Severe Acute Pancreatitis: Gut Barrier Failure, Systemic Inflammatory Response, Acute Lung Injury, and the Role of the Mesenteric Lymph

Inhibition of angiotensin II type 1 receptor reduces oxidative stress damage to the intestinal barrier in severe acute pancreatitis

Intestinal barrier injury is a common complication of severe acute pancreatitis (SAP), which is often accompanied by intestinal mucosal barrier injury and results in serious consequences. However, the exact mechanism remains unclear. We aimed to investigate whether angiotensin II type 1 receptor (AT1)-mediated oxidative stress is involved in SAP intestinal barrier injury and assessed the effects of inhibiting this pathway. The SAP model was established by retrograde bile duct injection of sodium taurocholate (5%). The rats were divided into three groups: the control group (SO), the SAP group (SAP), and the azilsartan intervention group (SAP + AZL). Serum amylase, lipase, and other indexes were measured to evaluate SAP severity in each group. Histopathological changes in the pancreas and intestine were evaluated by HE staining. The oxidative stress of intestinal epithelial cells was detected by superoxide dismutase and glutathione. We also detected the expression and distribution of intestinal barrier-related proteins. The results showed that the serum indexes, the severity of tissue damage, and the level of oxidative stress in the SAP + AZL group were significantly lower than in the SAP group. Our study provided hitherto undocumented evidence of AT1 expression in the intestinal mucosa, confirming that AT1-mediated oxidative stress is involved in SAP intestinal mucosal injury, and inhibiting this pathway could effectively reduce intestinal mucosal oxidative stress injury, providing a new and effective target for the treatment of SAP intestinal barrier injury.

Effectiveness of Chengqi-series decoctions in treating severe acute pancreatitis: A Systematic review and meta-analysis

BACKGROUND

Evidence suggests that Dachengqi and its modified decoctions are effective for treating abdominal pain, multiple organ dysfunction syndrome (MODS) and inflammation in various disease conditions. We performed a meta-analysis to ascertain the effectiveness of a series of chengqi decoctions in patients with severe acute pancreatitis (SAP).

METHODS

We searched Pubmed, Embase, Cochrane library, Web of Science, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature, Wanfang database and China Science and Technology Journal Database before August 2022 to identify eligible randomized controlled trials (RCTs). Mortality and MODS were chosen as primary outcomes. Secondary outcomes included time until relief of abdominal pain, APACHE II score, complications, effectiveness, IL-6 and TNF-α levels. The risk ratio (RR) and standardized mean difference (SMD) with a 95% confidence interval (CI) were selected as effect measures. The quality of evidence was independently assessed by two reviewers using Grading of Recommendations Assessment Development and Evaluation (GRADE) system.

RESULTS

Twenty-three RCTs (n = 1865) were finally included. The results showed that, compared with routine therapies, chengqi-series decoctions (CQSDs) treatment groups were associated with lower mortality rate (RR: 0.41, 95%CI: 0.32 to 0.53, p = 0.992) and incidence of MODS (RR: 0.48, 95%CI: 0.36 to 0.63, p = 0.885). They also reduced remission time of abdominal pain (SMD: -1.66, 95%CI: -1.98 to -1.35, p = 0.000), complications (RR: 0.52, 95%CI: 0.39 to 0.68, p = 0.716), APACHE II score (SMD: -1.04, 95%CI:-1.55 to -0.54, p = 0.003), IL-6 (SMD: -1.5, 95%CI: -2.16 to -0.85, p = 0.000), TNF-α (SMD: -1.18, 95%CI: -1.71 to -0.65, p = 0.000), and improved curative effectiveness (RR:1.22, 95%CI: 1.14 to 1.31, p = 0.757). The certainty of the evidence for these outcomes was low to moderate.

CONCLUSION

CQSDs seem to be effective therapy for SAP patients with notable reductions in mortality, MODS and abdominal pain, with low quality evidence. Large-scale, multi-center RCTs that are more meticulous are advised in order to produce superior evidence.

Extracellular Vesicle ITGAM and ITGB2 Mediate Severe Acute Pancreatitis-Related Acute Lung Injury

Integrins expressed on extracellular vesicles (EVs) secreted by various cancers are reported to mediate the organotropism of these EVs. Our previous experiment found that pancreatic tissue of mice with severe cases of acute pancreatitis (SAP) overexpresses several integrins and that serum EVs of these mice (SAP-EVs) can mediate acute lung injury (ALI). It is unclear if SAP-EV express integrins that can promote their accumulation in the lung to promote ALI. Here, we report that SAP-EV overexpress several integrins and that preincubation of SAP-EV with the integrin antagonist peptide HYD-1 markedly attenuates their pulmonary inflammation and disrupt the pulmonary microvascular endothelial cell (PMVEC) barrier. Further, we report that injecting SAP mice with EVs engineered to overexpress two of these integrins (ITGAM and ITGB2) can attenuate the pulmonary accumulation of pancreas-derived EVs and similarly decrease pulmonary inflammation and disruption of the endothelial cell barrier. Based on these findings, we propose that pancreatic EVs can mediate ALI in SAP patients and that this injury response could be attenuated by administering EVs that overexpress ITGAM and/or ITGB2, which is worthy of further study due to the lack of effective therapies for SAP-induced ALI.

Serum triglyceride levels are associated with recurrence in patients with acute hypertriglyceridemic pancreatitis

Aim

To analyze the clinical profile of patients with acute hypertriglyceridemic pancreatitis (HTGP) and explore risk factors for recurrence.

Methods

A retrospective observational study was conducted in patients who experienced an attack of HTGP for the first time. Patients were followed until the recurrence of acute pancreatitis (AP) or 1 year. The detailed clinical profile was compared between patients with or without recurrence. Multivariate logistic regression analysis was conducted to explore independent risk factors for recurrence.

Results

A total of 108 HTGP patients were included in this study with 73.1% being male, and the median age being 37 (interquartile range, IQR, 30.3–44.8) years. Recurrence occurred in 70 patients (64.8%). Compared with the nonrecurrent group, serum triglyceride (TG) levels before discharge [4.1 (2.8,6.3) mmol/L vs. 2.9 (2.2,4.2) mmol/L; p = 0.002], at 1 month [3.7 (2.3,9.7) mmol/L vs. 2.0 (1.4,2.7) mmol/L; p = 0.001], at 6 months [6.1 (3.1,13.1) mmol/L vs. 2.5 (1.1,3.5) mmol/L; p = 0.003] and 12 months [9.6 (3.5,20.0) mmol/L vs. 2.7 (1.6,5.5) mmol/L; p = 0.001] after discharge were higher in the recurrent group. Poor control of TG levels (TG > 3.1 mmol/l) at the 1-month follow-up after discharge and a high Charlson’s Comorbidity Index score (≥ 2 points) increased the risk of recurrence of HTGP.

Conclusion

High TG levels during follow-up and Charlson’s Comorbidity Index score were independently associated with recurrence in patients with HTGP.

A Prospective Study of Using Chaihu Shugan Powder Combined with Zu San Li Acupoint Stimulation to Improve the Prognosis of Liver Stagnation and Qi Stagnation Syndrome in Acute Pancreatitis

Background

This study aimed to explore the clinical efficacy of Chaihu Shugan powder combined with Zu San Li acupoint stimulation on the acute pancreatitis of liver and qi stagnation syndromes, the protection of intestinal barrier function, the prevention of severe tendency, and safety evaluation.

Method

Data were collected from October 2019-June 2021 at Xinhua Hospital, which is affiliated with Shanghai Jiao Tong University School of Medicine, Emergency Department. Eighty patients with acute pancreatitis were randomly divided into a control treatment group (40 people) and a combined traditional Chinese medicine (TCM) treatment group (40 people). Detailed records of hospitalised patients were obtained, including the general situation of patients' clinical diagnosis and clinical examination before and after treatment. The changes in inflammatory and immune indexes before and after treatment were recorded.

Result

Compared with the standard treatment group, the relief time of abdominal pain in the TCM treatment group was significantly shortened with statistically significant differences. Compared with the standard treatment group, the levels of WBC, ALT, CA, hemodiastase, lipase, TG, and other factors in the TCM treatment group decreased, whereas the levels of DB, SCR, cholesterol, K⁺, and other factors increased. The differences were statistically significant (P < 0.05).

