The importance of timing of decompression in severe acute pancreatitis combined with abdominal compartment syndrome. J Trauma Acute Care Surg. 2013;74:1060-1066. [PMID: 23511145 DOI: 10.1097/ta.0b013e318283d927]

Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) play a pivotal role in the pathophysiology of severe acute pancreatitis (SAP) and contribute to new-onset and persistent organ failure. The optimal management of ACS involves a multi-disciplinary approach, from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure (IAP). A targeted literature search from January 1, 2000, to November 30, 2022, revealed 20 studies and data was analyzed on the type and country of the study, patient demographics, IAP, type and timing of surgical procedure performed, post-operative wound management, and outcomes of patients with ACS. There was no randomized controlled trial published on the topic. Decompressive laparotomy is effective in rapidly reducing IAP (standardized mean difference = 2.68, 95% confidence interval: 1.19-1.47, P < 0.001; 4 studies). The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but, potentially lethal ACS. Disease-specific patient selection and the role of less-invasive decompressive measures, like subcutaneous linea alba fasciotomy or component separation techniques, is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS. This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP. However, there is a lack of high-quality evidence on patient selection, timing, and modality of surgical decompression. Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.

Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review

Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.

Who would benefit from open abdomen in severe acute pancreatitis?-a matched case-control study

BACKGROUND

Selection of patients for open abdomen (OA) treatment in severe acute pancreatitis (SAP) is challenging. Treatment related morbidity and risk of adverse events are high; however, refractory abdominal compartment syndrome (ACS) is potentially lethal. Factors influencing the decision to initiate OA treatment are clinically important. We aimed to study these factors to help understand what influences the selection of patients for OA treatment in SAP.

METHODS

A single center study of patients with SAP that underwent OA treatment compared with conservatively treated matched controls.

RESULTS

Within study period, 47 patients treated with OA were matched in a 1:1 fashion with conservatively treated control patients. Urinary output under 20 ml/h (OR 5.0 95% CI 1.8-13.7) and ACS (OR 4.6 95% CI 1.4-15.2) independently associated with OA treatment. Patients with OA treatment had significantly more often visceral ischemia (34%) than controls (6%), P = 0.002. Mortality among patients with visceral ischemia was 63%. Clinically meaningful parameters predicting developing ischemia were not found. OA treatment associated with higher overall 90-day mortality rate (43% vs 17%, P = 0.012) and increased need for necrosectomy (55% vs 21%, P = 0.001). Delayed primary fascial closure was achieved in 33 (97%) patients that survived past OA treatment.

CONCLUSION

Decreased urine output and ACS were independently associated with the choice of OA treatment in patients with SAP. Underlying visceral ischemia was strikingly common in patients undergoing OA treatment, but predicting ischemia in these patients seems difficult.

Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature

Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.

Pancreatic necrosis: Complications and changing trend of treatment

Incidence of acute pancreatitis seems to be increasing in the Western countries and has been associated with significantly increased morbidity. Nearly 80% of the patients with acute pancreatitis undergo resolution; some develop complications including pancreatic necrosis. Infection of pancreatic necrosis is the leading cause of death in these patients. A significant portion of these patients needs surgical interventions. Traditionally, the “gold standard” procedure has been the open surgical necrosectomy, which is now being completed by the relatively lesser invasive interventions. Minimally invasive surgical (MIS) procedures include endoscopic drainage, percutaneous image-guided catheter drainage, and retroperitoneal drainage. This review article discusses the open and MIS interventions for pancreatic necrosis with each having its own respective benefits and disadvantages are covered.

Pressure Distribution during Negative Pressure Wound Therapy of Experimental Abdominal Compartment Syndrome in a Porcine Model

