A randomised, double blind, multicentre trial of octreotide in moderate to severe acute pancreatitis

Effect of Aggressive Intravenous Fluid Resuscitation Versus Nonaggressive Fluid Resuscitation in the Treatment of Acute Pancreatitis: A Systematic Review and Meta-Analysis

OBJECTIVES

Despite the need for active fluid therapy, fluid management of most acute pancreatitis (AP) cases is still supportive. The aim of this review is to compare the effect of aggressive versus nonaggressive intravenous (IV) fluid resuscitation in the treatment of acute pancreatitis.

METHODS

A systematic search of medical databases, such as Medline, Google Scholar, Science Direct, Cochrane Central, was conducted for publication until April 2022. We included randomized controlled trials or cohort (prospective and retrospective) studies reporting the outcomes of AP in patients that were managed with aggressive and nonaggressive IV fluid resuscitation. The primary outcome of interest was in-hospital mortality.

RESULTS

Fourteen trials involving 3423 acute pancreatitis patients were included in the review. We did not observe any differences in the risk of mortality, persistent organ failure, and systemic inflammatory response syndrome in both study groups. However, there was an increased risk of development of pancreatic necrosis, renal failure, and respiratory failure in the aggressive fluid therapy group compared with nonaggressive therapy. The funnel plot showed no publication bias.

CONCLUSIONS

Aggressive fluid therapy did not improve mortality rates in acute AP patients and was associated with an increased risk of acute renal failure, and respiratory failure.

New insights into the etiology, risk factors, and pathogenesis of pancreatitis in dogs: Potential impacts on clinical practice

While most cases of pancreatitis in dogs are thought to be idiopathic, potential risk factors are identified. In this article we provide a state‐of‐the‐art overview of suspected risk factors for pancreatitis in dogs, allowing for improved awareness and detection of potential dog‐specific risk factors, which might guide the development of disease prevention strategies. Additionally, we review important advances in our understanding of the pathophysiology of pancreatitis and potential areas for therapeutic manipulation based thereof. The outcome of pathophysiologic mechanisms and the development of clinical disease is dependent on the balance between stressors and protective mechanisms, which can be evaluated using the critical threshold theory.

Prior Exposure to Nonsteroidal Anti-inflammatory Drugs Reduces the Rate of Organ Failure and In-Hospital Mortality in Acute Pancreatitis

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been linked recently to a lower expression of pro-inflammatory cytokines in humans with acute pancreatitis. Because it is unclear if this effect results in clinical benefits, the aim of this study was to determine if prior NSAID exposure improves immediate clinical outcomes.

METHODS

Retrospective medical record review of adult patients admitted with acute pancreatitis. Cases were extracted from a national Veterans Affairs database using International Classification of Diseases, Ninth Revision codes. Prior NSAIDs use was determined through pharmacy data claims. The rates of acute kidney injury, respiratory failure, cardiovascular failure, and in-hospital mortality were compared between those with prior NSAID use (AP+NSAID) and those without it (AP-NSAID) using univariate and multivariate analysis.

RESULTS

A total of 31,340 patients were identified: 28,364 AP+NSAID and 2976 AP-NSAID. The median age was 60 years, 68% were white, and the median hospital stay was 4 days. Approximately 2% of patients died during the hospitalization. After adjusting for demographics and other covariates, patients in the AP+NSAID arm had lower rates of acute kidney injury, P = .0002), cardiovascular failure (P = .025), any organ failure (P ≤ .0001), and in-hospital mortality (P < .0001).

CONCLUSION

Prior use of NSAIDs is associated with a lower incidence of organ failure and in-hospital mortality in adult patients with acute pancreatitis. The role of NSAIDs as therapeutic agents in this condition should be evaluated in interventional trials.

Clinical profile, etiology, and outcome of acute pancreatitis: Experience at a tertiary care center

Background:

Acute pancreatitis (AP) is an inflammatory process of the pancreas with varying degree of involvement of regional tissues. This was a population-based study on the incidence of AP. We aimed to determine the incidence, etiology, and outcome of AP.

Materials and Methodology:

This prospective study was conducted in the Department of Medicine, King George's Medical University, Lucknow, India, on 120 patients of AP. Clinical history, examination, and laboratory investigations were done. Severity of AP was assessed using the modified Atlanta classification.

