Frequency of pancreatitis in fulminant hepatic failure using isoenzyme markers

Liver transplantation for alcohol-associated liver disease

Alcohol-associated liver disease (ALD) is a major cause of morbidity and mortality worldwide, and a leading indication for liver transplantation (LT) in many countries, including the United States. However, LT for ALD is a complex and evolving field with ethical, social, and medical challenges. Thus, it requires a multidisciplinary approach and individualized decision-making. Short-term and long-term patient and graft survival of patients undergoing LT for ALD are comparable to other indications, but there is a continued need to develop better tools to identify patients who may benefit from LT, improve the pretransplant and posttransplant management of ALD, and evaluate the impact of LT for ALD on the organ donation and transplantation systems. In this review, we summarize the current evidence on LT for ALD, from alcohol-associated hepatitis to decompensated alcohol-associated cirrhosis. We discuss the indications, criteria, outcomes, and controversies of LT for these conditions and highlight the knowledge gaps and research priorities in this field.

Low liver reserve is a risk factor for acute pancreatitis in patients with acute liver failure

AIM

Acute pancreatitis is a complication of acute liver failure (ALF). This study aimed to investigate the prevalence of and clinical features associated with acute pancreatitis in patients with ALF.

METHODS

We retrospectively analyzed a cohort of ALF patients without hepatic encephalopathy diagnosed during a period 2011-2018, and compared clinical features between patients with acute pancreatitis and those without. Acute pancreatitis was diagnosed according to the Acute Pancreatitis Clinical Practice Guidelines 2021. A multivariate analysis was carried out to identify factors associated with acute pancreatitis.

RESULTS

There were 83 ALF patients without hepatic encephalopathy (34 men; 11 deaths; 6 liver transplants; median age, 63 years). Acute pancreatitis occurred in nine patients (10.8%). The median time duration from ALF to the onset of acute pancreatitis was 8 days. The survival rate was lower in patients with than those without acute pancreatitis (22% vs. 86%). The model for end-stage liver disease score (hazard ratio 1.10, 95% confidence interval 1.03-1.18) was found to be a significant factor associated with acute pancreatitis, whereas triglyceride, age, and sex were not.

CONCLUSIONS

A high model for end-stage liver disease score may be a marker to stratify patients with ALF at a risk of acute pancreatitis.

The First Successful Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure Caused by Severe Acute Necrotizing Pancreatitis: A Case Report

Liver transplantation (LT) is the only life-saving option when acute-on-chronic liver failure (ACLF) does not improve with conservative therapy. Acute pancreatitis (AP) can cause chronic liver disease progression to ACLF. However, deceased donor LT for patients with AP has had mixed results, and no consensus has been established regarding the indication for LT. We report the first successful living donor LT (LDLT) for ACLF caused by severe AP. The 38-year-old patient with alcoholic liver disease was transferred to our institute with worsening refractory ascites. During the pretransplant workup, she developed severe acute necrotizing pancreatitis, resulting in grade 3 ACLF. The patient's clinical course was further complicated by high levels of donor-specific antibodies and immune thrombocytopenia. The AP gradually improved after intensive care combined with artificial liver support. The patient successfully underwent urgent LDLT with upfront splenectomy and desensitization therapy, including plasm exchange, high-dose intravenous immunoglobulin, and anti-thymocyte globulin. No infection or recurrence of AP was observed postoperatively. We conclude that LDLT is a feasible option for ACLF patients caused by severe AP if a deceased donor is not readily available.

[Acute Liver Failure: Current Updates and Management]

Acute liver failure (ALF) is a rare disease condition with a dynamic clinical course and catastrophic outcomes. Several etiologies are involved in ALF. Hepatitis A and B infections and indiscriminate use of untested herbs or supplemental agents are the most common causes of ALF in Korea. Noninvasive neurological monitoring tools have been used in patients with ALF in recent times. Ongoing improvements in intensive care, including continuous renal replacement therapy, therapeutic plasma exchange, vasopressor, and extracorporeal membrane oxygenation, have reduced the mortality rate of patients with ALF. However, liver transplantation is still the most effective treatment for patients with intractable ALF. There is a need for further research in the areas of better prognostication and precise selection of patients for emergency transplantation.

β-hydroxybutyrate inhibits ferroptosis-mediated pancreatic damage in acute liver failure through the increase of H3K9bhb

Acute pancreatitis and hyperamylasemia are often seen in patients with acute liver failure (ALF). However, the underlying mechanisms remain elusive. This study describes pancreatic tissue damage and exocrine dysfunction in a mouse model of major-liver-resection-induced ALF. The analysis of 1,264 clinical cases of liver failure (LF) showed that the incidence of hyperamylasemia and hyperlipasemia in patients with LF is 5.5% and 20%, respectively. Metabolomic studies indicate that glutathione (GSH)-deficiency-caused ferroptosis contributes to pancreatic damage in mouse ALF. β-hydroxybutyrate (β-HB) is the only metabolite downregulated in the liver, serum, and pancreas. Our data suggest that β-HB protects pancreatic cells and tissues from GSH-deficiency-caused ferroptosis. β-HB administration in ALF mice restores the expression of ferroptosis-suppressor genes through histone H3 lysine 9 β-hydroxybutyrylation (H3K9bhb)-mediated chromatin opening. Our findings highlight β-HB as an endogenous metabolite regulating ferroptosis in the pancreas and extend our understanding of the pathophysiology of ALF-induced pancreatitis.

