Association of antioxidant enzyme gene polymorphisms and glutathione status with severe acute pancreatitis

Necrotizing Gallstone Pancreatitis in a Pediatric Patient: A Case Report and Review of Diagnostic and Management Challenges

Necrotizing gallstone pancreatitis is a rare and severe form of pancreatitis, particularly uncommon in the pediatric population. While gallstone pancreatitis is increasingly recognized in children, necrotizing cases remain exceptional. We report a four-and-a-half-year-old Pakistani American male presenting with generalized weakness, abdominal pain, and vomiting. Initial symptoms followed a recent upper respiratory infection. Clinical evaluation revealed an intermittently drowsy-appearing patient with a Glasgow Coma Scale (GCS) of 15 when fully alert, hypotension, diffuse abdominal tenderness, and signs of possible sepsis. Laboratory tests showed elevated lipase levels and conjugated hyperbilirubinemia. Ultrasound identified gallstones and necrotizing changes in the pancreas, which were later confirmed by CT imaging. The patient was admitted to the pediatric intensive care unit for aggressive management of necrotizing pancreatitis, including fluid resuscitation, antibiotic therapy, and nutritional support. He underwent laparoscopic cholecystectomy and developed Clostridium difficile colitis, which was managed with targeted antibiotics. The patient had a 26-day hospital stay and was followed up with negative results from clinical exome sequencing for related disorders. This case underscores the diagnostic and management complexities associated with pediatric necrotizing gallstone pancreatitis. The need for a multidisciplinary approach and adherence to clinical guidelines is emphasized. This report contributes valuable insights into the rare presentation of necrotizing pancreatitis in children and highlights the importance of early and comprehensive intervention.

Excess Iodine Consumption Induces Oxidative Stress and Pancreatic Damage Independently of Chemical Form in Male Wistar Rats: Participation of PPAR-γ and C/EBP-β

BACKGROUND

Human beings consume different chemical forms of iodine in their diet. These are transported by different mechanisms in the cell. The forms of iodine can be part of thyroid hormones, bind to lipids, be an antioxidant, or be an oxidant, depending on their chemical form. The excessive consumption of iodine has been associated with pancreatic damage and diabetes mellitus type 2, but the association between disease and the chemical form consumed in the diet is unknown. This research analyzes the effect of excessive iodine consumption as Lugol (molecular iodine/potassium iodide solution) and iodate on parameters of pancreatic function, thyroid and lipid profiles, antioxidant and oxidant status, the expression of IR/Akt/P-Akt/GLUT4, and transcription factors PPAR-γ and CEBP-β.

METHODS

Three groups of Wistar rats were treated with 300 μg/L of iodine in drinking water: (1) control, (2) KIO3, and (3) Lugol.

RESULTS

Lugol and KIO3 consumption increased total iodine levels. Only KIO3 increased TSH levels. Both induced high serum glucose levels and increased oxidative stress and pancreatic alpha-amylase activity. Insulin levels and antioxidant status decreased significantly. PPAR-γ and C/EBP-β mRNA expression increased.

CONCLUSION

The pancreatic damage, hypertriglyceridemia, and oxidative stress were independent of the chemical form of iodine consumed. These effects depended on PPAR-γ, C/EBP-β, GLUT-4, and IR.

Genetic polymorphisms in phase II metabolizing enzymes in alcoholic and idiopathic chronic pancreatitis: Indian scenario

AIM

To study polymorphisms in glutathione-S-transferases (GST-T1, GST-M1, GST-P1) and uridine-5'-diphosphate-glucuronosyl-transferases (UGT1A7) genes and the risk of developing chronic pancreatitis (CP) associated with these polymorphisms.

METHODS

This study included 49 alcoholic and 51 idiopathic chronic pancreatitis patients, 50 alcohol addicts and 50 healthy controls. Polymorphism(s) in GST-T1 and GST-M1 genes were assessed by multiplex polymerase chain reaction (PCR), while PCR-radiofrequency lesioning (RFLP) was employed to assess the same in GST-P1 and UGT1A7 genes. The differences in polymorphism frequency between groups and the risk of developing pancreatitis were assessed by the odds ratio.

RESULTS

Strong association of the null genotype of GST-T1 with CP susceptibility was observed. Alcoholics with the Val allele of GST-P1 have higher chances of having pancreatitis. Idiopathic pancreatitis patients with higher age at the onset of pain were found to have the null genotype of GST-M1.

CONCLUSION

Alcoholics with the null genotype of the GST-T1 gene and the Valine allele of the GST-P1 gene are at a higher risk of developing CP. Thus, genotyping of these genes may serve as an important screening tool for the identification of high-risk groups among alcoholics.

Gene expression, levels and polymorphism (Ala16Val) of Mitochondrial Superoxide Dismutase in Tuberculosis patients of Rajasthan

BACKGROUND

Infectious diseases cause redox imbalance and oxidative stress (OS) in host. Superoxide Dismutases(SOD) decrease this OS. SOD2 gene polymorphism can influence the expression and levels of enzyme.

AIM

To investigate the association of genetic polymorphism of MnSOD with enzyme levels and mRNA expression in TB patients.

METHODS

A total of 87 TB patients and 85 healthy individuals participated in the study. The serum SOD2 levels were measured by ELISA. Gene polymorphism was analysed using PCR-RFLP with BsaW1 as the restriction enzyme. Expression was studied by Real-TimePCR. Statistical significance was determined using the Mann-Whitney, Chi-square and Kruskal-Wallis tests and p value < 0.05 was considered statistically significant.

RESULTS

The median(IQR) serum SOD2 levels of TB patients were lower than those of healthy subjects (4.64(6.48) vs 11.35(20.36)ng/mL respectively,p < 0.001). SOD2 expression was significantly down-regulated in TB patients with a fold change value of 0.312. The Val/Val genotype was higher in the patient group than healthy subjects (36.8% vs 23.5%). However, the difference observed between serum SOD2 levels and mRNA expression in the different genotypes were statistically non-significant.

CONCLUSION

Significant difference was found between levels and expression of SOD2 in TB patients and healthy controls, but not for SOD2 gene polymorphism.

Tanshinone IIA Protects against Acute Pancreatitis in Mice by Inhibiting Oxidative Stress via the Nrf2/ROS Pathway

Background

Danshen (Salvia miltiorrhiza Bunge) and its main active component Tanshinone IIA (TSA) are clinically used in China. However, the effects of TSA on acute pancreatitis (AP) and its potential mechanism have not been investigated. In this study, our objective was to investigate the protective effects of TSA against AP via three classic mouse models.

Methods

Mouse models of AP were established by caerulein, sodium taurocholate, and L-arginine, separately. Pancreatic and pulmonary histopathological characteristics and serum amylase and lipase levels were evaluated, and changes in oxidative stress injury and the ultrastructure of acinar cells were observed. The reactive oxygen species (ROS) inhibitor N-Acetylcysteine (NAC) and nuclear factor erythroid 2-related factor 2 (Nrf2) knockout mice were applied to clarify the protective mechanism of the drug.

