Decreased mortality in acute pancreatitis related to early aggressive hydration

A meta-analysis of Lactate Ringer's solution versus Normal Saline in the treatment of acute pancreatitis

Fluid resuscitation is an important way in the treatment of acute pancreatitis (AP). This meta-analysis aimed to compare the safety and efficacy of Lactate Ringer's solution (LR) and Normal Saline (NS) in the treatment of patients with acute pancreatitis. Searched in PubMed, Web of Science Core Collection (Clarivate), Embase, Cochrane Library, CNKI, China Wanfang, and China VIP database. All randomized controlled clinical trials (RCTs) were identified. Six studies with 431 patients were included. Compared with NS, LR can significantly reduce the incidence of SIRS at 24h, reduce the length of hospitalization, moderate-severe AP, ICU admission and local complications, especially pancreatic necrosis. It is safe and effective to choose LR for fluid resuscitation in AP, but due to the small number of included studies, multi-center and large-sample RCTs are still needed for further verification. PROSPERO registration number: CRD42022322788.

Association between wait time of central venous pressure and 28-day mortality in critically patients with acute pancreatitis: A restrospective cohort study

Hemodynamic management is crucial in patients with acute pancreatitis. Central venous pressure (CVP) is widely used to assess volume status. Our aim was to determine the optimal time window for obtaining CVP measurements to prevent adverse outcomes in patients. This study utilized data from the Medical Information Mart for Intensive Care (MIMIC) IV database. The primary outcome under investigation was the 28-day mortality, while secondary outcomes included 90-day mortality and 1-year mortality. To categorize the study population, a CVP waiting time of 12 hours was employed as the grouping criterion, followed by the utilization of Cox regression analysis to compare the outcomes between the 2 groups. Our study included a total of 233 patients, among whom 154 cases (66.1%) underwent CVP measurements within 12 hours after admission to the Intensive Care Unit (ICU). Univariate and multivariate Cox regression analyses revealed a significantly increased risk of 28-day mortality in patients from the delayed CVP monitoring group compared to those who underwent early CVP measurements (HR = 2.87; 95% CI: 1.35-6.13; P = .006). Additionally, consistent results were observed for the risks of 90-day mortality (HR = 1.91; 95% CI: 1.09-3.35; P = .023) and 1-year mortality (HR = 1.84; 95% CI: 1.09-3.10; P = .023). In the ICU, an extended waiting time for CVP measurements in patients with acute pancreatitis was associated with an increased risk of 28-day mortality.

Evaluating the efficacy of different volume resuscitation strategies in acute pancreatitis patients: a systematic review and meta-analysis

INTRODUCTION

Acute pancreatitis poses a significant health risk due to the potential for pancreatic necrosis and multi-organ failure. Fluid resuscitation has demonstrated positive effects; however, consensus on the ideal intravenous fluid type and infusion rate for optimal patient outcomes remains elusive.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar for studies published between 2005 and January 2023. Reference lists of potential studies were manually searched to identify additional relevant articles. Randomized controlled trials and retrospective studies comparing high (≥ 20 ml/kg/h), moderate (≥ 10 to < 20 ml/kg/h), and low (5 to < 10 ml/kg/h) fluid therapy in acute pancreatitis were considered.

RESULTS

Twelve studies met our inclusion criteria. Results indicated improved clinical outcomes with low versus moderate fluid therapy (OR = 0.73; 95% CI [0.13, 4.03]; p = 0.71) but higher mortality rates with low compared to moderate (OR = 0.80; 95% CI [0.37, 1.70]; p = 0.55), moderate compared to high (OR = 0.58; 95% CI [0.41, 0.81], p = 0.001), and low compared to high fluids (OR = 0.42; 95% CI [0.16, 1.10]; P = 0.08). Systematic complications improved with moderate versus low fluid therapy (OR = 1.22; 95% CI [0.84, 1.78]; p = 0.29), but no difference was found between moderate and high fluid therapy (OR = 0.59; 95% CI [0.41, 0.86]; p = 0.006).

DISCUSSION

This meta-analysis revealed differences in the clinical outcomes of patients with AP receiving low, moderate, and high fluid resuscitation. Low fluid infusion demonstrated better clinical outcomes but higher mortality, systemic complications, and SIRS persistence than moderate or high fluid therapy. Early fluid administration yielded better results than rapid fluid resuscitation.

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Fluid resuscitation in the early management of acute pancreatitis - evidence from a systematic review and meta-analysis

BACKGROUND

Third space fluid loss is one of the hallmarks of the pathophysiology of acute pancreatitis (AP) contributing to complications, including organ failure and death. We conducted a systematic review of literature to determine the ideal fluid resuscitation in the early management of AP, primarily comparing aggressive versus moderate intravenous fluid resuscitation (AIR vs MIR).

METHODS

A systematic review of major reference databases was undertaken. Meta-analysis was performed using random-effects model. Bias was assessed using Cochrane risk of bias and ROBINS-I tools for randomized and non-randomised studies, respectively.

RESULTS

Twenty studies were included in the analysis. Though there was no significant difference in mortality between AIR and MIR groups (8.3% versus 6.0%; p = 0.3), AIR cohort had significantly higher rates of organ failure (p = 0.009), including pulmonary (p = 0.02) and renal (p = 0.01) complications. Similarly, there was no difference in mortality between normal saline (NS) and Ringer's lactate (RL) (3.17% versus 3.01%; p = 0.23), though patients treated with NS had a significantly longer length of hospital stay (LOS) (p = 0.009).

CONCLUSIONS

Current evidence appears to support moderate intravenous resuscitation (level of evidence, low) with RL (level of evidence, moderate) in the early management of AP.

Fluid resuscitation in acute pancreatitis

PURPOSE OF REVIEW

The purpose of the review is to critically evaluate the evidence from the literature to establish the current perspective on fluid resuscitation (FR) in acute pancreatitis (AP). We will review the rationale, type of fluid, rate of administration, total volume, duration, monitoring, ideal outcomes to be studied in clinical trials and recommendations for future studies.