(1) Introduction: Negative pressure wound therapy (NPWT) is a frequently applied open abdomen (OA) treatment. There are only a few experimental data supporting this method and describing the optimal settings and pressure distribution in the abdominal cavity during this procedure. The aim of our study was to evaluate pressure values at different points in the abdominal cavity during NPWT in experimental abdominal compartment syndrome (ACS) animal model; (2) Methods: In this study (permission Nr. 13/2014/UDCAW), 27 Hungahib pigs (15.4-20.2 kg) were operated on. ACS was generated by implanting a plastic bag in the abdomen through mini-laparotomy and filled with 2100-3300 mL saline solution (37 °C) to an intraabdominal pressure (IAP) of 30 mmHg. After 3 h, NPWT (Vivano Med^® Abdominal Kit, Paul Hartmann AG, Germany) or a Bogota bag was applied. The NPWT group was divided into -50, -100 and -150 mmHg suction groups. Pressure distribution to the abdominal cavity was monitored at 6 different points of the abdomen via a multichannel pressure monitoring system; (3) Results: The absolute pressure levels were significantly higher above than below the protective layer. The values of the pressure were similar in the midline and laterally. Amongst the bowels, the pressure values changed periodically between 0 and -12 mmHg which might be caused by peristaltic movements; (4) Conclusions: The porcine model of the present study seems to be well applicable for investigating ACS and NPWT. It was possible to provide valuable information for clinicians. The pressure was well distributed by the protective layer to the lateral parts of the abdomen and this phenomenon did not change considerably during the therapy.

Update: Role of surgery in acute necrotizing pancreatitis

Acute necrotizing pancreatitis is a prevalent disease with high morbidity and mortality. The development of radiologic and endoscopic techniques to manage pancreatic necrosis commands a multidisciplinary approach, which has considerably decreased the need for laparotomy. The objective of this update is to define the role of surgery in the multidisciplinary approach to management of necrotizing acute pancreatitis.

Rhubarb vs. glycerin enema for treatment of critically ill patients with intra-abdominal hypertension

Rhubarb has been used as an evacuant for thousands of years. However, recent research has indicated that rhubarb inhibits inflammation and protects organ function. In the current study, the use of rhubarb was investigated in patients with intra-abdominal hypertension (IAH). Specifically, its dual role in attenuating lung and bowel injury by catharsis and inhibiting inflammation was evaluated. Patients in the glycerin group (n=56) received 110 ml of glycerin enema by coloclysis once daily for 7 to 9 days. Patients in the rhubarb group (n=56) were treated with a mixture of 0.3 g/kg body weight rhubarb powder in 100 ml warm water. The Acute Physiology and Chronic Health Evaluation II (APACHE II), Sepsis-Related Organ Failure Assessment (SOFA), intra-abdominal pressure, procalcitonin (PCT), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α) and interleukin (IL)-6 levels were recorded. The duration of mechanical ventilation (MV), respiratory parameters, first day of enteral nutrition (EN), intensive care unit (ICU) hospital stay and 30-day mortality were also recorded. The APACHE II scores were significantly lower in the rhubarb group compared with the glycerin group from day 3 to 9 (P<0.05 at day 3 and 4; P<0.01 at day 5, 7 and 9). The SOFA scores were significantly lower in the rhubarb group compared with the glycerin group from day 5 to 9 (P<0.05). PCT levels were significantly lower from day 4 to 9 (P<0.05) and the CRP level was significantly lower from day 3 to 9 (P<0.05) in the rhubarb group compared with the glycerin group. The TNF-α and IL-6 were significantly lower in the rhubarb group compared with the glycerin group from day 3 to 9 (P<0.05 at day 3 and 4, P<0.01 at day 5, 7 and 9). The positive end-expiratory pressure and peak inspiratory pressure were significantly lower in the rhubarb group compared with the glycerin group at day 3, 5 and 7 (P<0.05 at day 3 and 5, P<0.01 at day 7), while the oxygenation index (P<0.05) and alveolar-arterial partial pressure of oxygen (P<0.05 at day 3 and 5, P<0.01 at day 7) were significantly improved. Significantly shorter durations of MV and ICU hospital stay, and earlier EN, were observed in the rhubarb group compared with the glycerin group (all P<0.05). Rhubarb treatment was indicated to be beneficial in IAH, by inhibiting inflammation and restoring intestinal function.

Neutrophil Gelatinase-Associated Lipocalin as a Marker for Renal Dysfunction Detection in Critically Ill Patients with Increased Intraabdominal Pressure

Introduction

Elevated intraabdominal pressure (IAP) it is known to have an impact on renal function trough the pressure transmitted from the abdominal cavity to the vasculature responsible for the renal blood flow. Intraabdominal pressure is found to be frequent in intensive care patients and also to be a predictor of mortality. Intra-abdominal high pressure is an entity that can have serious impact on intensive care admitted patients, studies concluding that if this condition progresses to abdominal compartment syndrome mortality is as high as 80%.