Results

In the caerulein-induced AP model, TSA administration reduced serum amylase and lipase levels and ameliorated the histopathological manifestations of AP in pancreatic tissue. Additionally, TSA appreciably decreased ROS release, protected the structures of mitochondria and the endoplasmic reticulum, and increased the protein expression of Nrf2 and heme oxygenase 1 of pancreatic tissue. In addition, the protective effects of TSA against AP were counteracted by blocking the oxidative stress (NAC administration and Nrf2 knockout in mice). Furthermore, we found that TSA protects pancreatic tissue from damage and pancreatitis-associated lung injury in two additional mouse models induced by sodium taurocholate and by L-arginine.

Conclusion

Our data confirmed the protective effects of TSA against AP in mice by inhibiting oxidative stress via the Nrf2/ROS pathway.

Current trends in pharmacological approaches for treatment and management of acute pancreatitis – a review

Objectives

Acute pancreatitis (AP) is an inimical disorder associated with overall mortality rates between 10-15%. It is a disorder of the exocrine pancreas which is characterized by local and systemic inflammatory responses primarily driven by oxidative stress and death of pancreatic acinar cells. The severity of AP ranges from mild pancreatic edema with complete recuperative possibilities to serious systemic inflammatory response resulting in peripancreatic/pancreatic necrosis, multiple organ failure, and death.

Key findings

We have retrieved the potential alternative approaches that are developed lately for efficacious treatment of AP from the currently available literature and recently reported experimental studies. This review summarizes the need for alternative approaches and combinatorial treatment strategies to deal with AP based on literature search using specific key words in PubMed and ScienceDirect databases.

Summary

Since AP results from perturbations of multiple signaling pathways, the so called “monotargeted smart drugs” of the past decade is highly unlikely to be effective. Also, the conventional treatment approaches were mainly involved in providing palliative care instead of curing the disease. Hence, many researchers are beginning to focus on developing alternate therapies to treat AP effectively. This review also summarizes the recent trends in the combinatorial approaches available for AP treatment.

Blockade of the trans-sulfuration pathway in acute pancreatitis due to nitration of cystathionine β-synthase

Acute pancreatitis is an inflammatory process of the pancreatic gland that may lead to dysregulation of the trans-sulfuration pathway. The aims of this work were firstly to study the methionine cycle as well as the trans-sulfuration pathway using metabolomic and proteomic approaches identifying the causes of this dysregulation in an experimental model of acute pancreatitis; and secondly to reveal the effects of S-adenosylmethionine administration on these pathways. Acute pancreatitis was induced by cerulein in mice, and a group of animals received S-adenosylmethionine treatment. Cerulein-induced acute pancreatitis rapidly caused marked depletion of methionine, S-adenosylmethionine, 5′-methylthioadenosine, cystathionine, cysteine, and glutathione levels in pancreas, but S-adenosylhomocysteine and homocysteine remained unchanged. Protein steady-state levels of S-adenosylhomocysteine-hydrolase and cystathionine gamma-lyase diminished but methylthioadenosine phosphorylase levels increased in pancreas with acute pancreatitis. Although cystathionine β-synthase protein levels did not change with acute pancreatitis, Nos2 mRNA and protein levels were markedly up-regulated and caused tyrosine nitration of cystathionine β-synthase in pancreas. S-adenosylmethionine administration enhanced Nos2 mRNA expression and cystathionine β-synthase nitration and triggered homocysteine accumulation in acute pancreatitis. Furthermore, S-adenosylmethionine administration promoted enrichment of the euchromatin marker H3K4me3 in the promoters of Tnf-α, Il-6, and Nos2 and enhanced the mRNA up-regulation of these genes. Accordingly, S-adenosylmethionine administration increased inflammatory infiltrate and edema in pancreas with acute pancreatitis. In conclusion, tyrosine-nitration of cystathionine β-synthase blockades the trans-sulfuration pathway in acute pancreatitis promoting homocysteine accumulation upon S-adenosylmethionine treatment.

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Acute pancreatitis induces nitration of cystathionine β-synthase (CBS).

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CBS nitration blockades the trans-sulfuration pathway in acute pancreatitis.

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SAM treatment enhances CBS nitration leading to homocysteine accumulation in pancreatitis.

MR imaging of hemorrhage associated with acute pancreatitis

PURPOSE

To study MRI findings of hemorrhage in acute pancreatitis (AP) and correlate the presence and extent of hemorrhage with the MR severity index (MRSI), Acute Physiology And Chronic Health Evaluation (APACHE) II scores, and clinical outcome.

MATERIALS AND METHODS

This retrospective study included 539 patients with AP. Hemorrhage was defined as areas of hyperintensity in or outside the pancreas on liver imaging with volume acceleration flexible (LAVA-Flex). The presence of hemorrhage was classified into three areas: within the pancreatic parenchyma, retroperitoneal space, and sub-or intraperitoneal space. Involvement of each area was awarded 1 point resulting in the hemorrhage severity index (HSI) score. The predicted severity of AP was graded by MRSI and APACHE II score. The association between HSI, MRSI, and APACHE II scores was analyzed. The length of hospital stay and organ dysfunction was used as clinical outcome parameters.

RESULTS

Among 539 AP patients, 62 (11.5%) had hemorrhage. The prevalence of hemorrhage was 1.1% (2/186), 13.9% (43/310), and 39.5% (17/43) in predicted mild, moderate, and severe AP, respectively, based on MRSI (χ² = 55.3, p = 0.00); and 7.7% (21/273) and 19.2% (18/94) in predicted mild and severe AP, respectively, based on APACHE II (χ² = 21.2, p = 0.00). HSI score significantly correlated with MRSI (r = 0.36, p < 0.001) and APACHE II scores (r = 0.21, p = 0.00). The prevalence of organ dysfunction was higher and length of hospital stay was longer in patients with hemorrhage than in those without hemorrhage (p < 0.01).

CONCLUSIONS

Hemorrhage in AP is common. The presence of hemorrhage, rather than its extent, correlates with poor clinical outcome.

Genetic Polymorphisms: A Novel Perspective on Acute Pancreatitis

Acute pancreatitis (AP) is a complex disease that results in significant morbidity and mortality. For many decades, it has compelled researchers to explore the exact pathogenesis and the understanding of the pathogenesis of AP has progressed dramatically. Currently, premature trypsinogen activation and NF-κB activation for inflammation are two remarkable hypotheses for the mechanism of AP. Meanwhile, understanding of the influence of genetic polymorphisms has resulted in tremendous development in the understanding of the advancement of complex diseases. Now, genetic polymorphisms of AP have been noted gradually and many researchers devote themselves to this emerging area. In this review, we comprehensively describe genetic polymorphisms combined with the latest hypothesis of pathogenesis associated with AP.

Alcohol Consumption and Cigarette Smoking are Important Modifiers of the Association Between Acute Pancreatitis and the PRSS1-PRSS2 Locus in Men

OBJECTIVES

The present study was designed to investigate whether the susceptibility to acute pancreatitis (AP) attributable to polymorphism rs10273639 at the PRSS1-PRSS2 locus is dependent on alcohol consumption and cigarette smoking.