RECENT FINDINGS

FR remains the key component of supportive therapy in AP. The paradigm has shifted from administration of aggressive fluid resuscitation towards more moderate FR strategies. Lactated Ringer's remains the preferred fluid for resuscitation. There remain critical gaps in knowledge regarding the end point(s) to indicate adequate resuscitation, and accurate assessments of fluid sequestration and intravascular volume deficit in AP.

SUMMARY

There is insufficient evidence to state that goal-directed therapy, using any of the parameters to guide fluid administration, reduces the risk of persistent organ failure, infected pancreatic necrosis, or mortality in AP, as well as the most appropriate method for the same.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy and safety of early enteral and intravenous fluid resuscitation in severe acute pancreatitis: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of enteral fluid resuscitation (via nasointestinal tube or colorectal tube) and intravenous fluid resuscitation (via intravenous route) in the early treatment of severe acute pancreatitis.

METHODS

In this study, 8 electronic databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, China HowNet database, Wanfang database, and VIP database) were searched to collect clinical studies from inception to June 12, 2022. After the quality evaluation and data extraction of the included studies, the RevMan 5.3 software was used for analysis.

RESULTS

A total of seven studies including 580 patients were studied in this meta-analysis, in which 291 cases were treated with enteral fluid resuscitation and 289 cases were treated with intravenous fluid resuscitation. Compared with the intravenous route group, the enteral route resuscitation group reduced the incidence of new organ failure (OR = 0.23, 95% CI: 0.12-0.43, P < 0.00001), the incidence of persistent organ failure (OR = 0.38, 95% CI: 0.22-0.64, P = 0.0003), the incidence of mechanical ventilation (OR = 0.15, 95% CI: 0.03-0.69, P = 0.01), the incidence of ICU care (OR = 0.49, 95% CI: 0.27-0.88, P = 0.02), and the incidence of pancreatic infection (OR = 0.38, 95% CI: 0.17-0.83, P = 0.02). There were no statistically significant differences in mortality (OR = 0.77, 95% CI: 0.35-1.66, P = 0.50), surgical intervention rate (OR = 0.47, 95% CI: 0.19-1.18, P = 0.11), and incidence of localized ascites (OR = 0.65, 95% CI: 0.25-1.73, P = 0.39).

CONCLUSION

Early enteral fluid resuscitation is safe and effective for in severe pancreatitis. But this conclusion needs to be verified by more additional multi-centre randomized controlled trials with large samples.

An Insight on Pharmacological and Mechanical Preventive Measures of Post-ERCP PANCREATITIS (PEP)—A Review

Pancreatitis is the most common complication following endoscopic retrograde cholangio-pancreatography (ERCP). With the progress of research in many drugs and technologies, promising efficacy has been achieved in preventing post-ERCP pancreatitis (PEP). Recently, combined prevention has received more attention in order to further reduce the incidence of PEP. However, there is no review about the combined prevention of PEP. This review summarizes the medication and ERCP techniques that are used to prevent PEP and emphasizes that appropriate combination prevention approaches should be based on risk stratification.

Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review

Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development of a Score for Predicting Severe Acute Pancreatitis at Admission

OBJECTIVES

The identification of patients at risk of developing a severe form of acute pancreatitis is a major issue. The goal of this study was to identify parameters at admission associated with severe pancreatitis to develop a predictive severity score.

METHODS

We conducted a retrospective study at Caen University Hospital between January 2014 and December 2017, including 504 patients hospitalized for acute pancreatitis, of whom 74 had a severe form. We developed a predictive score named Admission Severe Acute Pancreatitis (ASAP) score based on parameters associated with a severe form in multivariate analysis. We validated our score in an independent validation cohort of 80 patients.

RESULTS

Hypothermia, low oxygen saturation or albumin levels, and high creatinine levels were significantly associated with severe pancreatitis. The ASAP score showed notable predictive accuracy (area under receiver operating characteristic, 0.82), which was significantly higher than Sequential Organ Failure Assessment, persistent Systemic Inflammatory Response Syndrome, and Balthazar. Using the -2.1742 threshold, the ASAP score had a sensitivity and specificity of 74% and a negative predictive value of 95%. These predictive performances for ASAP score were confirmed in the validation cohort.

CONCLUSIONS

The ASAP score demonstrates remarkable predictive accuracy in distinguishing severe forms of acute pancreatitis.

Lactated Ringer Solution Is Superior to Normal Saline Solution in Managing Acute Pancreatitis: An Updated Meta-analysis of Randomized Controlled Trials

GOAL

The goal of this study was to further determine the role of lactated Ringer (LR) compared with normal saline (NS) in managing acute pancreatitis (AP) as a consideration of fluid resuscitation.

BACKGROUND

Fluid resuscitation play a critically important role in managing AP, and NS and LR solutions were common selection in clinical practice. However, it remains debate about which regime may be more better for patients with AP.

MATERIALS AND METHODS

The PubMed, Embase, and the Cochrane library were searched to find eligible randomized controlled trials focusing on the comparative efficacy and safety of LR and NS for the management of patients with AP.

RESULTS

Four eligible randomized controlled trials involving 248 patients to perform meta-analysis finally. Meta-analysis suggested no statistical difference between LR and NS groups in reducing the incidence of systemic inflammatory response syndrome at 24 hours [risk ratio (RR)=0.66, 95% confidence interval (CI)=0.33-1.31, P=0.24], 48 hours (RR=0.70, 95% CI=0.29-1.68, P=0.42), and 72 hours (RR=0.68, 95% CI=0.37-1.25, P=0.22). Meanwhile, no statistical difference was detected between LR and NS groups in terms of in-hospital mortality, incidence of local complications, pancreatic necrosis, organ failure, and developing moderate-to-severe AP, and the length of hospital stay. However, incidence of intensive care unit admission in LR group was significantly lower than that in NS group (RR=0.39, 95% CI=0.18-0.85; P=0.02).

CONCLUSION

The current updated meta-analysis indicates that LR may be superior to NS in managing patients with AP because of LR has a potential advantage in decreasing the incidence of pancreatic necrosis and intensive care unit admission compared with NS.