Aim

The aim of this study was to observe if a link between increased intraabdominal pressure and modification in renal function exists (NGAL, creatinine clearance).

Material and Method

The study enrolled 30 critically ill patients admitted in the Intensive Care Unit of SCJU TîrguMures between November 2015 and August 2016. The study enrolled adult, hemodynamically stable patients admitted in intensive critical care - defined by a normal blood pressure maintained without any vasopressor or inotropic support, invasive monitoring using PICCO device and abdominal pressure monitoring.

Results

The patients were divided into two groups based on the intraabdominal pressure values: normal intraabdominal pressure group= 52 values and increased intraabdominal group= 35 values. We compared the groups in the light of NGAL values, 24 hours diuresis, GFR and creatinine clearance. The groups are significantly different when compared in the light of NGAL values and GFR values. We obtained a statistically significant correlation between NGAL value and 24 hour diuresis. No other significant correlations were encountered between the studied items.

Conclusions

NGAL values are increased in patients with high intraabdominal pressure which may suggest its utility as a cut off marker for patients with increased intraabdominal pressure. There is a significant decreased GFR in patient with elevated intraabdominal pressure, observation which can help in early detection of renal injury in patients due to high intraabdominal pressure. No correlation was found between creatinine clearance and increased intraabdominal pressure.

Prevalence and diagnosis rate of intra-abdominal hypertension in critically ill adult patients: A single-center cross-sectional study

PURPOSE

To investigate the prevalence and diagnosis rate of intra-abdominal hypertension (IAH) in a mixed-population intensive care unit (ICU), and to investigate the knowledge of ICU staff regarding the guidelines published by the World Society of Abdominal Compartment Syndrome (WSACS) in 2013.

METHODS

A one-day cross-sectional study based on the WSACS 2013 guidelines was conducted in the general ICU of a tertiary teaching hospital in Chongqing, China. The included patients were divided into intravesical pressure (IVP) measured group and IVP unmeasured group. The epidemiologic data were recorded, and potential IAH risk factors (RFs) were collected based on the guidelines. IVP measurements were conducted by investigators every 4 h and the result was compared to that measured by the ICU staff to evaluate the diagnosis rate. Besides, a questionnaire was used to investigate the understanding of the guidelines among ICU staff.

RESULTS

Thirty-two patients were included, 14 in the IVP measured group and 18 in the IVP unmeasured group. The prevalence of IAH during the survey was 15.63% (5/32), 35.71% (5/14) in IVP measured group. Only one case of IAH had been diagnosed by the ICU physician and the diagnosis rate was as low as 20.00%. Logistic regression analysis showed that sequential organ failure assessment (SOFA) score was an independent RF for IAH (OR: 1.532, 95% CI: 1.029-2.282, p=0.036. Fourteen doctors and 5 nurses were investigated and the response rate was 67.86%. The average scores of the doctors and nurses were 27.14±20.16 and 16.00±8.94 respectively. None of them had studied the WSACS 2013 guidelines thoroughly.

CONCLUSION

Patients with a higher SOFA score has a higher incidence of IAH. The IAH prevalence in 14 ICU patients with indwelling catheter was 35.71%. Strengthening the wide and rational use of WSACS guideline is important to improve the diagnosis of IAH.

Can Femoral Venous Pressure be Used as an Estimate for Standard Vesical Intra-Abdominal Pressure Measurement?