Elevated Pancreatic Enzymes Associated with Acute Liver Injury Were Mediated by Tumor Necrosis Factor-Alpha Signaling

Background: Acute liver failure (ALF) is caused by massive hepatocyte death and accompanied by severe coagulation disorder and encephalopathy. It often leads to multiple organ failure and subsequently death. However, the association between ALF and other organ failure remains unclear. Objectives: Here, we evaluated patients with acute liver injury (ALI) and elevated pancreatic enzymes to demonstrate the association between ALI and pancreatic disorder. Methods: We conducted a single-center retrospective study to analyze patients with ALI. Between 2012 and 2017, 163 patients with ALI were treated in our hospital. We stratified patients based on whether serum amylase and lipase were elevated above 1.5 times the upper limit of normal. We compared the baseline characteristics, severity, prognosis, and serum cytokine levels between the two groups. Results: Of the 163 patients, 75 (54.0%) presented elevated pancreatic enzymes above 1.5 times the upper limit of normal. Computed tomography imaging findings associated with pancreatitis were observed in 29 patients (17.8%). The elevation of pancreatic enzymes was associated with ALI severity. High level of serum tumor necrosis factor-alpha (TNF-α) was associated with the elevation of pancreatic enzymes (elevation group Vs. no elevation group: 134.0 ± 177.2 pg/mL Vs. 89.4 ± 159.8 pg/mL). Conclusions: The elevation of pancreatic enzymes was often accompanied by ALI and associated with ALI severity. TNF-α signaling was involved in the elevation of pancreatic enzymes. It is possible that the pancreatic disorder reflected ALI severity, consequently correlated with mortality, and did not directly aggravate ALI pathogenesis. These findings provide novel insights into the pathogenesis of ALF.

Pancreatitis Associated with Viral Hepatitis: Systematic Review

Background: We conducted a systematic review in order to summarize the available data on pancreatitis associated with viral hepatitis. Methods: A comprehensive literature search of Medline, Scopus and ISI Web of Science databases was conducted and papers eligible for the inclusion identified. Results: In total, 46 studies reporting data on 73 patients were included in the analysis. Most of the cases were diagnosed in Asia (57.53%), followed by North America (23.29%), and Europe (13.70%). Most of the patients were affected by hepatitis A virus (HAV) (42.47%), followed by hepatitis E virus (HEV) (28.77%), hepatitis B virus (HBV) (8.22%), and hepatitis C virus (HCV) (1.37%), while 17.81% at the time of diagnosis were classified as affected by “hepatitis virus”. Pancreatitis was severe in 32.88% of cases. The respiratory system was affected in 2.74% of patients, 6.85% experienced renal failure, while 5.48% experienced a multiorgan dysfunction syndrome (MODS). Four patients (5.48%) needed pancreatic surgery. Despite the treatment, 21.92% of patients died. We identified fulminant hepatitis (p < 0.0001), MODS (p < 0.0001) and severe pancreatitis (p < 0.0001) to be significantly more present in patients who died in comparison to cured ones. Conclusion: Increased awareness of pancreatic involvement in viral hepatitis is needed because it can have a substantial impact on therapeutic approaches and outcomes.

Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure

Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.

Acute Hepatitis B with Pancreatitis and Cholecystitis Leading to Acute Liver Failure and Death

Acute liver failure is defined as severe acute liver injury, concurrent with encephalopathy and loss of hepatic synthetic function, in a patient without known pre-existing liver disease. Evaluation of acute liver failure in the emergency department should focus on identification of treatable causes. Acute liver failure from acute hepatitis B infection is a rare but potentially lethal occurrence. Multi-organ dysfunction from acute liver failure may be exacerbated by metabolic and inflammatory reactions associated with acute pancreatitis, which accompanies approximately 5% of cases of acute viral hepatitis. Transplant-free survival rate with liver failure from acute hepatitis B is unfortunately less than 20%.

Frequency and prognosis of acute pancreatitis associated with fulminant or non-fulminant acute hepatitis A: A systematic review

BACKGROUND

Acute pancreatitis (AP) in patients with fulminant viral hepatitis is well recognized and its mortality depends on the severity of hepatitis rather than pancreatitis. Acute pancreatitis associated with non-fulminant acute hepatitis A (AHA) has been rarely described, and is considered to have a benign course with good response to conservative management.

OBJECTIVE

To perform a systematic review of the frequency and prognosis of AP associated with fulminant or non-fulminant AHA.