Intravenous Ringers lactate versus normal saline for predominantly mild acute pancreatitis in a Nepalese Tertiary Hospital

Background

Acute pancreatitis (AP) is a common presentation in patients admitted with acute abdomen. Whether Ringers lactate (RL) or Normal Saline (NS) as a resuscitation fluid is better still remains unclear. The aim of this study is to compare the efficacy of RL and NS in terms of control of systemic inflammation by measuring indirect markers specifically Systemic Inflammation Response Syndrome (SIRS) scores and C- Reactive Protein (CRP) level.

Methods

This was an open label randomized trial conducted in a tertiary level hospital of Nepal. Ethical approval was obtained prior to the study. Patients with acute pancreatitis were randomized to either RL or NS group for the fluid resuscitation. The fluid was given as per the study protocol for three days for hydration. Baseline SIRS and CRP were recorded on admission and subsequently as defined. All the data were analyzed using SPSS ver 20.0 software.

Results

Total 51 patients were enrolled, 26 in RL and 25 in NS group. The commonest etiology of AP was alcohol (84.31%). SIRS was present in 46.2% and 64.0% of patients in RL and NS group respectively (p = 0.20) on admission. At least one SIRS criteria was still present in 44.0% of patients in the NS group compared to only 15.4% in the RL group after 24 hours (p = 0.025). The baseline CRP were comparable in both the groups. However after 72 hours, the increment of CRP was more in the NS group compared to the RL group; median value of 14.2 mg/dl (12.15, 16.45) and 22.2 mg/dl (18.20, 30.60) in RL and NS group respectively (p<0.001).

Conclusions

Ringers lactate was associated with a reduction in systemic inflammation compared to normal saline in patients with acute pancreatitis. Incidence of SIRS at 72 hours and occurrence of local complications were however similar in both the groups.

Anorexia nervosa and pancreatitis

Acute pancreatitis is a condition whereby erroneous activation of trypsin and zymogen results in pancreatic autodigestion. There are many aetiologies, with alcohol intake and gallstones being the most common. Anorexia nervosa is an eating disorder in which patients' reduced food intake and psychological aversion of weight gain can result in low body weight and malnourishment. The link between pancreatitis and anorexia nervosa is not well understood; this article explores the theorised pathophysiology connecting the two conditions, as well as the optimal management of patients when the conditions co-exist based on current literature. A literature search was performed using MEDLINE, EMBASE and CINAHL databases for all journal articles on the topic of presentations of acute or chronic pancreatitis in adults with anorexia nervosa. The literature proposes various links between anorexia nervosa and pancreatitis. It is theorised that pancreatitis may arise as a result of malnourishment itself or secondary to the refeeding process. Some explanations focus on the histopathological changes to the pancreas that malnourishment induces, while others focus on the enzymatic changes and oxidative damage that arise in the malnourished state. More mechanical mechanisms such as gastric dilatation, gastrointestinal ileus and compartmental fluid shift during refeeding have also been proposed as explanations for the link between the conditions. Some medications used in the management of anorexia nervosa have also been linked to pancreatitis.

Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type, rate and route

BACKGROUND

Adequate fluid resuscitation is paramount in the management of acute pancreatitis (AP). The aim of this study is to assess benefits and harms of fluid therapy protocols in patients with AP.

METHODS

MEDLINE, Embase, Science Citation Index and clinical trial registries were searched for randomised clinical trials published before May 2020, assessing types of fluids, routes and rates of administration.

RESULTS

A total 15 trials (1073 participants) were included. Age ranged from 38 to 73 years; follow-up period ranged from 0.5 to 6 months. Ringer lactate (RL) showed a reduced number of severe adverse events (SAE) when compared to normal saline (NS) (OR 0.48; 95%CI 0.29-0.81, p = 0.006); additionally, NS showed reduced SAE (RR 0.38; 95%IC 0.27-0.54, p < 0.001) and organ failure (RR 0.30; 95%CI 0.21-0.44, p < 0.001) in comparison with hydroxyethyl starch (HES). High fluid rate fluid infusion showed increased mortality (OR 2.88; 95%CI 1.41-5.88, p = 0.004), increased number of SAE (RR 1.42; 95%CI 1.04-1.93, p = 0.030) and higher incidence of sepsis (RR 2.80; 95%CI 1.51-5.19, p = 0.001) compared to moderate fluid rate infusion.

CONCLUSIONS

In patients with AP, RL should be preferred over NS and HES should not be recommended. Based on low-certainty evidence, moderate-rate fluid infusion should be preferred over high-rate infusion.

The impact of fluid resuscitation via colon on patients with severe acute pancreatitis

Severe acute pancreatitis (SAP) is a life-threatening disease. Fluid Resuscitation Via Colon (FRVC) may be a complementary therapy for early controlled fluid resuscitation. But its clinical application has not been reported. This study aims to explore the impact of FRVC on SAP. All SAP patients with the first onset within 72 h admitted to the hospital were included from January 2014 to December 2018 through electronic databases of Ruijin hospital and were divided into FRVC group (n = 103) and non-FRVC group (n = 78). The clinical differences before and after the therapy between the two groups were analyzed. Of the 181 patients included in the analysis, the FRVC group received more fluid volume and reached the endpoint of blood volume expansion ahead of the non-FRVC group. After the early fluid resuscitation, the inflammation indicators in the FRVC group were lower. The rate of mechanical ventilation and the incidence of hypernatremia also decreased significantly. Using pure water for FRVC was more helpful to reduce hypernatremia. However, Kaplan–Meier 90-day survival between the two groups showed no difference. These results suggest that the combination of FRVC might benefit SAP patients in the early stage of fluid resuscitation, but there is no difference between the prognosis of SAP patients and that of conventional fluid resuscitation. Further prospective study is needed to evaluate the effect of FRVC on SAP patients.

[Management of acute pancreatitis. A literature review]

The management of acute pancreatitis is now fairly codified, with specific recommendations developed by expert groups. These recommendations deal in particular with the minimum initial assessment, recognized severity scores, initial medical management with hyperhydration, preventive anticoagulation, early refeeding, delays in imaging and management of complications. In this work, we have tried to bring together the various recommendations, articles and studies dealing with this subject, based more particularly on European recommendations, in order to guide the management of acute pancreatitis in current practice.