Conclusion

Chaihu Shugan powder combined with Zu San Li acupoint stimulation can reduce the clinical manifestations of liver and qi stagnation syndromes of acute pancreatitis, protect the intestinal barrier function, prevent the tendency of severe illness and improve the prognosis.

Toll-Like Receptor 9 Signaling Pathway Contributes to Intestinal Mucosal Barrier Injury in Mice With Severe Acute Pancreatitis

OBJECTIVES

The purpose of this study was to investigate the role and mechanism of toll-like receptor 9 (TLR9) in intestinal mucosal barrier injury in mice with severe acute pancreatitis (SAP).

METHODS

The mice were randomly divided into 3 groups: control group, SAP group, and TLR9 antagonist-treated group. The expression of tumor necrosis factor-α, interleukin-1β, interleukin-6, diamine oxidase, and endotoxin core antibodies were detected by enzyme-linked immunosorbent assay. The protein expression of zonula occluden-1 (ZO)-1, occludin, TLR9, myeloid differentiation factor 88 (MyD88), tumor necrosis factor receptor-associated factor 6 (TRAF6), p-nuclear factor (NF)-κB p65, and NF-κB p65 were detected by Western blot. TdT-mediated dUTP nick-end labeling staining was used for detecting intestinal epithelial cell apoptosis.

RESULTS

The expression of TLR9 and its related pathway proteins MyD88, TRAF6, and p-NF-κB p65 in the intestinal tract of SAP mice were significantly increased compared with that of control mice. Inhibition of the TLR9 expression could reduce the level of serum proinflammatory cytokines, reduce the apoptosis of intestinal epithelial cells, improve intestinal permeability, and ultimately reduce the damage of intestinal mucosal barrier function in SAP.

CONCLUSIONS

Toll-like receptor 9/MyD88/TRAF6/NF-κB signaling pathway plays an important role in intestinal mucosal barrier injury of SAP.

Beneficial Effect of Kidney Bean Resistant Starch on Hyperlipidemia-Induced Acute Pancreatitis and Related Intestinal Barrier Damage in Rats

Accumulating attention has been focused on resistant starch (RS) due to its blood-lipid-lowering activities. However, reports on the potential bioactivities of RS for preventing hyperlipidemia acute pancreatitis (HLAP) are limited. Therefore, in this study, an acute pancreatitis model was set up by feeding a hyperlipidemia diet to rats, and subsequently evaluating the anti-HLAP effect of RS in kidney beans. The results show that the IL-6, IL-1β, and TNF-α of serum in each RS group were decreased by 18.67-50.00%, 7.92-22.89%, and 8.06-34.04%, respectively, compared with the model group (MOD). In addition, the mRNA expression of tight junction protein ZO-1, occludin, and antibacterial peptides CRAMP and DEFB1 of rats in each RS group increased by 26.43-60.07%, 229.98-279.90%, 75.80-111.20%, and 77.86-109.07%, respectively. The height of the villi in the small intestine and the thickness of the muscle layer of rats were also increased, while the depth of the crypt decreased. The present study indicates that RS relieves intestinal inflammation, inhibits oxidative stress, and prevents related intestinal barrier damage. These results support the supplementation of RS as an effective nutritional intervention for HLAP and associated intestinal injury.

Proton Pump Inhibitors Were Associated With Reduced Pseudocysts in Acute Pancreatitis: A Multicenter Cohort Study

Background: Acute pancreatitis (AP) is a systemic inflammatory disorder with a wide spectrum of clinical symptoms that can range from mild to severe. Previous preclinical study results suggest that proton pump inhibitors (PPIs) can inhibit exocrine pancreatic secretion and exert anti-inflammatory properties, which might in turn improve the outcome of AP.

Aim: We conducted this multicenter, retrospective cohort study to investigate the potential effects of PPIs on the mortality, and total duration of hospital stay and local complication occurrence of patients with AP.

Methods: A total of 858 patients with AP were included. All patients presented to the hospital within 48 h of symptom onset and were divided into the following two groups: patients who were treated with PPIs (n = 684) and those not treated with PPIs (n = 174). We used propensity score matching (PSM) analysis to reduce confounding bias before comparing the outcomes between the two groups.

Results: Before PSM analysis, there were significant differences in a number of parameters between the two groups, including age, sex, hematocrit, blood urea nitrogen, peritonitis signs, Ranson’s score, and Acute Physiology Chronic Health Evaluation II score and organ failure occurrence. Before PSM, the PPIs group had a higher rate of mortality than the control group [RR = 1.065; 95% confidence ratio (CI) 1.045–1.086; p = 0.001]. After PSM, there was no significant difference in mortality (RR = 1.009; 95% CI, 0.999–1.019; p = 0.554) or total hospital stay (p = 0.856), although the PPIs group had a lower occurrence of pancreatic pseudocyst (RR = 0.416; 95% CI 0.221–0.780; p = 0.005).

Conclusion: This study showed that PPIs therapy was not associated with reduced mortality or total hospital stay, but was associated with a reduction in the occurrence of pseudocysts in patients with acute pancreatitis.

Assessment of Prophylactic Carbapenem Antibiotics Administration for Severe Acute Pancreatitis: An Updated Systematic Review and Meta-Analysis

BACKGROUND

The effectiveness of prophylactic antibiotics in severe acute pancreatitis (SAP) remains a debatable issue. This meta-analysis aimed to determine the efficacy of prophylactic carbapenem antibiotics in SAP.

METHODS

This meta-analysis of prophylactic carbapenem antibiotics for SAP was conducted in PubMed, EMBASE, Web of Science, MEDLINE, and Cochrane Library up to February 2021. The related bibliographies were manually searched. The primary outcomes involved infected pancreatic or peripancreatic necrosis, mortality, complications, infections, and organ failure.

RESULTS

Seven articles comprised 5 randomized controlled trials and 2 retrospective observational studies, including 3,864 SAP participants. Prophylactic carbapenem antibiotics in SAP were associated with a statistically significant reduction in the incidence of infections (odds ratio [OR]: 0.27; p = 0.03) and complications (OR: 0.48; p = 0.009). Nevertheless, no statistically significant difference was demonstrated in the incidence of infected pancreatic or peripancreatic necrosis (OR: 0.74; p = 0.24), mortality (OR: 0.69; p = 0.17), extrapancreatic infection (OR: 0.64, p = 0.54), pulmonary infection (OR: 1.23; p = 0.69), blood infection (OR: 0.60; p = 0.35), urinary tract infection (OR: 0.97; p = 0.97), pancreatic pseudocyst (OR: 0.59; p = 0.28), fluid collection (OR: 0.91; p = 0.76), organ failure (OR: 0.63; p = 0.19), acute respiratory distress syndrome (OR: 0.80; p = 0.61), surgical intervention (OR: 0.97; p = 0.93), dialysis (OR: 2.34; p = 0.57), use of respirator or ventilator (OR: 1.90; p = 0.40), intensive care unit treatment (OR: 2.97; p = 0.18), and additional antibiotics (OR: 0.59; p = 0.28) between the experimental and control groups.

CONCLUSIONS

It is not recommended to administer routine prophylactic carbapenem antibiotics in SAP.