RATIONALE

An increasing number of reports describe AP associated with AHA. Some life-threatening complications related to AP may occur, and death has been reported. In addition, it is possible that early diagnosis of these cases may help in reducing the morbidity and mortality.

DATA SOURCES

Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, Google Scholar, and reference lists of relevant articles.

STUDY SELECTION

All available studies discussing AP associated with fulminant or non-fulminant AHA.

DATA EXTRACTION AND ASSESSMENT

Two blinded independent observers extracted and assessed the frequency of AP associated with AHA based on large studies including all cases of AHA observed during a prolonged period of time, diagnosis of AHA based on anti-HAV IgM, diagnosis of fulminant hepatitis (FH) based on the American Association for the study of Liver Diseases (AASLD) position paper, diagnosis of AP based on the American College of Gastroenterology (ACG) guidelines, diagnosis of AP associated with AHA based on Makharia's association, and diagnosis of AP severity based on the Revision of the Atlanta Classification (RAC). We have developed a tool for risk of bias assessment of case reports and case-series and applied it to the included studies.

RESULTS

The frequency of reported AP associated with AHA is 0-0.1%. Thirty-eight publications with a total of 54 patients meeting the inclusion criteria have been published. Twenty-two studies had a low risk for bias, 10 had moderate risk and 6 had high risk. Patients originated from all continents but most of them were from Asia. The median age at diagnosis was 16 years (range: 2-81) with a male to female ratio of 2. The median interval between the onset of jaundice and onset of AP pain was 4 days (range: 0-30). AP was severe in 9% of patients. The median hospital stay for AP was 8 days (range: 3-35). Most cases occur in patients without FH (94%). Mortality was reported in 2 patients (3.7%).

CONCLUSION

Acute pancreatitis associated with AHA is rare with an estimated frequency of 0-0.1%. Fifty-four documented cases, mostly in Asian patients, have been reported. The median age of patients is 16 years with a M/F ratio of 2. Acute pancreatitis occurs less than one week after the onset of jaundice and mostly in patients without FH. Acute pancreatitis in this setting is severe in 9% of patients with a mortality rate similar to all other causes of AP.

Liver transplantation for acute liver failure accompanied by severe acute pancreatitis

The role of liver transplantation (LT) in acute liver failure (ALF) complicated by severe acute pancreatitis is still unclear. We here report a case of deceased-donor LT for idiopathic ALF accompanied by severe acute pancreatitis. A 58-year-old man with no history of liver disease presented with idiopathic ALF and acute pancreatitis. After careful consideration, he received a liver from a deceased donor. Following surgery, the patient's liver function rapidly reverted to normal level and the acute pancreatitis simultaneously subsided. The patient later developed a pancreatic pseudocyst, which was treated successfully with combination interventional radiology. LT can be considered for ALF associated with severe acute pancreatitis if there is no clinical evidence of an absolute contraindication for organ transplantation, such as systemic or local infection. Moreover, we recommend a close follow-up by ultrasonography to allow early detection and treatment of pancreatic pseudocysts following surgery.

Hyperamylasemia as an Early Predictor of Mortality in Patients with Acute Paraquat Poisoning

Background

Paraquat (PQ) is a non-selective and fast-acting contact herbicide which has been widely used in developing countries. Hyperamylasemia was reported in patients with PQ poisoning. This study investigated the predictive value and clinical characteristics of hyperamylasemia in patients with PQ poisoning.

Material/Methods

This study included 87 patients with acute PQ poisoning admitted from July 2012 to May 2015. Data were collected from medical records. Receiver operating characteristic (ROC) analysis was conducted to analyze the discriminatory potential of serum amylase with respect to 90-day mortality.

Results

Of 87 patients, 29 patients had elevated serum amylase. We found that serum amylase was significantly higher among patients with AKI than those with non-AKI (p<0.001), and was an independent predictor of mortality (hazard ratio [HR]=3.644; 95% [CI], 1.684–7.881; p=0.001). The area under the ROC curve for the serum amylase (area under curve [AUC]=0.796; 95% [CI], 0.690–0.903) had a better discriminatory potential than plasma PQ concentration (0.698;0.570–0.825) or urinary PQ concentration (0.647;0.514–0.781) in predicting 90-day mortality.

Conclusions

Hyperamylasemia is a valuable early predictor of 90-day mortality in PQ poisoning.

Acute Hepatitis E-Associated Acute Pancreatitis: A Single Center Experience and Literature Review

OBJECTIVE

Because acute pancreatitis (AP) associated with acute hepatitis E is rarely reported, we present such a case series.

METHODS

Records of patients admitted with AP to our institution between May 2007 and December 2013 were reviewed. Diagnosis of AP and acute hepatitis E was based on high serum amylase and/or lipase (>3 times the upper normal limit) and abdominal imaging and presence of serum IgM antibodies against hepatitis E virus, respectively. Other causes of AP were excluded by appropriate evaluation.