Does the Implementation of a Clinical Care Pathway Have an Impact on Early Intravenous Fluid Therapy of Acute Pancreatitis?: A Pilot Quality Improvement Study

OBJECTIVES

Early intravenous fluid (IVF) resuscitation is crucial in the management of acute pancreatitis; variation in IVF prescription practice had been demonstrated. This pilot study aims to assess whether the implementation of an Acute Pancreatitis Care Pathway (APCP) produces a change toward a more adequate IVF regimen in the first 24 hours.

METHODS

Patients with confirmed diagnosis of acute pancreatitis, from July 2015 to February 2016 (group 1) and from September 2017 to March 2018 (group 2), were considered. The APCP was developed between March 2016 and August 2017. Median IVF rate, volume, and type infused in the first 24 hours, were compared between groups. Nonparametric data were analyzed with the Mann-Whitney U test, differences in frequencies with the McNemar test; significance was set at P < 0.05.

RESULTS

Seventy-two patients were included, 36 in each group. In the first 24 hours, the median IVF rate was 177 mL/h vs 225 mL/h (P = 0.004); Ringer lactate infusion was 30% vs 77.8% (P = 0.0003). The median total IVF volume did not differ between groups.

CONCLUSIONS

The implementation of the APCP has the potential to lead to a successful change in early IVF resuscitation practice.

Impact of early aggressive fluid resuscitation in acute pancreatitis

BACKGROUND/OBJECTIVES

Acute pancreatitis management guidelines recommend early aggressive hydration to improve clinical outcomes. We aim to evaluate the influence of early fluid therapy (total intravenous fluids in the first 24 h [IVF/24hrs]) on clinical outcomes in patients with acute pancreatitis.

METHODS

This was a retrospective chart review of all patients admitted for acute pancreatitis between July 2011 to December 2015. IVF/24hrs was categorized into 3 groups according to tertiles. Logistic regression was performed to evaluate predictors of persistent organ failure and in-hospital mortality.

RESULTS

A total of 310 patients were included: Conservative (IVF/24hrs < 2.8L, n = 102), Moderate (IVF/24hrs 2.8-4.475L, n = 105) and Aggressive (IVF/24hrs ≥ 4.475, n = 103). Most patients (80.6%) were African Americans, 91.3% had mild acute pancreatitis (BISAP score ≤ 2). The Aggressive IVF group had higher incidence of persistent organ failure (16.5% vs 4.9% and 7.6%, p = 0.013), and longer length of hospital stay (9.2 ± 10.7 vs 6.5 ± 7.3 and 6.8 ± 5.7 days, P = 0.032). However, IVF/24hr did not correlate with length of hospital stay (PCC 0.08, p = 0.174). On multivariate analysis, only organ failure at admission was an independent predictor of persistent organ failure (OR 16.1, p < 0.001). Persistent organ failure and local complications were found to be the only independent predictors in-hospital mortality (OR 27.6, p < 0.001 and OR 16.95, p = 0.001 respectively). There was no difference in clinical outcomes in African Americans compared to other races.

CONCLUSIONS

More aggressive early IVF therapy in a predominantly mild acute pancreatitis cohort, was not associated with improvement in persistent organ failure, length of hospital stay, or in-hospital mortality.

Management of Severe Acute Pancreatitis

Purpose of review

There have been significant advancements in different aspects of management of severe acute pancreatitis (SAP). Our review of the most recent literature focuses on severity prediction, fluid resuscitation, analgesic administration, nutrition, and endoscopic intervention for SAP and its extra-pancreatic complications.

Recent findings

Recent studies on serum cytokines for the prediction of SAP have shown superior prognostic performance when compared with conventional laboratory tests and clinical scoring systems. In patients with established SAP and vascular leak syndrome, intravenous fluids should be administered with caution to prevent intra-abdominal hypertension and volume overload. Endoscopic retrograde cholangiopancreatography improves outcomes only in AP patients with suspected cholangitis. Early enteral tube-feeding does not appear to be superior to on-demand oral feeding. Abdominal compartment syndrome is a highly lethal complication of SAP that requires percutaneous drainage or decompressive laparotomy. Endoscopic transmural drainage followed by necrosectomy (i.e., “step-up approach”) is the treatment strategy of choice in patients with symptomatic or infected walled-off pancreatic necrosis.

Summary

SAP is a complex clinical syndrome associated with a high mortality rate. Early prediction of SAP remains challenging due to the limited accuracy of the available prediction tools. Early fluid resuscitation, organ support, enteral nutrition, and prevention of/or prompt recognition of abdominal compartment syndrome remain cornerstones of its management. A step-up, minimally invasive drainage/debridement is the preferred approach for patients with infected pancreatic necrosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of Care Indicators in Patients with Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common and expensive condition. Improving quality of care in AP is vital to minimizing cost and improving patient outcomes. However, there has been little work accomplished toward developing and validating explicit quality indicators (QIs) in AP.

AIMS

To define quality of care in patients with AP by developing explicit QIs using standardized techniques.

METHODS

We used the UCLA/RAND Delphi panel approach to combine a comprehensive literature review with the collective judgment of experts to identify a defined set of process measures for AP.

RESULTS

We produced 164 candidate QIs after a comprehensive literature review. After Delphi review, 75 had a median rating ≥ 7. We excluded 11 QIs where the disagreement index exceeded 1.0 and combined indicators overlapping in content to produce a final list of 22 QIs. Overall, 8 QIs related to diagnosis, prevention, or determination of etiology, 2 QIs focused on determination of severity, 3 QIs captured fluid resuscitation, 2 QIs measured nutrition, 1 QI use of antibiotics, and 6 QIs captured endoscopic or surgical management.

CONCLUSIONS

We have developed 22 QIs spanning the spectrum of AP management including diagnosis, risk stratification, and pharmacological and endoscopic therapy. These QIs will facilitate future quality improvement by practitioners and organizations who treat patients with AP and further identify areas that are amenable to improvement to enhance patient care. We anticipate that this QI set will represent the first step in determining a framework for demonstrating value in the care of patients with AP.

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.

Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management

INTRODUCTION

Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology.

METHODS

A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets.

RESULTS

Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary.

DISCUSSION

Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.