Results:

A total of 120 patients comprising of 88 men (73.33%) and 32 women (26.66%) were recruited. The mean age of study participant was 36.96 ± 13.44 years. The most common presentation was abdominal pain followed by vomiting. The leading etiological factors were alcohol in 85 patients (70.8%) and gallstones in 25 (20.8%). It was idiopathic 5 patients (4.1%). Mortality was seen in three (2.5%) patients, all of which had severe pancreatitis. Patients with body mass index (BMI) ≥25 kg/m², Hematocrit (HCT) ≥44% and C-reactive protein (CRP) ≥150 mg/l had an increased risk of developing a severe AP.

Conclusions:

Alcohol and gallstones were the most common etiological factors of AP, whereas HCT, CRP, and BMI were the useful predictors of severe pancreatitis.

Drugs in Focus: Octreotide Use in Children With Gastrointestinal Disorders

ABSTRACT

Octreotide, a somatostatin analogue, has been used for more than 20 years in children with gastrointestinal bleeding, chylothorax or chylous ascites, intestinal lymphangiectasia, pancreatitis, intestinal dysmotility, and severe diarrhoea; however, until now, there is a lack of randomised clinical trials evaluating the efficacy of this compound in childhood. Hence, we aimed to review the literature in order to determine the evidence of its use and safety in children, using PubMed from 2000 to 2021 with the search terms "octreotide" and "children" and "bleeding or chylous ascites or chylothorax or acute pancreatitis or lymphangiectasia or diarrhoea or intestinal dysmotility".

The Role of Endoscopic Transpapillary Stenting of the Main Pancreatic Duct during the Endoscopic Treatment of Pancreatic Fluid Collections

Endotherapy is a recognized, widely available, and minimally invasive treatment method for pancreatic fluid collections (PFCs) formed in the course of acute pancreatitis (AP). The use of endoscopic techniques in the treatment of main pancreatic duct (MPD) disruption due to AP remains unclear. In this article, a comprehensive review of current literature referencing our observations was performed to identify publications on the role of MPD stenting in patients undergoing endoscopic drainage of PFCs resulting from AP. In this paper, we attempt to clarify this most controversial aspect of endotherapy for PFCs based on existing knowledge and our own experience regarding the endoscopic treatment of AP sequelae. Endoscopic retrograde pancreatography should be performed in all patients undergoing endoscopic drainage of walled-off pancreatic necrosis to assess the integrity of the main pancreatic duct and to implement endotherapy if pancreatic duct disruption is detected. Passive transpapillary drainage is an effective method for treating MPD disruption in the course of necrotizing AP and is one of the key components of endoscopic therapy for local pancreatic necrosis. Conversely, in patients with pancreatic pseudocysts, passive transpapillary drainage reduces the effectiveness of endoscopic treatment and should not be used even in cases of MPD disruption during transmural drainage of pancreatic pseudocysts. In conclusion, the use of transpapillary drainage should depend on the type of the PFC. This conclusion is of great clinical importance, as it can help improve the results of pancreatic endotherapy for fluid collections resulting from AP.

Carbachol protects the intestinal barrier in severe acute pancreatitis by regulating Cdc42/F-actin cytoskeleton

The present study aimed to investigate the effect of carbachol on the intestinal tight-junction barrier in a rat model of severe acute pancreatitis (SAP) without aggravating pancreatic injury, and to determine whether cell division cycle 42 (Cdc42)/F-actin could have a regulatory role. Rats were separated into a sham-operation (SO) group (n=10), SO + carbachol group (n=10), SAP group (n=60) and SAP + carbachol group (n=60). Sodium taurocholate (5%) was retrogradely injected into the biliopancreatic duct of rats to induce SAP. Subsequently, 16S rRNA sequencing was used to detect bacterial translocation (BT) in the gut of surviving animals. Hematoxylin and eosin staining was used to detect morphological changes in the pancreas and intestine. The expression of F-actin and tight junction proteins was analyzed by western blotting and immunofluorescence, and Cdc42 expression was analyzed by immunohistochemistry and western blotting. The results demonstrated that the intestinal injury in SO and SO + carbachol groups was lower than that in the SAP + carbachol group (P<0.05); however, the intestinal injury was similar in the SO and SO + carbachol groups (P>0.05), and was significantly more severe in the SAP group compared with the SAP + carbachol group (P<0.05). Similarly, pancreatic injury in the SAP and SAP + carbachol groups was significantly higher compared with the SO and SO + carbachol groups (P<0.05); however, pancreatic injury was similar in the SAP and SAP + carbachol groups (P>0.05), and in the SO and SO + carbachol groups (P>0.05). Furthermore, the mortality rate and BT in the SAP group were significantly higher compared with the SAP + carbachol group (mortality rate, 50% vs. 30%, P<0.05; BT, 60% vs. 33.3%, P<0.05). In addition, the expression of Cdc42, F-actin and claudin-2 was significantly higher in the SAP and SAP + carbachol groups compared with the SO and SO + carbachol groups (P<0.05), and the expression of occludin and zonula occludens-1 were significantly higher in the SO and SO + carbachol groups compared with the SAP and SAP + carbachol groups (P<0.05). In conclusion, these findings demonstrated that carbachol may protect the intestinal barrier in the SAP rat model without aggravating pancreatic injury via regulation of Cdc42/F-actin expression.