RESULTS

Of 790 patients with AP, 16 (2.1%; median [range] age, 25 [16-54] years; 15 males) had hepatitis E and no other cause of AP; coexistent hepatitis A and B were present in two and one of them, respectively. Acute pancreatitis began (median [range], 8 [0-35] days) after acute hepatitis and was mild in 10 and severe in 6. Complications included intra-abdominal collections (5), acute renal failure (4), and acute lung injury (2). Median (range) bilirubin, alanine aminotransferase, and prothrombin time were 9.8 (0.4-25) mg/dL, 822 (54-4009) IU/L, 14.6 (9.7-27.4) seconds, respectively. Acute liver failure occurred in 1 patient only. No patient needed surgical, endoscopic, or percutaneous intervention.

CONCLUSIONS

Acute pancreatitis associated with hepatitis E is not uncommon and usually has good prognosis.

Extra-hepatic manifestations associated with hepatitis E virus infection: a comprehensive review of the literature

Background and aims: Hepatitis E virus (HEV) infection is a significant public health problem that afflicts almost 20 million individuals annually and causes acute liver injury in 3.5 million, with approximately 56 000 deaths. As with other viral hepatitides, extra-hepatic manifestations could represent an important aspect of this infection. The spectrum of these manifestations is still emerging. Acute pancreatitis and neurological, musculoskeletal, hematological, renal, and other immune-mediated manifestations have been described. The aim of this article is to comprehensively review the published literature of extra-hepatic manifestations associated with HEV infection.

Data sources: We searched the PubMed database using the MeSH term “hepatitis E” and each of the extra-hepatic manifestations associated with HEV infection. No language or date restrictions were set in these searches. Searches retrieving articles with non-A, non-B hepatitis were excluded. Additional articles were identified through the reference lists of included articles.

Results: Several extra-hepatic manifestations associated with HEV infection have been published. The temporal association between some extra-hepatic manifestations and HEV infection and the exclusion of other possible etiologies suggests that HEV infection could have caused some of them. According to the available data, HEV infection appears to be strongly associated with acute pancreatitis, neurological disorders (with primarily dominant peripheral nerve involvement, most commonly manifested as Guillain-Barré syndrome, followed by neuralgic amyotrophy), hematological diseases (hemolytic anemia due to glucose phosphate dehydrogenase deficiency, and severe thrombocytopenia), glomerulonephritis, and mixed cryoglobulinemia. More data are needed to clarify whether an association exists with musculoskeletal or other immune-mediated manifestations.

Conclusions: HEV infection should be considered in patients with acute pancreatitis, Guillain-Barré syndrome, neuralgic amyotrophy, hemolytic anemia due to glucose phosphate dehydrogenase deficiency, severe thrombocytopenia, glomerulonephritis, and mixed cryoglobulinemia. Alternatively, signs and symptoms of these conditions should be sought in patients with acute or chronic HEV infection. More data are needed to confirm the role of HEV in other extra-hepatic disorders.

Frequency and prognosis of acute pancreatitis associated with acute hepatitis E: A systematic review

BACKGROUND

The association of acute pancreatitis (AP) with viral hepatitis is well known, and is usually attributed to HAV, HBV, or HCV. AP related to acute hepatitis E (AHE) has been rarely described, and the typical profile is that of a young male, residing in an endemic area, presenting with mild to moderate pancreatitis, and improving with conservative management.

RATIONALE

An increasing number of reports describe AP associated with AHE. Some life-threatening complications related to AP may occur, and death has been reported. In addition, it is possible that early diagnosis of these cases may help in reducing the morbidity and mortality.

OBJECTIVE

Perform a systematic review to study cases of AP associated with AHE and to assess their prognosis.

DATA SOURCES

PubMed, EMBASE, Scopus, and the Cochrane library.

STUDY SELECTION

All available studies discussing AP associated with AHE.

DATA EXTRACTION AND ASSESSMENT

Two blinded independent observers extracted and assessed the studies for diagnosis of AHE based on serological and/or molecular techniques, diagnosis of fulminant hepatitis based on the American Association for the study of Liver Diseases (AASLD) position paper, diagnosis of AP based on the American College of Gastroenterology (ACG) guidelines, diagnosis of AP associated with AHE based on Makharia's association, and diagnosis of AP severity based on the Revision of the Atlanta Classification (RAC).

RESULTS

Thirteen case reports and 4 case series were found with 55 patients meeting the inclusion criteria. All patients originated from Southern Asia or had a recent travel to that area. The mean age at diagnosis was 28 years with a male to female ratio of 18:1. The mean interval between the onset of jaundice and the onset of AP pain was 10 days. AP was mild or moderately severe in 45 patients (82%), and severe in 10 patients (18%). Mortality was reported in 2 patients (3.6%).