Sampling Thoracic Duct Lymph After Esophagectomy: A Pilot Study Investigating the "Gut-Lymph" Concept

Introduction: Gut-lymph in animal models of acute disease is altered by intestinal ischemia and contributes to the development of systemic inflammation and organ dysfunction. Investigating gut-lymph in humans is hampered difficulty in accessing the thoracic duct (TD) for lymph sampling. The aims of this study were to develop and pilot a technique of intraoperative TD cannulation with delayed embolization to serially measure TD lymph pressure, flow, and composition (including markers of intestinal injury) during the early postoperative period and in response to enteral feeding and vasopressor treatment. Methods: A Seldinger technique was used for percutaneous TD cannulation during an Ivor Lewis esophagogastrectomy. Lymph flow rate and pressure were measured. TD lymph and plasma were sampled at 12 hourly intervals for up to 120 hours after surgery and before TD embolization. Biochemistry, lipids, cytokines, and markers of intestinal injury were measured before and after enteral feeding commenced at 36 hours. Results: Intraoperative TD cannulation was technically feasible in three of four patients. Delayed TD embolization was only successful in one of three patients, with two patients requiring a re-thoracotomy to treat chylothorax. Profound changes in TD composition, but not flow rate, occurred over time and in response to enteral feeding and vasopressors. TD lymph compared with plasma had significantly higher lipase (1.4-17 × ), interleukin-6 (8-108 × ), tumor necrosis factor-α (2.7-17 × ), d-lactate (0.3-23 × ), endotoxin (0.1-41 × ), and intestinal fatty acid binding protein (1.1-853 × ). Conclusions: Although TD cannulation and lymph sampling were successful, TD embolization failed in two of three patients. The composition of sampled TD lymph changed dramatically in response to enteral feeding, indicating intestinal ischemia that could be exacerbated by nonselective vasopressors. The higher concentration of proinflammatory cytokines and gut injury markers in TD lymph, compared with plasma, lends support to the gut-lymph concept.

PSD-95 protects the pancreas against pathological damage through p38 MAPK signaling pathway in acute pancreatitis

Acute pancreatitis is one of the leading causes of gastrointestinal disorder-related hospitalizations, yet its pathogenesis remains to be fully elucidated. Postsynaptic density protein-95 (PSD-95) is closely associated with tissue inflammation and injury. We aimed to investigate the expression of PSD-95 in pancreatic acinar cells, and its function in regulating the inflammatory response and pancreatic pathological damage in acute pancreatitis. A mouse model of edematous acute pancreatitis was induced with caerulein and lipopolysaccharide in C57BL/6 mice. Tat-N-dimer was injected to inhibit the PSD-95 activity separately, or simultaneously with SB203580, inhibitor of p38 MAPK phosphorylation. Rat pancreatic acinar cells AR42J were cultured with 1 μM caerulein to build a cell model of acute pancreatitis. PSD-95-knockdown and negative control cell lines were constructed by lentiviral transfection of AR42J cells. Paraffin-embedded pancreatic tissue samples were processed for routine HE staining to evaluate the pathological changes of human and mouse pancreatic tissues. Serum amylase and inflammatory cytokine levels were detected with specific ELISA kits. Immunofluorescence, immunohistochemical, Western-blot, and qRT-PCR were used to detect the expression levels of PSD-95, p38, and phosphorylated p38. Our findings showed that PSD-95 is expressed in the pancreatic tissues of humans, C57BL/6 mice, and AR42J cells, primarily in the cytoplasm. PSD-95 expression increased at 2 h, reaching the peak at 6 h in mice and 12 h in AR42J cells. IL-6, IL-8, and TNF-α increased within 2 h of disease induction. The pancreatic histopathologic score was greater in the PSD-95 inhibition group compared with the control (P < 0.05), while it was lesser when phosphorylation of p38 MAPK was inhibited compared with the PSD-95 inhibition group (P < 0.05). Moreover, phosphorylation of p38 MAPK increased statistically after PSD-95 knocked-down. In conclusion, PSD-95 effectively influences the pathological damage of the pancreas in acute pancreatitis by affecting the phosphorylation of p38 MAPK.

Extracellular vesicles and pancreatitis: mechanisms, status and perspectives

Comprehensive reviews and large population-based cohort studies have played an important role in the diagnosis and treatment of pancreatitis and its sequelae. The incidence and mortality of pancreatitis have been reduced significantly due to substantial advancements in the pathophysiological mechanisms and clinically effective treatments. The study of extracellular vesicles (EVs) has the potential to identify cell-to-cell communication in diseases such as pancreatitis. Exosomes are a subset of EVs with an average diameter of 50~150 nm. Their diverse and unique constituents include nucleic acids, proteins, and lipids, which can be transferred to trigger phenotypic changes of recipient cells. In recent years, many reports have indicated the role of EVs in pancreatitis, including acute pancreatitis, chronic pancreatitis and autoimmune pancreatitis, suggesting their potential influence on the development and progression of pancreatitis. Plasma exosomes of acute pancreatitis can effectively reach the alveolar cavity and activate alveolar macrophages to cause acute lung injury. Furthermore, upregulated exosomal miRNAs can be used as biomarkers for acute pancreatitis. Here, we summarized the current understanding of EVs in pancreatitis with an emphasis on their biological roles and their potential use as diagnostic biomarkers and therapeutic agents for this disease.

Infectious Complications of Acute Pancreatitis Is Associated with Peripheral Blood Phagocyte Functional Exhaustion

BACKGROUND

Infected pancreatic necrosis is one of the most severe complications of acute pancreatitis (AP). The development of secondary infection doubles the risk of death during the late stage of necrotizing pancreatitis. Phagocytes play a major role in AP pathogenesis, as well as in local and systemic complications of the disease.

AIMS

We aimed to investigate the relationship between quantitative and functional indices of circulating phagocyte at the time of admission and onset of infectious complications in patients with AP afterward.

METHODS

A post hoc analysis of 97 patients with AP was conducted. The metabolic state of peripheral blood neutrophils and monocytes was analyzed based on their phagocytic activity and generation of reactive oxygen species (ROS), which were determined by flow cytometry on admission. The clinical end point was marked by onset of infectious complications of AP.

RESULTS

On admission, baseline values and reactivity reserve of monocyte and neutrophil phagocytic activity in AP patients, who developed septic complications, were substantially decreased, whereas monocyte ROS generation was dramatically increased as compared to the group without infectious processes. ROC curve was obtained both for neutrophil and monocyte phagocytosis reactivity reserve expressed as modulation coefficient values and categorized as the risk factor of infectious complications, showing an area under curve of 0.95 (P < 0.0001) and 0.84 (P < 0.0001), respectively.

CONCLUSIONS

Early (at the time of admission) detection of quantitative and functional indices of circulating phagocytes can be useful for the prediction of septic complications in SAP patients.

The impacts of acid suppression on duodenal microbiota during the early phase of severe acute pancreatitis

Duodenal dysbiosis may be potential infection risks in patients with severe acute pancreatitis (SAP). Acid-suppression drugs (ACDs) are widely used in SAP patients in Asian countries. However, the impact of ACDs on duodenal microbiota during the early phase of SAP is still unknown. This randomized controlled clinical trial evaluated the impacts of esomeprazole (Eso), one of ACDs on duodenal microbiota during the first week of SAP with duodenal aspirates culture and 16sRNA Illumina sequencing analysis. 66 patients were randomized as 1:1 ratio into Eso group (Eso 40 mg/day) and Eso-N group (no Eso). The occurrence of duodenal bacterial overgrowth (DBO) was significantly higher in Eso group (about 85%) than that in Eso-N group (about 42%). The duodenal microbiota of the SAP patients shifted away from that of the normal control. There were differences between the Eso-N and Eso groups including enriched abundances of the class Negativicutes, order Selenomonadales and genus Veillonella. Acid suppression significantly increased incidence of Candida oesophagitis (CE) by 8-folds but did not increase other infectious events. In conclusion, acid suppression greatly increased the occurrence of DBO, duodenal dysbiosis and CE during the first week of SAP. Restrictive use of acid-suppressing medications might be helpful to reduce CE and potential risk of pancreatic infection in SAP patients.Trial registration: Chictr.org, ChiCTR-IPR-16008301, Registered April 18 2016, http://www.chictr.org.cn/showproj.aspx?proj=14089 .