METHODS

A total of 603 unrelated Russian individuals including 304 patients with physician-diagnosed AP and 299 sex- and age-matched healthy controls have been recruited for the study. A polymorphism rs10273639 (-408C>T) of PRSS1-PRSS2 was genotyped by TaqMan-based assay.

RESULTS

A variant allele -408T (P = 0.003) and genotypes -408CT plus TT (P = 0.002) were associated with decreased AP risk only in men. The odds ratios for AP in the CC homozygotes versus the variant genotypes were 1.95 [95% confidence interval (CI), 0.65-5.85; P = 0.23], 1.72 (95% CI, 0.93-3.20; P = 0.08), and 2.37 (95% CI, 1.09-5.13; P = 0.03) for men who consumed up to 28, 29 to 59, and more than 60 alcohol drinks a week, respectively. Cigarette smokers with the -408CC genotype had an increased risk of AP (odds ratio, 2.07; 95% CI, 1.25-3.42; P = 0.004), whereas nonsmoker carriers did not have a disease risk (odds ratio, 1.48; 95% CI, 0.58-3.82; P = 0.42).

CONCLUSIONS

We confirmed a robust association of polymorphism rs10273639 at PRSS1-PRSS2 with AP in the Russian population. The present study is the first to show that relationship between the locus and disease is significantly modified by alcohol consumption and cigarette smoking.

Clinical practice guideline: management of acute pancreatitis

ABSTRACT

There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.

Improvement of kidney redox states contributes to the beneficial effects of dietary pomegranate peel against barium chloride-induced nephrotoxicity in adult rats

CONTEXT

Pomegranate (Punica granatum L., Punicaceae) is known to possess enormous antioxidant activity.

OBJECTIVE

This study investigates the protective effects of pomegranate peel against barium-mediated renal damage.

MATERIALS AND METHODS

Rats were exposed during 21 days either to barium (67 ppm), barium + pomegranate peel (5% of diet) or to only pomegranate peel (5% of diet).

RESULTS

Exposure rats to barium provoked a significant increase in kidney malondialdehyde (MDA), advanced oxidation protein products (AOPP) and hydrogen peroxide (H2O2) levels. Creatinine, urea and uric acid levels in plasma and urine were also modified. Superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) activities, non protein thiol (NPSH) and reduced glutathione (GSH) levels were decreased. Metallothionein (MT) production was increased and their genes expressions were up-regulated. All these changes were improved by dietary pomegranate peel. Moreover, the distorted histoarchitecture in kidney of barium group was alleviated by pomegranate peel.

CONCLUSION

Our data showed, for the first time, the protective effects of pomegranate peel against barium-induced renal oxidative damage.

Acute pancreatitis with gradient echo T2*-weighted magnetic resonance imaging

BACKGROUND

To study gradient recalled echo (GRE) T2*-weighted imaging (T2*WI) for normal pancreas and acute pancreatitis (AP).

METHODS

Fifty-one patients without any pancreatic disorders (control group) and 117 patients with AP were recruited. T2* values derived from T2*WI of the pancreas were measured for the two groups. The severity of AP was graded by the magnetic resonance severity index (MRSI) and the Acute Physiology and Chronic Healthy Evaluation II (APACHE II) scoring system. Logistic regression was used to analyze the relationship between the T2* values and AP severity. The usefulness of the T2* value for diagnosing AP and the relationship between the T2* values and the severity of AP were analyzed.

RESULTS

On GRE-T2*WI, the normal pancreas showed a well-marinated and consistently homogeneous isointensity. Edematous AP, as well as the non-necrotic area in necrotizing AP, showed ill-defined but homogeneous signal intensity. AP with pancreatic hemorrhage showed a decreased T2* value and a signal loss on the signal decay curve. The T2* value of pancreas in the AP group was higher than that of the control group (t=-8.20, P<0.05). The T2* value tended to increase along with the increase in MRSI scores but not with the APACHE II scores (P>0.05). AP was associated with a one standard deviation increment in the T2* value (OR =1.37; 95% CI: 1.216-1.532).

CONCLUSIONS

T2*WI demonstrates a few characteristics of the normal pancreas and AP, which could potentially be helpful for detecting hemorrhage, and contributes to diagnosing AP and its severity.

Review article: recent advances in pharmacogenetics and pharmacokinetics for safe and effective thiopurine therapy in inflammatory bowel disease

BACKGROUND

Azathioprine and mercaptopurine have a pivotal role in the treatment of inflammatory bowel disease (IBD). However, because of their complex metabolism and potential toxicities, optimal use of biomarkers to predict adverse effects and therapeutic response is paramount.

AIM

To provide a comprehensive review focused on pharmacogenetics and pharmacokinetics for safe and effective thiopurine therapy in IBD.

METHODS

A literature search up to July 2015 was performed in PubMed using a combination of relevant MeSH terms.

RESULTS

Pre-treatment thiopurine S-methyltransferase typing plus measurement of 6-tioguanine nucleotides and 6-methylmercaptopurine ribonucleotides levels during treatment have emerged with key roles in facilitating safe and effective thiopurine therapy. Optimal use of these tools has been shown to reduce the risk of adverse effects by 3-7%, and to improve efficacy by 15-30%. For the introduction of aldehyde oxidase (AOX) into clinical practice, the association between AOX activity and AZA dose requirements should be positively confirmed. Inosine triphosphatase assessment associated with adverse effects also shows promise. Nucleoside diphosphate-linked moiety X-type motif 15 variants have been shown to predict myelotoxicity on thiopurines in East Asian patients. However, the impact of assessments of xanthine oxidase, glutathione S-transferase, hypoxanthine guanine phosphoribosyltransferase and inosine monophosphate dehydrogenase appears too low to favour incorporation into clinical practice.

CONCLUSIONS

Measurement of thiopurine-related enzymes and metabolites reduces the risk of adverse effects and improves efficacy, and should be considered part of standard management. However, this approach will not predict or avoid all adverse effects, and careful clinical and laboratory monitoring of patients receiving thiopurines remains essential.

Compliance with Evidence-Based Guidelines in Acute Pancreatitis: an Audit of Practices in University of Toronto Hospitals

Despite existing evidence-based practice guidelines for the management of acute pancreatitis, clinical compliance with recommendations is poor. We conducted a retrospective review of 248 patients admitted between 2010 and 2012 with acute pancreatitis at eight University of Toronto affiliated hospitals. We included all patients admitted to ICU (52) and 25 ward patients from each site (196). Management was compared with the most current evidence used in the Best Practice in General Surgery Management of Acute Pancreatitis Guideline. Fifty-six patients (22.6 %) had only serum lipase tested for biochemical diagnosis. Admission ultrasound was performed in 174 (70.2 %) patients, with 69 (27.8 %) undergoing ultrasound and CT. Of non-ICU patients, 158 (80.6 %) were maintained nil per os, and only 18 (34.6 %) ICU patients received enteral nutrition, commencing an average 7.5 days post-admission. Fifty (25.5 %) non-ICU patients and 25 (48.1 %) ICU patients received prophylactic antibiotics. Only 24 patients (22.6 %) with gallstone pancreatitis underwent index admission cholecystectomy. ERCP with sphincterotomy was under-utilized among patients with biliary obstruction (16 [31 %]) and candidates for prophylactic sphincterotomy (18 [22 %]). Discrepancies exist between the most current evidence and clinical practice within the University of Toronto hospitals. A guideline, knowledge translation strategy, and assessment of barriers to clinical uptake are required to change current clinical practice.