Nutrition management in acute pancreatitis: Clinical practice consideration

Acute pancreatitis (AP) is a common gastrointestinal disease and the leading cause of hospital admission and healthcare burden among gastrointestinal disorders in many countries. Patients can present with varying degrees of inflammation and disease severity, ranging from self-limiting mild AP to devastating and fatal severe AP. Many factors contribute to malnutrition in AP, especially abnormal metabolism and catabolism related to inflammation. The concept of “pancreatic rest” is not evidence-based. There is however, emerging evidence that supports the use of oral or enteral nutrition to improve nutrition status and to reduce local and systemic inflammation, complications, and death. In mild disease, patients are generally able to initiate solid oral diet and do not require specialized nutrition care such as enteral or parenteral nutrition. In contrast, nutrition interventions are imperative in moderately severe and severe AP. The current article aims to review the latest evidence and suggest practical nutrition interventions in patients with AP, including nutrition requirements, routes of nutrition treatment, types of formula, and the role of nutritional supplements, such as glutamine, probiotics, omega-3 fatty acids, and antioxidants.

Pharmacologic management and prevention of acute pancreatitis

PURPOSE OF REVIEW

The present article will focus in pharmacologic agents that have been studied to improve acute pancreatitis outcomes, and to prevent the disease at different levels.

RECENT FINDINGS

Too little and too much early fluid resuscitation can be harmful. The optimal volume, rate, and duration of intravenous fluid therapy is still unknown. Nonopioid analgesics should be the first line of analgesia in patients with acute pancreatitis. A few pharmacologic agents evaluated in acute pancreatitis have resulted in positive pilot trials; however, larger randomized clinical trials (RCTs) are needed before final conclusions. Statin use is associated with lower incidence of acute pancreatitis in the general population and ongoing studies are evaluating its preventive role in acute pancreatitis recurrences. The preventive role of rectal indomethacin in post-endoscopic retrograde cholangiopancreatography pancreatitis is indisputable, with subject selection and timing of administration requiring further investigation.

SUMMARY

There is still no proven effective disease-specific pharmacologic therapy that changes the natural history of acute pancreatitis. New therapeutic targets and pharmacologic agents are in the horizon. Careful refinement in study design is needed when planning future RCTs. There is also a need for drug development aiming at reducing the incidence of the disease and preventing its sequelae.

Management of Severe Acute Pancreatitis

Acute pancreatitis is one of the most common causes of hospitalisation from gastrointestinal diseases. The causes of pancreatitis vary between countries. Acute pancreatitis is classified based on Revised Atlanta classification 2013 as mild, moderately severe and severe acute pancreatitis. Acute pancreatic severity can be stratified by scoring systems such as Ranson's score, BISAP score, APACHE-II score, SOFA score. In severe acute pancreatitis, to diagnose, abdominal pain raised amylase or lipase, supported imaging finding and organ failure. Organ failure can be diagnosed by using Modified Marshall Scoring System. Management is started conservatively, which are fluid resuscitation, enteral nutrition, analgesics, and antibiotics. Surgical management is indicated when infected pancreas necrosis is detected. In this review, we will discuss the current management based on recent research.

Successful Management of a Child With Drug-induced Necrotizing Pancreatitis During Acute Lymphoblastic Leukemia Therapy: A Case Report

Acute pancreatitis in children acute lymphoblastic leukemia is commonly caused by drugs, for example, L-Asparaginase, pegapargase, steroids. The incidence of this complication is estimated at 6.7% to 18%. Although the majority of drug-induced acute pancreatitis cases are mild, severe cases can rarely occur. This work presents a case of successful management of a child with drug-induced necrotizing pancreatitis during acute lymphoblastic leukemia therapy. This case illustrates that comprehensive care and immediate intensive treatment can rescue patient despite poor prognosis. Administration of octreotide may serve a role in limiting the severity of the disease.