CONCLUSION

Fifty-five cases of acute pancreatitis associated with AHE are reported in the literature. Acute pancreatitis in this setting is severe in approximately one fifth of patients with an overall mortality rate similar to all other causes of AP.

Acute hepatitis E complicated by acute pancreatitis and multiorgan dysfunction

We report this rare case of a 27-year-old man who presented with acute hepatitis E and went on to develop acute epigastric pain. He was diagnosed to have acute severe pancreatitis with shock and acute renal failure due to hepatitis E. Such a phenomenon has rarely been reported in the literature, with patients following a benign course and complete recovery after conservative management and analgesia. Awareness of this potentially life-threatening complication, especially in young men from endemic areas with acute hepatitis E presenting with abdomen pain has been highlighted.

Acute pancreatitis complicating acute hepatitis A virus infection

Acute pancreatitis complicating acute hepatitis A is very rare especially in children. We report here an 11 year old female patient with picture of acute hepatitis proved to be caused by hepatitis A. One week later patient's condition worsened, she was jaundiced, with persistent vomiting and looked acutely ill and uncomfortable with severe steady abdominal pain mainly in the epigastrium and upper quadrants. Acute pancreatitis was suspected and proved by a clinical picture associated with elevated serum amylase and serum lipase and by MRCP. The patient was managed conservatively with gradual clinical and laboratory improvement, and she was discharged after one week in a good clinical condition.

Acute pancreatitis: a rare complication of acute hepatitis E

Hepatitis E is an emerging imported disease in Europa but autochthonous cases are described for some years. Extra-hepatic associated manifestations are published. We report a case of acute necrotizing pancreatitis associated with imported acute viral E hepatitis (genotype 1a) in a 26 years old French man travelling and originated from Pakistan. The outcome is favourable spontaneously in two months. This life-threatening hepatitis E related complication is unknown in Europa where genotype 3 virus strains prevail. The clinical presentation is stereotyped with the onset of pancreatitis in the second or third weeks of hepatitis evolution in an Indian male in his second or third decade infected with genotype 1 strain. No pancreatitis-related death is reported in the 13 previous reported cases.

Therapeutic hypothermia for acute liver failure

Cerebral edema is a potentially life-threatening complication of acute liver failure, the syndrome of abrupt loss of liver function in a patient with a previously healthy liver. Although the prevalence of cerebral edema appears to be decreasing, patients with rapidly progressive (hyperacute) liver failure, such as after acetaminophen overdose, remain at highest risk. In severe cases of cerebral edema, intracranial hypertension develops and leads to brain death after brainstem herniation or to anoxic brain injury and permanent neurologic impairment. Intracranial hypertension in patients with acute liver failure often can be temporarily controlled by manipulating body position, increasing the degree of sedation, and increasing blood osmolarity through pharmacologic means. However, these maneuvers often postpone, but do not eliminate, the risk of brainstem herniation unless orthotopic liver transplantation or spontaneous liver regeneration follows in short order. To buy time, the induction of therapeutic hypothermia (core temperature 32 degrees C-35 degrees C) has been shown to effectively bridge patients to transplant. Similar to the experience in patients with cerebral edema after other neurologic insults, hypothermia reduces cerebral edema and intracranial hypertension in patients with acute liver failure by decreasing splanchnic ammonia production, restoring normal regulation of cerebral hemodynamics, and lowering oxidative metabolism within the brain. Hypothermia may also ameliorate the degree of liver injury. Hypothermia has not been adequately studied for its safety and theoretically may increase the risk of infection, cardiac dysrhythmias, and bleeding, all complications independently associated with acute liver failure. Therefore, although an ample body of experimental and human data provides a rationale for the use of therapeutic hypothermia in patients with acute liver failure, multicenter, randomized, controlled clinical trials are needed to confirm that hypothermia secures brain viability and improves survival without causing harm.

Acute pancreatitis complicating spontaneous acute exacerbation of chronic hepatitis B virus infection: case report and review of the literature

Acute pancreatitis may complicate viral hepatitis B, as well as the other causes of viral hepatitis. There have been reports of acute pancreatitis complicating acute exacerbations of chronic hepatitis B virus infection, most of which were related to immunosuppressive treatment or organ transplantation. However, acute pancreatitis complicating spontaneous acute exacerbation of chronic hepatitis B virus infection is rare. We report a case of acute pancreatitis that developed while a spontaneous acute exacerbation of chronic hepatitis B virus infection was underway in a healthy carrier.

The role of etiology in the hyperamylasemia of acute liver failure

OBJECTIVES

Hyperamylasemia (HA) is often reported in patients with acute liver failure (ALF). Direct toxic effects of acetaminophen on the pancreas have been postulated, but the occurrence of HA in other etiologies raises the question of whether multiorgan failure is part of the pathogenesis of HA in this setting. Our main aim was to describe and analyze the incidence, clinical characteristics, and outcomes of HA in ALF of different etiologies.