Role of Biomarkers in Diagnosis and Prognostic Evaluation of Acute Pancreatitis

Acute pancreatitis is a potentially life threatening disease. The spectrum of severity of the illness ranges from mild self-limiting disease to a highly fatal severe necrotizing pancreatitis. Despite intensive research and improved patient care, overall mortality still remains high, reaching up to 30–40% in cases with infected pancreatic necrosis. Although little is known about the exact pathogenesis, it has been widely accepted that premature activation of digestive enzymes within the pancreatic acinar cell is the trigger that leads to autodigestion of pancreatic tissue which is followed by infiltration and activation of leukocytes. Extensive research has been done over the past few decades regarding their role in diagnosis and prognostic evaluation of severe acute pancreatitis. Although many standalone biochemical markers have been studied for early assessment of severity, C-reactive protein still remains the most frequently used along with Interleukin-6. In this review we have discussed briefly the pathogenesis and the role of different biochemical markers in the diagnosis and severity evaluation in acute pancreatitis.

Role of oxidative stress mediated by glutathione-s-transferase in thiopurines' toxic effects

Azathioprine (AZA), 6-mercaptopurine (6-MP), and 6-thioguanine (6-TG) are antimetabolite drugs, widely used as immunosuppressants and anticancer agents. Despite their proven efficacy, a high incidence of toxic effects in patients during standard-dose therapy is recorded. The aim of this study is to explain, from a mechanistic point of view, the clinical evidence showing a significant role of glutathione-S-transferase (GST)-M1 genotype on AZA toxicity in inflammatory bowel disease patients. To this aim, the human nontumor IHH and HCEC cell lines were chosen as predictive models of the hepatic and intestinal tissues, respectively. AZA, but not 6-MP and 6-TG, induced a concentration-dependent superoxide anion production that seemed dependent on GSH depletion. N-Acetylcysteine reduced the AZA antiproliferative effect in both cell lines, and GST-M1 overexpression increased both superoxide anion production and cytotoxicity, especially in transfected HCEC cells. In this study, an in vitro model to study thiopurines' metabolism has been set up and helped us to demonstrate, for the first time, a clear role of GST-M1 in modulating AZA cytotoxicity, with a close dependency on superoxide anion production. These results provide the molecular basis to shed light on the clinical evidence suggesting a role of GST-M1 genotype in influencing the toxic effects of AZA treatment.

Redox signaling in acute pancreatitis

Acute pancreatitis is an inflammatory process of the pancreatic gland that eventually may lead to a severe systemic inflammatory response. A key event in pancreatic damage is the intracellular activation of NF-κB and zymogens, involving also calcium, cathepsins, pH disorders, autophagy, and cell death, particularly necrosis. This review focuses on the new role of redox signaling in acute pancreatitis. Oxidative stress and redox status are involved in the onset of acute pancreatitis and also in the development of the systemic inflammatory response, being glutathione depletion, xanthine oxidase activation, and thiol oxidation in proteins critical features of the disease in the pancreas. On the other hand, the release of extracellular hemoglobin into the circulation from the ascitic fluid in severe necrotizing pancreatitis enhances lipid peroxidation in plasma and the inflammatory infiltrate into the lung and up-regulates the HIF-VEGF pathway, contributing to the systemic inflammatory response. Therefore, redox signaling and oxidative stress contribute to the local and systemic inflammatory response during acute pancreatitis.

Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis

BACKGROUND

The gut is implicated in the pathogenesis of acute pancreatitis but there is discrepancy between individual studies regarding the prevalence of gut barrier dysfunction in patients with acute pancreatitis. The aim of this study was to determine the prevalence of gut barrier dysfunction in acute pancreatitis, the effect of different co-variables, and changes in gut barrier function associated with the use of various therapeutic modalities.

METHODS

A literature search was performed using PRISMA and MOOSE guidelines. Summary estimates were presented as pooled prevalence of gut barrier dysfunction and the associated 95 per cent c.i.

RESULTS

A total of 44 prospective clinical studies were included in the systematic review, of which 18 studies were subjected to meta-analysis. The pooled prevalence of gut barrier dysfunction was 59 (95 per cent c.i. 48 to 70) per cent; the prevalence was not significantly affected by disease severity, timing of assessment after hospital admission or type of test used, but showed a statistically significant association with age. Overall, nine of 13 randomized clinical trials reported a significant improvement in gut barrier function following intervention compared with the control group, but only three of six studies that used standard enteral nutrition reported a statistically significant improvement in gut barrier function after intervention.

CONCLUSION

Gut barrier dysfunction is present in three of five patients with acute pancreatitis, and the prevalence is affected by patient age but not by disease severity. Clinical studies are needed to evaluate the effect of enteral nutrition on gut function in acute pancreatitis.

Magnetic resonance imaging for the normal mesostenium and involvement of the mesostenium in acute pancreatitis

The main point of this paper is to study MRI findings of the normal mesostenium and the involvement of the mesostenium in acute pancreatitis and to discuss the relationship between the involvement of the mesostenium and the severity of acute pancreatitis. In clinical practice, the mesenterical involvement in acute pancreatitis was often observed on MRI in daily works, which was little recorded in the reported studies. We conducted the current study to assess the mesenterical involvement in acute pancreatitis with MRI. We found that the mesenterical involvement of acute pancreatitis patients is common on MRI. The mesenterical involvement has a positive correlation with the MR severity index and the Acute Physiology and Chronic Healthy Evaluation II scoring system. It has been shown that MR can be used to visualize mesenterical involvement, which is a supplementary indicator in evaluating the severity of acute pancreatitis and local and systemic complications.

Redox regulation of antioxidants, autophagy, and the response to stress: implications for electrophile therapeutics

Redox networks in the cell integrate signaling pathways that control metabolism, energetics, cell survival, and death. The physiological second messengers that modulate these pathways include nitric oxide, hydrogen peroxide, and electrophiles. Electrophiles are produced in the cell via both enzymatic and nonenzymatic lipid peroxidation and are also relatively abundant constituents of the diet. These compounds bind covalently to families of cysteine-containing, redox-sensing proteins that constitute the electrophile-responsive proteome, the subproteomes of which are found in localized intracellular domains. These include those proteins controlling responses to oxidative stress in the cytosol-notably the Keap1-Nrf2 pathway, the autophagy-lysosomal pathway, and proteins in other compartments including mitochondria and endoplasmic reticulum. The signaling pathways through which electrophiles function have unique characteristics that could be exploited for novel therapeutic interventions; however, development of such therapeutic strategies has been challenging due to a lack of basic understanding of the mechanisms controlling this form of redox signaling. In this review, we discuss current knowledge of the basic mechanisms of thiol-electrophile signaling and its potential impact on the translation of this important field of redox biology to the clinic. Emerging understanding of thiol-electrophile interactions and redox signaling suggests replacement of the oxidative stress hypothesis with a new redox biology paradigm, which provides an exciting and influential framework for guiding translational research.