Intra-abdominal hypertension (IAH) is highly prevalent in critically ill patients admitted to the intensive care unit and is associated with an increased morbidity and mortality. The present study investigated whether femoral venous pressure (EVP) can be used as a surrogate parameter for intra-abdominal pressure (IAP) measured via the bladder in IAH grade II (IAP <20 mmHg) or grade III (IAP ≥20 mmHg). This was a single-centre prospective study carried out in a tertiary adult intensive care unit. IAP was measured via the bladder with a urinary catheter with simultaneous recording of the FVP via a femoral central line. If the IAP was <20 mmHg external weight to a maximum of 10 kg was applied to the abdomen with subsequent measurements of IAP and FVP. Eleven patients were enrolled into the study. IAH (IAP >12 mmHg) was identified in five patients (42%) and abdominal compartment syndrome (ACS, IAP >20 mmHg with new onset organ failure) in two (18%) with all-cause study mortality of 18%. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 21 ± 5, Simplified Acute Physiology (SAPS 2) score 49 ± 8, and Sequential Organ Failure Assessment (SOFA) score 9 ± 3. At baseline the bias between IAP and FVP was 3.2 with a precision of 3.63 mmHg (limits of agreement [LA] −4.1, 10.4). At 5 kg and 10 kg, the bias was 2.5 with a precision of 3.92 mmHg (LA-5.4, 10.3) and 2.26 mmHg (LA-2.1, 7.0) respectively. A receiver operating characteristic analysis for FVP to predict IAH showed an area under the curve of 0.87 (95% confidence interval 0.74–0.94, P=0.0001). FVP cannot be recommended as a surrogate measure for IAP even at IAP values above 20 mmHg. However, an elevated FVP was a good predictor of IAH.

Influence of Ventilation Parameters on Intraabdominal Pressure

Introduction

Intraabdominal pressure monitoring is not routinely performed because the procedure assumes some invasiveness and, like other invasive procedures, it needs to have a clear indication to be performed. The causes of IAH are various. Mechanically ventilated patients have numerous parameters set in order to be optimally ventilated and it is important to identify the ones with the biggest interference in abdominal pressure. Although it was stated that mechanical ventilation is a potential factor of high intraabdominal pressure the set parameters which may lead to this diagnostic are not clearly named.

Objectives

To evaluate the relation between intraabdominal pressure and ventilator parameters in patients with mechanical ventilation and to determine the correlation between intraabdominal pressure and body mass index.

Material and method

This is an observational study which enrolled 16 invasive ventilated patients from which we obtained 61 record sheets. The following parameters were recorded twice daily: ventilator parameters, intraabdominal pressure, SpO2, Partial Oxygen pressure of arterial blood. We calculated the Body Mass Index (BMI) for each patient and the volume tidal/body weight ratio for every recorded data point.

Results

We observed a significant correlation between intraabdominal pressure (IAP) and the value of PEEP (p=0.0006). A significant statistical correlation was noted regarding the tidal volumes used for patient ventilation. The mean tidal volume was 5.18 ml/kg. Another significant correlation was noted between IAP and tidal volume per kilogram (p=0.0022). A positive correlation was found between BMI and IAP (p=0.0049), and another one related to the age of the enrolled patients. (p=0.0045).

Conclusions

The use of positive end-expiratory pressures and high tidal volumes during mechanical ventilation may lead to the elevation of intraabdominal pressure, a possible way of reducing this risk would be using low values of PEEP and also low volumes for the setting of ventilation parameters. There is a close positive correlation between the intraabdominal pressure levels and body mass index.

Clinical value of intra-abdominal pressure monitoring and prognosis in severe acute pancreatitis patients with intra-abdominal hypertension

AIM: To assess the clinical value of intra-abdominal pressure monitoring in severe acute pancreatitis patients with intra-abdominal hypertension (IAH).

METHODS: Clinical data for 30 patients with severe acute pancreatitis and intra-abdominal hypertension were analyzed retrospectively, including the relation of intra-abdominal pressure with abdominal perfusion pressure, blood lactic acid, C-reaction protein (CRP), acute physiology and chronic health evaluation II score (APACHE II), days in intensive care unit, number of affected organs, and risk factors for prognosis.

RESULTS: Abdominal perfusion pressure (APP) was negatively correlated with intra-abdominal pressure (IAP) pre- and post-treatment. IAP was positively correlated with blood lactic acid (BLA), CRP, APACHE II, days in ICU, and number of affected organs (P < 0.05). IAP was negatively correlated with prognosis (P < 0.05). IAP, APACHE II, and number of affected organs were independent risk factors for prognosis in severe acute pancreatitis patients with IAH.

CONCLUSION: IAP, APACHE II, and number of affected organs are independent risk factors for prognosis in severe acute pancreatitis patients with IAH.