The interplay between the gut microbiota and NLRP3 activation affects the severity of acute pancreatitis in mice

Early dysbiosis of the gut microbiota is associated with the severity of acute pancreatitis (AP), although the underlying mechanism is unclear. Here, we investigated the role of crosstalk between NLRP3 and the gut microbiota in the development of AP utilizing gut microbiota deficient mice, as well as NLRP3 knockout (KO) mouse models. Pancreatic damage and systemic inflammation were improved in antibiotic-treated (Abx) and germ-free (GF) mice, accompanied by weakened activity of the intestinal NLRP3 inflammasome. Interestingly, fecal microbiota transplantation (FMT) reactivated the intestinal NLRP3 inflammasome and exacerbated the disease in Abx and GF mice. Although the gut barrier in GF and Abx mice was disrupted, gut microbiota deficiency ameliorated the severity of AP, probably due to the reduction in bacterial translocation from the gut to the pancreas. The composition of the gut microbiota was significantly different between NLRP3 KO mice and wild-type (WT) mice at baseline, and there were alterations in response to the induction of AP. While a dramatic shift in the gut microbiota with overgrowth of Escherichia-Shigella was observed in WT mice suffering from AP, there was no significant change in NLRP3 KO mice with or without AP, suggesting that NLRP3 deficiency counteracts AP-induced microbial disturbance. With a strengthened gut barrier and decreased systemic inflammation, NLRP3 KO mice showed less severe AP, as revealed by reduced pancreatic neutrophilic infiltration and necrosis. Taken together, these results identified the bidirectional modulation between the gut microbiota and NLRP3 in the progression of AP, which suggests the interplay of the host and microbiome during AP.

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

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

Single immunoglobulin and Toll‑interleukin‑1 receptor domain containing molecule protects against severe acute pancreatitis in vitro by negatively regulating the Toll‑like receptor‑4 signaling pathway: A clinical and experimental study

Single immunoglobulin and Toll-interleukin-1 receptor domain-containing molecule (SIGIRR) is a specific inhibitor of IL-1R and Toll-like receptor (TLR) signaling and considered a potential target for the treatment of inflammatory diseases. Pathogenic mechanisms associated with the TLR4 signaling pathway have a critical role in the development of severe acute pancreatitis (SAP). The aim of the present study was to determine the role of SIGIRR in the regulation of TLR4 signaling during the progression of SAP. Pancreatitis-associated ascitic fluid (PAAF) was collected from patients with SAP. Murine RAW264.7 macrophages were transfected with a SIGIRR overexpression plasmid and co-cultured with the PAAF from the donors in order to evaluate the effect of SIGIRR in vitro. The mRNA expression of TLR4, SIGIRR and other key downstream signaling molecules was quantified using semi-quantitative PCR with agarose gel electrophoresis. Furthermore, the levels of pro-inflammatory cytokines in the culture supernatant were detected using ELISA. In contrast to SIGIRR, the mRNA expression levels of TLR4, myeloid differentiation factor 88 (MyD88), IL-1R-associated kinase-1 (IRAK-1) and TNF receptor-associated factor-6 (TRAF-6) were significantly increased in RAW264.7 cells following treatment with PAAF. Furthermore, TLR4, MyD88, IRAK-1 and TRAF-6 mRNA levels were significantly downregulated following SIGIRR overexpression and PAAF treatment in RAW264.7 cells. The levels of IL-2, IL-12, IL-17 and IFN-γ in the culture supernatant were also significantly decreased, while IL-10 levels were increased. Overall, SIGIRR negatively regulated the TLR4 signaling pathway to protect against the development of SAP in an in vitro model. Therefore, SIGIRR may represent a promising therapeutic target for SAP.

Nutrition Management in Acute Pancreatitis

Acute pancreatitis (AP) is one of the most prevalent gastrointestinal conditions necessitating inpatient care. In the United States, over 275,000 patients are hospitalized for management of AP, with an estimate that over $2.5 billion is spent annually in treatment, with incidence continuing to rise. AP is a highly inflammatory and catabolic state, putting all patients with the condition at risk of malnutrition. Numerous approaches to nutrition support in pancreatitis have been evaluated and remain controversial. In this narrative review, we aim to give an overview of indications for nutrition and approach to management of nutrition in severe and predicted severe AP based on currently available data.

Proteomic analysis reveals the protective effects of emodin on severe acute pancreatitis induced lung injury by inhibiting neutrophil proteases activity

Acute lung injury (ALI) is the most common remote organ complication induced by severe acute pancreatitis (SAP). Almost 60-70% SAP-induced deaths are caused by ALI. Efficient clinical therapeutic strategy for SAP-induced ALI is still lacking. In this study, we demonstrate that Emodin (EMO) can significantly alleviate SAP-induced ALI. We investigate the therapeutic mechanisms of EMO by proteomic analysis, which indicates that EMO protects lung tissue against SAP-ALI by negative regulation of endopeptidase activity and inhibition of collagen-containing extracellular matrix degradation. Protein-protein interaction analysis showed Lamc2, Serpina1 and Serpinb1 play important roles in the above pathways. This study elucidates the possible mechanism and suggests the candidacy of EMO in the clinical treatment of SAP-ALI. SIGNIFICANCE: ALI is a major leading cause of death in SAP. DEX is the standard of care drug for treatment of SAP-ALI, but often associated with inevitable side effects. In the present study, EMO was demonstrated to greatly alleviate the lung injury induced by SAP. Through proteomic analysis, the recovered protein profiles in response to EMO treatment in SAP-ALI rat models was obtained, among which Lamc2, Serpina1 and Serpinb1 were discovered as crucial regulatory proteins in SAP-ALI disease. Our study provides the underlying mechanisms and novel targets of EMO protective effect against SAP-ALI.

Effects of sildenafil on inflammatory injury of the lung in sodium taurocholate-induced severe acute pancreatitis rats

BACKGROUND

Inflammatory response and acute lung injury (ALI) occur in sodium taurocholate-induced severe acute pancreatitis (SAP). Because sildenafil has anti-inflammatory, anti-oxidant and immune-modulating effects, we investigated its effect on inflammatory and lung injury in sodium taurocholate-induced SAP-associated ALI rat lung.

METHODS

Sodium taurocholate-induced SAP rats received sildenafil (100 mg/kg) or not and were compared to age-matched normal control animals. We evaluated inflammatory response by detecting the expression of inflammatory factors including IL-1β, IL-6 and TNF-α, and detected the level of lung injury through histopathological evaluation. Moreover, we also tested the protein expression of PCNA, P21, Bcl-2 and Bax in the lung.

RESULTS

Sildenafil administration rats had a low level of lung injury and inflammation. In addition, sildenafil significantly increased the expression of proliferation-related markers and decreased the expression of apoptosis-related markers in lung tissue.

CONCLUSIONS

Sildenafil administration may attenuate inflammation and lung injury by promoting proliferation and suppressing apoptosis in SAP rats.

Predictive value of long non-coding RNA intersectin 1-2 for occurrence and in-hospital mortality of severe acute pancreatitis

Background

This study aimed to investigate the predictive value of long non‐coding RNA intersectin 1‐2 (lnc‐ITSN1‐2) for severe acute pancreatitis (SAP) risk, and its correlation with disease severity and in‐hospital mortality in SAP patients.

Methods

Plasma samples from 60 SAP, 60 moderate‐severe acute pancreatitis (MSAP) and 60 mild acute pancreatitis (MAP) patients were collected within 24 hours, and plasma samples from 60 age and gender‐matched healthy controls (HCs) were collected when enrollment. Lnc‐ITSN1‐2 was detected by reverse transcription‐quantitative polymerase chain reaction. In AP patients, disease severity was evaluated and in‐hospital deaths were recorded.

Results

Lnc‐ITSN1‐2 was increased in SAP patients compared with MSAP, MAP patients, and HCs, and it is well‐discriminated SAP patients from MSAP patients (area under curve (AUC): 0.699, 95% confidence interval (CI): 0.605‐0.792), MAP patients (AUC: 0.862, 95% CI: 0.798‐0.926), and HCs (AUC: 0.958, 95% CI: 0.925‐0.990). For disease severity, lnc‐ITSN1‐2 was positively correlated with Ranson's score, acute pathologic and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, and C‐reactive protein (CRP) in SAP patients, MSAP patients, and MAP patients; meanwhile, the correlation coefficients were highest in SAP patients. Furthermore, lnc‐ITSN1‐2 displayed a good predictive value for increased in‐hospital mortality in SAP (AUC: 0.803, 95% CI: 0.673‐0.933) and MSAP (AUC: 0.854, 95% CI: 0.752‐0.956) patients, which was similar with several common prognostic factors (including Ranson's score, APACHE II score, SOFA score, and CRP).