The normal transverse mesocolon and involvement of the mesocolon in acute pancreatitis: an MRI study

Objective

To study the MRI findings of the normal transverse mesocolon and the involvement of the mesocolon in acute pancreatitis (AP) as well as the relationship between the involvement of the mesocolon and the severity of AP.

Materials and Methods

Forty patients without pancreatic disorders were retrospectively analyzed to observe the normal transverse mesocolon using MRI; 210 patients with AP confirmed by clinical and laboratory tests were retrospectively analyzed using MRI to observe transverse-mesocolon involvement (TMI). The severity of TMI was recorded as zero points (no abnormalities and transverse-mesocolon vessel involvement), one point (linear and patchy signal in the transverse mesocolon) or two points (transverse-mesocolon effusion). The AP severity was graded by the MRI severity index (MRSI) and the Acute Physiology And Chronic Healthy Evaluation II (APACHE II) scoring system. The correlations of TMI with MRSI and APACHE-II were analyzed.

Results

In a normal transverse mesocolon, the display rates of the middle colic artery, the middle colic vein and the gastrocolic trunk on MRI were 95.0%, 82.5% and 100.0%, respectively. Of the 210 patients with AP, 130 patients (61.9%) had TMI. According to the TMI grading, 40%, 39% and 20% of the patients were graded at zero, one and two points, respectively. TMI was strongly correlated with the MRSI score (r = 0.759, P = 0.000) and the APACHE-II score (r = 0.384, P = 0.000).

Conclusion

MRI could be used to visualize transverse-mesocolon involvement. The severity of TMI could reflect that of AP in the clinical setting and imaging. TMI might be a supplementary indicator of the severity of AP.

Variation in the γ-glutamyltransferase 1 gene and risk of chronic pancreatitis

OBJECTIVE

Individuals with chronic pancreatitis are at increased risk for pancreatic cancer. We hypothesized that genetic variation in the γ-glutamyltransferase 1 (GGT1) gene, which was recently reported associated with pancreatic cancer risk in a genome-wide association study, is also associated with risk of chronic pancreatitis.

METHODS

Associations between common polymorphisms in GGT1 and chronic pancreatitis were evaluated using data and samples from the North American Pancreatitis Study 2. Patients (n = 496) and control subjects (n = 465) were genotyped for 4 single-nucleotide polymorphisms: rs4820599, rs2017869, rs8135987, and rs5751901. Odds ratios (ORs) and corresponding 95% confidence intervals (95% CI) for chronic pancreatitis risk were calculated using multiple logistic regression models. Interactions with cigarette smoking and alcohol use were explored.

RESULTS

Single-nucleotide polymorphisms rs8135987 and rs4820599 were both statistically significantly associated with risk of chronic pancreatitis; compared with common allele homozygotes, individuals with at least 1 minor allele were at increased risk (rs8135987: OR, 1.36; 95% CI, 1.03-1.80 [P(trend) = 0.01]; rs4820599: OR, 1.39; 95% CI, 1.04-1.84 [P(trend) = 0.0]; adjusted for age, sex, race, smoking status, and alcohol use). No significant interactions with cigarette smoking and alcohol use were observed.

CONCLUSION

Our results suggest that common variation in the GGT1 gene may also affect risk of chronic pancreatitis.

Acute necrotizing pancreatitis in children

OBJECTIVE

To describe the etiologic factors, course, and outcome of acute necrotizing pancreatitis in children.

STUDY DESIGN

We performed a retrospective study of children with necrotizing pancreatitis diagnosed during the last 21 years at Yale-New Haven Children's Hospital. Computed tomography (CT) criteria were used to diagnose necrotizing pancreatitis and to assess severity index. Charts were reviewed to collect demographics, etiology, details of hospital stay, complications, and outcome.

RESULTS

Seven children (mean age, 11.6 years; range, 4-17.8 years) had necrotizing pancreatitis. Etiologic factors were medications, diabetes, and gallstones. All had prolonged hospitalization (9-40 days; mean, 20 days) and 5 patients required admission to the pediatric intensive care unit. During the hospital stay, patients developed complications involving the respiratory, hematologic, renal, metabolic, and circulatory systems. All patients had aggressive supportive medical therapy, and none required surgery. There were no deaths attributable to pancreatitis. Late complications after hospital discharge occurred in 5 patients and included pseudocysts, transient hyperglycemia, diabetes, and pancreatic exocrine insufficiency. The CT severity index correlated with the risk of complications.

CONCLUSIONS

A cute necrotizing pancreatitis has a variable etiology in children. CT scan is useful in the diagnosis and assessment of severity. Necrotizing pancreatitis in children is associated with severe acute and late complications and requires intensive medical therapy.

Controversial role of toll-like receptors in acute pancreatitis

Acute pancreatitis (AP) is a common clinical condition with an incidence of about 300 or more patients per million annually. About 10%-15% of patients will develop severe acute pancreatitis (SAP) and of those, 10%-30% may die due to SAP-associated complications. Despite the improvements done in the diagnosis and management of AP, the mortality rate has not significantly declined during the last decades. Toll-like receptors (TLRs) are pattern-recognition receptors that seem to play a major role in the development of numerous diseases, which make these molecules attractive as potential therapeutic targets. TLRs are involved in the development of the systemic inflammatory response syndrome, a potentially lethal complication in SAP. In the present review, we explore the current knowledge about the role of different TLRs that have been described associated with AP. The main candidate for targeting seems to be TLR4, which recognizes numerous damage-associated molecular patterns related to AP. TLR2 has also been linked with AP, but there are only limited studies that exclusively studied its role in AP. There is also data suggesting that TLR9 may play a role in AP.

Audit of patients with severe acute pancreatitis admitted to an intensive care unit

BACKGROUND

Severe acute pancreatitis (SAP) is a disease with high morbidity and mortality. We undertook a study of patients with SAP admitted to the intensive care unit (ICU) of a tertiary referral hospital.

METHODS

Between 2002 and 2007, 50 patients with SAP were admitted in our intensive care unit (ICU). Data were collected from their medical records and their clinical profile, course and outcome were retrospectively analyzed. Patients were categorized into survivor and nonsurvivor groups, and were further classified based on interventions such as percutaneous drainage and surgical necrosectomy.

RESULTS

SAP contributed 5 % of total ICU admissions during the study period. Median age of survivors (n = 20) was 34 against 44 years in nonsurvivors (n = 30). Median Acute Physiology and Chronic Health Evaluation (APACHE) II score in nonsurvivors was 16.5 (8-32) vs. 12.5 (5-20) in survivors (p = 0.002). Patients with APACHE II score ≥12 had mortality >80 % compared to 23 % with score <12 (p < 0.001). Median Sequential Organ Failure Assessment (SOFA) scores on admission and on days 3, 7, 14, and 21 were significantly higher in nonsurvivors compared to survivors (p < 0.05). Mean (SD) intraabdominal pressure was 23 (3.37) mmHg in nonsurvivors vs. 19.05 (2.51) in survivors (p < 0.05). Patients with renal failure had significant mortality (p < 0.001). Length of ICU stay, requirement for vasopressor, total parenteral nutrition, and the amount of blood and blood product transfusions differed significantly between patients with and without intervention.