Recognition and management of intra-abdominal hypertension and abdominal compartment syndrome; a survey among Dutch surgeons

Purpose

Intra-abdominal hypertension (IAH) and Abdominal compartment syndrome (ACS) are relatively rare, but severe complications. Although many advances were made in recent years, the recognition and management remain subject of debate. The aim of this study was to determine the current state of awareness, knowledge and use of evidence-based medicine regarding IAH and ACS among Dutch surgeons.

Methods

A literature-based and expert consensus survey was developed. One surgeon in every hospital in The Netherlands was asked to complete the online questionnaire.

Results

Sixty of 87 (69 %) invited surgeons completed the questionnaire. Intra-abdominal pressure (IAP) was measured using intra-vesical methods by 55 (98 %) respondents. Diuretics (N = 38; 63 %) and laparotomy (N = 33; 55 %) were considered useful treatments for IAH or prevention of ACS by a majority. Only 16 (27 %) respondents used these guidelines in daily practice, and 37 (62 %) respondents are willing to do so. Although 35 (58 %) surgeons agreed that IAH is only a symptom, not requiring treatment. Forty-one percent of experienced respondents suggested that prevalence of ACS remained unchanged. Nearly all respondents (N = 59; 98 %) believed that open abdomen management improves patient outcomes, many (N = 46; 77 %) confirm the high complications rate of this treatment.

Conclusion

The definitions of IAH and ACS and the related diagnostic and therapeutic challenges are relatively well known by Dutch surgeons. Despite limited use of the evidence-based guidelines, the willingness to do so is high. Most respondents favor open abdomen treatment for patients with imminent ACS, despite the high complication rates associated with this treatment.

Decompressive laparotomy for abdominal compartment syndrome

Background

The effect of decompressive laparotomy on outcomes in patients with abdominal compartment syndrome has been poorly investigated. The aim of this prospective cohort study was to describe the effect of decompressive laparotomy for abdominal compartment syndrome on organ function and outcomes.

Methods

This was a prospective cohort study in adult patients who underwent decompressive laparotomy for abdominal compartment syndrome. The primary endpoints were 28‐day and 1‐year all‐cause mortality. Changes in intra‐abdominal pressure (IAP) and organ function, and laparotomy‐related morbidity were secondary endpoints.

Results

Thirty‐three patients were included in the study (20 men). Twenty‐seven patients were surgical admissions treated for abdominal conditions. The median (i.q.r.) Acute Physiology And Chronic Health Evaluation (APACHE) II score was 26 (20–32). Median IAP was 23 (21–27) mmHg before decompressive laparotomy, decreasing to 12 (9–15), 13 (8–17), 12 (9–15) and 12 (9–14) mmHg after 2, 6, 24 and 72 h. Decompressive laparotomy significantly improved oxygenation and urinary output. Survivors showed improvement in organ function scores, but non‐survivors did not. Fourteen complications related to the procedure developed in eight of the 33 patients. The abdomen could be closed primarily in 18 patients. The overall 28‐day mortality rate was 36 per cent (12 of 33), which increased to 55 per cent (18 patients) at 1 year. Non‐survivors were no different from survivors, except that they tended to be older and on mechanical ventilation.

Conclusion

Decompressive laparotomy reduced IAP and had an immediate effect on organ function. It should be considered in patients with abdominal compartment syndrome.

Improves organ function

Intra-abdominal pressure: Time ripe to revise management guidelines of acute pancreatitis?

AIM

To systematically review evidence on pathophysiology of intra-abdominal pressure (IAP) in acute pancreatitis (AP) with its clinical correlates.

METHODS

Systematic review of available evidence in English literature with relevant medical subject heading terms on PubMed, Medline and Scopus with further search from open access sources on internet as suggested by articles retrieved.

RESULTS

Intra-abdominal hypertension (IAH) is increasingly gaining recognition as a point of specific intervention with potential to alter disease outcome and improve mortality in AP. IAH can be expected in at least 17% of patients presenting with diagnosis of AP to a typical tertiary care hospital (prevalence increasing to 50% in those with severe disease). Abdominal compartment syndrome can be expected in at least 15% patients with severe disease. Recent guidelines on management of AP do not acknowledge utility of surveillance for IAP other than those by Japanese Society of Hepato-Biliary-Pancreatic Surgery. We further outline pathophysiologic mechanisms of IAH; understanding of which advances our knowledge and helps to coherently align common observed variations in management related conundrums (such as fluid therapy, nutrition and antibiotic prophylaxis) with potential to further individualize treatment in AP.