Acute Pancreatitis in Advanced Chronic Kidney Disease and Kidney Transplant Recipients: Results of a US Nationwide Analysis

Objective

To study the prevalence, etiology, and outcome of acute pancreatitis (AP) in kidney transplant and stage 5 chronic kidney disease (CKD) populations in comparison to a non-CKD cohort.

Patients and Methods

Using the Nationwide Inpatient Sample database, we identified patients with acute pancreatitis as the primary discharge diagnosis, after which propensity scores were used to create 2 cohorts of patients: 1 with CKD (n=13,425) and 1 without CKD (n=13,425). The CKD group was subsequently subdivided into dialysis-independent stage 5 CKD (n=690), dialysis-dependent stage 5 CKD (n=11,415), and kidney transplant recipients (n=1320). Patients younger than 18 years old, those who received a kidney transplant during the incident admission, and pancreas transplant recipients were excluded.

Results

The adjusted odds ratios (ORs) of AP were comparable between the no CKD, stage 5 CKD, and kidney transplant populations. Adjusted inpatient mortality was highest in patients with dialysis-dependent stage 5 CKD (OR, 2.72; 95% CI, 2.2-3.3; P<.01), followed by kidney transplant recipients (OR, 2.29; 95% CI, 1.12-4.51; P=.02), compared to the non-CKD group. Patients with stage 5 CKD experienced higher rates of shock and intensive care unit admission and had more prolonged and costly hospitalizations than the non-CKD group (P<.01 for all). Hypercalcemia was the most common cause of AP in both dialysis-dependent and dialysis-independent patients with stage 5 CKD, while viral and drug-induced pancreatitis were more prevalent in the transplant recipients.

Conclusion

Despite comparable adjusted prevalence of AP among the stage 5 CKD, transplant, and non-CKD populations, mortality, morbidity, and resource utilization were higher in the patients with stage 5 CKD and transplant recipients. Hypercalcemia is the most common cause of AP in the stage 5 CKD population irrespective of dialysis requirement.

Risk Stratification and Early Conservative Treatment of Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a potentially life-threatening common gastrointestinal disorder with increasing incidence around the globe. Although the majority of cases will take an uneventful, mild course, a fraction of patients is at risk of moderately severe or severe pancreatitis which is burdened with substantial morbidity and mortality. Early identification of patients at risk of a severe disease course and an adopted treatment strategy are crucial to avoid adverse outcomes.

SUMMARY

In this review we summarize the most recent concepts of severity grading in patients diagnosed with AP by adopting recommendations of current guidelines and discussing them in the context of the available literature. The severity of AP depends on the presence of local and/or systemic complications and organ failure. To predict the severity early in the disease course, host-specific factors (age, comorbidities, body mass index), clinical risk factors (biochemical and physiological parameters and scoring systems), as well as the response to initial therapy need to be considered and revisited in the short term. Depending on the individual risk and comorbidity the initial treatment can be guided, which will be discussed in the second part of this review.

KEY MESSAGE

Predicting the severity of AP and adapting the individual treatment strategy requires multidimensional risk assessment and close observation during the early phase of AP development.

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

Aim

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

Methods

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

Results

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

Conclusions

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

Acute Pancreatitis Caused by Tamoxifen-Induced Severe Hypertriglyceridemia After 4 Years of Tamoxifen Use

We report a case of a 55-year-old woman with hypertension and diabetes mellitus, who took tamoxifen for the past 4 years. She presented with acute pancreatitis caused by markedly elevated serum triglycerides (3,883 mg/dL). Tamoxifen is known to cause a mild increase in serum triglycerides, but it rarely increases to such high levels to cause acute pancreatitis. The patient recovered well, and tamoxifen was switched to letrozole. It is crucial to monitor serum lipids up to 4 years and beyond for patients on tamoxifen, particularly in patients with known dyslipidemia or diabetes mellitus.

Aggressive Resuscitation Is Associated with the Development of Acute Kidney Injury in Acute Pancreatitis

INTRODUCTION

The association between early resuscitation volume and clinical outcomes remains controversial in acute pancreatitis. In the present study, we aimed to identify the association between resuscitation volume and the development of acute kidney injury (AKI) and other clinical outcome metrics.

METHODS

Patients admitted to our center with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) from January 2009 to December 2013 were reviewed retrospectively. Patients were stratified into two groups on the basis of the volume of fluid infused during the first 24 h. The primary clinical endpoint was incidence of AKI. Moreover, AKI lasting time, utilization of continuous renal replacement therapy and lasting time, creatinine increase, and other clinical metrics were also compared. The potential risk factors of new-onset AKI were also analyzed.

RESULTS

A total of 179 patients were included, and aggressive fluid resuscitation (≥ 4 l) was associated with increased incidence of AKI compared with nonaggressive group (53.12% vs. 25.64%, p = 0.008), longer AKI lasting time (p = 0.038), and increased creatinine increase (p < 0.001) during hospitalization. Moreover, utilization of continuous renal replacement therapy was more frequent in aggressive group (40.63% vs. 24.36%, p = 0.108), and the lasting time of continuous renal replacement therapy was also longer (p = 0.181), though both not statistically different. Moreover, in multivariate analysis, aggressive resuscitation [OR 4.36 (1.52-13.62); p = 0.001] and chloride exposure [OR 2.53 (1.26-5.21); p = 0.012] in the first 24 h were risk factors of new-onset AKI.

CONCLUSION

In patients with MSAP and SAP, aggressive fluid resuscitation was associated with increased incidence and longer duration of AKI. Moreover, aggressive resuscitation and chloride exposure in the first 24 h were risk factors of new-onset AKI.

Impact of continuous regional arterial infusion in the treatment of acute necrotizing pancreatitis: analysis of a national administrative database

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.

Comparison of normal saline versus Lactated Ringer's solution for fluid resuscitation in patients with mild acute pancreatitis, A randomized controlled trial

BACKGROUND/OBJECTIVES

Aggressive fluid resuscitation is recommended for initial management of acute pancreatitis. However, there are few studies which focus on types of fluid therapy.

METHODS

We performed a randomized controlled trial in patients with acute pancreatitis. The patients were randomized into two groups. Each group received Normal Saline solution (NSS) or Lactated Ringer's solution (LRS) through a goal-directed fluid resuscitation protocol. Systemic inflammatory response syndrome (SIRS) at 24 and 48 h, mortality, presence of local complications and inflammatory markers were measured.