CONCLUSIONS

APACHE II and SOFA scores and other clinical data correlated with outcome in SAP admitted to ICU.

Nutritional support in acute pancreatitis

Acute pancreatitis can present as a mild or severe disease. Most patients have a mild disease and recover without requiring nutritional support. Patients with severe acute pancreatitis may develop systemic inflammatory response syndrome and progress to multi-organ failure. These ill patients have high metabolism and protein catabolism. Hence, the nutritional management of these patients can be challenging. The aim of nutritional support is to meet the elevated metabolic demands as far as possible without stimulating pancreatic secretion and yet maintaining the gut integrity. The concept of pancreatic rest has evolved over the years. To date, there is a substantial scientific proof that enteral nutrition (EN) in comparison to parenteral nutrition significantly reduces infectious complications, surgical interventions and mortality in predicted severe acute pancreatitis. EN may be able to improve outcome in these patients if given early. In this review, we summarized the current knowledge on nutrition in acute pancreatitis and shared our local experience.

The Renin-angiotensin system and reactive oxygen species: implications in pancreatitis

SIGNIFICANCE

The renin-angiotensin system (RAS) is a circulating hormonal system involved in the regulation of blood pressure and circulating fluid electrolytes. Recent findings have revealed that locally generated angiotensin (Ang) II plays a pivotal role in normal physiology as well as pathophysiology in various tissues and organs, including the pancreas. This review article summarizes current progress that has been made in elucidating the putative roles of Ang II in both acute and chronic pancreatitis.

RECENT ADVANCES

A convergence of evidence suggests that the underlying mechanism may involve reactive oxygen species (ROS)-generating systems, such as nicotinamide adenine dinucleotide phosphate oxidase, and subsequent elevation of proinflammatory and profibrogenic gene expression as well as protein activity. More importantly, Ang II-induced ROS interacts with other ROS-generating systems to positively feed-forward the ROS-induced signaling.

CRITICAL ISSUES AND FUTURE DIRECTIONS

Advances in basic research indicate that RAS blockers may provide potential therapeutic role for the management of pancreatic inflammation and, more importantly, pancreatitis-associated complications. Genetic alterations resulting from a malfunction in the epigenetic control of pancreatic RAS could be a causative factor in the development of pancreatitis.

Insight into the 6-thiopurine-mediated termination of the invasive motility of tumor cells derived from inflammatory breast cancer

Our study showed that a combination of 6-thiopurine (6-TP) drugs and a redox agent effectively inhibits the motility of SUM cells derived from human inflammatory breast cancer (IBC) cells and RhoC-overexpressed mammary epithelium cells. This 6-TP-mediated inhibition of cell motility occurs because the treated 6-TPs target and inactivate RhoC. A molecular mechanism for inactivation by the 6-TP-mediated RhoC is proposed by which treated TPs are converted in cells into 6-thioguanosine phosphate (6-TGNP). This 6-TGNP in turn reacts with the Cys(20) side chain of the redox-sensitive GXXXCGK(S/T)C motif of RhoC to produce a 6-TGNP-RhoC disulfide adduct. A redox agent synergistically enhances the formation process of this disulfide. The adduct that is formed impedes RhoC guanine nucleotide exchange, which populates an inactive RhoC. Our results suggest that 6-TGNP can also react with the redox-sensitive GXXXCGK(S/T)C and GXXXXGK(S/T)C motif of RhoA and Rac, respectively, to produce a 6-TGNP-RhoA and 6-TGNP-Rac disulfide adduct. However, given that RhoC has been shown to be overexpressed in ∼90% of IBC lesions, the populated RhoC but not other Rho proteins is likely to be a primary target for 6-TPs and a redox agent to terminate the metastasis of IBC.

Beneficial role of naringin, a flavanoid on nickel induced nephrotoxicity in rats

This study was conducted to investigate the beneficial role of naringin on nickel induced nephrotoxicity. Nickel (Ni) (20mg/kg body weight (b.w.) was administered intraperitoneally (i.p.) for 20 days. Naringin was administered orally (20, 40 and 80 mg/kg b.w.) with i.p. administration of Ni. Ni administration increased the levels of serum urea, uric acid and creatinine with a significant decrease in creatinine clearance and decreased levels of urea, uric acid and creatinine in urine. The levels of lipid peroxidation markers and nickel concentration in blood and kidney were also increased. While, the activities of enzymic and non-enzymic antioxidants were decreased. Treatment with naringin attenuated the alterations in the renal and urine markers, decreasing lipid peroxidation markers, increasing the antioxidant cascade and decreasing the nickel concentration in blood and kidney. All these changes were supported by histopathological observations. These findings demonstrate that naringin exerts a protective effect against nickel toxicity.

The association between GSTT1, M1, and P1 polymorphisms with coronary artery disease in Western Iran

DNA damage which occurred by the effect of oxidant and mutant agents has an essential role in the development of atherosclerosis. To investigate the possible association between GSTs polymorphism with coronary artery disease (CAD), we investigated the frequency of GSTT1, M1, and P1 genotypes in patients with CAD compared to controls. The genotypes of GSTT1, M1, and P1 were determined in 209 angiographically documented CAD patients and 108 normal coronary artery cases (as controls) by Multiplex Polymerase Chain Reaction and PCR-RFLP. In CAD patients, the frequency of GSTT1-null genotype was significantly (P = 0.025) lower than that in control. The presence of this genotype was associated with 2.2-fold increased risk of CAD. However, the frequency of GSTM1 and GSTP1 genotypes were not significantly different comparing both groups (P = 0.405 and P = 0.521, respectively). Moreover, non smokers patients had a lower frequency of GSTM1-null genotype (29.2%) compared to non smoker controls (43.5%, P = 0.043). Also, the frequency of both GSTT1-null and GSTM1-null genotypes in patients (3.8%) was significantly lower compared to controls with the same genotypes (10.2%, P = 0.014). Our results indicated that a reduction in the frequency of GSTT1-null and GSTM1-null genotypes that observed in our study might be involved in the pathogenesis of CAD in our population.

Acute pancreatitis

Acute pancreatitis (AP) is an important cause of morbidity and mortality worldwide and the annual incidence appears to be increasing. It presents as a mild self-limiting illness in 80% of patients. However, one-fifth of these develop a severe complicated life-threatening disease requiring intensive and prolonged therapeutic intervention. Alcohol and gallstone disease remain the commonest causes of AP but metabolic abnormalities, obesity and genetic susceptibility are thought be increasingly important aetiological factors. The prompt diagnosis of AP and stratification of disease severity is essential in directing rapid delivery of appropriate therapeutic measures. In this review, the range of diagnostic and prognostic assays, severity scoring systems and radiological investigations used in current clinical practice are described, highlighting their strengths and weaknesses. Increased understanding of the complex pathophysiology of AP has generated an array of new potential diagnostic assays and these are discussed. The multidisciplinary approach to management of severe pancreatitis is outlined, including areas of controversy and novel treatments.

