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Jha SK, Jha P, Karki P. Necrotizing pancreatitis in an 8-year-old girl: a case report from Nepal. Ann Med Surg (Lond) 2024; 86:5639-5642. [PMID: 39239060 PMCID: PMC11374229 DOI: 10.1097/ms9.0000000000002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 07/31/2024] [Indexed: 09/07/2024] Open
Abstract
Introduction and importance Necrotizing pancreatitis is an uncommon diagnosis in pediatric patients. Early diagnosis is difficult as the presentation varies significantly. However, it should be in the differential diagnosis of abdominal pain in the pediatric age group. Case presentation An 8-year-old girl arrived with a 1-day history of vomiting, constipation, and abrupt, increasing epigastric discomfort. She didn't have any noteworthy family or medical background. Upon examination, she seemed to be afebrile but also had discomfort in her stomach and symptoms of dehydration. An enlarged pancreas with necrotizing pancreatitis was seen in the first imaging. She received intravenous fluids, antibiotics, and analgesics as a treatment for her acute severe pancreatitis diagnosis. Since the patient continued to have fever, meropenem was prescribed in place of ceftriaxone at first. After 10 days of uncomplicated hospitalization, she was released from the hospital. Discussion Once rare, pediatric pancreatitis now affects 3-13 out of every 100 000 people yearly. Although it is uncommon (<1% in children), necrotizing pancreatitis can happen. Its causes are similar to those of acute pancreatitis, involving genetic abnormalities and certain drugs. Abdominal discomfort, fever, vomiting, and nausea are among the symptoms. Imaging methods like contrast-enhanced CT are used in diagnosis. Surgery has given way to less intrusive techniques like catheter drainage as a form of treatment. Surgery is seldom required in pediatric instances, which are often handled conservatively. Conclusion Childhood necrotizing pancreatitis is uncommon but dangerous; prompt diagnosis and prompt treatment are essential.
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Affiliation(s)
- Saroj Kumar Jha
- Department of Internal Medicine, Gajendra Narayan Singh Hospital, Rajbiraj
| | - Pinky Jha
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Pearlbiga Karki
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
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Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, Todi SK, Mohan A, Hegde A, Jagiasi BG, Krishna B, Rodrigues C, Govil D, Pal D, Divatia JV, Sengar M, Gupta M, Desai M, Rungta N, Prayag PS, Bhattacharya PK, Samavedam S, Dixit SB, Sharma S, Bandopadhyay S, Kola VR, Deswal V, Mehta Y, Singh YP, Myatra SN. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024; 28:S104-S216. [PMID: 39234229 PMCID: PMC11369928 DOI: 10.5005/jp-journals-10071-24677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 09/06/2024] Open
Abstract
How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.
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Affiliation(s)
- Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Subhash K Todi
- Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Ashit Hegde
- Department of Medicine & Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, India
| | - Camila Rodrigues
- Department of Microbiology, P D Hinduja National Hospital, Mumbai, India
| | - Deepak Govil
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Divya Pal
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mukesh Desai
- Department of Immunology, Pediatric Hematology and Oncology Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Narendra Rungta
- Department of Critical Care & Anaesthesiology, Rajasthan Hospital, Jaipur, India
| | - Parikshit S Prayag
- Department of Transplant Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Srinivas Samavedam
- Department of Critical Care, Ramdev Rao Hospital, Hyderabad, Telangana, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Sudivya Sharma
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Susruta Bandopadhyay
- Department of Critical Care, AMRI Hospitals Salt Lake, Kolkata, West Bengal, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Vikas Deswal
- Consultant, Infectious Diseases, Medanta - The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Yogendra P Singh
- Department of Critical Care, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Razjouyan H, Maranki JL. Endoscopic Retrograde Cholangiopancreatography for the Management of Pancreatic Duct Leaks and Fistulas. Gastrointest Endosc Clin N Am 2024; 34:405-416. [PMID: 38796289 DOI: 10.1016/j.giec.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Pancreatic duct (PD) leaks are a common complication of acute and chronic pancreatitis, trauma to the pancreas, and pancreatic surgery. Diagnosis of PD leaks and fistulas is often made with contrast-enhanced pancreatic protocol computed tomography or magnetic resonance imaging with MRCP. Endoscopic retrograde pancreatography with pancreatic duct stenting in appropriately selected patients is often an effective treatment, helps to avoid surgery, and is considered first-line therapy in cases that fail conservative management.
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Affiliation(s)
- Hadie Razjouyan
- Division of Gastroenterology and Hepatology, Penn State College of Medicine, Penn State Health, 500 University Drive, HU850, Hershey, PA 17033, USA
| | - Jennifer L Maranki
- Division of Gastroenterology and Hepatology, Penn State College of Medicine, Penn State Health, 500 University Drive, HU850, Hershey, PA 17033, USA.
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Tomanguillo J, Searls L, Annie FH, Kemper S, Drabish K, Naravadi V. A Nationwide Analysis of Fluid Resuscitation Outcomes in Patients With Acute Pancreatitis. Cureus 2023; 15:e50182. [PMID: 38192944 PMCID: PMC10771961 DOI: 10.7759/cureus.50182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Traditionally, fluid resuscitation has been the foundation of effective acute pancreatitis (AP) treatment. Experts advocate for aggressive intravenous fluid (IVF) resuscitation, especially within the first 24 hours. Research suggests limited efficacy of this approach; in fact, some studies show there may be a risk of increased complications. The aim of this study was to assess outcomes of aggressive IVF resuscitation in patients with AP. METHODS We queried the TriNetX Research Network (Cambridge, Massachusetts, United States) for patients admitted between January 1, 2010, and December 31, 2020, with a diagnosis of AP and who had received IVF on admission for at least 24 hours. We compared two cohorts; cohort 1 consisted of patients receiving aggressive IVF resuscitation (>3 ml/kg/hr), and cohort 2 was comprised of patients receiving non-aggressive (≤1.5 ml/kg/hr) IVF resuscitation. We compared mortality during index hospitalization, hospital length of stay (HLS), mechanical ventilation rates, acute kidney injury (AKI), and severe sepsis between the cohorts with propensity scoring matched (PSM) pairs of patients. A sub-analysis of patients with severe AP was performed. RESULTS After comparing the two well-matched PSM cohorts (3,680/3,680), we found no significant differences in mortality, HLS, mechanical ventilation rates, AKI, or severe sepsis. We found similar results after conducting the sub-analysis of patients with severe pancreatitis. CONCLUSIONS We found no significant differences in mortality and HLS when comparing rates of IVF resuscitation.
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Affiliation(s)
- Julton Tomanguillo
- Internal Medicine, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
| | - Lauren Searls
- Internal Medicine, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
| | - Frank H Annie
- Cardiology, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
| | - Suzanne Kemper
- Outcomes Research, Charleston Area Medical Center (CAMC) Health Education and Research Institute, Charleston, USA
| | - Kerry Drabish
- Research, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
| | - Vishnu Naravadi
- Gastroenterology, Charleston Area Medical Center (CAMC) Institute for Academic Medicine, Charleston, USA
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Navlani LL, Verma A, Meshram R, Vaibhav V, Parate SV. Challenges in Diagnosing Sudden Death Caused by Acute Hemorrhagic Pancreatitis: An Autopsy-Based Case Report. Cureus 2023; 15:e49500. [PMID: 38152772 PMCID: PMC10752382 DOI: 10.7759/cureus.49500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 12/29/2023] Open
Abstract
Forensic pathologists frequently encounter cases of sudden natural death. Most sudden natural deaths are attributed to cardiac causes. Acute pancreatitis, especially hemorrhagic pancreatitis, is an infrequent yet critical contributor to sudden death. The role of a forensic pathologist is imperative in such cases to find out the cause of the sudden death and to either confirm or refute any allegations. In this context, we describe a case of a 34-year-old male who experienced sudden death due to acute hemorrhagic pancreatitis, highlighting the need for a detailed autopsy, pathophysiological insights, and diagnostic challenges.
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Affiliation(s)
- Lakhan Lal Navlani
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Arushi Verma
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Raviprakash Meshram
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Vikas Vaibhav
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Shailesh V Parate
- Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Rishikesh, IND
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Varda B, Alani M, Ahmed S. A Rare Case of Spontaneous Fungal Peritonitis Caused by Candida lusitaniae in a Patient With Necrotizing Pancreatitis. Cureus 2023; 15:e40237. [PMID: 37435273 PMCID: PMC10332884 DOI: 10.7759/cureus.40237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Candida lusitaniae is a rare cause of peritonitis most commonly associated with peritoneal dialysis patients. Pancreatitis is one possible cause of ascites with a low serum ascites albumin gradient. Herein, we present a case of spontaneous fungal peritonitis caused by Candida lusitaniae in a patient with necrotizing pancreatitis. The patient was treated with antifungal medication, while her pancreatitis was managed endoscopically with necrosectomy. She improved clinically and was discharged in stable condition.
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Affiliation(s)
- Bianca Varda
- Internal Medicine, St. Joseph's Hospital and Medical Center, Phoenix, USA
- Internal Medicine, Loyola University Medical Center, Chicago, USA
| | | | - Shifat Ahmed
- Gastroenterology, Creighton University School of Medicine, St. Joseph's Hospital and Medical Center, Phoenix, USA
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7
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Kumar M, Sonika U, Sachdeva S, Dalal A, Narang P, Mahajan B, Singhal A, Srivastava S. Natural History of Asymptomatic Walled-off Necrosis in Patients With Acute Pancreatitis. Cureus 2023; 15:e34646. [PMID: 36895535 PMCID: PMC9990741 DOI: 10.7759/cureus.34646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/07/2023] Open
Abstract
Background and objectives Studies on the natural history of asymptomatic walled-off necrosis (WON) in acute pancreatitis (AP) are scarce. We conducted a prospective observational study to look for the incidence of infection in WON. Material and methods In this study, we included 30 consecutive AP patients with asymptomatic WON. Their baseline clinical, laboratory, and radiological parameters were recorded and followed up for three months. Mann Whitney U test and unpaired t-tests were used for quantitative data and chi-square and Fisher's exact tests were used for qualitative data analysis. A p-value <0.05 was considered significant. Receiver operating characteristic curve (ROC) analysis was done to identify the appropriate cutoffs for the significant variables. Results Of the 30 patients enrolled, 25 (83.3%) were males. Alcohol was the most common etiology. Eight patients (26.6%) developed an infection on follow-up. All were managed by drainage either percutaneously (n=4, 50%) or endoscopically (n=3, 37.5%). One patient required both. No patient required surgery and there was no mortality. Median baseline C-reactive protein (CRP) was higher in infection group 76 (IQR=34.8) mg/L vs asymptomatic group, 9.5 mg/dl (IQR=13.6), p<0.001. IL-6 and tumor necrosis factor (TNF)-alpha was also higher in the infection group. The size of the largest collection (157.50±33.59 mm vs 81.95±26.22 mm, P<0.001) and CT severity index (CTSI) (9.50±0.93 vs 7.82±1.37, p<0.01) were also higher in infection group as compared to the asymptomatic group. ROC curve analysis of baseline CRP (cutoff 49.5mg/dl), size of WON (cutoff 127mm) and CTSI (cutoff of 9) showed AUROC (area under ROC) of 1, 0.97, and 0.81 respectively for the future development of infection in WON. Conclusion Around one-fourth of asymptomatic WON patients developed an infection during three-months follow-up. Most patients with infected WON can be managed conservatively.