RESULTS

Forty-seven patients were included. Twenty-four patients (51%) received NSS and 23 patients received LRS. There was significant reduction in SIRS after 24 h among subjects who resuscitated with LRS compared with NSS (4.2% in NSS, 26.1% in LRS, P = 0.02). However, SIRS reduction at 48 h was not different between groups (33.4% in NSS, 26.1% in LRS, P = 0.88). Mortality was not different between NSS and LRS (4.2% in NSS, 0% in LRS, P = 1.00). CRP, ESR and procalcitonin increased at 24 h and 48 h after admission with no difference between the two groups. Local complications were 29.2% in NSS and 21.7% in LRS (P = 0.74). The median length of hospital stay was not significantly different in the two groups (5.5 days in NSS, 6 days in LRS, P = 0.915).

CONCLUSIONS

Lactated Ringer's solution was superior to NSS in SIRS reduction in acute pancreatitis only in the first 24 h. But SIRS at 48 h and mortality were not different between LRS and NSS.

Comparative effectiveness of elemental formula in the early enteral nutrition management of acute pancreatitis: a retrospective cohort study

Background

Although enteral nutrition has become one of the standard therapies for patients with acute pancreatitis, the optimal formulae for enteral nutrition have been under debate. Elemental formula is assumed to be suitable in the treatment of patients with acute pancreatitis because it has less stimulating effects for exocrine secretions of the pancreas, simultaneously maintaining gut immunity; however, clinical studies corroborating this assumption have been scarce.

Methods

We conducted a retrospective cohort study using a Japanese national administrative database between 2010 and 2015. Patients with acute pancreatitis who received enteral feeding within 3 days of admission were identified and divided into two groups according to whether elemental formula was administered. We assessed the impact of elemental formula for the outcomes (primary, in-hospital mortality; secondary, development of sepsis, hospital-free days at 90 days, and total health-care costs) using a multivariate mixed-effect regression analysis and propensity score matching analysis adjusted by a well-validated case-mix adjustment model. Analysis for the subpopulation of patients with severe acute pancreatitis was also performed.

Results

Of 243,312 patients with acute pancreatitis, 948 patients were identified and classified into the elemental formula group (N = 382) and the control group (N = 566). No significant differences were observed for in-hospital mortality [10.2% in the elemental formula group vs. 11.0% in the control group; adjusted adds ratio (95% confidence interval; CI) = 0.94 (0.53–1.67)], sepsis development [5.0 vs. 7.1%; adjusted adds ratio (95% CI) = 0.66 (0.34–1.28)], mean hospital-free days [54 days vs. 51 days; adjusted difference (95% CI) = 2 days (− 2 to 5)], and mean total health-care costs [$29,360 vs. $34,214; adjusted difference (95% CI) = − $4250 (− 8643 to 141)]. Similar results were also observed in patients with severe acute pancreatitis.

Conclusions

The results of our retrospective cohort study using a large-scale national database did not demonstrate the benefit of elemental formula compared to semi-elemental and polymeric formulae in patients with acute pancreatitis. Further assessment of alternative nutritional strategy is expected.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0414-6) contains supplementary material, which is available to authorized users.

Association of Total Fluid Intake and Output with Duration of Hospital Stay in Patients with Acute Pancreatitis

Background/Aims

The aim of this study was to evaluate the association of fluid balance with outcomes in patients hospitalized with acute pancreatitis (AP).

Methods

This was a retrospective study of patients hospitalized between May 2008 and June 2016 with AP and a clinical order for strict recording of intake and output. Data collected included various types of fluid intake and output at 24 and 48 hours after admission. The primary outcome was length of stay (LOS). Analysis was performed using single-variable and multivariable negative binomial regression models.

Results

Of 1256 patients hospitalized for AP during the study period, only 71 patients (5.6%) had a clinical order for strict recording of intake and output. Increased urine output was associated with a decreased LOS at 24 and 48 hours in univariable analysis. An increasingly positive fluid balance (total intake minus urine output) at 24 hours was associated with a longer LOS in multivariable analysis.

Conclusions

Few patients hospitalized for AP had a documented order for strict monitoring of fluid intake and output, despite the importance of monitoring fluid balance in these patients. Our study suggests an association between urine output and fluid balance with LOS in AP.

Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

BACKGROUND

Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed.

METHODS

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation.

RESULTS

The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP.

CONCLUSIONS

This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.

Which Patients with Mild Acute Pancreatitis Require Prolonged Hospitalization?

Objectives:

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

Methods:

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

Results:

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

Conclusions:

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

Acute Pancreatitis: Etiology, Pathology, Diagnosis, and Treatment

Acute pancreatitis is a fascinating disease. In the United States, the two most common etiologies of acute pancreatitis are gallstones and excessive alcohol consumption. The diagnosis of acute pancreatitis is made with a combination of history, physical examination, computed tomography scan, and laboratory evaluation. Differentiating patients who will have a benign course of their pancreatitis from patients who will have severe pancreatitis is challenging to the clinician. C-reactive protein, pro-calcitonin, and the Bedside Index for Severity of Acute Pancreatitis appeared to be the best tools for the early and accurate diagnosis of severe pancreatitis. Early laparoscopic cholecystectomy is indicated for patients with mild gallstone pancreatitis. For patients who are going to have a prolonged hospitalization, enteral nutrition is preferred. Total parenteral nutrition should be reserved for patients who cannot tolerate enteral nutrition. Prophylactic antibiotics are not indicated for patients with pancreatic necrosis. Surgical intervention for infected pancreatic necrosis should be delayed as long as possible to improve patient outcomes.

The Efficiency of Aggressive Hydration With Lactated Ringer Solution for the Prevention of Post-ERCP Pancreatitis: A Systematic Review and Meta-analysis

BACKGROUND

As shown in studies, aggressive hydration during the perioperative period of endoscopic retrograde cholangiopancreatography (ERCP) effectively prevents post-ERCP pancreatitis (PEP). We conducted a systematic review and meta-analysis to evaluate the clinical effectiveness and safety of aggressive hydration with lactated Ringer solution at preventing PEP.