The effect of thymosin α1 for prevention of infection in patients with severe acute pancreatitis

INTRODUCTION

Severe acute pancreatitis (SAP) is an acute inflammatory disease with prolonged clinical course, which is complicated by the presence of persistent organ failure and severe infection. Infection mainly occurs in the late phase of SAP and it is found to be the main cause of death. Therefore, developing strategies for the prevention of SAP-related infection has been a crucial approach to improve patients' outcomes. Due to remarkable immune-cells-regulating properties, thymosin α1 has been recognized as a promising immune therapy, especially in several infectious diseases. Recently, thymosin α1 has been given high expectations to exert clinical benefits in the prevention of SAP-related infection.

AREAS COVERED

The review of currently available strategies for SAP-related infection prevention and the use of thymosin α1 in SAP patients.

EXPERT OPINION

The current available strategies achieve limited success for preventing SAP-related infection. A possible explanation is that the trigger of infection, immunosuppression has not been concurrently resolved. The application of thymosin α1 in a clinical study showed a prophylactic effect against SAP-related infection. However, the use of thymosin α1 in SAP patients is still at an early stage of clinical investigation and requires high-quality and large sample size evidences.

The effect of non-steroidal anti-inflammatory drugs on severity of acute pancreatitis and pancreatic necrosis

Introduction Acute pancreatitis (AP) is a common emergency presentation and can be disabling. There is significant morbidity and mortality associated with AP, and it places a considerable burden on the healthcare system. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to have a protective effect in some elective contexts. This retrospective study aimed to evaluate the effect of NSAIDs on the course of AP and the severity of the disease. Methods A retrospective analysis was carried out of 324 patients admitted as an emergency with a diagnosis of AP to two UK hospitals. Patients were divided into two groups: those already taking NSAIDs for other co-morbidities and those not taking NSAIDs. Variables compared included: admission to a high dependency or intensive care unit; pancreatic necrosis; pseudocyst development; need for surgery; serum inflammatory markers; modified early warning scores on days 1, 3 and 5; length of stay; and mortality. Results Patients not taking NSAIDs were more likely to have a C-reactive protein level of ≥150mg/l (p=0.007). Patients in the NSAID group experienced less pancreatic necrosis (p=0.019) and lower rates of pseudocyst formation (p=0.010). Other variables showed no difference between the two groups, specifically length of stay and mortality. Conclusions Routine NSAID use may exert a protective effect on the development of AP, its severity, and complications. Therapeutic use of NSAIDs in acute presentations with pancreatitis should be further evaluated.

Pharmacological interventions for acute pancreatitis

BACKGROUND

In people with acute pancreatitis, it is unclear what the role should be for medical treatment as an addition to supportive care such as fluid and electrolyte balance and organ support in people with organ failure.

OBJECTIVES

To assess the effects of different pharmacological interventions in people with acute pancreatitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2016, Issue 9), MEDLINE, Embase, Science Citation Index Expanded, and trial registers to October 2016 to identify randomised controlled trials (RCTs). We also searched the references of included trials to identify further trials.

SELECTION CRITERIA

We considered only RCTs performed in people with acute pancreatitis, irrespective of aetiology, severity, presence of infection, language, blinding, or publication status for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We did not perform a network meta-analysis as planned because of the lack of information on potential effect modifiers and differences of type of participants included in the different comparisons, when information was available. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) for the binary outcomes and rate ratios with 95% CIs for count outcomes using a fixed-effect model and random-effects model.

MAIN RESULTS

We included 84 RCTs with 8234 participants in this review. Six trials (N = 658) did not report any of the outcomes of interest for this review. The remaining 78 trials excluded 210 participants after randomisation. Thus, a total of 7366 participants in 78 trials contributed to one or more outcomes for this review. The treatments assessed in these 78 trials included antibiotics, antioxidants, aprotinin, atropine, calcitonin, cimetidine, EDTA (ethylenediaminetetraacetic acid), gabexate, glucagon, iniprol, lexipafant, NSAIDs (non-steroidal anti-inflammatory drugs), octreotide, oxyphenonium, probiotics, activated protein C, somatostatin, somatostatin plus omeprazole, somatostatin plus ulinastatin, thymosin, ulinastatin, and inactive control. Apart from the comparison of antibiotics versus control, which included a large proportion of participants with necrotising pancreatitis, the remaining comparisons had only a small proportion of patients with this condition. Most trials included either only participants with severe acute pancreatitis or included a mixture of participants with mild acute pancreatitis and severe acute pancreatitis (75 trials). Overall, the risk of bias in trials was unclear or high for all but one of the trials.