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Affiliation(s)
- Manish Kumar
- Gastroenterology, Govind Ballabh Pant Hospital, New Delhi, IND
| | - Ujjwal Sonika
- Gastroenterology, Govind Ballabh Pant Hospital, New Delhi, IND
| | | | - Ashok Dalal
- Gastroenterology, Govind Ballabh Pant Hospital, New Delhi, IND
| | - Poonam Narang
- Radiology, Govind Ballabh Pant Hospital, New Delhi, IND
| | - Bhawna Mahajan
- Biochemistry, Govind Ballabh Pant Hospital, New Delhi, IND
| | - Ankush Singhal
- Biochemistry, Govind Ballabh Pant Hospital, New Delhi, IND
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8
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Clinical characteristics and risk factors of organ failure and death in necrotizing pancreatitis. BMC Gastroenterol 2023; 23:19. [PMID: 36658497 PMCID: PMC9850524 DOI: 10.1186/s12876-023-02651-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Organ failure (OF) and death are considered the most significant adverse outcomes in necrotizing pancreatitis (NP). However, there are few NP-related studies describing the clinical traits of OF and aggravated outcomes. PURPOSE An improved insight into the details of OF and death will be helpful to the management of NP. Thus, in our research, we addressed the risk factors of OF and death in NP patients. METHODS We performed a study of 432 NP patients from May 2017 to December 2021. All patients with NP were followed up for 36 months. The primary end-points were risk factors of OF and death in NP patients. The risk factors were evaluated by logistic regression analysis. RESULTS NP patients with OF or death patients were generally older, had a higher APACHE II score, longer hospital stay, longer ICU stay, as well as a higher incidence of severe acute pancreatitis (SAP), shock and pancreatic necrosis. Independent risk factors related to OF included BMI, APACHE II score and SAP (P < 0.05). Age, shock and APACHE II score (P < 0.05) were the most significant factors correlated with the risk of death in NP patients. Notably, increased mortality was linked to the number of failed organs. CONCLUSIONS NP is a potentially fatal disease with a long hospital or ICU stay. Our study indicated that the incidence of OF and death in NP patients was 69.9% and 10.2%, respectively. BMI, SAP, APACHE II score, age and shock are potential risk factors of OF and death in NP patients. Clinicians should focus on these factors for early diagnosis and appropriate therapy.
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Necrotizing soft tissue infection of the upper leg as first presentation of necrotizing pancreatitis: a case report. Acta Gastroenterol Belg 2022; 85:518-521. [DOI: 10.51821/85.3.8934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Acute pancreatitis can be complicated with necrosis of the pancreatic or peripancreatic tissue. This necrosis can become liquified and form a well-defined wall (walled-off necrosis or WON) and can become infected and form abscesses. Necrotizing soft tissue infections are rare infections of the deep tissue and subcutaneous fat and are mostly caused by trauma or perforated visceral organs. They can, however, rarely be caused by infected retroperitoneal collections. To date only 3 case reports have been published of a necrotizing soft tissue infection complicating a necrotizing pancreatitis. Both acute, complicated pancreatitis and necrotizing soft tissue infections carry a high mortality and morbidity rate with surgery being the mainstay therapy for the latter, often leaving the patient disfigured. We report the case of a 62-year-old man presenting to the emergency department with a painful and erythematous rash of the upper leg as complication of an acute necrotizing pancreatitis.
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Vogel M, Ehlken H, Kluge S, Roesch T, Lohse AW, Huber S, Sterneck M, Huebener P. High risk of complications and acute-on-chronic liver failure in cirrhosis patients with acute pancreatitis. Eur J Intern Med 2022; 102:54-62. [PMID: 35672219 DOI: 10.1016/j.ejim.2022.05.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/18/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND & AIMS Acute pancreatitis (AP) is a frequent indication for hospitalization and may present with varying degrees of severity. AP often coincides with hepatic disease, yet the impact of liver cirrhosis (LC) on the course of AP is uncertain, and early identification of patients at risk for complications remains challenging. We aimed to assess the impact of LC on the development of pancreatic and extra-pancreatic complications of AP, and to identify predictors of adverse outcomes in cirrhotic patients. METHODS All adult patients with LC and AP (LC-AP, n = 52) admitted to our institution between 01/2011-03/2020 were subjected to a 1:2 matched-pair analysis with patients with AP but without LC (NLC-AP, n = 104). RESULTS At hospital admission, Glasgow-Imrie and Ranson scores as well as markers of systemic inflammation were comparable in LC-AP and NLC-AP patients, and both groups had similar rates of necrotizing AP. Infectious complications were more prevalent, and medical interventions were performed more often and with higher complication rates in LC-AP patients. While only 12.5% of NLC-AP patients developed organ failures, 48% of LC-AP patients developed single (7.7%) or multiple organ failure (40.4%), resulting in 44% of LC-AP patients with acute-on-chronic liver failure (ACLF). Patients with overt portal hypertension were particularly prone for decompensation. Mortality was higher among LC-AP compared to NLC-AP patients (6-month mortality 25% vs. 1.9%, p < 0.001), and SOFA and MELD scores at admission most accurately predicted outcomes in LC-AP. CONCLUSION Among AP patients, concomitant cirrhosis substantially increases the risk for infections, periprocedural complications, multiorgan failure and death.
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Affiliation(s)
- Michael Vogel
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno Ehlken
- Department for Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Roesch
- Department for Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samuel Huber
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Huebener
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Zhang J, Wang Y, Liu B, Liu X, Xu Z. Activity of Ligustrum vulgare L extracts against acute pancreatitis in murine models by regulation of p38 MAPK and NF-κB signaling pathways. Saudi J Biol Sci 2022; 29:273-278. [PMID: 35002419 PMCID: PMC8716890 DOI: 10.1016/j.sjbs.2021.08.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 01/30/2023] Open
Abstract
Pancreatitis is a fatal disease associated with significant mortality and morbidity. At present, no specific treatment is available for pancreatitis and the patients are mainly treated with supportive medication. The need for specific antipancreatitic chemotherapy is an urgent medical obligation. In the current study, protective effects of the methanolic extract of the Ligustrum vulgare berries were investigated in the rat model of acute pancreatitis. Acute pancreatitis (AP) was induced in the male Sprague-Dawley (SD) rats by cerulein injection. Fruit extract of L. vulgare L extract was prepared using the methanol. Treatment effects of L. vulgare were evaluated in AP rats. Serum levels of lipase, amylase, proinflamatory cytokines (TNF-α, IL-6, TL-1β), lipid peroxidase (LPO), myeloperoxidase (MPO) were determined. Histological changes in the pancreas were assessed. L. vulgare treatment prevented the increase in serum amylase and lipase levels, reduced the disease progression in pancreas, and reduced the serum levels of tumour necrosis factor (TNF)-α, interleukin (IL)-6, and IL-1β in AP rats. Moreover, L. vulgare significantly suppressed pancreatic edema, inhibited oxidative damage (MPO activity and SOD activity), and inhibited the expression of NF-κB/p65 and activation (phosphorylation) of the inhibitor of NF-κB (IκBα) and p38 MAPKs. Histological examinations showed that L. vulgare significantly reduced the inflammatory and fibrotic changes. The results indicated the potent pancreato-protective effects of L. vulgare in AP.
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Affiliation(s)
- Jing Zhang
- Department of Gastroenterology, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, Hubei 441000, China
| | - Yi Wang
- Department of General Surgery, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, Hubei 441000, China
| | - Bo Liu
- Department of Gastroenterology, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, Hubei 441000, China
| | - Xiaoyun Liu
- Department of ICU, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, Hubei 441000, China
| | - Zhengqin Xu
- Department of ICU, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, Hubei 441000, China
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12
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[Imaging diagnostics in acute pancreatitis]. Internist (Berl) 2021; 62:1044-1054. [PMID: 34524469 DOI: 10.1007/s00108-021-01153-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
Abdominal imaging is an important component of the diagnostics of acute pancreatitis. In addition to the clinical features and the laboratory constellation, it serves to establish the diagnosis or the exclusion of other diseases and also the identification and assessment of the course of local complications and vascular changes that can arise during the course of acute pancreatitis. Due to the numerous imaging examination methods that are available, their combination options and the different examination times, there are diverse application options that have to be taken into account, such as the severity and duration of the disease, concomitant diseases and complications of acute pancreatitis. A rational use of imaging is an important prerequisite for high quality and at the same time cost-effective patient care. This review summarizes the current importance of imaging in acute pancreatitis, with particular reference to the updated S3 guidelines on acute pancreatitis.
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Basukala S, Shah KB, Karki B, Thapa N, Basukala B, Karki S, Pathak BD. Acute hemorrhagic necrotizing pancreatitis in patient with COVID-19: a case report and review of literature. J Surg Case Rep 2021; 2021:rjab401. [PMID: 34567518 PMCID: PMC8460276 DOI: 10.1093/jscr/rjab401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/19/2021] [Indexed: 01/19/2023] Open
Abstract
Novel coronavirus disease 2019 (COVID-19) pandemic was originated in Wuhan, China, in December 2019. So far, more than 4 million people worldwide have been infected with the virus. Various manifestations of coronavirus have been reported since the pandemic began. Among them, acute abdomen is one of the manifestations of COVID-19. Some studies have reported acute pancreatitis in several patient due to COVID-19 infection. In this study, we report a rare case in whom SARS-CoV-2 caused acute severe hemorrhagic necrotizing pancreatitis.
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Affiliation(s)
- Sunil Basukala
- Department of Surgery, Nepal Army Institute of Health Science (NAIHS), Kathmandu, Nepal
| | - Kunda Bikram Shah
- Department of Surgery, Nepal Army Institute of Health Science (NAIHS), Kathmandu, Nepal
| | - Bibek Karki
- Department of Radio Diagnosis, Nepal Army Institute of Health Science (NAIHS), Kathmandu, Nepal
| | - Narayan Thapa
- Department of Surgery, Nepal Army Institute of Health Science (NAIHS), Kathmandu, Nepal
| | - Bikram Basukala
- Department of Surgery, Nepal Army Institute of Health Science (NAIHS), Kathmandu, Nepal
| | - Saurav Karki
- Department of Surgery, Nepal Army Institute of Health Science (NAIHS), Kathmandu, Nepal
| | - Bishnu Deep Pathak
- Department of Surgery, Nepal Army Institute of Health Science (NAIHS), Kathmandu, Nepal
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Overexpression of miR-122 Impairs Intestinal Barrier Function and Aggravates Acute Pancreatitis by Downregulating Occludin Expression. Biochem Genet 2021; 60:382-394. [PMID: 34235595 DOI: 10.1007/s10528-021-10106-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
Acute pancreatitis (AP) causes intestinal barrier damage, resulting in systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS), which are important factors affecting AP severity and mortality. Here, we studied the mechanism of miR-122 in regulating intestinal barrier function in AP. AP rat model was constructed via intraperitoneal injection of ketamine, and primary intestinal epithelial cells were isolated from rats for in vitro studies. HE staining was used to assess pathological alterations of pancreas and intestines tissues. Inflammatory factors were detected by ELISA assay. qRT-PCR and WB were used to detect the expressions of miR-122 and occluding, respectively. Then dual-luciferase reporter assay, intestinal permeability test, and cell permeability were performed in vivo and in vitro to probe the molecular mechanism of miR-122 in regulating intestinal barrier function in AP. The expression of miR-122 was upregulated in AP rats, while the expression of occludin was downregulated, and the intestinal permeability was increased in AP rats and primary intestinal epithelial cells isolated from rats. Inhibition of miR-122 regulated intestinal barrier function through mediating occludin expression. miR-122 regulated intestinal barrier function to affect AP through mediating occludin expression in vivo. These results provided evidence that miR-122 overexpression impaired intestinal barrier function via regulation of occludin expression, thus promoting AP progression.