Pharmacogenomics in the treatment of inflammatory bowel disease

In recent years, the benefits of early aggressive treatment paradigms for inflammatory bowel disease have emerged. Symptomatic improvement is no longer considered adequate; instead, the aim of treatment has become mucosal healing and altered natural history. Nonetheless, we still fail to achieve these end points in a large number of our patients. There are many reasons why patients fail to respond or develop toxicity when exposed to drugs used for inflammatory bowel disease, but genetic variation is likely to account for a significant proportion of this. Some examples, notably thiopurine methyltransferase polymorphism in thiopurine treatment, are already established in clinical practice. We present a review of the expanding literature in this field, highlighting many interesting developments in pharmacogenomics applied to inflammatory bowel disease and, where possible, providing guidance on the translation of these developments into clinical practice.

-651C/T promoter polymorphism in the CD14 gene is associated with severity of acute pancreatitis in Japan

PURPOSE

This study aimed to clarify the association of the promoter variants in the CD14 gene with pancreatic diseases in Japan.

METHODS

Three hundred forty-six unrelated patients with acute pancreatitis (AP) (107 with severe and 239 with mild), 263 patients with chronic pancreatitis (CP), 264 patients with pancreatic neoplasm, and 319 healthy controls were genotyped for the single nucleotide polymorphisms at positions -260 and -651 from the AUG start codon in the CD14 gene by polymerase chain reaction-restriction enzyme digestion.

RESULTS

The allele and genotype frequencies of the -260C/T and -651C/T polymorphisms did not differ between controls and patients with AP. In subgroup analyses, patients with severe AP had more -651C allele than controls [P = 0.005; odds ratio (OR) 1.71; 95% confidence interval (CI) = 1.18-2.49] or patients with mild AP (P = 0.001; OR 1.95; 95% CI = 1.33-2.85). Genotype -651CC was more common (P = 0.001 vs. controls and P = 0.001 vs. mild AP), and -651CT was less (P = 0.009 vs. controls and P = 0.007 vs. mild AP) in patients with severe AP than in healthy controls or patients with mild AP. The frequencies of pseudocyst development and requirement of surgery were higher in AP patients with -651CC than in those without this genotype. The -260C/T polymorphism was not associated with the severity of AP. The allele and genotype frequencies of both polymorphisms did not differ between controls and patients with CP or pancreatic neoplasm.

CONCLUSION

-651C/T promoter polymorphism in the CD14 gene was associated with severity of AP in Japan.

Microsatellite polymorphism in intron 2 of human Toll-like receptor 2 gene is associated with susceptibility to acute pancreatitis in Japan

This study evaluated the association of the polymorphisms in the Toll-like receptor (TLR)2 and TLR4 genes with acute pancreatitis (AP) in Japan. The numbers of guanine-thymine [(GT)n] repeats in intron 2 of the TLR2 gene were counted in 202 unrelated patients with AP (80 with severe and 122 with mild disease) and in 286 healthy controls, using polymerase chain reaction and Genescan analysis. The alleles were divided into three subclasses: (GT)16 or less as the S allele; between (GT)17 and (GT)22 as the M allele; and (GT)23 or more as the L allele. Asp299Gly and Thr399Ile polymorphisms in the TLR4 gene were examined by polymerase chain reaction-restriction fragment length polymorphism analysis. Patients with AP had more S alleles (p < 0.001; odds ratio = 2.37; 95% confidence interval = 1.78-3.17) and fewer M alleles (p < 0.001; odds ratio = 0.40; 95% confidence interval 0.31-0.52) than did healthy controls. Genotypes SS and SL were more common, whereas MM and ML were less common in patients with AP. In subgroup analyses, the genotypes including S alleles were more common in patients with severe AP than in controls. No Asp299Gly and Thr399Ile polymorphisms were detected. In conclusion, microsatellite polymorphism in intron 2 of the TLR2 gene was associated with susceptibility to AP and its severity in Japan.

The role of epoxide hydrolase Y113H gene variant in pancreatic diseases

OBJECTIVES

Chronic pancreatitis (CP) and pancreatic adenocarcinoma (pCA) are associated with risk factors such as alcohol intake and tobacco smoking. Microsomal epoxide hydrolase (EPHX1) is a phase II detoxifying enzyme capable of tobacco-borne toxicant inactivation. We studied the role of the EPHX1 c.337T>C (p.Y113H) variant, whichleads to altered enzyme activity, in pancreatic diseases.

METHODS

We genotyped 2391 patients by melting curve analysis. We enrolled 367 patients with pCA, 341 patients with alcoholic CP (aCP), 431 patients with idiopathic CP or hereditary pancreatitis, 192 patients with acute pancreatitis, and 679 controls of German descent. We replicated data in 77 patients with aCP and 304 controls from The Netherlands.

RESULTS

In German patients with aCP, Y113 was more common than in controls (allele frequencies, 0.73 vs 0.68; risk ratio, 1.21 [95% confidence interval, 1.05-1.39]). However, we could not confirm this association in the Dutch population (allele frequencies, 0.62 vs 0.68, P=not significant). In total, Y113 frequency was 0.71 in aCP and 0.68 in controls (P = not significant). Allele frequencies did not differ in the other disease groups (acute pancreatitis, 0.69; idiopathic CP or hereditary pancreatitis, 0.68; pCA, 0.68; and control, 0.68).

CONCLUSIONS

The EPHX1 Y113H variant is not associated with pancreatic diseases indicating that EPHX1 does not play a significant role in the initiation of pancreatic inflammation or cancer.

Transsulfuration pathway defects and increased glutathione degradation in severe acute pancreatitis

Glutathione depletion is a consistent feature of the progression of mild to severe acute pancreatitis. In this study, we examined the temporal relationship between cysteine, homocysteine, and cysteinyl-glycine levels; total reduced erythrocyte glutathione; gamma-glutamyl transpeptidase activity; and disease severity. Initially, cysteine concentration was low, at levels similar to those of healthy controls. However, glutathione was reduced whilst cysteinyl glycine and gamma-glutamyl transpeptidase activity were increased in both mild and severe attacks. As the disease progressed, glutathione and cysteinyl glycine were further increased in mild attacks and cysteine levels correlated with homocysteine (r = 0.8, P < 0.001) and gamma-glutamyl transpeptidase activity (r = 0.75, P < 0.001). The progress of severe attacks was associated with glutathione depletion, reduced gamma-glutamyl transpeptidase activity, and increased cysteinyl glycine that correlated with glutathione depletion (r = 0.99, P = 0.01). These results show that glutathione depletion associated with severe acute pancreatitis occurs despite an adequate cysteine supply and could be attributed to heightened oxidative stress coupled to impaired downstream biosynthesis.