MATERIALS AND METHODS

We searched all relevant research from PubMed, the Cochrane Library, Embase, the Web of Science, ClinicalTrial.gov, and Scopus database for randomized controlled trials (RCTs) published before March 2017. Reference lists from reviews or relevant articles were screened for RCTs. The primary outcomes were the incidence of PEP and the incidence of moderate to severe pancreatitis. The secondary outcomes were the incidence of hyperamylasemia and pain and the length of hospital stay. The meta-analysis was conducted using the Cochrane Program Review Manager.

RESULTS

Three RCTs were included in our study. On the basis of the results of the meta-analysis, the aggressive hydration group had a lower incidence of pancreatitis after ERCP [odds ratio (OR)=0.29; 95% confidence interval (CI), 0.16-0.53]; a lower incidence of moderate to severe PEP (OR=0.16; 95% CI, 0.03-0.96); lower incidence of hyperamylasemia (OR=0.38; 95% CI, 0.25-0.59); lower risk of pain (OR=0.17; 95% CI, 0.08-0.38); and a shorter duration of hospital stay (standardized mean difference=-0.41; 95% CI, -0.69 to -0.14).

CONCLUSIONS

Aggressive hydration with lactated Ringer solution can reduce the overall incidence of PEP, moderate to severe pancreatitis and hyperamylasemia, shorten the length of hospitalization and reduce pain.

Circulating microRNA 216 as a Marker for the Early Identification of Severe Acute Pancreatitis

BACKGROUND

To study the value of circulating microRNA 216 (miR-216) as a marker for the severity of acute pancreatitis (AP) in both murine models and patients.

MATERIALS AND METHODS

Mice with AP were induced by intraperitoneal injection of 50μg/kg/hour cerulean either 7 times, sacrificed at 8, 9, 10, 11 or 12 hours after the first injection, or 12 times, sacrificed at 24 hours after the first injection. Plasma samples and data from patients with AP were obtained from a prospective cohort. Quantitative reverse transcription polymerase chain reaction was used to determine the miR-216a and miR-216b level.

RESULTS

The upregulation of miR-216a and miR-216b in the serum of mice was induced by cerulean injection in both the 7- and 12-injection groups (P < 0.05). The downregulation of miR-216a in pancreatic tissues of mice with AP was detected (P < 0.05), but no difference was observed in pancreatic miR-216b levels among any of the groups (all P > 0.05). The serum miR-216a level was positively correlated with pancreatic histopathology severity scores, and was negatively correlated with pancreatic miR-216a (r = -0.483, P = 0.009). The plasma miR-216a level was significantly upregulated in patients with severe AP (SAP) compared with patients with mild AP (MAP) or moderate severe AP (MSAP) (SAP versus MAP, P = 0.04; SAP versus MSAP, P = 0.00), but no difference was seen between patients with MAP and those with MSAP (P = 0.73).

CONCLUSIONS

Circulating miR-216a might be a potential biomarker for the early identification of SAP.

An international multicenter study of early intravenous fluid administration and outcome in acute pancreatitis

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.

Analysis of Treatment-Related Factors Affecting Mortality in Patients with Severe Necrotizing Acute Pancreatitis

The aim of the paper was to determine the factors related to the initial therapy that may contribute to death from severe necrotizing acute pancreatitis and to analyze their clinical importance as well as possible additive effects.

A retrospective case-control study included all adult patients treated for severe necrotizing acute pancreatitis in the Clinical Center of Kragujevac, Serbia, during the five-year period (2006-2010.). The cases (n = 41) were patients who died, while the controls (n = 69) were participants who survived. In order to estimate the relationship between potential risk factors and observed outcome, crude and adjusted odds ratios (OR) with 95 % confidence intervals (CI) were calculated in logistic regression models.

Significant association with observed outcome was shown for the use of gelatin and/or hydroxyethyl starch (adjusted OR 12.555; 95 % CI 1.150-137.005), use of albumin (adjusted OR 27.973; 95 % CI 1.741-449.373), use of octreotide (adjusted OR 16.069; 95 % CI 1.072-240.821) and avoiding of enteral feeding (adjusted OR 3.933; 95 % CI 1.118-13.829), while the use of nonsteroidal anti-inflammatory drugs had protective role (adjusted OR 0.057; 95 % CI 0.004-0.805).

The risk of death in patients with predicted severe necrotizing acute pancreatitis could be reduced with avoidance of treatment with colloid solutions, albumin and octreotide, as well as with an early introduction of oral/enteral nutrition and use of nonsteroidal anti-inflammatory drugs.

Origin, Presentation, and Clinical Course of Nonpancreatic Hyperlipasemia

OBJECTIVE

The diagnosis of acute pancreatitis (AP) is defined as a constellation of abnormal pancreatic enzymes, imaging, and characteristic pain. The origin and clinical significance of isolated hyperlipasemia is unclear.

METHODS

We prospectively evaluated patients with serum lipase level greater than 3 times the upper limit of normal (ULN) admitted to Los Angeles County Hospital from October 2014 to April 2015. Patients were identified by a daily laboratory query used to support an ongoing randomized trial of goal-directed therapy for AP (NCT 01761539). Nonpancreatic hyperlipasemia (NPHL) was defined as a serum lipase level greater than 3 times the ULN without characteristic pain or imaging.

RESULTS

Among 221 patients with lipase level greater than 3 times the ULN, 170 met criterion for AP, and 51 did not. The leading etiologies for NPHL were decompensated cirrhosis and renal failure. Patients with NPHL were significantly older and had more comorbidities and lower serum lipase levels (360 ± 36 vs 1453 ± 135 IU/L, P < 0.001). There were no differences in length of hospitalization, intensive care unit admission, or mortality.

CONCLUSIONS

Elevated serum lipase level has many nonpancreatic origins, with liver and renal failure being the most frequent. Distinct clinical features can help to differentiate between AP and NPHL.

Predicting severe acute pancreatitis in children based on serum lipase and calcium: A multicentre retrospective cohort study

OBJECTIVE

This study aims to identify predictors of severe paediatric AP based on laboratory trends and peak/trough values on day 2 (D2) after presentation. The performance of identified predictors was first assessed and then combined with the previously validated sensitive predictor serum lipase ≥7 times the upper limit of normal (× ULN) on day 1 (D1).