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CT severity indices derived from low monoenergetic images at dual-energy CT may improve prediction of outcome in acute pancreatitis. Eur Radiol 2021; 31:4710-4719. [PMID: 33404695 DOI: 10.1007/s00330-020-07477-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/14/2020] [Accepted: 11/05/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine whether imaging features and severity indices using low monoenergetic DECT images improve diagnostic conspicuity and outcome prediction in acute pancreatitis compared to conventional images. METHODS A retrospective study of patients with clinical and radiographic signs of acute pancreatitis who underwent 50 contrast-enhanced CT exams conducted on a single-source DECT was performed. Representative conventional and 50 keV-monoenergetic images were randomized and presented to four abdominal radiologists to determine preferred imaging for detecting fat stranding and parenchymal inflammation. Contrast and signal-to-noise ratios were constructed for necrotic, hypoattenuated, inflamed, and healthy parenchyma. These parameters and the CT severity index (CTSI) were compared between conventional and low monoenergetic images using paired t tests and correlated to clinical outcome. RESULTS Although preference for conventional images was noted for subtle peri-pancreatic fat stranding (169/200 (85%) reads), there was clear preference for low monoenergetic images among all readers for pancreatic inflammation evaluation (188/200 (94%) reads). Moreover, identification of small, hypoattenuating inflammatory foci on monoenergetic images alone in 13/50 (26%) cases resulted in upstaged CTSI from mild to moderate in 7/50 (14%), associated with longer hospitalization (16 ± 17 days vs. 5 ± 2 days; p < 0.05), ICU admission, and drainage. Quantitatively, a twofold difference between normal and inflamed parenchyma attenuation was identified for monoenergetic (44.8 ± 27.6) vs. conventional (25.1 ± 14.7) images (p < 0.05). Significant increases were seen in the monoenergetic SNR and CNR compared to the conventional images (p < 0.05). CONCLUSIONS DECT low monoenergetic images afford better tissue assessment and demarcation of inflamed pancreatic parenchyma. Additionally, they provide improved characterization of the extent parenchymal necrosis, enabling better classification that may better predict severe clinical outcomes. KEY POINTS • DECT low monoenergetic images afford better tissue assessment and demarcation of inflamed pancreatic parenchyma and provide improved characterization of the extent parenchymal necrosis. • Qualitatively, low monoenergetic images were preferred over conventional DECT images for the evaluation of pancreatic inflammation; and quantitatively, there is a twofold difference between normal and inflamed parenchyma attenuation, SNR, and CNR between monoenergetic vs. conventional images. • Monoenergetic imaging identified additional small, hypoattenuating inflammatory foci in 26% resulting in an upstaged CT severity index in 14% associated with longer hospitalization, ICU admission, and drainage, thereby enabling better classification and better prediction of severe clinical outcomes.
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Identification of Dysfunctional Gut Microbiota Through Rectal Swab in Patients with Different Severity of Acute Pancreatitis. Dig Dis Sci 2020; 65:3223-3237. [PMID: 32076933 DOI: 10.1007/s10620-020-06061-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) has a wide spectrum of severity and can be associated with considerable morbidity and mortality. Whether gut microbiota dysbiosis is associated with AP severity remains obscure. AIMS We aim to investigate the differences in the alterations of gut microbiota in different grades of AP severity. METHODS We collected clinical information and rectal swab samples from 80 individuals. The gut microbiota was tested by 16S rRNA gene sequencing, gut microbiota species composition analysis, difference analysis, random forest model prediction analysis, and gut microbiota species correlation network analysis. RESULTS There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant species in mild, moderately severe, and severe AP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased species in mild AP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in moderately severe AP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in severe AP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for mild AP and Eubacterium_hallii and Anaerococcus for moderately severe AP. There was a positive interaction between Firmicutes and Bacteroidetes in mild AP. CONCLUSIONS The disturbed gut microbiota is different among grades of AP, suggesting their potential role in the progression of disease severity. There was a different microbiota profile in different severity grades. Bacteroides, Escherichis-Shigella, and Enterococcus were dominant gut microbiota species in MAP, MSAP, and SAP, respectively. Finegoldia was the most significantly increased and Blautia the most decreased gut microbiota species in MAP. Anaerococcus was the most significantly increased and Eubacterium hallii the most decreased species in MSAP. Enterococcus was the most significantly increased and Eubacterium hallii the most decreased species in SAP. Finegoldia, Eubacterium_hallii, and Lachnospiraceae were potential diagnostic biomarkers for MAP and Eubacterium_hallii and Anaerococcus for MSAP. There was a positive interaction between Firmicutes and Bacteroidetes in MAP.
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Ooe Y, Sakai S, Kinoshita J, Makino I, Nakamura K, Miyashita T, Tajima H, Takamura H, Ninomiya I, Fushida S, Ohta T. Severe acute pancreatitis caused by adhesive intestinal obstruction following fundoplication. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Leonard-Murali S, Lezotte J, Kalu R, Blyden DJ, Patton JH, Johnson JL, Gupta AH. Necrotizing pancreatitis: A review for the acute care surgeon. Am J Surg 2020; 221:927-934. [PMID: 32878690 DOI: 10.1016/j.amjsurg.2020.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/30/2020] [Accepted: 08/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients. METHODS In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified. RESULTS Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience. CONCLUSION Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward.
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Affiliation(s)
- Shravan Leonard-Murali
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Jonathan Lezotte
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Richard Kalu
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Dionne J Blyden
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Joe H Patton
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Jeffrey L Johnson
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Arielle H Gupta
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
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Anandan RR, Patil S, Renganathan R, Varatharajaperumal RK, Ramasamy R, Arunachalam VK. Extra Pancreatic Necrotic Volume: Can It Prognosticate Acute Necrotising Pancreatitis— A Prospective Study. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2020. [DOI: 10.1055/s-0040-1714446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Abstract
Background Acute necrotizing pancreatitis (ANP) is associated with higher mortality and morbidity. We need a method which is accurate in predicting the prognosis, and when applied early in the disease process, can help in closer monitoring and early initiation of treatment for at-risk patients.
Objectives The aim of this prospective study was to assess the extra pancreatic necrosis (EPN) volume in patients with ANP and compare it with outcome variables such as organ failure, death and need for intervention as well as to compare the predictive power of EPN volume with modified CT severity index (CTSI).
Materials and Methods The study had 48 patients with clinical diagnosis of acute pancreatitis, who underwent Contrast enhanced CT (CECT) between 3–6 days of onset. In all these patients, EPN volume (in cubic centimetre) and modified CTSI score were calculated and compared with the patient outcome parameters such as duration of hospital/ICU stay, need for percutaneous/surgical intervention, evidence of infection and organ failure. The results were compared with assess the predictive power of EPN volume.
Statistical analysis The analysis was done in SPSS version 16.0 for windows. Pearson Correlation was used to assess the significant relationship between selected objective variables.
Results EPN volume (>/= to 360 cc) had a statistically significant correlation with outcome parameters as well as in predicting overall organ failure. In our study, Modified CTSI had no significant correlation with the above mentioned factors.
Conclusions The volume of EPN calculated between 3rd and 6th day of onset of symptoms showed a significant correlation with the outcome in patients with ANP.
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Affiliation(s)
- Rinoy Ram Anandan
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Santosh Patil
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Rupa Renganathan
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | | | - Rajkumar Ramasamy
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
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Ikarashi S, Kawai H, Hayashi K, Kohisa J, Sato T, Nozawa Y, Morita S, Oka H, Sato M, Aruga Y, Yoshikawa S, Terai S. Risk factors for walled-off necrosis associated with severe acute pancreatitis: A multicenter retrospective observational study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:887-895. [PMID: 32506672 DOI: 10.1002/jhbp.787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/02/2020] [Accepted: 06/01/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study aimed to identify the risk factors for walled-off necrosis (WON) associated with severe acute pancreatitis (SAP). METHODS This retrospective study was conducted in eight institutions in Japan between 2014 and 2017. We analyzed WON incidence, patient characteristics, and risk factors for WON in patients with SAP who were observed for >28 days. RESULTS Of 134 patients with SAP, WON occurred in 40 (29.9%). Male sex (P = .045), body mass index (BMI) ≥25 (P < .001), post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (P = .020), and disseminated intravascular coagulation (DIC) (P = .001) were more frequent in the WON group than in the non-WON group. On admission, the frequency of white blood cell counts ≥ 12 000/µL (P = .037) and hypoenhanced pancreatic lesion on computed tomography (P = .047) were significantly higher in the WON group. In multivariate analysis, BMI ≥ 25 (odds ratio [OR] 5.73, 95% confidence interval [CI] 1.95-16.8; P = .002), post-ERCP (OR 8.08, 95% CI 1.57-41.7; P = .013), and DIC (OR 3.52, 95% CI 1.20-10.4; P = .022) were independent risk factors for WON. CONCLUSIONS High BMI, post-ERCP pancreatitis, and DIC are risk factors for the development of WON associated with SAP.
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Affiliation(s)
- Satoshi Ikarashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hirokazu Kawai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Shibata, Japan
| | - Kazunao Hayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Junji Kohisa
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Department of Gastroenterology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Toshifumi Sato
- Department of Internal Medicine, Niigata Prefectural Shibata Hospital, Shibata, Japan
| | - Yujiro Nozawa
- Department of Gastroenterology and Hepatology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Shinichi Morita
- Department of Gastroenterology and Hepatology, Uonuma Institute of Community Medicine Niigata University Hospital, Minami-Uonuma, Japan
| | - Hiromitsu Oka
- Department of Internal Medicine, Nagaoka Chuo General Hospital, Nagaoka, Japan
| | - Munehiro Sato
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Yukio Aruga
- Department of Internal Medicine, Niigata Prefectural Central Hospital, Joetsu, Japan
| | - Seiichi Yoshikawa
- Department of Gastroenterology, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Abstract
Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.
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Karakulak S, Narcı H, Ayrık C, Erdoğan S, Üçbilek E. The prognostic value of immature granulocyte in patients with acute pancreatitis. Am J Emerg Med 2020; 44:203-207. [PMID: 32220526 DOI: 10.1016/j.ajem.2020.03.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/16/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Acute pancreatitis is the inflammation of the pancreas. It can range from mild forms to life-threatening severe cases. There is not yet a marker that can detect severe cases in the early period. Early diagnosis and treatment of this disease has critical importance for prognosis. In this study, we aimed to investigate the percentage of immature granulocyte (IG %) in patients with acute pancreatitis in order to predict the severity of the disease and in-hospital mortality. METHOD This study was carried out retrospectively in academic emergency department (ED), faculty of medicine between 01.01.2017 and 30.06.2019. The patients were divided into three groups as mild, moderate and severe. In addition, the patients were divided into two groups: those discharged from the hospital and those who died in the hospital. IG % and other laboratory parameters of the patients were recorded in the study form. The primary outcome for this study is the value of IG% in predicting severity in AP patients. A receiver operating characteristic (ROC) curve analysis was performed. RESULTS A total of 218 patients (107 male) were included in the study. The mean age of the patients was 56.9 ± 18.3 years. It was found that IG% levels were higher in patients with severe pancreatitis (p = .018). In the ROC analysis that was done to determine the severity of the disease, the cut-off value of IG% was found as >1.1. As such case, specificity was %38.89, sensitivity was 95.00%, positive predictive value (PPV) was 41.18% and negative predictive value (NPV) was found as 94.53% (Area Under Curve (AUC) = 0.698). In ROC analysis that was performed to determine in-hospital mortality, the cut-off value of IG level was found as >1.8, sensitivity was 50.00%, specificity was 97.12%, PPV was 45.45% and NPV was found as 97.58% (AUC = 0.708). CONCLUSıONS: This study shows that higher IG% levels may correlate with higher disease severity and in-hospital mortality in patients with acute pancreatitis.