Conclusion

Lnc‐ITSN1‐2 might be a potential biomarker for discrimination of SAP to improve the prognosis of SAP patients.

Pulmonary complications of acute pancreatitis

Introduction: Acute pancreatitis is an inflammatory condition of the pancreas, which runs a severe course in 20% of patients, wherein it is associated with high mortality. It is associated with several pleuro-pulmonary complications with variable severity that may occur either in isolation but are frequently present in combination. Clinicians need to be aware of these complications for early and appropriate management.Areas covered: We performed a systematic search of the PUBMED database (1970-2019) to identify relevant articles focusing on pleuro-pulmonary complications that may occur in patients with acute pancreatitis. We also retrieved articles describing the pathophysiological mechanisms and treatment approach of the various complications.Expert opinion: Acute pancreatitis is usually a self-limiting disease, but the development of organ failure during the course worsens the clinical outcome. Pulmonary complications usually occur early in the course of acute pancreatitis. Clinicians need to recognize the various pulmonary complications of acute pancreatitis, early during the disease, and manage them appropriately and aggressively to improve outcomes.

New insights into acute pancreatitis

The incidence of acute pancreatitis continues to increase worldwide, and it is one of the most common gastrointestinal causes for hospital admission in the USA. In the past decade, substantial advancements have been made in our understanding of the pathophysiological mechanisms of acute pancreatitis. Studies have elucidated mechanisms of calcium-mediated acinar cell injury and death and the importance of store-operated calcium entry channels and mitochondrial permeability transition pores. The cytoprotective role of the unfolded protein response and autophagy in preventing sustained endoplasmic reticulum stress, apoptosis and necrosis has also been characterized, as has the central role of unsaturated fatty acids in causing pancreatic organ failure. Characterization of these pathways has led to the identification of potential molecular targets for future therapeutic trials. At the patient level, two classification systems have been developed to classify the severity of acute pancreatitis into prognostically meaningful groups, and several landmark clinical trials have informed management strategies in areas of nutritional support and interventions for infected pancreatic necrosis that have resulted in important changes to acute pancreatitis management paradigms. In this Review, we provide a summary of recent advances in acute pancreatitis with a special emphasis on pathophysiological mechanisms and clinical management of the disorder.

Prediction and evaluation of the severity of acute respiratory distress syndrome following severe acute pancreatitis using an artificial neural network algorithm model

BACKGROUND

To predict the risk and severity of acute respiratory distress syndrome (ARDS) following severe acute pancreatitis (SAP) by artificial neural networks (ANNs) model.

METHODS

ANNs model was constructed by clinical data of 217 SAP patients. The model was first trained on 152 randomly chosen patients, validated and tested on the 33 patients and 32 patients respectively. Statistical analysis was used to assess the value of it.

RESULTS

The training, validation, and test set were not significantly different for 13 variables. After training, ANNs retained excellent pattern recognition ability. When ANNs model was applied to the test set, it revealed a sensitivity of 87.5%, and an accuracy of 84.43%. Significant differences were found between ANNs model and logistic regression model. When ANNs model is used to identify ARDS, the area under ROC was 0.859 + 0.048. Meanwhile, pancreatic necrosis rate, lactic dehydrogenase and oxyhemoglobin saturation were the most important independent variables. Compared with the Berlin definition, the ANN model shows a good accuracy of 73.1% for total severity of ARDS.

CONCLUSION

ANNs model is a valuable tool in dealing with risk prediction of ARDS following SAP. In addition, it can extract informative risk factors of ARDS via the ANNs model.

MR imaging for acute pancreatitis: the current status of clinical applications

Acute pancreatitis is a common clinical acute abdomen. Imaging examinations play an important role in the management of acute pancreatitis. MR imaging is a noninvasive examination with high tissue contrast and a variety of acquisition sequences that can help determine the diagnosis, complications and severity of acute pancreatitis. The acute pancreatitis classification working group modified the Atlanta classification in 2012 to improve clinical evaluations and standardize the radiologic nomenclature for acute pancreatitis. In particular, the redefinition of necrotizing pancreatitis offers a new understanding of this disease. In clinical practice, there is still a lack of unifying standards between radiologists and physicians, such as for the imaging features of pseudocysts, walled-off necrosis, peripancreatic necrosis and especially for the MR imaging features of acute pancreatitis. In this article, we review the 2012 revised Atlanta classification of acute pancreatitis and recent advances in the clinical applications of MR imaging (MRI) in acute pancreatitis by showing how MRI can provide more optimized information for clinical diagnosis and treatment plan.

Sustained bile drainage decreases the organs injuries via inflammation-associated factors modulation in a severe acute pancreatitis rat model

The timely and effective treatment for severe acute pancreatitis (SAP) is favorable to prognosis. Decompression of the bile duct might be a feasible way to decrease the progression of SAP. The present study investigated the effects of sustained bile external drainage on organs injury caused by SAP in Sprague-Dawley (SD) rats and the mechanisms involved. A total of 72 female SD rats weighting 190-230 g were randomly divided into four groups (n=18): Sham operation group (SOG), SOG + bile drainage group (BDG), SAP group, and SAP + BDG. Sodium taurocholate solution (4%; 1 mg/kg body weight) was used to set up SAP model via injection of retrograde puncture of biliopancreatic duct through the duodenum. A cannula was inserted into the bile duct and fixed externally to establish BDG model. At each time points (t=3, 6, 12; n=6), tissues from the liver, lung, and pancreas, and blood samples were collected. Serum amylase (AMY) was analyzed in all the samples. The levels of tumor necrosis factor-α (TNF-α), heme oxygenase-1 (HO-1), interleukin-10 (IL-10) and high mobility group box 1 (HMGB1) were detected by ELISA. Hematoxylin-eosin staining was performed to observe the histopathological changes, and nuclear transcription factor (NF)-κB-p65 levels in the pancreas were analyzed by western blotting. The data indicated that BDG alleviated the SAP progression and multiple organs injuries. Meanwhile, the histopathological changes of the pancreas, liver, and lungs were improved by BDG. BDG decreased the pathological scores of pancreas significantly (P<0.05). The levels of AMY, TNF-α, HMGB1, and NF-κB-p65 were significantly downregulated by BDG (P<0.05), while the level of HO-1 was upregulated and IL-10 was unchanged. In summary, BDG may attenuate the multiple organs injuries caused by SAP via downregulation of TNF-α, HMGB1, NF-κB-p65 and upregulation of HO-1.

Qingyi decoction attenuates severe acute pancreatitis in rats via inhibition of inflammation and protection of the intestinal barrier

OBJECTIVE

Qingyi decoction (QYD) has beneficial effects in severe acute pancreatitis (SAP). We assessed the therapeutic effect and mechanisms of QYD in SAP.

METHODS

A rat model of SAP was induced by pancreatic ductal injection of sodium taurocholate. QYD was administered intragastrically immediately postoperatively and once every 12 hours. Serum amylase, endotoxin, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and D-lactate levels were measured at 12, 24, and 48 hours. Histological changes in the pancreas and ileum were analyzed. Expression of nuclear factor kappa-light-chain-enhancer of activated B cells p65 (NF-κB p65), Toll-like receptor 4 (TLR4), and zonula occludens-1 (ZO-1) in the small intestinal mucosa was also assessed.

RESULTS

Pancreatic tissue showed extracellular space expansion, inflammatory infiltration, vessels with necrotic walls, and hemorrhage. Ileal tissue showed hemorrhage, inflammatory infiltration, and ileal mucosa destruction. These histological features were dramatically improved by QYD. Increased serum levels of amylase, endotoxin, TNF-α, IL-6, and D-lactic acid were significantly decreased by QYD administration. Increased expression of NF-κB p65 and TLR4 and decreased expression of ZO-1 in the ileal mucosa were also restored to normal levels by QYD treatment.

CONCLUSION

QYD alleviates SAP by reducing intestinal barrier dysfunction, inhibiting intestinal bacteria and endotoxin translocation, and preventing NF-κB activation.