METHODS

A retrospective review of children with AP (January 2000-July 2011) was performed at three tertiary referral hospitals (two in Australia, one in the Netherlands). Trends of candidate predictors were analysed using the percentage change from D1 to D2 or peak/trough values within 48 h after presentation.

RESULTS

175 AP episodes (including 50 severe episodes [29%]) were identified. Serum lipase ≥50% decrease on D2 (sensitivity 73%, specificity 54%) and calcium trough ≤2.15 mmol/L within 48 h (sensitivity 59%, specificity 81%) were identified as statistically significant predictors for severe AP. By combining the newly identified predictors with the previously validated predictor serum lipase ≥7× ULN on D1 (sensitivity 82%, specificity 53%), specificity improved to predict severe AP on D2 with the addition of: (i) serum lipase ≥50% decrease (sensitivity 67%, specificity 79%), or (ii) trough calcium ≤2.15 mmol/L (sensitivity 46%, specificity 89%).

CONCLUSIONS

Serum lipase and calcium, may be helpful in predicting severity of paediatric AP. There may be a clinical role on D1 for using serum lipase ≥7× ULN (high sensitivity), and on D2 for combining D1 serum lipase ≥7× ULN with calcium trough ≤2.15 mmol/L within 48 h (high specificity) to help predict severe paediatric AP.

Circulating nucleosomes as predictive markers of severe acute pancreatitis

Background

The components of nucleosomes, which contain DNA and histones, are released into the circulation from damaged cells and can promote inflammation. We studied whether the on-admission levels of circulating nucleosomes predict the development of severe acute pancreatitis (AP), in particular among the patients who present without clinical signs of organ dysfunction.

Methods

This is a prospective study of 74 AP patients admitted to Helsinki University Hospital from 2003 to 2007. Twenty-three patients had mild, 27 moderately severe, and 24 severe AP as defined by the revised Atlanta criteria. 14/24 severe AP patients had no sign of organ dysfunction on admission (modified marshall score <2). Blood samples were obtained on admission and the plasma levels of nucleosomes were measured using enzyme-linked immunosorbent assay.

Results

The on-admission levels of nucleosomes were significantly higher in severe AP than in mild or moderately severe AP (p < 0.001 for all), higher in non-survivors (n = 8) than in survivors (p = 0.019), and correlated with the on-admission levels of C-reactive protein (p < 0.001) and creatinine (p < 0.001). Among the AP patients who presented without organ dysfunction, the on-admission nucleosome level was an independent predictor of severe AP (p = 0.038, gender-adjusted forward-stepping logistic regression).

Conclusions

Circulating nucleosome levels may be helpful in identifying, on admission to hospital, the AP patients who present without clinical signs of organ dysfunction, and, yet, are bound to develop organ dysfunction during hospitalization.

Aggressive hydration with Lactated Ringer's solution as the prophylactic intervention for postendoscopic retrograde cholangiopancreatography pancreatitis: A randomized controlled double-blind clinical trial

Background:

Pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP) and may cause significant morbidity and even death. There is no effective prophylactic intervention for patients with average risk yet. This study aims to investigate preventive effect of aggressive hydration for post-ERCP pancreatitis.

Materials and Methods:

In a double-blind controlled setting, 150 patient were randomly assigned to receive either aggressive hydration with lactated Ringer's solution (3 mL/kg/h during ERCP, followed by a 20 mL/kg bolus and 3 mL/kg/h for 8 h after the procedure, n = 75) or standard amount of hydration (1.5 mL/kg/h during and for 8 h after ERCP, n = 75). Patients were observed for volume overload as well as pancreatic pain and serum levels of amylase at baseline and 2, 8, and 24 h after ERCP. Post-ERCP pancreatitis was defined as hyperamylasemia (level of amylase >300) and pancreatic pain during the 24 h follow-up. Hyperamylasemia and pancreatic pain were the secondary end points.

Results:

Mean age of the patients was 50.8 ± 13.5 years. Most of the patients were female (66%). Pancreatitis developed in 21 patients, including 22.7% of patients receiving standard hydration and 5.3% patients receiving aggressive hydration (P = 0.002). Hyperamylasemia was detected in 44.0% of patients receiving standard hydration and 22.7% of patients aggressive hydration (P = 0.006). The pancreatic pain was reported by 5.3% of patients receiving aggressive hydration and 37.3% of patients receiving standard hydration (P ≤ 0.005).

Conclusion:

Aggressive hydration with lactated Ringer's solution may effectively prevent post-ERCP pancreatitis as well as hyperamylasemia and pancreatic pain in patients with average risk.

[Recent Advances in Management of Acute Pancreatitis]

Acute pancreatitis is common but remains a condition with significant morbidity and mortality. Despite a better understanding of the pathophysiology of acute pancreatitis achieved during the past few decades, there is no specific pharmacologic entity available. Therefore, supportive care is still the mainstay of treatment. Recently, novel interventions for increasing survival and minimizing morbidity have been investigated, which are highlighted in this review.

Clinical update on fluid therapy and nutritional support in acute pancreatitis

BACKGROUND/OBJECTIVES

The aim of this focused review is to provide a valuable and updated source of information for clinical practice on fluid therapy (FT) and nutritional support in acute pancreatitis (AP).

METHODS

The review encompasses important new clinical information that has become available for understanding and offering these specific treatments since the 2013 publication of two guidelines, both the joint International Association of Pancreatology and American Pancreatic Association and the American College of Gastroenterology. The 2015 Revised Japanese Guideline is discussed selectively. To this end, the review is divided into 7 sections, including timing and cause of mortality; severity classification systems; predicting severity; response to treatment; nutritional support; fluid therapy and steps for further research.

CONCLUSIONS

In mild AP, begin oral feeding when nausea, vomiting and abdominal pain are improving. In (predicted) severe AP, feeding decisions should commence by 72 h, offering oral feeding if GI symptoms improve or enteral feeding if patients are symptomatic and/or intolerant to orals. All patients should be offered goal-directed FT during the first 6-12 h of presentation. Cautious FT is advised in those age >55 years or with preexisting organ failure or predictors of developing fluid sequestration.