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Affiliation(s)
- Serkan Karakulak
- Mersin University, Faculty of Medicine, Department of Emergency Medicine, Mersin, Turkey
| | - Hüseyin Narcı
- Mersin University, Faculty of Medicine, Department of Emergency Medicine, Mersin, Turkey.
| | - Cüneyt Ayrık
- Mersin University, Faculty of Medicine, Department of Emergency Medicine, Mersin, Turkey
| | - Semra Erdoğan
- Mersin University, Faculty of Medicine, Department of Biostatistics, Mersin, Turkey
| | - Enver Üçbilek
- Mersin University, Faculty of Medicine, Department of Gastroenterology, Mersin, Turkey
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The protective effect of betacellulin against acute pancreatitis is ERBB4 dependent. J Gastroenterol 2020; 55:317-329. [PMID: 31456099 DOI: 10.1007/s00535-019-01613-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The EGFR ligand betacellulin (BTC) has been previously shown to protect mice against experimentally induced acute pancreatitis (AP). BTC binds both autonomous ERBB receptors EGFR and ERBB4. In this study, we evaluated the mechanism underlying the protection from AP-associated inflammation in detail. METHODS AP was induced with cerulein or L-arginine and investigated in a pancreas-specific ERBB4 knockout and in an EGFR knockdown mouse model (EgfrWa5/+). Pancreatitis was evaluated by scoring inflammation, necrosis, and edema, while microarrays were performed to analyze alterations in the transcriptome between mice with AP and animals which were protected against AP. The intracellular domain (ICD) of ERBB4 was analyzed in different cell compartments. RESULTS While the pancreas of BTC transgenic mice in the background of EgfrWa5/+ is still protected against AP, the BTC-mediated protection is no longer present in the absence of ERBB4. We further demonstrate that BTC activates the ICD of ERBB4, and increases the expression of the extracellular matrix (ECM) proteins periostin and matrix gla protein as well as the ECM modulators matrix metalloproteinases 2 and 3, but only in the presence of ERBB4. Notably, the increased expression of these proteins is not accompanied by an increased ECM amount. CONCLUSIONS These findings suggest that BTC derivates, as a drug, or the ERBB4 receptor, as a druggable target protein, could play an important role in modulating the course of AP and even prevent AP in humans.
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Eupatilin Ameliorates Cerulein-Induced Pancreatitis Via Inhibition of the Protein Kinase D1 Signaling Pathway In Vitro. Pancreas 2020; 49:281-289. [PMID: 32011533 DOI: 10.1097/mpa.0000000000001488] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the effects of eupatilin on protein kinase D1 (PKD1) and nuclear factor kappa B (NF-κB) signaling pathways in cerulein-induced in vitro pancreatitis. METHODS We used collagenase digestion to isolate pancreatic acinar cells from male C57BL/6 mice. In vitro acute pancreatitis was induced by treatment with a supramaximal dose of cerulein. Eupatilin was pretreated before stimulation with cerulein. RESULTS Eupatilin significantly reduced cerulein-induced amylase release in pancreatic acini. Eupatilin treatment downregulated cerulein-induced expression of interleukin (IL)-1β, IL-6, and CC chemokine ligands 2 and 5, but it upregulated expression of IL-4 and IL-10. We demonstrated that eupatilin pretreatment attenuated cerulein-induced necrosis in isolated pancreatic acinar cells. This effect of eupatilin was confirmed by lactic dehydrogenase assay, fluorescence-activated cell sorting analysis, and cytopathologic analysis. Eupatilin inhibited cerulein-induced activation of PKD1/NF-κB and the nuclear translocation of NF-κB. CONCLUSIONS Our data demonstrated that eupatilin is a potential therapeutic candidate for the treatment of pancreatitis through its ability to reduce cellular necrosis and inflammatory responses by inhibition of the PKD1/NF-κB signaling pathway.
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Jain S, Padhan R, Bopanna S, Jain SK, Dhingra R, Dash NR, Madhusudan KS, Gamanagatti SR, Sahni P, Garg PK. Percutaneous Endoscopic Step-Up Therapy Is an Effective Minimally Invasive Approach for Infected Necrotizing Pancreatitis. Dig Dis Sci 2020; 65:615-622. [PMID: 31187325 DOI: 10.1007/s10620-019-05696-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/03/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) is a major complication of acute pancreatitis (AP), which may require necrosectomy. Minimally invasive surgical step-up therapy is preferred for IPN. AIM To assess the effectiveness of percutaneous endoscopic step-up therapy in patients with IPN and identify predictors of its success. METHODS Consecutive patients with AP hospitalized to our tertiary care academic center were studied prospectively. Patients with IPN formed the study group. The treatment protocol for IPN was percutaneous endoscopic step-up approach starting with antibiotics and percutaneous catheter drainage, and if required necrosectomy. Percutaneous endoscopic necrosectomy (PEN) was performed using a flexible endoscope through the percutaneous tract under conscious sedation. Control of sepsis with resolution of collection(s) was the primary outcome measure. RESULTS A total of 415 patients with AP were included. Of them, 272 patients had necrotizing pancreatitis and 177 (65%) developed IPN. Of these 177 patients, 27 were treated conservatively with antibiotics alone, 56 underwent percutaneous drainage alone, 53 required underwent PEN as a step-up therapy, 1 per-oral endoscopic necrosectomy, and 52 required surgery. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully-34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died due to organ failure-7 after PEN and 4 after surgery. Independent predictors of mortality were > 50% necrosis and early organ failure. CONCLUSION Percutaneous endoscopic step-up therapy is an effective strategy for IPN. Organ failure and extensive pancreatic necrosis predicted a suboptimal outcome in patients with infected necrotizing pancreatitis.
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Affiliation(s)
- Saransh Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Padhan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil Kumar Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajan Dhingra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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Liao R, Xue L, Qiang Z, Zhang C, Liu Y. Release of endogenous hydrogen sulfide in enteric nerve cells suppresses intestinal motility during severe acute pancreatitis. Acta Biochim Biophys Sin (Shanghai) 2020; 52:64-71. [PMID: 31889183 DOI: 10.1093/abbs/gmz139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Indexed: 12/13/2022] Open
Abstract
Previous studies have shown that during severe acute pancreatitis (SAP) attacks, hydrogen sulfide (H2S) is released in the colon. However, the roles played by H2S in regulating enteric nerves remain unclear. In this study, we examined the association between SAP-induced H2S release and loss of intestinal motility, and also explored the relevant mechanism in enteric nerve cells. A rat SAP model was constructed and enteric nerve cells were prepared. Intestinal mobility was evaluated by measuring the number of bowel movements at indicated time points and by performing intestinal propulsion tests. The production of inflammatory cytokines during a SAP attack was quantified by ELISA, and the levels of cystathionine-γ-lyase (CSE) and cystathionine-β-synthase (CBS) were examined by immunohistochemistry and western blot analysis. In vivo studies showed that PI3K/Akt/Sp1 signaling in enteric nerve cells was blocked, confirming the mechanism of endogenous H2S formation by western blot analysis and immunofluorescence. Our results also showed that rats with SAP symptoms had reduced intestinal motility. Furthermore, PI3K/Akt/Sp1 signaling was triggered and CSE expression was up-regulated, and these changes were associated with H2S formation in the colon. In addition, propargylglycine reduced the levels of inflammatory cytokines and suppressed the release of H2S. Enteric nerve cells that were incubated with LY294002 and transfected with a Sp1-knockdown vector displayed decreased levels of CSE production, which led to a decrease in H2S production. These results suggest that SAP symptoms suppressed the intestinal motility of rats via the release of H2S in enteric nerve cells, which was dependent on the inflammation-induced PI3K/Akt/Sp1 signaling pathway.
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Affiliation(s)
- Ribin Liao
- Department of Gastroenterology, The Second Affiliated Hospital of Guilin Medical University, Guilin 541100, China
| | - Liwei Xue
- Department of Gastroenterology, The Second Affiliated Hospital of Guilin Medical University, Guilin 541100, China
| | - Zhanrong Qiang
- Department of Gastroenterology, The Second Affiliated Hospital of Guilin Medical University, Guilin 541100, China
| | - Cheng Zhang
- Department of Gastroenterology, The Second Affiliated Hospital of Guilin Medical University, Guilin 541100, China
| | - Ying Liu
- Department of Gastroenterology, The Second Affiliated Hospital of Guilin Medical University, Guilin 541100, China
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Wang N, Meng W, Jia R, Xiang S. Rab GTPase 21 mediates caerulin-induced TRAF3-MKK3-p38 activation and acute pancreatitis response. Biochem Biophys Res Commun 2019; 518:50-58. [PMID: 31402118 DOI: 10.1016/j.bbrc.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/02/2019] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis (AP) is a severe inflammatory disease. Caerulin induces significant pro-inflammatory responses in macrophages, causing serve damage to pancreatic acinar cells. The potential role of Rab GTPase 21 (Rab21) in this process was tested in this study. In murine bone marrow-derived macrophages (BMDMs), caerulin induced Rab21-TRAF3-MKK3 complex association. Rab21 silencing (by targeted shRNAs) or knockout (by CRISPR/Cas9 method) largely inhibited caerulin-induced MKK3-TRAF3 association, downstream MKK3-p38 activation and production of several pro-inflammatory cytokines (IL-1β, TNF-α and IL-17). Conversely, ectopic Rab21 overexpression in BMDMs potentiated caerulin-induced MKK3-TRAF3 association and pro-inflammatory cytokines production. The cytotoxicity of caerulin-activated BMDMs to co-cultured pancreatic acinar cells was alleviated by Rab21 knockdown or knockout, but exacerbated with Rab21 overexpression. In vivo, administration of Rab21 shRNA lentivirus significantly attenuated pancreatic and systemic inflammations in caerulin-injected AP mice. Collectively, our results suggest that Rab21 mediates caerulin-induced MKK3-p38 activation and pro-inflammatory responses.
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Affiliation(s)
- Na Wang
- Department of Gastroenterology, Shanghai Tongren Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenying Meng
- Department of Gastroenterology, Shanghai Tongren Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rongrong Jia
- Department of Gastroenterology, Shanghai Tongren Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Shihao Xiang
- Department of Gastroenterology, Shanghai Tongren Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Huang H, Chen W, Tang G, Liang Z, Qin M, Qin M, Tang Y, Qin H, Chang R. Optimal timing of contrast-enhanced computed tomography in an evaluation of severe acute pancreatitis-associated complications. Exp Ther Med 2019; 18:1029-1038. [PMID: 31363364 PMCID: PMC6614731 DOI: 10.3892/etm.2019.7700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/12/2019] [Indexed: 12/11/2022] Open
Abstract
Dynamic contrast-enhanced computed tomography (CECT) has been used previously to evaluate severe acute pancreatitis (SAP)-associated complications. However, optimal time points of CECT have not yet been established. The present study aimed to determine optimal timings for CECT to be undertaken for patients with SAP. The results of CECT from 309 patients with SAP, who were classified into either infected or non-infected SAP groups, were retrospectively analyzed. The severity and alterations in the periods within 72 h to >4 weeks of SAP onset were also assessed. In the analysis of the disease severity and changes, acute peripancreatic fluid collection was detected, where the number of areas increased within 1 week of SAP onset but decreased within 4 weeks and longer. However, no significant differences were observed between the infected and non-infected groups. The acute necrotic collection (ANC) areas were ≤30% of the area of the pancreas, with significantly more ANC areas and pancreatic necrosis in the infected SAP group compared with the non-infected SAP group at a time interval of >4 weeks. The exudation of pleural effusion (PE) was elevated within 1 week, but decreased within 2 weeks and longer. The difference in the alteration of the exudation of PE was not statistically different between the two groups. In conclusion, the results suggest that the period between 72 h and 1 week of SAP onset is optimal timing of CECT to assess SAP-associated complications, particularly for infected SAP patients.