Inhibition of PAK1 alleviates cerulein-induced acute pancreatitis via p38 and NF-κB pathways

Acute pancreatitis is a life-threatening disease accompanied by systemic inflammatory response. NF-κB and p38 signal pathways are activated in AP induced by cerulein. And PAKs are multifunctional effectors of Rho GTPases with kinase activity. In the present study, the function of P21-activated kinase 1 (PAK1) in AP was investigated, and found that PAK1 was up-regulated in pancreas of AP mice model, and led to NF-κB and p38 pathway activation. PAK1 inhibition by shRNA or small molecule inhibitor FRAX597 decreased NF-κB and p38 activity, also alleviated the pathological damage in the pancreas of AP mice model, including decreasing the amylase and lipase levels in serum, decreasing the levels of tumor necrosis factor-α, interleukin-6, and interleukin-1β in AP. These results suggested that PAK1 inhibition protects against AP by inhibiting NF-κB and p38 pathways, and indicated that PAK1 is a potential therapy to alleviate AP patients in clinic, and these need to be explored further.

Clinical effects of hemoadsorption with CytoSorb® in patients with severe acute pancreatitis: A case series

Hemoadsorption using CytoSorb^® has recently gained attention as a new therapy aimed at modulating the inflammatory response syndrome in critically ill patients. The aim of our study was to assess the clinical effects of CytoSorb in patients with severe acute pancreatitis. We prospectively included 12 patients admitted to the intensive care unit for severe acute pancreatitis. After inclusion, continuous venovenous hemodiafiltration in conjunction with CytoSorb was applied. Clinical data, number of organ dysfunctions, paraclinical data, and vasopressor support were collected before and after the treatment. The use of CytoSorb was associated with a decrease in C-reactive protein from 242 (30, 300) to 180 (20, 252) mg/L (p = 0.04) and procalcitonin from 2.21 (0.01, 15.02) to 1.10 (0.01, 3.79) ng/mL (p = 0.02). The median vasopressor support was 0.1 (0, 0.9) mg/h at the beginning of the treatment and it was discontinued in all cases after the treatment. In conclusion, the use of CytoSorb in patients with severe acute pancreatitis was associated with improved hemodynamics and decreased inflammatory markers.

Artificial neural network algorithm model as powerful tool to predict acute lung injury following to severe acute pancreatitis

OBJECTIVE

The aim of this study is to predict the risk of severe acute pancreatitis (SAP) associated with acute lung injury (ALI) by artificial neural networks (ANNs) model.

METHODS

The ANNs and logistic regression model were constructed using clinical and laboratory data of 217 SAP patients. The models were first trained on 152 randomly chosen patients, validated and tested on the 33 patients and 32 patients respectively. Statistical indices were used to evaluate the value of the forecast in two models.

RESULTS

The training set, validation set and test set were not significantly different for any of the 13 variables. After training, the back propagation network retained excellent pattern recognition ability. When the ANNs model was applied to the test set, it revealed a sensitivity of 87.5%, specificity of 83.3%. The accuracy was 84.43%. Significant differences could be found between ANNs model and logistic regression model in these parameter. When ANNs model was used to identify ALI, the area under receiver operating characteristic curve was 0.859 ± 0.048, which demonstrated the better overall properties than logistic regression modeling (AUC = 0.701 + 0.041) (95% CI: 0.664-0.857). Meanwhile, pancreatic necrosis rate, lactic dehydrogenase and oxyhemoglobin saturation were the important factors among all thirteen independent variable for ALI.

CONCLUSION

The ANNs model was a valuable tool in dealing with the clinical risk prediction problem of ALI following to SAP. In addition, our approach can extract informative risk factors of ALI via the ANNs model.

Enteral nutrition provided within 48 hours after admission in severe acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

Whether to conduct enteral nutrition in patients with severe acute pancreatitis (SAP) during the active phase of intestinal stress or to feed during remission remains controversial. This study was aimed to evaluate the efficacy and safety of enteral nutrition within 48 hours after admission in the patients with SAP or predicted severe acute pancreatitis (pSAP).

METHODS

We searched PubMed, EMBASE, Web of Science, and the Cochrane Library before December 2017. Randomized controlled trials of early enteral nutrition (starting within 48 hours after admission) versus late enteral nutrition or total parental nutrition in severe acute pancreatitis or predicted severe acute pancreatitis were selected.

RESULTS

Ten randomized controlled trials containing 1051 patients were included. Comparing early enteral nutrition to late enteral nutrition or total parental nutrition in SAP or pSAP, the pooled risk ratios were 0.53 (95% confidence interval [CI] 0.35-0.81, P = .003) for mortality, 0.58 (95% CI 0.43-0.77, P = .0002) for multiple organ failure (MOF), 0.50 (95% CI 0.33-0.75, P = .0008) for operative intervention, 0.75 (95% CI 0.61-0.93, P = .009) for systemic infection, 0.42 (95% CI 0.26-0.69, P = .0005) for local septic complications, 0.84 (95% CI 0.74-0.96, P = .01) for gastrointestinal symptoms. 0.87 (95% CI 0.74-1.02, P = .08) for systemic inflammatory response syndrome (SIRS), and 1.24 (95% CI 0.66-2.31, P = .50) for other local complications.

CONCLUSIONS

Enteral nutrition within 48 hours after admission is efficient and safe for the patients with SAP or pSAP.

Leptin alleviates intestinal mucosal barrier injury and inflammation in obese mice with acute pancreatitis

BACKGROUND/OBJECTIVES

Obesity is an independent risk factor for severe acute pancreatitis (AP). Leptin plays an important role in energy homeostasis. It has been reported that leptin might also participate in the regulation of the intestinal mucosal barrier and inflammatory response. This study aimed to evaluate the effects of leptin on the intestinal mucosal barrier and inflammatory injury in obese mice with AP.

SUBJECTS/METHODS

AP was induced in leptin-deficient (ob/ob) or wild type (WT) mice by peritoneal injection of caerulein. The animals were divided into 4 groups: WT mice with or without exogenous leptin injection and ob/ob mice with or without leptin treatment. The inflammatory scoring of the pancreas and intestine were evaluated. Intestinal permeability, ileal interleukin (IL)-6 and IL-1β, proliferation, apoptosis and intestinal expression levels of claudin-1 and occludin were measured.

RESULTS

Pancreatic pathologic scores (8.50 ± 0.96 vs. 3.78 ± 1.35, p < 0.001), pancreatic levels of IL-6 (8.34 ± 3.21 ng/mg vs. 4.99 ± 0.53 ng/mg, p = 0.022), intestinal oedema scores (2.25 ± 0.46 vs. 1.14 ± 0.69, p = 0.001) and intestinal permeability to FD4 (0.78 ± 0.06 μg/ml vs. 0.53 ± 0.11 μg/ml, p < 0.001) were significantly higher in ob/ob mice than those in WT mice. Leptin replacement in ob/ob mice greatly improved the intestinal permeability (FD4 0.66 ± 0.03 μg/ml, vs. 0.78 ± 0.06 μg/ml, p = 0.012), increased the ileal expression of claudin-1(1.07 ± 0.08 vs. 0.83 ± 0.07 relative densitometry, p = 0.001) and reduced intestinal IL-6 and IL-1β to levels comparable to those in WT mice. The pancreatic level of IL-6 in ob/ob mice treated with leptin was also significantly decreased relative to that of untreated ob/ob mice (4.45 ± 1.71 ng/mg vs. 8.34 ± 3.21 ng/mg, p = 0.010).

CONCLUSIONS

Obesity may aggravate intestinal inflammation and increase intestinal permeability under the condition of acute pancreatitis. Exogenous leptin supplementation was in favour of anti-inflammation and improvement of intestinal mucosal barrier.

Lymphatic dysfunction in critical illness

PURPOSE OF REVIEW

The essential role of the lymphatic system in fluid homeostasis, nutrient transport, and immune trafficking is well recognized; however, there is limited understanding of the mechanisms that regulate lymphatic function, particularly in the setting of critical illness. The lymphatics likely affect disease severity and progression in every condition, from severe systemic inflammatory states to respiratory failure. Here, we review structural and functional disorders of the lymphatic system, both congenital and acquired, as they relate to care of the pediatric patient in the intensive care setting, including novel areas of research into medical and procedural therapeutic interventions.