Imaging assessment of acute pancreatitis: a review

Acute pancreatitis is one of the more commonly encountered etiologies in the emergency setting. While in the majority of cases it is a self-limiting disease which responds rapidly to conservative management, in some cases acute pancreatitis may present with a more pronounced, sometimes dramatic, clinical picture and requires immediate medical care to avoid fatal complication. In this context, imaging plays a significant role because it enables identification of the development of the disease and local/systemic complications. The purpose of this article is to offer an overview of the disease and a spectrum of imaging findings in patients with acute pancreatitis, emphasizing the role of ultrasound, computed tomography, and magnetic resonance imaging according to the appropriate clinical context and advantages and limitations of each imaging modality are examined.

Role of oxidative stress in pancreatic inflammation

Reactive oxygen and reactive nitrogen species (ROS/RNS) have been implicated in the pathogenesis of acute and chronic pancreatitis. Clinical and basic science studies have indicated that ROS/RNS formation processes are intimately linked to the development of the inflammatory disorders. The detrimental effects of highly reactive ROS/RNS are mediated by their direct actions on biomolecules (lipids, proteins, and nucleic acids) and activation of proinflammatory signal cascades, which subsequently lead to activation of immune responses. The present article summarizes the possible sources of ROS/RNS formation and the detailed signaling cascades implicated in the pathogenesis of pancreatic inflammation, as observed in acute and chronic pancreatitis. A therapeutic ROS/RNS-scavenging strategy has been advocated for decades; however, clinical studies examining such approaches have been inconsistent in their results. Emerging evidence indicates that pancreatitis-inducing ROS/RNS generation may be attenuated by targeting ROS/RNS-generating enzymes and upstream mediators.

Probiotics enhance pancreatic glutathione biosynthesis and reduce oxidative stress in experimental acute pancreatitis

Factors determining severity of acute pancreatitis (AP) are poorly understood. Oxidative stress causes acinar cell injury and contributes to the severity, whereas prophylactic probiotics ameliorate experimental pancreatitis. Our objective was to study how probiotics affect oxidative stress, inflammation, and acinar cell injury during the early phase of AP. Fifty-three male Sprague-Dawley rats were randomly allocated into groups: 1) control, 2) sham procedure, 3) AP with no treatment, 4) AP with probiotics, and 5) AP with placebo. AP was induced under general anesthesia by intraductal glycodeoxycholate infusion (15 mM) and intravenous cerulein (5 microg.kg(-1).h(-1), for 6 h). Daily probiotics or placebo were administered intragastrically, starting 5 days prior to AP. After cerulein infusion, pancreas samples were collected for analysis including lipid peroxidation, glutathione, glutamate-cysteine-ligase activity, histological grading of pancreatic injury, and NF-kappaB activation. The severity of pancreatic injury correlated to oxidative damage (r = 0.9) and was ameliorated by probiotics (1.5 vs. placebo 5.5; P = 0.014). AP-induced NF-kappaB activation was reduced by probiotics (0.20 vs. placebo 0.53 OD(450nm)/mg nuclear protein; P < 0.001). Probiotics attenuated AP-induced lipid peroxidation (0.25 vs. placebo 0.51 pmol malondialdehyde/mg protein; P < 0.001). Not only was AP-induced glutathione depletion prevented (8.81 vs. placebo 4.1 micromol/mg protein, P < 0.001), probiotic pretreatment even increased glutathione compared with sham rats (8.81 vs. sham 6.18 miccromol/mg protein, P < 0.001). Biosynthesis of glutathione (glutamate-cysteine-ligase activity) was enhanced in probiotic-pretreated animals. Probiotics enhanced the biosynthesis of glutathione, which may have reduced activation of inflammation and acinar cell injury and ameliorated experimental AP, via a reduction in oxidative stress.

Genetic polymorphism of MCP-1-2518, IL-8-251 and susceptibility to acute pancreatitis: a pilot study in population of Suzhou, China

AIM

To study the relationship between MCP-1-2518A/G, IL-8-251A/T polymorphism and acute pancreatitis (AP) in the Han population of Suzhou, China.

METHODS

A case-control study was conducted to compare the distribution of genotype and genetic frequency of MCP-1-2518A/G, IL-8-251A/T gene polymorphism among AP (n = 101), including mild AP (n = 78) and severe AP (n = 23) and control healthy individuals (n = 120) with polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and DNA sequencing, and analyze the relationship between the MCP-1-2518A/G, IL-8-251A/T gene polymorphism and the susceptibility to AP.

RESULTS

Significant differences were found in the distribution of genotype of MCP-1-2518A/G between the healthy control group and mild AP group (chi2 = 32.015, P < 0.001), the same was evident between the healthy control group and severe AP group (chi2 = 12.932, P < 0.05) in Suzhou. However, no difference of genotypic distribution was noted between MAP and SAP (chi2 = 0.006, P = 0.997). The genetic frequencies of G allele in mild AP were 72.4% (113/156) and 76.1% (35/46) in severe AP, both were higher than the controls, 47.1% (113/240) (chi2 = 24.804; P < 0.001, and chi2 = 13.005; P < 0.001), but no difference was found between severe AP and mild AP (chi2 = 0.242; P = 0.623). No difference was found in the distribution of genotype of IL-8-251A/T between the healthy control group and AP group neither in the frequency of A and T allele.

CONCLUSION

The MCP-1-2518 AA genotype of the population in Suzhou may be a protective genotype of AP, while one with higher frequency of G allele is more likely to suffer from pancreatitis. But the genotype of AA and the frequency of G allele could not predict the risk of severe AP. No correlation is found between the IL-8-251 polymorphism and the liability of AP.

Severe acute pancreatitis: Pathogenetic aspects and prognostic factors

Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality. The purpose of this study is to review pathogenesis and prognostic factors of severe acute pancreatitis (SAP). An extensive medline search was undertaken with focusing on pathogenesis, complications and prognostic evaluation of SAP. Cytokines and other inflammatory markers play a major role in the pathogenesis and course of SAP and can be used as prognostic markers in its early phase. Other markers such as simple prognostic scores have been found to be as effective as multifactorial scoring systems (MFSS) at 48 h with the advantage of simplicity, efficacy, low cost, accuracy and early prediction of SAP. Recently, several laboratory markers including hematocrit, blood urea nitrogen (BUN), creatinine, matrix metalloproteinase-9 (MMP-9) and serum amyloid A (SAA) have been used as early predictors of severity within the first 24 h. The last few years have witnessed a tremendous progress in understanding the pathogenesis and predicting the outcome of SAP. In this review we classified the prognostic markers into predictors of severity, pancreatic necrosis (PN), infected PN (IPN) and mortality.

The Atlanta Classification of acute pancreatitis revisited

BACKGROUND

In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed.

METHODS

A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used.

RESULTS

A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections.

CONCLUSION

The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.

Advances in research of severe acute pancreatitis complicated by lung injury

Lung injury is one of the most common complications of severe acute pancreatitis (SAP). At present, the pathogenesis of SAP complicated by lung injury still remains unclear. However, great attention has been paid to it at home and abroad. Many factors such as pancreatic enzyme, polymorphonuclear neutrophil, oxygen free radical, cytokine, microcirculatory disturbance, complement, kinin, NO and ET play an important role in the pathogenesis of SAP by interacting with each other. This paper reviews the advances in the pathogenesis of SAP complicated by lung injury and related studies in order to provide the theoretical basis for its effective prevention and treatment.