunosuppressive environment, which is thought to promote tumor progression and invasion. Here we review the current literature describing the role of the immune response in the progressive development of pancreatic cancer, with a focus on the mechanisms that drive recruitment and activation of immune cells at the tumor site, and our current understanding of the function of the immune cell types at the tumor. Recent clinical and preclinical data are reviewed, detailing the involvement of the immune response in pancreatitis and pancreatic cancer, including the role of specific cytokines and implications for disease outcome. Acute pancreatitis is characterized by a predominantly innate immune response, while chronic pancreatitis elicits an immune response that involves both innate and adaptive immune cells, and often results in profound systemic immune-suppression. Pancreatic adenocarcinoma is characterized by marked immune dysfunction driven by immunosuppressive cell types, tumor-promoting immune cells, and defective or absent inflammatory cells. Recent studies reveal that immune cells interact with cancer stem cells and tumor stromal cells, and these interactions have an impact on development and progression of pancreatic ductal adenocarcinoma (PDAC). Finally, current PDAC therapies are reviewed and the potential for harnessing the actions of the immune response to assist in targeting pancreatic cancer using immunotherapy is discussed.

Observational study of intra-abdominal pressure monitoring in acute pancreatitis

BACKGROUND

Intra-abdominal hypertension (IAH) is predictive of adverse outcome in critically ill patients; however, its role in acute pancreatitis is unclear, and prospective studies are lacking. We aimed to determine the overall incidence and predictive value of IAH on mortality in acute pancreatitis.

METHODS

Transvesical IAP was measured on admission and every 4 hours within high-dependency unit/intensive care unit. Serum biochemistry and physiologic parameters permitted calculation of Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, Imrie, and Ranson scores. The primary end point was 30-day mortality.

RESULTS

A total of 218 patients with acute pancreatitis were recruited; 30-day mortality was greater in patients with IAH (IAP ≥12 mmHg; 37%) than no IAH (2%; P < .001). A total of 14% of patients had IAH on admission; another 3% developed IAH in hospital. Mortality was greater in the latter group (37% vs 50%; P < .01). In the majority of cases IAH developed in line with other organ failure; however, there were several patients in whom the development of IAH appeared to be the sentinel event before rapid clinical decline. An IAP threshold of 9 mmHg had best predictive value for mortality (sensitivity 86%, specificity 87%; area under the ROC curve 0.91). This finding was comparable with other validated markers of severe pancreatitis (Imrie ≥3: sensitivity 51%, specificity 70%; Acute Physiology and Chronic Health Evaluation II: sensitivity 67%, specificity 96%; C-reactive protein >150: sensitivity 89%, specificity 83%).

CONCLUSION

IAP is a good predictor of mortality and organ failure in acute pancreatitis and compares favorably with other validated prognostic scores. Whether IAH is a phenomenon causative of organ failure or an epiphenomenon, occurring in conjunction with other organ dysfunction, remains unclear.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute pancreatitis: a prospective study on incidence, etiology, and outcome

BACKGROUND AND AIMS

Prospective and population-based studies on the incidence of acute pancreatitis (AP) are lacking. Alcohol consumption has increased considerably in Iceland during the last decade. We aimed to determine the incidence, etiology, severity, and complications of AP and compare the results with a previous study on AP in Iceland.

METHODS

A prospective population-based study of patients diagnosed with AP at the National University Hospital of Iceland during 1 year (2010-2011). Information on symptoms, etiology, and complications was registered.

RESULTS

During the study period, 134 patients were diagnosed with AP, 78 men (58%), median age 57 years (interquartile range 42-71). Overall, 89/104 (86%) patients had their first attack of pancreatitis, yielding a crude incidence of 40/100 000 inhabitants/year. The major etiological groups were as follows: gallstones, 52 cases (42%); alcohol 29, (23%); postendoscopic retrograde cholangio-pancreatography in 12 (9.5%); medications in eight (6.3%); and idiopathic in 15 (12%). Alcohol was more often the cause in men (25 vs. 4, P<0.05) but the incidence of gallstone-induced pancreatitis was similar in men and women (26 vs. 27). Seven patients had severe complications, three had pancreatic necrosis, two had pseudocysts, and one developed renal failure. Another patient developed acute respiratory distress syndrome and was admitted to the ICU. No patient died of AP during the study period.