METHODS

Patients enrolled in the Acute Liver Failure Study Group registry with an admission amylase value available were included. For the purpose of this analysis, HA was defined as > or =3x upper limits of normal. Patients were classified as having acetaminophen (APAP)- or non-APAP-induced ALF, and by amylase group: normal (<115), mildly elevated (115-345), or HA (>345). Significant variables identified by univariate analysis were added to a multiple linear regression model. The primary outcome was overall survival.

RESULTS

In total, 622 eligible patients were identified in the database, including 287 (46%) with APAP-induced ALF; 76 (12%) patients met the criteria for HA. Among patients with HA, 7 (9%) had documented clinical pancreatitis. The incidence of HA was similar among APAP (13%) and non-APAP (12%) patients. Although HA was associated with renal failure and greater Model for End-stage Liver Disease scores for both groups, HA was not an independent predictor of mortality in multivariate analysis.

CONCLUSIONS

Although not an independent predictor of mortality, HA in ALF was present in all etiologies and was associated with diminished overall survival. HA appeared to be related to renal dysfunction in both groups and multiorgan failure in non-APAP ALF.

Hepatitis viruses causing pancreatitis and hepatitis: a case series and review of literature

OBJECTIVES

Association between acute pancreatitis and acute viral hepatitis (AVH) is more frequent than previously thought. Most cases are hepatitis A or B virus related. Only 6 cases of acute pancreatitis with acute hepatitis E virus (HEV)-related hepatitis has been reported so far.

METHODS

We analyzed the hospital records of 334 patients of acute pancreatitis admitted from December 2004 to March 2006. Seven patients had an associated AVH.

RESULTS

Of these, 4 had HEV-related and 3 had hepatitis A virus-related AVH. All but one were young males who presented with abdominal pain during the second to third week of hepatitis illness. None had a history of biliary colic, alcoholism, abdominal trauma, or intake of drugs causing pancreatitis or a family history of pancreatitis. Mean bilirubin was 10.74 mg/dL; alanine aminotransferase levels, 482.85 IU/L; and serum amylase, 1263.57 IU/L. All patients had an imaging evidence of pancreatitis. Two patients with HEV-related disease had grades D to E pancreatitis. All were managed conservatively and recovered completely.

CONCLUSIONS

Association between acute pancreatitis and nonfulminant viral hepatitis is now more frequently recognized. Seen more commonly in young males during the second and third week of hepatitis illness, HEV might be associated with severe pancreatitis.

Acute pancreatitis in acute viral hepatitis

AIM: To elucidate the frequency and characteristics of pancreatic involvement in the course of acute (nonfulminant) viral hepatitis.

METHODS: We prospectively assessed the pancreatic involvement in patients with acute viral hepatitis who presented with severe abdominal pain.

RESULTS: We studied 124 patients with acute viral hepatitis, of whom 24 presented with severe abdominal pain. Seven patients (5.65%) were diagnosed to have acute pancreatitis. All were young males. Five patients had pancreatitis in the first week and two in the fourth week after the onset of jaundice. The pancreatitis was mild and all had uneventful recovery from both pancreatitis and hepatitis on conservative treatment. The etiology of pancreatitis was hepatitis E virus in 4, hepatitis A virus in 2, and hepatitis B virus in 1 patient. One patient had biliary sludge along with HEV infection. The abdominal pain of remaining seventeen patients was attributed to stretching of Glisson’s capsule.

CONCLUSION: Acute pancreatitis occurs in 5.65% of patients with acute viral hepatitis, it is mild and recovers with conservative management.

Fecal elastase 1, serum amylase and lipase levels in children with cholestasis

BACKGROUND/AIM

The pancreatic functions of children with cholestatic liver diseases were unclear. Due to anatomic vicinity and common ontogenic origin, hepatobiliary disorders of infancy may also affect pancreatic function. The aim of the study was to evaluate the exocrine pancreatic function and common pancreatic function tests in children with cholestatic disorders.

METHODS

In 40 children with cholestasis, fecal elastase 1 (FE1) concentrations were measured. Serum amylase and lipase values were tested. The diagnoses included 32 patients with extrahepatic cholestasis (biliary atresia (BA) and choledochal cyst), and 8 patients with intrahepatic cholestasis (progressive familial intrahepatic cholestasis and Alagille syndrome). None had renal insufficiency or clinical symptoms/signs of acute pancreatitis.

RESULTS

All the patients had normal FE1 (>200 microg/g). Nineteen percent (7/37) had elevated serum amylase levels (>100 U/l). Thirty-two percent (12/37) had elevated serum lipase levels above the normal (>120 U/l). Seventy-three percent (8/11) of BA patients with bilirubin >2 mg/dl had elevated serum lipase levels compared to 18% (3/17) with bilirubin < or = 2 mg/dl (p = 0.0036). None had detectable pancreatic abnormality on ultrasonography and magnetic resonance images.