RECENT FINDINGS

The mainstay of current therapies for congenital and acquired lymphatic abnormalities has involved nonspecific medical management or surgical procedures to obstruct or divert lymphatic flow. With the development of dynamic contrast-enhanced magnetic resonance lymphangiography, image-directed percutaneous intervention may largely replace surgery. Because of new insights into the mechanisms that regulate lymphatic biology, pharmacologic inhibitors of mTOR and leukotriene B4 signaling are each in Phase II clinical trials to treat abnormal lymphatic structure and function, respectively.

SUMMARY

As our understanding of normal lymphatic biology continues to advance, we will be able to develop novel strategies to support and augment lymphatic function during critical illness and through convalescence.

Nursing care of elderly patients with drug-induced severe pancreatitis by continuous closed high flow peritoneal lavage combined with continuous blood purification

AIM

To explore the nursing effect of closed high-flow peritoneal lavage combined with continuous blood purification in elderly patients with drug-induced severe pancreatitis.

METHODS

A total of 50 elderly patients with drug-induced severe acute pancreatitis who received continuous closed high flow peritoneal lavage combined with blood purification between January 2017 and January 2018 at our emergency internal medicine department were enrolled as an experimental group. Fifty elderly patients with drug-induced severe pancreatitis who received basic nursing measures only were included as a control group. The average frequency of complications, number of treatment cycles, number of cycles required for serum amylase recovery, and duration of abdominal pain in the two groups were statistically analyzed. The changes of liver and kidney function, APACHE Ⅱ, and CTSI score were also recorded and compared.

RESULTS

The average frequency of complications, number of treatment cycles, number of cycles required for serum amylase recovery, and duration of abdominal pain were significantly lower in the experimental group than in the control group (P < 0.05). The liver and kidney function of the patients in the experimental group were obviously superior to those before treatment (P < 0.05), while the difference in the control group did not reach statistical significance. The APACHE Ⅱ and CTSI scores in the experimental group were significantly lower than those in the control group (P < 0.05).

CONCLUSION

Continuous closed high-flow peritoneal lavage combined with blood purification can effectively reduce symptoms, shorten the treatment cycle, and improve prognosis in elderly patients with drug-induced severe acute pancreatitis.

Application of semi-automated ultrasonography on nutritional support for severe acute pancreatitis

OBJECTIVE

To evaluate the application value of semi-automated ultrasound on the guidance of nasogastrojejunal tube replacement for patients with acute severe pancreatitis (ASP), as well as the value of the nutritional support for standardized treatment in clinical practice.

METHODS

The retrospective research was performed in our hospital, and 34 patients suffering from ASP were enrolled into this study. All these identified participants ever received CT scans in order to make definitive diagnoses. Following, these patients received semi-automated ultrasound examinations within 1 days after their onset, in order to provide enteral nutrititon treatment via nasogastrojejunal tube, or freehand nasogastrojejunal tube replacement. In terms of statistical analysis, the application value of semi-automated ultrasound guidance on nasogastrojejunal tube replacement was evaluated, and was compared with tube replacement of no guidance. After cathetering, the additional enteral nutrition was provided, and its therapeutic effect on SAP was analyzed in further.

RESULTS

A total of 34 patients with pancreatitis were identified in this research, 29 cases with necrosis of pancreas parenchyma. After further examinations, 32 cases were SAP, 2 cases were mild acute pancreatitis. When the firm diagnosis was made, additional enteral nutrition (EN) was given, all the patient conditions appeared good, and they all were satisfied with this kind of nutritional support. According to our clinical experience, when there was 200-250 ml liquid in the stomach, the successful rate of intubation appeared higher. Additionally, the comparison between ultrasound-guided and freehand nasogastrojejunal tube replacement was made. According to the statistical results, in terms of the utilization ratio of nutritional support, it was better in ultrasound-guided group, when compared with it in freehand group, within 1 day, after 3 days and after 7 days (7/20 versus 2/14; P < 0.05; 14/20 versus 6/14; P < 0.05; 20/20 versus 12/14; P < 0.05). Besides, the complications caused by cathetering between two groups was not statistically different (P > 0.05).

CONCLUSIONS

It can be indicated that semi-automated ultrasound guidance is a reliable method for nasogastrojejunal tube replacement, and should be substituted for no guidance of cathetering. In terms of therapeutic effect of EN, additional nutritional support contributed to significantly improve the prognosis of SAP patients, and should be widely recommended in clinical practice. Surely, this conclusion should be evaluated in further, by means of randomized controlled trials and economic evaluation.

Effects of Panax notoginseng saponins on severe acute pancreatitis through the regulation of mTOR/Akt and caspase-3 signaling pathway by upregulating miR-181b expression in rats

BACKGROUND

In China, Panax notoginseng has been used to treat oxidative stress-related diseases for a long time. Panax notoginseng saponins is an extract from Panax notoginseng Ledeb. Its therapeutic potential is related to antioxidant activity, but related mechanisms are still unclear. The study aims to assess the protection effects of Panax notoginseng saponins in the taurocholate-induced rat model of acute pancreatitis (AP) and explore underlying mechanisms.

METHODS

A rat model of severe acute pancreatitis (SAP) was established in rats induced with taurocholate. Panax notoginseng saponins was firstly administered in the treatment group via intravenous injection. After 2 h, taurocholate administration was performed. After 24 h, the expression levels of miR-181b, Beclin1, LC3-II, Akt and mTOR from pancreas tissues were measured by Western Blotting and RT-PCR. Then the expression levels of Caspase-3 and Blc-2 were determined by immunohistochemistry. Apoptosis was assessed by the TUNEL assay. Amylase and lipase in serum were determined by ELISA and pancreatic water contents in pancreatic tissue were measured. After eosin and hematoxylin staining, the histologic analysis was performed.

RESULTS

After SAP induction by taurocholate and the treatment with Panax notoginseng saponins for 24 h, we detected the up-regulated miR-181b, the reduced Bcl-2 expression, the increased activity of mTOR/Akt, the blocked Beclin1 and LC3-II expressions, and the enhanced Caspase-3 expression. Serum lipase and amylase levels were significantly decreased in the treatment group of Panax notoginseng saponins compared to the control group. Histological analysis results verified the attenuation effects of Panax notoginseng saponins on taurocholate-induced pancreas injury, apoptosis, and autophagy.

CONCLUSION

By up-regulating the miR-181b expression level, Panax notoginseng saponins significantly reduced taurocholate-induced pancreas injury and autophagy and increased apoptosis. The significant protection effects of Panax notoginseng saponins suggested its potential in treating taurocholate induced-acute pancreatitis.

Pharmacokinetics and pharmacodynamics of Shengjiang decoction in rats with acute pancreatitis for protecting against multiple organ injury

AIM

To explore the pharmacokinetics and pharmacodynamics of Shengjiang decoction (SJD) in rats with acute pancreatitis (AP) for protecting against multiple organ injury.

METHODS

An AP model was established by retrograde perfusion of 3.5% sodium taurocholate into the biliopancreatic duct, and a control group (CG) received 0.9% sodium chloride instead. Twelve male Sprague-Dawley rats were randomly divided into a CG treated with SJD (CG + SJD) and a model group treated with SJD (MG + SJD), both of which were orally administered with SJD (5 g/kg) 2 h after surgery. Blood samples were collected via the tail vein at 10, 20, and 40 min and 1, 2, 3, 4, 6, 8, and 12 h after a single dose of SJD to detect its main components using high-performance liquid chromatography-tandem mass spectrometry. The pharmacokinetic parameters were compared. In the pharmacodynamic experiment, 18 male Sprague-Dawley rats were randomly divided into a CG, an AP model group (MG), and an SJD treated AP group (SJDG). Serum amylase, lipase, and inflammatory cytokines were measured, and heart, lung, liver, spleen, pancreas, kidney, and intestine tissues were collected for pathological examination.