CONCLUSION

The incidence of AP has not increased significantly in Iceland in the last decade. Alcohol-induced pancreatitis has not increased proportionally despite increased alcohol consumption in Iceland. In a population-based setting, the vast majority of AP is of mild severity.

Long-term effectiveness of cholecystectomy and endoscopic sphincterotomy in the management of gallstone pancreatitis

BACKGROUND

Gallstone pancreatitis (GSP) is a common condition, accounting for 30-40 % of all pancreatitis cases. All GSP patients should undergo definitive treatment to prevent further attacks. This study aimed to investigate the long-term outcome after definitive treatment in England by cholecystectomy, endoscopic sphincterotomy (ES), or both.

METHODS

Hospital episode statistics data were used to identify patients admitted for the first time with GSP between January and December 2005. These patients were followed for 18 months to identify those who underwent definitive treatment. Treatment groups then were followed until December 2010 to identify readmissions with a further GSP attack as an emergency or admissions with complications of gallstone disease.

RESULTS

5,079 patients admitted with a first bout of GSP between January and December 2005. The in-hospital mortality rate was 7.8 %. Of those who survived the initial attack, 2,511 went on to have a cholecystectomy, 419 had an ES alone, and 496 had ES followed by cholecystectomy. Recurrent pancreatitis after definitive treatment was more common among patients treated with ES (6.7 %) than among those treated with cholecystectomy (4.4 %) or ES followed by cholecystectomy (1.2 %) (p < 0.05). Admissions with other complications attributable to gallstones in patients treated with ES alone were similar to those seen in patients who had received no definitive treatment (12.2 vs. 9.4 %).

CONCLUSIONS

Cholecystectomy offers better protection than ES against further bouts of pancreatitis in patients with GSP, but ES is an acceptable alternative. Interval cholecystectomy in patients treated initially with ES was the most effective method of preventing further pancreatitis, and the patients who underwent treatment by ES alone remained at risk of readmission with gallstone-related problems. Patients who have undergone ES and are fit for surgery should have a cholecystectomy.

Effect of obesity and decompressive laparotomy on mortality in acute pancreatitis requiring intensive care unit admission

Background

Controversy still exists on the effect that obesity has on the morbidity and mortality in severe acute pancreatitis (SAP). The primary purpose of this study was to compare the mortality rate of obese versus nonobese patients admitted to the ICU for SAP. Secondary goals were to assess the potential risk factors for abdominal compartment syndrome (ACS) and to investigate the performance of validated scoring systems to predict ACS and in-hospital mortality.

Methods

A retrospective cohort of adults admitted to the ICU for SAP was stratified by their body mass index (BMI) as obese and nonobese. The rates of morbidity, mortality, and ACS were compared by univariate and multivariate regression analyses. Areas under the curve (AUC) were used to evaluate the discriminating performance of severity scores and other selected variables to predict mortality and the risk of ACS.

Result

Forty-five patients satisfied the inclusion criteria and 24 (53 %) were obese with similar characteristics to nonobese patients. Among all the subjects, 11 (24 %) died and 16 (35 %) developed ACS. In-hospital mortality was significantly lower for obese patients (12.5 vs. 38 %; P = 0.046) even though they seemed to develop ACS more frequently (41 vs. 28 %; P = 0.533). At multivariable analysis, age was the most significant factor associated with in-hospital mortality (odds ratio (OR) = 1.273; 95 % confidence interval (CI) 1.052–1.541; P = 0.013) and APACHE II and Glasgow-Imrie for the development of ACS (OR = 1.143; 95 % CI 1.012–1.292; P = 0.032 and OR = 1.221; 95 % CI 1.000–1.493; P = 0.05) respectively. Good discrimination for in-hospital mortality was observed for patients’ age (AUC = 0.846) and number of comorbidities (AUC = 0.801). ACS was not adequately predicted by any of the clinical severity scores (AUC = 0.548–0.661).

Conclusions

Patients’ age was the most significant factor associated with mortality in patients affected by SAP. Higher APACHE II and Glasgow-Imrie scores were associated with the development of ACS, but their discrimination performance was unsatisfactory.