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Affiliation(s)
- Huali Huang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Wenjing Chen
- Department of Gastroenterology of The First People's Hospital of Nanning City, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530022, P.R. China
| | - Guodu Tang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Zhihai Liang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Mengbin Qin
- Department of Gastroenterology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530007, P.R. China
| | - Minzhen Qin
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Yongfeng Tang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Heping Qin
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Renjie Chang
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
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Choi K, Flynn DE, Karunairajah A, Hughes A, Bhasin A, Devereaux B, Chandrasegaram MD. Management of infected pancreatic necrosis in the setting of concomitant rectal cancer: A case report and review of literature. World J Gastrointest Surg 2019; 11:237-246. [PMID: 31123561 PMCID: PMC6513786 DOI: 10.4240/wjgs.v11.i4.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatitis with infected necrosis is a severe complication of acute pancreatitis and carries with it high rates of morbidity and mortality. The management of infected pancreatic necrosis alongside concomitant colorectal cancer has never been described in literature.
CASE SUMMARY A 77 years old gentleman presented to the Emergency Department of our hospital complaining of ongoing abdominal pain for 8 h. The patient had clinical features of pancreatitis with a raised lipase of 3810 U/L, A computed tomography (CT) abdomen confirmed pancreatitis with extensive peri-pancreatic edema. During the course of his admission, the patient had persistent high fevers and delirium thought secondary to infected necrosis, prompting the commencement of broad-spectrum antibiotic therapy with Piperacillin/Tazobactam. Subsequent CT abdomen confirmed extensive pancreatic necrosis (over 70%). Patient was managed with supportive therapy, nutritional support and gut rest initially and improved over the course of his admission and was discharged 42 d post admission. He represented 24 d following his discharge with fever and chills and a repeat CT abdomen scan noted gas bubbles within the necrotic pancreatic tissue thereby confirming infected necrotic pancreatitis. This CT scan also revealed asymmetric thickening of the rectal wall suspicious for malignancy. A rectal cancer was confirmed on flexible sigmoidoscopy. The patient underwent two endoscopic necrosectomies and was treated with intravenous antibiotics and was discharged after 28 d. Within 1 wk post discharge, the patient commenced a course of neoadjuvant radiotherapy and subsequently underwent concomitant chemotherapy prior to undergoing a successful Hartmann’s procedure for treatment of his colorectal cancer.
CONCLUSION This case highlights the efficacy of endoscopic necrosectomy, early enteral feeding and targeted antibiotic therapy for timely management of infected necrotic pancreatitis. The prompt resolution of pancreatitis permitted the patient to undergo neoadjuvant treatment and resection for his concomitant colorectal cancer.
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Affiliation(s)
- Kihoon Choi
- Department of Surgery, Gold Coast University Hospital, Southport, QLD 4215, Australia
| | - David E Flynn
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Anitha Karunairajah
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Andrew Hughes
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Ambika Bhasin
- Department of Radiology, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
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Smith ZL, Gregory MH, Elsner J, Alajlan BA, Kodali D, Hollander T, Sayuk GS, Lang GD, Das KK, Mullady DK, Early DS, Kushnir VM. Health-related quality of life and long-term outcomes after endoscopic therapy for walled-off pancreatic necrosis. Dig Endosc 2019; 31:77-85. [PMID: 30152143 DOI: 10.1111/den.13264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Walled-off pancreatic necrosis (WON) frequently develops after necrotizing pancreatitis. Endoscopic drainage has become the preferred modality for symptomatic or infected WON. The aim of the present study was to assess health-related quality of life (HR-QOL) and long-term outcomes in patients undergoing endoscopic drainage for WON. METHODS Patients undergoing endoscopic drainage of WON from January 2006 to May 2016 were identified. Data recorded included demographic information, and the incidence of long-term sequelae including pancreatic endocrine and exocrine insufficiency. Attempts were made to contact all patients. HR-QOL was assessed using the SF-36 questionnaire. RESULTS Eighty patients were analyzed, 41 (51.3%) of whom completed the SF-36. One-year all-cause mortality was 6.2%, and disease-related mortality was 3.7%. A notable proportion of patients developed exocrine insufficiency (32.5%), endocrine insufficiency (27.7%), and long-term opiate use (42.5%). Development of exocrine insufficiency was predictive of lower total SF-36 scores (P = 0.016). Patients with WON had better HR-QOL compared with cohorts of irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). In patients developing exocrine insufficiency versus healthy controls, poorer scores in the physical role (P < 0.001), general health (P < 0.001), vitality (P = 0.001), and emotional role (P = 0.029) domains were observed. Exocrine insufficiency patients had better HR-QOL than the IBS and IBD cohorts, although these differences were less pronounced. CONCLUSION After undergoing endoscopic drainage for WON, patients have relatively preserved HR-QOL. The subset of patients that develop exocrine insufficiency have significantly poorer HR-QOL compared to healthy controls, although not to the degree of chronic gastrointestinal disorders such as IBS and IBD.
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Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Martin H Gregory
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Jeffrey Elsner
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Bader A Alajlan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Divya Kodali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, USA
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Analysis of a Step-Up Approach Versus Primary Open Surgical Necrosectomy in the Management of Necrotizing Pancreatitis: Experience in a Cohort of Patients at a US Academic Medical Center. Pancreas 2018; 47:1317-1321. [PMID: 30211807 DOI: 10.1097/mpa.0000000000001154] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES An increasing number of providers have begun to use a minimally invasive step-up approach as opposed to traditional surgical necrosectomy in the management of acute necrotizing pancreatitis. Studies have shown mixed results, thus we hypothesized that the step-up approach is safer and associated with decreased mortality and length of stay (LOS). METHODS This is a retrospective cohort study of patients admitted from January 2010 to March 2015 who underwent interventions for walled-off pancreatic necrosis (WOPN). Primary outcomes included LOS after intervention and mortality, in-hospital and 90-day, with secondary outcomes of procedural complications. RESULTS Sixty-nine patients developed WOPN requiring intervention during the study period. In-hospital mortality was 5.6% (n = 2) in the step-up cohort compared with 18.2% (n = 6) in the surgical cohort (relative risk, 3.27; 95% confidence interval, 0.71-15.09). Ninety-day mortality was 9.1% (n = 3) in the step-up cohort and 21.9% (n = 7) in the surgical cohort (relative risk, 2.41; 95% confidence interval, 0.68-8.50). Postintervention LOS was 8 days in the step-up cohort and 17 days in the surgical cohort (P = 0.62). CONCLUSIONS A step-up approach, as compared with primary surgical necrosectomy in the management of WOPN, results in clinically significant decreases in mortality and LOS.
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Case BM, Jensen KK, Bakis G, Enestvedt BK, Shaaban AM, Foster BR. Endoscopic Interventions in Acute Pancreatitis: What the Advanced Endoscopist Wants to Know. Radiographics 2018; 38:2002-2018. [PMID: 30265612 DOI: 10.1148/rg.2018180066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Endoscopic interventions play an important role in the modern management of pancreatic fluid collections. Successful management of pancreatitis is dependent on proper classification of the disease and its local complications. The 2012 revised Atlanta classification divides acute pancreatitis into subtypes of necrotizing pancreatitis and interstitial edematous pancreatitis (IEP) on the basis of the radiologic presence or absence of necrosis, respectively. Local complications of IEP include acute pancreatic fluid collections and pseudocysts, which contain fluid only and are differentiated by the time elapsed since the onset of symptoms. Local complications of necrotizing pancreatitis include acute necrotic collections and walled-off necrosis, which contain nonliquefied necrotic debris and are differentiated by the time elapsed since the onset of symptoms. Endoscopic techniques are used to treat local complications of pancreatitis, often in a step-up approach, by which less invasive techniques are preferred initially with potential subsequent use of more invasive procedures, dependent on the patient's clinical response and collection evolution. Common interventions performed by the advanced endoscopist include endoscopic transmural drainage and endoscopic transmural necrosectomy. However, some collections require a multimodal approach with adjunctive placement of percutaneous drainage catheters or the use of videoscopic-assisted retroperitoneal débridement. Additional endoscopic interventions may be required in the setting of pancreatic or biliary duct stones or strictures. Common complications of endoscopic intervention in the setting of pancreatitis include bleeding, infection, perforation, and stent migration. This article reviews the classification of acute pancreatitis, familiarizes radiologists with the common endoscopic techniques used in its management, and improves identification of the clinically relevant imaging findings and procedural complications related to endoscopic interventions in pancreatitis. ©RSNA, 2018.
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Affiliation(s)
- Brendan M Case
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Kyle K Jensen
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Gene Bakis
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Brintha K Enestvedt
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Akram M Shaaban
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
| | - Bryan R Foster
- From the Department of Diagnostic Radiology (B.M.C., K.K.J., B.R.F.) and Department of Medicine, Division of Gastroenterology (B.K.E.), Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; Portland Gastroenterology Center, Portland, Maine (G.B.); and Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.)
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Impact of continuous regional arterial infusion in the treatment of acute necrotizing pancreatitis: analysis of a national administrative database. J Gastroenterol 2018; 53:1098-1106. [PMID: 29564566 DOI: 10.1007/s00535-018-1452-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although continuous regional arterial infusion (CRAI) of protease inhibitors and broad antibiotics has been suggested as one of the therapeutic option for patients with acute necrotic pancreatitis (ANP), the effectiveness has not been well-corroborated in clinical studies. METHODS We conducted a retrospective cohort study using a Japanese national administrative database. Severe acute pancreatitis patients with a poorly enhanced pancreas region (i.e., definitive or clinically suspected ANP) were identified and dichotomized according to whether CRAI was performed. We compared the outcomes of in-hospital mortality, surgical interventions, hospital-free days, and healthcare costs between groups adjusted by the well-validated case-mix adjustment model using a multivariate mixed-effect regression analysis and a propensity score matching analysis. RESULTS Of 243,312 acute pancreatitis patients, 702 eligible patients were identified, of these 339 patients underwent CRAI. The case-mix adjustment model established had good predictability for in-hospital mortality with an area under the receiver operating characteristics curve of 0.87. CRAI was significantly associated with reduced in-hospital mortality [14.5% in the CRAI group vs. 18.2% in the non-CRAI group, adjusted odds ratio (95% confidence interval; CI) = 0.60 (0.36-0.97)]. Significant associations were not observed for the frequency of surgical interventions and mean hospital-free days; however, significantly higher healthcare costs were observed in the CRAI group. Results of the propensity score matching analysis did not alter these results. CONCLUSIONS Analysis of a nationwide large-scale database suggested that CRAI was significantly associated with reduced in-hospital mortality for patients with ANP. Further randomized controlled trials are warranted.