CONCLUSIONS

None of the cholestatic children in this study had exocrine pancreatic insufficiency as detected by FE1. Hyperamylasemia and/or hyperlipasemia were frequently found. In children with BA, those with impaired biliary excretion tended to have elevated serum pancreatic enzymes as compared with those who had no jaundice. A decreased hepatic metabolism may be the cause.

Hyperamylasaemia and acute pancreatitis in paracetamol poisoning

BACKGROUND

Hyperamylasaemia and even acute pancreatitis have been reported in patients with paracetamol poisoning.

AIMS

To describe the incidence, clinical characteristics, and prognostic implications of hyperamylasaemia in paracetamol poisoning.

PATIENTS

Six hundred and two patients transferred to a specialized unit with severe paracetamol poisoning and 212 unselected patients admitted from the local region.

METHODS

Retrospective study based on hospital charts. The optimum threshold of serum amylase to discriminate non-survivors was identified.

RESULTS

An elevated serum amylase (>100 U/L) occurred in 28 of the unselected patients (13%), in 218 of the transferred patients (36%), and in 118 of 148 patients (80%) with fulminant hepatic failure. Only 33 cases of paracetamol-associated acute pancreatitis were diagnosed. A threshold serum amylase of 150 U/L to discriminate non-survivors had sensitivity 76%, specificity 85%, positive predictive value 33%, and negative predictive value 97%. In a logistic regression analysis, a serum amylase > 150 U/L was associated with an excess mortality (odds ratio 5.0, 2.6-9.7).

CONCLUSIONS

Hyperamylasaemia is frequent in patients with paracetamol poisoning, whereas clinical acute pancreatitis occurs rarely. The incidence of hyperamylasaemia increases with the degree of hepatic dysfunction. A serum amylase exceeding 1.5 times the upper normal limit indicates a poor prognosis.

Stimulatory effects of bilirubin on amylase release from isolated rat pancreatic acini

Considered to be an etiologic factor of acute pancreatitis, hypersecretion of pancreatic juice and digestive enzymes is often associated with hyperbilirubinemia. We explored the intracellular mechanisms through which bilirubin affects pancreatic exocrine secretory function by examining the effect of bilirubin on isolated rat pancreatic acini. Bilirubin stimulated amylase release in a concentration- and time-dependent manner, significantly increasing amylase release at concentrations >5 mg/100 ml and after 15 min of incubation. Coincubation of bilirubin with vasoactive intestinal polypeptide, 8-bromo-cAMP, or A-23187 had a synergistic effect on amylase release, whereas coincubation with CCK-8, carbamylcholine, or 12-O-tetradecanoylphorbol 13-acetate had an additive effect. Bilirubin did not affect acinar cAMP content or Ca(2+) efflux. Intracellular Ca(2+) pool depletion had no influence on bilirubin-evoked amylase release. The protein kinase C (PKC) inhibitors staurosporine and calphostin C partially but significantly inhibited bilirubin-stimulated amylase release, whereas the PKA inhibitor H-89 did not. The tyrosine kinase (TK) inhibitor genistein, phospholipase A(2) (PLA(2)) inhibitor indoxam, and PLC inhibitor U-73122 also inhibited amylase release. Bilirubin significantly translocated PKC activity from the cytosol to the membrane fraction and activated TK in cytosol and membrane fractions. These results indicate that bilirubin stimulates amylase release by activating PKC and TK in rat pancreatic acini and that PLC and PLA(2) partly mediate this process.

Acute pancreatitis complicating acute exacerbation of chronic hepatitis B infection carries a poor prognosis

The clinical outcome of acute pancreatitis complicating acute exacerbation of chronic hepatitis virus B (HBV) infection has never been studied. Ninety patients with acute pancreatitis were recruited. Five patients (5.6%) (Group 1) had acute pancreatitis superimposed on acute exacerbation of chronic HBV infection with no other causes of acute pancreatitis being identified. The clinical outcome of these five patients was compared to the 85 non-HBV infected patients (Group 2) with acute pancreatitis. A third group (Group 3) of patients (n=406) with acute exacerbation of chronic HBV infections without acute pancreatitis was also recruited for comparison. Group 1 had a significantly higher mortality rate (4 out of 5, 80%) compared to those of Group 2 (13 out of 85, 15.3%, P=0.0041) and Group 3 (9 out of 406, 2.2%, P < 0.0001). In Group 1 patients, the acute pancreatitis occurred during the initial rise of HBV DNA with relatively low or normal level of alanine aminotransferase (ALT) in two patients, during the rise of ALT with declining level of HBV DNA in one patient, and during the cholestatic phase of the acute exacerbation in one patient. The acute pancreatitis was clinically silent and only diagnosed by computerized tomography in the remaining patient. Direct viral damage and/or immunological attack to the pancreatic tissue were probably the underlying pathogenesis of the acute pancreatitis in these patients. In conclusion, acute pancreatitis complicating acute exacerbation of chronic HBV infection carried an extremely poor prognosis with high mortality.