CONCLUSION

We suggest that IAP be given its due place in future practice guidelines and that recommendations be formed with help of a broader panel with inclusion of clinicians experienced in management of IAH.

Acute pancreatitis

PURPOSE OF REVIEW

To review the changing insights in the pathophysiology and management of acute pancreatitis.

RECENT FINDINGS

The outdated 1992 Atlanta classification has been replaced by two new classifications, both of which acknowledge the role of organ dysfunction in determining the outcome of acute pancreatitis, and both of which have introduced a new category of 'moderate' pancreatitis. The new classifications will allow fewer patients to be classified as severe, which better reflects the risk of dying of the disease. Intra-abdominal hypertension has emerged as a relevant issue, and strategies to lower intra-abdominal pressure may often be required. Antibiotic prophylaxis has been discontinued for some time, but aggressive fluid resuscitation is also being questioned, and the role of surgery is further reduced as percutaneous drainage of collections has shown to reduce the need for more surgical interventions. If needed, surgery should be as conservative as possible, with minimally invasive strategies preferable. Newer techniques such as endoscopic transgastric drainage are being developed, but their exact role has yet to be defined.

SUMMARY

Management of severe acute pancreatitis is changing fundamentally. 'Less is more' is the new paradigm in acute pancreatitis - less antibiotics, less fluids, less surgery, which should eventually lead to less morbidity and mortality.

Current concepts of the role of abdominal compartment syndrome in acute pancreatitis - an opportunity or merely an epiphenomenon

The association of acute pancreatitis (AP) with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) has only recently been recognized. The detrimental effects of raised intra-abdominal pressure in cardiovascular, pulmonary and renal systems have been well established. Although IAH was associated with a higher APACHE II score and multi-organ dysfunction syndrome (MODS) in severe acute pancreatitis, a causal relationship between ACS and MODS in SAP is yet to be established. It is therefore debatable whether IAH is a phenomenon causative of organ failure or an epiphenomenon seen in conjunction with other organ dysfunction. This review systemically examines the pathophysiological basis and clinical relevance of ACS in AP and summarizes all the available evidence in its management.

Electroacupuncture Ameliorates Acute Lung Injury through Promoting Gastrointestinal Motility in Rats with Acute Pancreatitis

Objective. Gastrointestinal disfunction and acute lung injury (ALI) were common in acute pancreatitis (AP). The effect of electro-acupuncture (EA) on gastrointestinal motility and ALI in rats with AP was investigated to verify the theory of "lung and large intestine are interior exteriorly related" in traditional Chinese medicine. Methods. Male Sprague-Dawley rats were randomly divided into the normal group, model group, and EA group. AP model was established by three injections of 20% L-arginine at 1 h intervals. EA were applied to bilateral ST-25 and ST-36 for 30 minutes twice a day after modeling for 3 days. Arterial blood, pancreas, lung, and intestinal tissues were collected for detecting the inflammatory factors and histopathology. Intestinal propulsion rate (IPR) was also measured at 72 h. Results. EA treatment improved IPR and increased CCK-8 level compared with model group (P < 0.05). It lowered the serum levels of TNF- α and IL-6 and increased the level of IL-4 with no effect on IL-10. EA treatment reduced serum vasoactive intestinal peptide (VIP) and myeloperoxidase (MPO) level in the lung and the pathologic scores of pancreas, lung and intestine were decreased (P < 0.05). Conclusion. EA treatment could promote gastrointestinal motility through inhibiting VIP, and promoting CCK expression and regulate pro- and anti-inflammatory mediators to ameliorate ALI in AP.

Early management of acute pancreatitis

Acute pancreatitis is the most common gastro-intestinal indication for acute hospitalization and its incidence continues to rise. In severe pancreatitis, morbidity and mortality remains high and is mainly driven by organ failure and infectious complications. Early management strategies should aim to prevent or treat organ failure and to reduce infectious complications. This review addresses the management of acute pancreatitis in the first hours to days after onset of symptoms, including fluid therapy, nutrition and endoscopic retrograde cholangiography. This review also discusses the recently revised Atlanta classification which provides new uniform terminology, thereby facilitating communication regarding severity and complications of pancreatitis.