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Jia R, Ma J, Meng W, Wang N. Dihydromyricetin inhibits caerulin-induced TRAF3-p38 signaling activation and acute pancreatitis response. Biochem Biophys Res Commun 2018; 503:1696-1702. [PMID: 30055802 DOI: 10.1016/j.bbrc.2018.07.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 07/20/2018] [Indexed: 12/16/2022]
Abstract
Acute pancreatitis (AP) is a common inflammatory disease in gastrointestinal tract. Our previous study has shown that caerulin induces TNF receptor-associated factor 3 (TRAF3)-p38 signaling activation and pro-inflammatory response in macrophages, causing damage to co-cultured pancreatic acinar cells. Dihydromyricetin (DHM) is a flavonoid extracted from Ampelopsis grossedentata, which has displayed anti-inflammation and anti-oxidant functions. Our results here show that DHM potently inhibited caerulin-induced expression and productions of multiple pro-inflammatory cytokines (IL-1β, TNF-α and IL-17) in murine bone marrow-derived macrophages (BMDMs). DHM significantly inhibited caerulin-induced TRAF3 protein stabilization, TRAF3-mitogen-activated protein kinase kinase 3 (MKK3) association and following MKK3-p38 activation in BMDMs. Significantly, DHM was ineffective against caerulin in TRAF3-silenced BMDMs. Importantly, DHM supplement attenuated the cytotoxicity of caerulin-activated BMDMs to co-cultured pancreatic acinar cells, resulting in significantly decreased acinar cell death and apoptosis. In vivo, DHM co-administration largely attenuated pancreatic and systemic inflammation in caerulin-injected AP mice. Together, DHM inhibits caerulin-induced TRAF3-p38 signaling activation and AP response. DHM could be further studied as a potential anti-AP agent.
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Affiliation(s)
- Rongrong Jia
- Department of Gastroenterology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiali Ma
- Department of Gastroenterology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenying Meng
- Department of Gastroenterology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Na Wang
- Department of Gastroenterology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Calycosin alleviates cerulein-induced acute pancreatitis by inhibiting the inflammatory response and oxidative stress via the p38 MAPK and NF-κB signal pathways in mice. Biomed Pharmacother 2018; 105:599-605. [PMID: 29890468 DOI: 10.1016/j.biopha.2018.05.080] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 01/30/2023] Open
Abstract
Acute pancreatitis (AP) is a common acute abdominal disease accompanied by systemic inflammatory response syndrome, and could even be complicated by multiple-organ damage. This study aimed to examine whether calycosin, an isoflavone isolated from Radix astragali with antioxidant and anti-inflammatory activity, could protect against AP induced by cerulein. To this end, Balb/C mice were injected with cerulein (50 μg/kg) to establish the animal model of AP. Calycosin (25 and 50 mg/kg, p.o.) was administered 1 h prior to the first cerulein injection. After the last injection of cerulein, the mice were sacrificed and blood was obtained for cytokine analysis. The pancreas was removed for morphological examination, myeloperoxidase (MPO) and malondialdehyde (MDA) analyses, immunohistochemistry, and western blot analysis. Calycosin treatment reversed the increased serum levels of amylase and lipase, alleviated the pathological damage in the pancreas, and decreased the levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-1β in mice with AP. Additionally, calycosin significantly reduced cerulein-induced pancreatic edema, inhibited MPO activity and increased superoxide dismutase (SOD) activity, and inhibited the expression of NF-κB/p65 and phosphorylation of the inhibitor of NF-κB (IκBα) and p38 MAPK. These results suggested that calycosin protects against AP by exerting anti-inflammatory and anti-oxidative stress effects via the p38 MAPK and NF-κB signal pathways. Calycosin's benefits for AP patients need to be explored further.
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Protective Effect of Scopoletin Against Cerulein-Induced Acute Pancreatitis and Associated Lung Injury in Mice. Pancreas 2018; 47:577-585. [PMID: 29595543 DOI: 10.1097/mpa.0000000000001034] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The present study aimed to evaluate the protective effects of scopoletin (SC) on cerulein-induced acute pancreatitis (AP) and associated lung injury in mice. METHODS Acute pancreatitis was induced in male Swiss mice by 6 consecutive hourly intraperitoneal injections of cerulein (50 μg/kg). Scopoletin was administered 1 hour (intraperitoneal, 10 mg/kg) after the first cerulein injection. RESULTS Administration of SC attenuated the severity of AP and associated lung injury as shown by histology, reduced myeloperoxidase, and serum amylase activity. Further, the anti-inflammatory effect of SC was associated with a reduction of pancreatic and pulmonary proinflammatory cytokines (interleukin 1β and tumor necrosis factor α) and hydrogen sulfide. Moreover, SC inhibited cerulein-induced nuclear factor κB activation in both pancreas and lung. Also, SC treatment further enhances the beneficial effect by reducing cerulein-induced mast cell activation as shown by reduced monocyte chemoattractant protein 1, interleukin 33, and preprotachykinin A expression (encodes neuropeptide substance P) in the pancreas and lungs. CONCLUSIONS The present findings show for the first time that in AP SC may exhibit an anti-inflammatory effect by down-regulating substance P and hydrogen sulfide signaling via nuclear factor κB pathway.
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Gerosa M, Chiarelli M, Guttadauro A, De Simone M, Tagliabue F, Costa M, Terragni S, Cioffi U. Wirsung atraumatic rupture in patient with pancreatic pseudocysts: a case presentation. BMC Gastroenterol 2018; 18:52. [PMID: 29685110 PMCID: PMC5913810 DOI: 10.1186/s12876-018-0781-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 04/17/2018] [Indexed: 01/02/2023] Open
Abstract
Background Pancreatic duct disruption is a challenging condition leading to pancreatic juice leakage and consequently to pancreatic fluid collections. The manifestations of pancreatic main duct leak include pseudocysts, walled-off necrosis, pancreatic fistulas, ascites, pleural and pericardial effusions. Pseudocyst formation is the most frequent outcome of a pancreatic duct leak. Case presentation We describe a case of a 64-year old man with large multiple pancreatic cysts discovered for progressive jaundice and significant weight loss in the absence of a previous episode of acute pancreatitis. Computed tomography scan showed lesion with thick enhancing walls. The main cyst dislocated the stomach and the duodenum inducing intra and extrahepatic bile ducts enlargement. Magnetic resonance cholangiopancreatography revealed a communication between the main pancreatic duct and the cystic lesions due to Wirsung duct rupture. Endoscopic ultrasound guided fine needle aspiration cytology did not show neoplastic cells and cyst fluid analysis revealed high amylase concentration. Preoperative exams were suggestive but not conclusive for a benign lesion. Laparotomy was necessary to confirm the presence of large communicating pseudocysts whose drainage was performed by cystogastrostomy. Histology confirmed the inflammatory nature of the cyst wall. Subsequently, the patient had progressive jaundice resolution. Conclusion Pancreatic cystic masses include several pathological entities, ranging from benign to malignant lesions. Rarely pseudocysts present as complex cystic pancreatic lesions with biliary compression in absence of history of acute pancreatitis. We describe the rare case of multiple pancreatic pseudocysts due to Wirsung duct rupture in absence of previous trauma or acute pancreatitis. Magnetic resonance showed the presence of communication with the main pancreatic duct and endoscopic ultrasound fine needle aspiration suggested the benign nature of the lesion.
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Affiliation(s)
- Martino Gerosa
- Department of Surgery, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Marco Chiarelli
- Department of Surgery, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Angelo Guttadauro
- Department of Surgery, University of Milan-Bicocca, Istituti Clinici Zucchi, Via Zucchi 24, 20900, Monza, Italy
| | - Matilde De Simone
- Department of Surgery, University of Milan, Via F. Sforza 35, 20122, Milan, Italy
| | - Fulvio Tagliabue
- Department of Surgery, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Melchiorre Costa
- Department of Surgery, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Sabina Terragni
- Department of Surgery, University of Milan-Bicocca, Istituti Clinici Zucchi, Via Zucchi 24, 20900, Monza, Italy
| | - Ugo Cioffi
- Department of Surgery, University of Milan, Via F. Sforza 35, 20122, Milan, Italy.
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Sahar N, Kozarek RA, Kanji ZS, Chihara S, Gan SI, Irani S, Larsen M, Ross AS, Gluck M. The microbiology of infected pancreatic necrosis in the era of minimally invasive therapy. Eur J Clin Microbiol Infect Dis 2018; 37:1353-1359. [PMID: 29675786 DOI: 10.1007/s10096-018-3259-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/10/2018] [Indexed: 12/21/2022]
Abstract
We aimed to determine the microbiology of infected walled-off pancreatic necrosis (WON) in an era of minimally invasive treatment, since current knowledge is based on surgical specimens performed over two decades ago. We retrospectively analyzed a prospectively maintained database of patients who were treated for symptomatic WON using combined endoscopic and percutaneous drainage between 2008 and 2017. Aspirates from WON at initial treatment were evaluated. One hundred eighty-two patients were included with a mean age of 56 of whom 67% were male. Culture results were obtained at a median of 45 days from onset of acute pancreatitis of which 41% were infected. Candida spp. accounted for 27%; yet, multidrug-resistant organisms were found in only five patients. Approximately 64% were transferred to our institution for continuation of care. Of those, 55% were infected, most frequently with Candida spp., Enterococcus spp., and coagulase-negative Staphylococcus. Patients seen and admitted initially at our institution had milder forms of pancreatitis, fewer comorbidities, and 85% had symptomatic sterile WON. Empiric antibiotic use successfully predicted infection 70% of the time. Multivariate analysis demonstrated that elderly age, severity of pancreatitis, and prior use of antibiotics were indicators of infection. Necrotic pancreatic tissue remains sterile in the majority of cases treated with minimally invasive therapy, enabling judicious selection of antibiotics. Candida and Enterococcus spp. were common. Patients at highest risk for infection were previously treated with antibiotics and those transferred from outside institutions.
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Affiliation(s)
- Nadav Sahar
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Richard A Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Zaheer S Kanji
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Shingo Chihara
- Section of Infectious Diseases, Department of Internal Medicine, Virginia Mason Medical Center, Seattle, USA
| | - S Ian Gan
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Andrew S Ross
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA
| | - Michael Gluck
- Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Avenue, C3-GAS, Seattle, WA, 98101, USA.
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Chen HJ, Wang JJ, Tsay WI, Her SH, Lin CH, Chien CC. Epidemiology and outcome of acute pancreatitis in end-stage renal disease dialysis patients: a 10-year national cohort study. Nephrol Dial Transplant 2018; 32:1731-1736. [PMID: 28088773 DOI: 10.1093/ndt/gfw400] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/12/2016] [Indexed: 12/24/2022] Open
Abstract
Background The objective of this study is to determine the incidence and severity of acute pancreatitis (AP) in patients with end-stage renal disease (ESRD) on dialysis and whether the dialysis modality [hemodialysis (HD) versus peritoneal dialysis (PD)] confers a higher risk for AP as well as complications or mortality related to AP. Methods We analyzed national health insurance claims data of 67 078 ESRD patients initiating dialysis between 1999 and 2007 in Taiwan. All patients were followed up from the start of their dialysis to first AP diagnosis, death, end of dialysis or 31 December 2008. Cox proportional hazards models were used to identify risk factors. Results The cumulative incidence rates of AP were 0.6, 1.7, 2.6, 3.4 and 4% at 1, 3, 5, 7 and 9 years, respectively. ESRD patients on HD and PD had an AP incidence of 5.11 and 5.86 per 1000 person-years, respectively. Independent risk factors for AP in this population were being elderly, being female, having biliary stones or liver disease, and being on PD. Severe AP occurred in 44.9% of the HD patients and in 36% of the PD patients. Patients with AP on HD had a higher incidence of upper gastrointestinal (UGI) bleeding than those on PD (P = 0.002). In contrast, those with AP on PD had a higher incidence of need for total parenteral nutrition (TPN) support than those on HD (P = 0.072). Overall in-hospital mortality was 8.1%. The risk factors for mortality after an AP attack were male gender, increased age, AP severity, and the presence of diabetes mellitus or liver disease. Conclusions ESRD patients on PD were at higher risk for AP than those on HD. HD patients with AP attacks had a greater incidence of UGI bleeding and PD patients with AP attacks a more frequent need for TPN support.