RESULTS

The MG + SJD displayed significantly shorter mean residence time (MRT) and higher clearance (CL) for emodin and aloe-emodin; significantly shorter time of maximum concentration and T_1/2 and a lower area under curve (AUC) for aloe-emodin; a significantly higher AUC and lower CL for rhein; and longer MRT and lower CL for chrysophanol than the CG + SJD. In the pharmacodynamic experiment, the amylase, interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α levels in the MG were higher than those in the CG (P < 0.05). After the herbal decoction treatment, the SJDG had higher IL-10 and lower TNF-α levels than the MG (P < 0.05). The MG had the highest pathological scores, and the pathological scores of the lung, pancreas, kidney, and intestine in the SJDG were significantly lower than those in the MG (P < 0.05).

CONCLUSION

AP may have varying effects on the pharmacokinetics of the major SJD components in rats. SJD might alleviate pathological injuries of the lung, pancreas, kidney, and intestine in rats with AP via regulating pro- and anti- inflammatory responses, which might guide the clinical application of SJD for AP treatment.

Gastrointestinal tract involvement in acute pancreatitis: initial findings and follow-up by magnetic resonance imaging

Background

To study the initial and follow up patterns of gastrointestinal tract involvement in acute pancreatitis (AP) using magnetic resonance imaging (MRI).

Methods

A total of 209 patients with AP undergoing abdominal MRI on 1.5 T MRI were compared to 100 control patients selected from our daily clinical caseload who underwent MRI over the same recruitment period and had no other disease which can cause abnormality of gastrointestinal tract. Initial and follow up MRI examinations of gastrointestinal tract abnormalities were noted for AP patients. The severity of AP was graded by the MRSI and APACHE II. Spearman correlation of gastrointestinal tract involvement with MRSI and APACHE II was analyzed.

Results

In 209 patients with AP, 63% of the AP patients on their initial MRI exams and 5% of control subjects had at least one gastrointestinal tract abnormality (P<0.05). In the control group, thirty-seven patients were normal on MRI, 24 patients with renal cysts, eighteen patients with liver cysts, eleven patients with liver hemangiomas, and ten patients with splenomegaly. The abnormalities of gastrointestinal tract observed in AP patients included thickened stomach wall (20%), thickened duodenum wall (27%), thickened ascending colon wall (11%), thickened transverse colon wall (15%), and thickened descending colon wall (26%), among others. Gastrointestinal tract abnormalities were correlated with the MRSI score (r=0.46, P<0.05) and APACHE II score (r=0.19, P<0.05). Among 62 patients who had follow up examinations, 26% of patients had gastrointestinal tract abnormality, which was significantly lower than that in the initial exams (P<0.05). Resolution of gastrointestinal tract abnormal MRI findings coincided with symptom alleviation in AP patients.

Conclusions

Gastrointestinal tract abnormalities on MRI are common in AP and they are positively correlated with the severity of AP. It may add value for determining the severity of AP.

Enteric glia cells are critical to limiting the intestinal inflammatory response after injury

Vagal nerve stimulation (VNS) has been shown to limit intestinal inflammation following injury; however, a direct connection between vagal terminals and resident intestinal immune cells has yet to be identified. We have previously shown that enteric glia cell (EGC) expression is increased after injury through a vagal-mediated pathway to help restore gut barrier function. We hypothesize that EGCs modulate immune cell recruitment following injury and relay vagal anti-inflammatory signals to resident immune cells in the gut. EGCs were selectively ablated from an isolated segment of distal bowel with topical application of benzalkonium chloride (BAC) in male mice. Three days following BAC application, mice were subjected to an ischemia-reperfusion injury (I/R) by superior mesenteric artery occlusion for 30 min. VNS was performed in a separate cohort of animals. EGC⁺ and EGC^- segments were compared utilizing histology, flow cytometry, immunohistochemistry, and intestinal permeability. VNS significantly reduced immune cell recruitment after I/R injury in EGC⁺ segments with cell percentages similar to sham. VNS failed to limit immune cell recruitment in EGC^- segments. Histologic evidence of gut injury was diminished with VNS application in EGC⁺ segments, whereas EGC^- segments showed features of more severe injury. Intestinal permeability increased following I/R injury in both EGC⁺ and EGC^- segments. Permeability was significantly lower after VNS application compared with injury alone in EGC⁺ segments only (95.1 ± 30.0 vs. 217.6 ± 21.7 μg/ml, P < 0.05). Therefore, EGC ablation uncouples the protective effects of VNS, suggesting that vagal-mediated signals are translated to effector cells through EGCs.NEW & NOTEWORTHY Intestinal inflammation is initiated by local immune cell activation and epithelial barrier breakdown, resulting in the production of proinflammatory mediators with subsequent leukocyte recruitment. Vagal nerve stimulation (VNS) has been shown to limit intestinal inflammation following injury; however, direct connection between vagal terminals and resident intestinal immune cells has yet to be identified. Here, we demonstrate that intact enteric glia cells are required to transmit the gut anti-inflammatory effects of VNS.

Sham Feeding with Chewing Gum in Early Stage of Acute Pancreatitis: A Randomized Clinical Trial

Background

The correlation between sham feeding and acute pancreatitis (AP) has only been examined in limited studies. We aimed to investigate the efficacy and safety of sham feeding in the early stage of AP.

Material/Methods

A randomized controlled clinical trial was performed. Equal groups of AP patients were recruited. Patients in the sham feeding group received chewing gum 4 times a day after admission. All patients in the trial received standard treatment consistent with the guidelines for AP. The primary outcomes were mortality, length of stay (LOS), and medical expenses. Secondary outcomes were the incidence of complications and other adverse events, return of gastrointestinal function, the details of enteral nutrition and intra-abdominal pressure.

Results

From May 2014 to December 2015, a total of 204 patients were recruited. The LOS and hospital costs in the sham feeding group were reduced, although mortality was equivalent between groups. The return of gastrointestinal function occurred earlier in the sham feeding group, with no complications related to gum chewing.

Conclusions

Sham feeding with chewing gum is safe and efficacious in the early stage of AP.

Change in biliary motility in rats with severe acute pancreatitis and its effect

AIM: To observe the change in biliary motility in rats with severe acute pancreatitis and study its effect.

METHODS: Severe acute pancreatitis was induced in 28 male Sprague-Dawley rats by injection of sodium taurocholate into the pancreatobiliary duct. These rats were randomly divided into an experiment group (n = 14) and a control group (n = 14). Another 14 male SD rats injected with saline served as a sham operation group (SO group, n = 14). The experiment group was pretreated by intraperitoneal injection of anisodamine at 20 mg/kg. The control group was pretreated with saline. Twenty-four hours after operation, quantitative ^99mTc-EHIDA hepatobiliary dynamic imaging was performed in each group. Plasma levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-1β and endotoxin (ET) were detected, and the levels of cholecystokinin 8 (CCK8) in plasma, gallbladder and duodenal tissues were also measured. Abdominal viscera bacterial translocation rates were compared among these groups.

RESULTS: In comparison with the SO group and experiment group, a significant delay in duodenal appearance time (DAT) was noted in the control group (56.73 s ± 12.34 s vs 48.44 s ± 11.12 s, 29.52 s ± 11.83 s). A lower level of CCK8 in duodenal tissue was found in the control group than in the SO group and experiment group (5.24 pg/mL ± 0.56 pg/mL vs 5.81 pg/mL ± 0.45 pg/mL, 6.25 pg/mL ± 0.53 pg/mL). The levels of TNF-α, IL-1β, and ET were significantly higher in the control group and experiment group at 24 h after operation than in the SO group (P < 0.05 for all). The levels of TNF-α and ET were significantly lower in the experiment group than in the control group (ET: 0.148 EU/mL ± 0.032 EU/mL vs 0.320 EU/mL ± 0026 EU/mL, P = 0.040; TNF-α: 89.24 pg/mL ± 34.45 pg/mL vs 123.18 pg/mL ± 41.24 pg/mL, P = 0.049). The abdominal viscera bacterial translocation rate was significantly higher in the control group than in the other two groups (0.714% vs 0.573%, 0.143%, P < 0.05).

CONCLUSION: The inhibition of biliary motility was observed in rats with acute pancreatitis, and the change in biliary motility may promote viscera bacterial translocation.