Acute pancreatitis associated with viral hepatitis: a report of six cases with review of literature

Association of hepatitis viruses with acute pancreatitis in the setting of nonfulminant viral hepatitis is rare. We report six cases of nonfulminant viral hepatitis complicated by acute pancreatitis, including the first documented case of hepatitis E virus (HEV) associated acute pancreatitis. The other five patients had acute viral hepatitis caused by hepatitis A infection. Besides features of viral hepatitis, the presence of typical abdominal pain, high serum amylase, and ultrasound or CT scan features suggested the diagnosis of acute pancreatitis. This complication generally developed in the initial phase of the hepatitic illness. All of the patients had mild to moderate pancreatitis that recovered uneventfully with conservative treatment.

Serum pancreatic enzyme concentrations in chronic viral liver diseases

Serum amylase and lipase concentrations were determined in 78 patients with chronic liver diseases [26 chronic active hepatitis (CAH) and 52 liver cirrhosis] and in 15 healthy subjects. Pancreatic isoamylase concentrations and macroamylase complexes were assayed in hyperamylasemic sera. Serum amylase levels were abnormally elevated in 27 patients (35%; 22 liver cirrhosis, 5 CAH), whereas serum lipase levels were elevated in 16 patients (21%; 15 liver cirrhosis, 1 CAH). In 9 of the 27 hyperamylasemic patients, the hyperamylasemia was of pancreatic type. Macroamylasemic complexes were not detected in hyperamylasemic sera. Patients with liver cirrhosis had serum levels of amylase and lipase significantly higher than both the healthy subjects and the patients with CAH, while no significant differences were found in serum levels of these enzymes in patients with CAH as compared to the healthy subjects. A decreased liver metabolism of serum amylase and lipase in patients with chronic infective liver disease, especially in those having liver cirrhosis, may lead to an accumulation of these enzymes in the blood.

Acute pancreatitis and fulminant hepatic failure

BACKGROUND

The association of acute pancreatitis with fulminant hepatic failure (FHF) was first recognized in 1973. Since then, few studies have described the clinical profile of the FHF patient with acute pancreatitis. Identification of the distinguishing attributes of pancreatitis in combination with FHF will provide a more sound basis for clinical management. The purposes of this study were to identify distinguishing clinical characteristics of acute pancreatitis in FHF and to compare outcomes with those of patients with acutely decompensated chronic liver disease and acute pancreatitis (DECOMP).

STUDY DESIGN

This was a retrospective survey of 30 patients with FHF and 30 with DECOMP admitted during the period July 1995 to July 1997.

RESULTS

The prevalence of acute pancreatitis in FHF and DECOMP was 33% and 23%, respectively. Acute pancreatitis was associated with severe hepatocellular synthetic dysfunction, renal insufficiency, requirement for endotracheal intubation, increased acuity of illness at the time of ICU admission, more rapid decompensation during the disease, and significantly greater mortality in both the FHF and DECOMP groups.

CONCLUSIONS

In both FHF and DECOMP, acute pancreatitis increases disease acuity and mortality. Acute pancreatitis does not occur with significantly greater frequency in FHF. Implementation of orthotopic liver transplantation may not be warranted in this setting.

Fatal necrotizing pancreatitis caused by hepatitis B virus infection in a liver transplant recipient

A 32-year-old man who had undergone liver transplantation for fulminant hepatitis due to HBV infection developed fatal acute necrotizing pancreatitis on the 60th post-transplant day, while showing signs of intense viral replication. Immunohistochemistry and in situ hybridization of the pancreas following autopsy showed the presence of HBsAG and HBV-DNA in the cytoplasm of acinar cells, together with the picture of necrotizing pancreatitis. Clinical and histological features seem to indicate that pancreatitis was directly caused by HBV infection.

Isoamylase determination by isoelectric focusing in pancreatic disorders. A potential clinical aid

Isoamylase analysis by isoelectric focusing was performed in the serum of 30 healthy volunteers, 65 patients with acute or chronic pancreatic diseases, nine with acute abdomen, four with macroamylasemia, and four with duodenal duplication. In controls, up to four fractions (2 salivary, 2 pancreatic) were found; the pancreatic fractions were as a mean 44.7% (SD 8.6) of total. In chronic pancreatitis, only patients with steatorrhea showed a significant reduction of pancreatic isoamylase (p less than 0.001). In all patients with acute pancreatitis or pseudocysts, an additional fraction (similar to the so-called P3 fraction) was resolved. Moreover, additional isoenzymes were found in all patients with severe acute pancreatitis or pseudocysts, and not in controls or patients with mild forms, acute abdomen or duodenal duplication. A similar pattern was shown in a stored control serum after 10 mo at -20 degrees C. These fractions disappeared after successful surgical drainage. No specific alteration was found in pancreatic cancer. Amylase fractionation by isoelectric focusing can be used to confirm an acute pancreatitis, and to monitor patients with pancreatic pseudocysts and collections after surgical drainage.