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Affiliation(s)
- Hung-Jui Chen
- Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Wen-Ing Tsay
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taiwan
| | - Shwu-Huey Her
- Division of Controlled Drugs, Food and Drug Administration, Ministry of Health and Welfare, Taiwan
| | - Cheng-Heng Lin
- Department of Gastroenterology and Hepatology, Chi-Mei Medical Center, Tainan, Taiwan
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Roch AM, Maatman T, Carr RA, Easler JJ, Schmidt CM, House MG, Nakeeb A, Ceppa EP, Zyromski NJ. Evolving treatment of necrotizing pancreatitis. Am J Surg 2017; 215:526-529. [PMID: 29167024 DOI: 10.1016/j.amjsurg.2017.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/12/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Over the past decade, the treatment of necrotizing pancreatitis (NP) has incorporated greater use of minimally invasive techniques, including percutaneous drainage and endoscopic debridement. No study has yet compared outcomes of patients treated with all available techniques. We sought to evaluate the evolution of NP treatment at our high volume pancreas center. We hypothesized that minimally invasive techniques (medical only, percutaneous, and endoscopic) were used more frequently in later years. METHODS Treatment strategy of NP patients at a single academic medical center between 2005 and 2014 was reviewed. Definitive management of pancreatic necrosis was categorized as: 1) medical treatment only; 2) surgical only; 3) percutaneous (interventional radiology - IR) only; 4) endoscopic only; and 5) combination (Surgery ± IR ± Endoscopy). RESULTS 526 NP patients included biliary (45%), alcoholic (17%), and idiopathic (20%) etiology. Select patients were managed exclusively by medical, IR, or endoscopic treatment; use of these therapies remained relatively consistent over time. A combination of therapies was used in about 30% of patients. Over time, the percentage of NP patients managed without operation increased from 28% to 41%. 247 (47%) of patients had operation as the only NP treatment; an additional 143 (27%) required surgery as part of a multidisciplinary management. CONCLUSION Select NP patients may be managed exclusively by medical, IR, or endoscopic treatment. Combination treatment is necessary in many NP patients, and surgical treatment continues to play an important role in the definitive therapy of necrotizing pancreatitis patients.
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Affiliation(s)
- Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rose A Carr
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey J Easler
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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Sahar N, Kozarek R, Kanji ZS, Ross AS, Gluck M, Gan SI, Larsen M, Irani S. Do lumen-apposing metal stents (LAMS) improve treatment outcomes of walled-off pancreatic necrosis over plastic stents using dual-modality drainage? Endosc Int Open 2017; 5:E1052-E1059. [PMID: 29090245 PMCID: PMC5658217 DOI: 10.1055/s-0043-111794] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 05/15/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic ultrasound-guided drainage of symptomatic walled-off pancreatic necrosis (WON) usually has been performed with double pigtail plastic stents (DPS) and more recently, with lumen-apposing metal stents (LAMS). However, LAMS are significantly more expensive and there are no comparative studies with DPS. Accordingly, we compared our experience with combined endoscopic and percutaneous drainage (dual-modality drainage [DMD]) for symptomatic WON using LAMS versus DPS. PATIENTS AND METHODS Patients who underwent DMD of WON between July 2011 and June 2016 using LAMS were compared with a matched group treated with DPS. Technical success, clinical success, need for reintervention and adverse events (AE) were recorded. RESULTS A total of 50 patients (31 males, 25 patients treated with LAMS and 25 patients treated with DPS) were matched for age, sex, computed tomography severity index, and disconnected pancreatic ducts. Technical success was achieved in all patients. Mean days hospitalized post-intervention (14.5 vs. 13.1, P = 0.72), time to resolution of WON (77 days vs. 63 days, P = 0.57) and mean follow-up (207 days vs. 258 days, P = 0.34) were comparable in both groups. AEs were similar in both groups (6 vs. 8, P = 0.53). Patients treated with LAMS had significantly more reinterventions per patient (1.5 vs. 0.72, P = 0.01). CONCLUSIONS In treatment of symptomatic WON using DMD, LAMS did not shorten time to percutaneous drain removal and was not associated with fewer AEs.
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Affiliation(s)
- Nadav Sahar
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Richard Kozarek
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Zaheer S. Kanji
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Andrew S. Ross
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Michael Gluck
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - S. Ian Gan
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Michael Larsen
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States,Corresponding author Shayan Irani Division of Gastroenterology and HepatologyVirginia Mason Medical Center1100 Ninth Avenue, C3-GASSeattle, WA 98101+1-206-625-7195
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Jia R, Ma J, Xiang S, Meng W, Wang N. Caerulin-induced pro-inflammatory response in macrophages requires TRAF3-p38 signaling activation. Biochem Biophys Res Commun 2017; 494:358-364. [PMID: 28988112 DOI: 10.1016/j.bbrc.2017.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/04/2017] [Indexed: 12/17/2022]
Abstract
Acute pancreatitis is a common threat to human health. Caerulin provokes severe inflammations, causing injuries to surrounding pancreatic cells. TNF receptor-associated factor 3 (TRAF3) is a highly versatile regulator of immune response. The current study aims to understand the potential effect of TRAF3 on caerulin-induced pro-inflammatory responses. In the primary-cultured mouse bone marrow-derived macrophages (BMDMs), caerulin induced TRAF3 protein stabilization, which formed a complex with mitogen-activated protein kinase kinase 3 (MKK3) to mediate downstream p38 activation. Lentiviral shRNA-mediated TRAF3 stable knockdown significantly attenuated caerulin-induced MKK3-p38 activation and production of several key pro-inflammatory cytokines, including interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α) and IL-17. Remarkably, TRAF3 knockdown in caerulin-stimulated BMDMs also alleviated cytotoxicity to Panc02 and primary mouse pancreatic cells. Thus, TRAF3 is required for caerulin-induced p38 activation and macrophage-mediated pro-inflammatory responses. TRAF3 expression in macrophages could be a novel therapeutic target protein for the treatment of acute pancreatitis.
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Affiliation(s)
- Rongrong Jia
- Department of Gastroenterology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiali Ma
- Department of Gastroenterology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shihao Xiang
- Department of Gastroenterology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenying Meng
- Department of Gastroenterology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Na Wang
- Department of Gastroenterology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Predictive Value of Computed Tomography Scans and Clinical Findings for the Need of Endoscopic Necrosectomy in Walled-off Necrosis From Pancreatitis. Pancreas 2017; 46:1039-1045. [PMID: 28796138 DOI: 10.1097/mpa.0000000000000881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Choosing the best treatment option at the optimal point of time for patients with walled-off necrosis (WON) is crucial. We aimed to identify imaging parameters and clinical findings predicting the need of necrosectomy in patients with WON. METHODS All patients with endoscopically diagnosed WON and pseudocyst were retrospectively identified. Post hoc analysis of pre-interventional contrast-enhanced computed tomography was performed for factors predicting the need of necrosectomy. RESULTS Sixty-five patients were included in this study. Forty patients (61.5%) were diagnosed with pseudocyst and 25 patients (38.5%) with WON. Patients with WON mostly had acute pancreatitis with biliary cause compared with more chronic pancreatitis and toxic cause in pseudocyst group (P = 0.002 and P = 0.004, respectively). Logistic regression revealed diabetes as a risk factor for WON. Computed tomography scans revealed 4.62% (n = 3) patients as false positive and 24.6% (n = 16) as false negative findings for WON. Reduced perfusion and detection of solid findings were independent risk factors for WON. CONCLUSIONS Computed tomography scans are of low diagnostic yield when needed to predict treatment of patients with pancreatic cysts. Reduced pancreatic perfusion and solid findings seem to be a risk factor for WON, whereas patients with diabetes seem to be at higher risk of developing WON.
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Green DL, Cook JB, Triemer HL, Galloway JR. Vancomycin Concentrations in Necrotic Pancreatic Tissue: A Pilot Study. Hosp Pharm 2017. [DOI: 10.1177/001857870303800909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose: To determine vancomycin concentrations in necrotic pancreatic tissue of intensive care unit (ICU) patients with acute necrotizing pancreatitis. Methods: The prospective, observational pilot study was conducted at a university-based tertiary hospital. The patient population consisted of 11 patients with necrotizing pancreatitis receiving vancomycin and undergoing necrosectomy. Tissue samples taken during surgical debridement were assayed for vancomycin by immunoassay. Patients were divided into steady state and nonsteady-state groups. Two patients were excluded because necrosectomy was not performed, and one tissue sample could not be assayed because of contamination. Results: The mean tissue concentration was 5.84 mcg/mL (ranging from 3.1 mcg/mL to 8.94 mcg/mL). Four patients in the nonsteady-state group, who each received a single dose of vancomycin, had a mean tissue concentration of 4.5 ± 1.68 mcg/mL, compared with 7.76 ± 1.05 mcg/mL for the four steady-state patients. Conclusion: The data shows that vancomycin is detectable in necrotic pancreas tissue but possibly not in concentrations sufficient to prevent or treat bacterial contamination in patients with pancreatic necrosis.
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Affiliation(s)
- David L. Green
- Department of Pharmaceutical Services; Emory University Hospital, Atlanta, GA
| | | | - Helen L. Triemer
- Kidney Transplant Service, Department of Pharmaceutical Services, Emory University Hospital
| | - John R. Galloway
- Surgical Intensive Care Unit, Department of Surgery, Emory University Hospital. At the time of the study, Dr. Cook was a Pharmacy Practice Resident at Emory University Hospital
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Kaistha S, Kumar A, Ramakrishnan TS. Necrotizing Fasciitis: A Rare Complication of Acute Necrotizing Pancreatitis. J Clin Diagn Res 2017; 11:PD05-PD06. [PMID: 28764243 PMCID: PMC5535435 DOI: 10.7860/jcdr/2017/27032.10032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/09/2017] [Indexed: 02/07/2023]
Abstract
Necrotizing pancreatitis occurs in 10 to 25% of patients requiring hospital admission for acute pancreatitis and carries a high mortality rate. Necrotizing pancreatitis can cause a spectrum of complications. However, we report an extremely rare complication of necrotizing pancreatitis: necrotizing fasciitis of the abdominal wall. A 56-year-old male patient presented to our center with discoloration of skin over left flank of 15 days duration and pus discharge from it since three days. Two months back he was managed at a private hospital as a case of acute necrotizing pancreatitis and was discharged after one week of inpatient treatment. After discharge patient continued to have malaise and weakness but was able to do his routine day to day activity. On presentation at our hospital, patient was in septic shock and was taken emergently to operating theatre for debridement. However, later, the patient succumbed to his illness. Necrotizing fasciitis is an extremely uncommon complication of necrotizing pancreatitis and has a fulminant course. Timely detection and debridement can avert a potential mortality.
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Affiliation(s)
- Sumesh Kaistha
- Assistant Professor, Department of Surgery, Command Hospital Air force, Bangalore, Karnataka, India
| | - Ameet Kumar
- Assistant Professor, Department of Surgery, Command Hospital Air force, Bangalore, Karnataka, India
- NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Ameet Kumar, Department of Surgery, Command Hospital Air Force, Agram Post, Bangalore-560007, Karnataka, India. E-mail:
| | - TS Ramakrishnan
- Professor, Department of Surgery, Command Hospital Air force, Bangalore, Karnataka, India
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Bulyez S, Pereira B, Caumon E, Imhoff E, Roszyk L, Bernard L, Bühler L, Heidegger C, Jaber S, Lefrant JY, Chabanne R, Bertrand PM, Laterre PF, Guerci P, Danin PE, Escudier E, Sossou A, Morand D, Sapin V, Constantin JM, Jabaudon M. Epidural analgesia in critically ill patients with acute pancreatitis: the multicentre randomised controlled EPIPAN study protocol. BMJ Open 2017; 7:e015280. [PMID: 28554928 PMCID: PMC5730003 DOI: 10.1136/bmjopen-2016-015280] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is associated with high morbidity and mortality in its most severe forms. Most patients with severe AP require intubation and invasive mechanical ventilation, frequently for more than 7 days, which is associated with the worst outcome. Recent increasing evidence from preclinical and clinical studies support the beneficial effects of epidural analgesia (EA) in AP, such as increased gut barrier function and splanchnic, pancreatic and renal perfusion, decreased liver damage and inflammatory response, and reduced mortality. Because recent studies suggest that EA might be a safe procedure in the critically ill, we sought to determine whether EA reduced AP-associated respiratory failure and other major clinical outcomes in patients with AP. METHODS AND ANALYSIS The Epidural Analgesia for Pancreatitis (EPIPAN) trial is an investigator-initiated, prospective, multicentre, randomised controlled two-arm trial with assessor-blinded outcome assessment. The EPIPAN trial will randomise 148 patients with AP requiring admission to an intensive care unit (ICU) to receive EA (with patient-controlled epidural administration of ropivacaine and sufentanil) combined with standard care based on current recommendations on the treatment of AP (interventional group), or standard care alone (reference group). The primary outcome is the number of ventilator-free days at day 30. Secondary outcomes include main complications of AP (eg, organ failure and mortality, among others), levels of biological markers of systemic inflammation, epithelial lung injury, renal failure, and healthcare-associated costs. ETHICS AND DISSEMINATION The study was approved by the appropriate ethics committee (CPP Sud-Est VI). Informed consent is required. If the combined application of EA and standard care proves superior to standard care alone in patients with AP in the ICU, the use of EA may become standard practice in experienced centres, thereby decreasing potential complications related to AP and its burden in critically ill patients. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02126332.
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Affiliation(s)
- Stéphanie Bulyez
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Elodie Caumon
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Etienne Imhoff
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laurence Roszyk
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Lise Bernard
- Department of Pharmacy, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, Clermont-Ferrand, France
| | - Leo Bühler
- Department of Surgery, Geneva university hospitals, Geneva, Switzerland
| | - Claudia Heidegger
- Division of Intensive Care, Geneva university hospitals, Geneva, Switzerland
| | - Samir Jaber
- Department of Anesthesiology and Critical Care Medicine B (DAR B), Saint-Eloi teaching hospital, Montpellier university hospital, Montpellier, France
| | - Jean-Yves Lefrant
- Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes university hospital and EA 2992, Université Montpellier, Nîmes, France
| | - Russell Chabanne
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Pierre-François Laterre
- Department of Critical Care Medicine, Saint Luc university hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Philippe Guerci
- Department of Anesthesiology and Intensive Care Medicine, Nancy university hospital, Nancy, France
| | - Pierre-Eric Danin
- Anesthesia and Surgical Intensive Care, Nice Archet 2 university hospital and INSERM U1065, team 8, Nice, France
| | - Etienne Escudier
- Intensive Care Unit, Annecy Genevois general hospital, Annecy, France
| | - Achille Sossou
- Department of Anesthesiology and Critical Care Medicine, Emile-Roux general hospital, Le Puy-en-Velay, France
| | - Dominique Morand
- Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
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Dual drainage using a percutaneous pancreatic duct technique contributed to resolution of severe acute pancreatitis. Clin J Gastroenterol 2017; 10:191-195. [PMID: 28236277 DOI: 10.1007/s12328-017-0720-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/07/2017] [Indexed: 01/12/2023]
Abstract
A 66-year-old man was admitted for severe acute alcoholic pancreatitis with infected pancreatic necrosis (IPN). Abdominal computed tomography revealed an inflamed pancreatic head, a dilated main pancreatic duct (MPD), and a large cavity with heterogeneous fluid containing gas adjacent to the pancreatic head, and extending to the pelvis. The cavity was drained percutaneously near the pancreatic head on admission; another tube was inserted into the pelvic cavity on hospital day 3. The drained fluid contained pus with high amylase concentration. Nasopancreatic drainage tube placement was unsuccessfully attempted on hospital day 9. On hospital day 23, percutaneous puncture of the MPD and placement of a pancreatic duct drainage tube was performed. Pancreatography revealed major extravasation from the pancreatic head. The IPN cavity receded; the percutaneous IPN drainage tube was removed on hospital day 58. On hospital day 83, the pancreatic drainage was changed to a transpapillary pancreatic stent, and the patient was discharged. Measuring the amylase concentration of peripancreatic fluid collections can aid in the diagnosis of pancreatic duct disruption; moreover, dual percutaneous necrotic cavity drainage plus pancreatic duct drainage may be essential for treating IPN. If transpapillary drainage tube placement is difficult, percutaneous pancreatic duct drainage may be feasible.
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Endothelial markers are associated with pancreatic necrosis and overall prognosis in acute pancreatitis: A preliminary cohort study. Pancreatology 2016; 17:45-50. [PMID: 28007459 DOI: 10.1016/j.pan.2016.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/13/2016] [Accepted: 12/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endothelial injury is believed to play an important role in the evolution of pancreatic microcirculatory dysfunction and pancreatic necrosis (PN) in patients with acute pancreatitis (AP). The aim of this study was to investigate the role of three endothelial markers (von Willebrand factor, vWF; E-selectin; endothelial protein C receptor, EPCR) in the early phase of AP, especially the relationship between endothelial markers and PN. METHODS From March 2015 to March 2016, 57 AP patients admitted within 72 h of symptom onset in our hospital were included for this study. Blood samples were taken on admission and the clinical characteristics and outcomes of these patients were recorded. The levels of vWF, E-selectin and EPCR were measured using ELISA for analysis and compared with other severity markers of AP. RESULTS All the three markers were significantly different in healthy control, mild, moderate and severe AP patients. Moreover, the endothelial markers, especially vWF, also showed significant difference in patients with different extent of PN, as well as those with or without MODS. Additionally, the levels of endothelial markers correlated well with other commonly used markers of AP severity. CONCLUSION Elevated endothelium-related mediators (vWF, E-selectin and EPCR) appear to participate in the development of PN and may be a potential indicator of overall prognosis. Our results may help clinicians better understand the pathophysiological process of the development of PN.
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Fontana F, Cappelli G. Acute pancreatitis associated with everolimus after kidney transplantation: a case report. BMC Nephrol 2016; 17:163. [PMID: 27793122 PMCID: PMC5084425 DOI: 10.1186/s12882-016-0376-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/25/2016] [Indexed: 11/29/2022] Open
Abstract
Background Acute pancreatitis (AP) following KT is a rare and often fatal complication of the early post-transplant period. Common causative factors for AP are rare after KT; anti-rejection drugs as CyA, prednisone and MMF have been implicated, although evidence is not strong and we found no reports on possible causative role for mTOR inhibitors. Case presentation A 55-year-old Caucasian man with end-stage renal disease due to idiopathic membrano-prolipherative glomerulonephritis underwent single kidney transplantation (KT) from cadaveric donor. Anti-rejection protocol was based on Basiliximab induction followed by prednisone and mycophenolate mophetil (MMF) and Cyclosporine; Everolimus (Eve) was scheduled to substitute MMF at week 3. At day 1 he had an asymptomatic elevation of pancreatic enzymes, spontaneously resolved. The further course was unremarkable and on day 19 he started Eve, with following asymptomatic rise in pancreatic enzymes. At day 33 the patient presented with abdominal pain and a marked elevation in serum amylase (1383 U/l) and lipase (1015 U/l), normal liver enzymes and bilirubin, no hypercalcemia, mild elevation in triglycerids; RT-PCRs for Cytomegalovirus or Epstein-Barr virus were negative. The patient had no history of alcohol abuse; ultrasound, CT and MRI found no evidence of biliary lithiasis. CT scans showed a patchy fluid collection in the pancreatic head area, consistent with idiopathic necrotizing pancreatitis. The patient was treated medically and Eve was withdrawn 1 week after. Patient underwent guided drainage of the fluid collection, but developed bacterial sepsis; surgical intervention was required with debridement of necrotic tissue, lavage and drainage; immunosuppression was totally withdrawn. Following course was complicated with multiple systemic infection. Transplantectomy for acute rejection was performed, and patient entered hemodialysis. Conclusions Our patient had a presentation that is consistent for a causative role of Eve. A predisposing condition (acute pancreatic insult during transplant surgery) spontaneously resolved, relapsed and evolved rapidly in AP after the initiation of treatment with Eve with a consistent time latency. None of the well-known common causative factors for AP was present. We discourage the use of Eve in patients with recent episodes of sub-clinical pancreatitis, since it may represent a precipitating factor or interfere with resolution.
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Affiliation(s)
- Francesco Fontana
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy.
| | - Gianni Cappelli
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
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Singh VK, Gardner TB, Papachristou GI, Rey-Riveiro M, Faghih M, Koutroumpakis E, Afghani E, Acevedo-Piedra NG, Seth N, Sinha A, Quesada-Vázquez N, Moya-Hoyo N, Sánchez-Marin C, Martínez J, Lluís F, Whitcomb DC, Zapater P, de-Madaria E. An international multicenter study of early intravenous fluid administration and outcome in acute pancreatitis. United European Gastroenterol J 2016; 5:491-498. [PMID: 28588879 DOI: 10.1177/2050640616671077] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 08/29/2016] [Indexed: 12/16/2022] Open
Abstract
AIMS Early aggressive fluid resuscitation in acute pancreatitis is frequently recommended but its benefits remain unproven. The aim of this study was to determine the outcomes associated with early fluid volume administration in the emergency room (FVER) in patients with acute pancreatitis. METHODS A four-center retrospective cohort study of 1010 patients with acute pancreatitis was conducted. FVER was defined as any fluid administered from the time of arrival to the emergency room to 4 h after diagnosis of acute pancreatitis, and was divided into tertiles: nonaggressive (<500 ml), moderate (500 to 1000 ml), and aggressive (>1000 ml). RESULTS Two hundred sixty-nine (26.6%), 427 (42.3%), and 314 (31.1%) patients received nonaggressive, moderate, and aggressive FVER respectively. Compared with the nonaggressive fluid group, the moderate group was associated with lower rates of local complications in univariable analysis, and interventions, both in univariable and multivariable analysis (adjusted odds ratio (95% confidence interval): 0.37 (0.14-0.98)). The aggressive resuscitation group was associated with a significantly lower need for interventions, both in univariable and multivariable analysis (adjusted odds ratio 0.21 (0.05-0.84)). Increasing fluid administration categories were associated with decreasing hospital stay in univariable analysis. CONCLUSIONS Early moderate to aggressive FVER was associated with lower need for invasive interventions.
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Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, USA
| | - Georgios I Papachristou
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Mónica Rey-Riveiro
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Mahya Faghih
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Efstratios Koutroumpakis
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Elham Afghani
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Nelly G Acevedo-Piedra
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Nikhil Seth
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Amitasha Sinha
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Noé Quesada-Vázquez
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Neftalí Moya-Hoyo
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Claudia Sánchez-Marin
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Juan Martínez
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Félix Lluís
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - David C Whitcomb
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Pedro Zapater
- Clinical Pharmacology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Enrique de-Madaria
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
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