SOURCE OF FUNDING

seven trials were not funded or funded by agencies without vested interest in results. Pharmaceutical companies partially or fully funded 21 trials. The source of funding was not available from the remaining trials.Since we considered short-term mortality as the most important outcome, we presented only these results in detail in the abstract. Sixty-seven studies including 6638 participants reported short-term mortality. There was no evidence of any differences in short-term mortality in any of the comparisons (very low-quality evidence). With regards to other primary outcomes, serious adverse events (number) were lower than control in participants taking lexipafant (rate ratio 0.67, 95% CI 0.46 to 0.96; N = 290; 1 study; very low-quality evidence), octreotide (rate ratio 0.74, 95% CI 0.60 to 0.89; N = 770; 5 studies; very low-quality evidence), somatostatin plus omeprazole (rate ratio 0.36, 95% CI 0.19 to 0.70; N = 140; 1 study; low-quality evidence), and somatostatin plus ulinastatin (rate ratio 0.30, 95% CI 0.15 to 0.60; N = 122; 1 study; low-quality evidence). The proportion of people with organ failure was lower in octreotide than control (OR 0.51, 95% CI 0.27 to 0.97; N = 430; 3 studies; very low-quality evidence). The proportion of people with sepsis was lower in lexipafant than control (OR 0.26, 95% CI 0.08 to 0.83; N = 290; 1 study; very low-quality evidence). There was no evidence of differences in any of the remaining comparisons in these outcomes or for any of the remaining primary outcomes (the proportion of participants experiencing at least one serious adverse event and the occurrence of infected pancreatic necrosis). None of the trials reported heath-related quality of life.

AUTHORS' CONCLUSIONS

Very low-quality evidence suggests that none of the pharmacological treatments studied decrease short-term mortality in people with acute pancreatitis. However, the confidence intervals were wide and consistent with an increase or decrease in short-term mortality due to the interventions. We did not find consistent clinical benefits with any intervention. Because of the limitations in the prognostic scoring systems and because damage to organs may occur in acute pancreatitis before they are clinically manifest, future trials should consider including pancreatitis of all severity but power the study to measure the differences in the subgroup of people with severe acute pancreatitis. It may be difficult to power the studies based on mortality. Future trials in participants with acute pancreatitis should consider other outcomes such as complications or health-related quality of life as primary outcomes. Such trials should include health-related quality of life, costs, and return to work as outcomes and should follow patients for at least three months (preferably for at least one year).

Acute pancreatitis patient registry to examine novel therapies in clinical experience (APPRENTICE): an international, multicenter consortium for the study of acute pancreatitis

Background

We have established a multicenter international consortium to better understand the natural history of acute pancreatitis (AP) worldwide and to develop a platform for future randomized clinical trials.

Methods

The AP patient registry to examine novel therapies in clinical experience (APPRENTICE) was formed in July 2014. Detailed web-based questionnaires were then developed to prospectively capture information on demographics, etiology, pancreatitis history, comorbidities, risk factors, severity biomarkers, severity indices, health-care utilization, management strategies, and outcomes of AP patients.

Results

Between November 2015 and September 2016, a total of 20 sites (8 in the United States, 5 in Europe, 3 in South America, 2 in Mexico and 2 in India) prospectively enrolled 509 AP patients. All data were entered into the REDCap (Research Electronic Data Capture) database by participating centers and systematically reviewed by the coordinating site (University of Pittsburgh). The approaches and methodology are described in detail, along with an interim report on the demographic results.

Conclusion

APPRENTICE, an international collaboration of tertiary AP centers throughout the world, has demonstrated the feasibility of building a large, prospective, multicenter patient registry to study AP. Analysis of the collected data may provide a greater understanding of AP and APPRENTICE will serve as a future platform for randomized clinical trials.

Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment

Walled-off necrosis (WON) is a relatively new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.

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.

Advances in Management of Acute Pancreatitis

This article reviews advances in the management of acute pancreatitis. Medical treatment has been primarily supportive for this diagnosis, and despite extensive research efforts, there are no pharmacologic therapies that improve prognosis. The current mainstay of management, notwithstanding the ongoing debate regarding the volume, fluid type, and rate of administration, is aggressive intravenous fluid resuscitation. Although antibiotics were used consistently for prophylaxis in severe acute pancreatitis to prevent infection, they are no longer used unless infection is documented. Enteral nutrition, especially in patients with severe acute pancreatitis, is considered a cornerstone in management of this disease.

Recent Advances in Managing Acute Pancreatitis

This article will review the recent advances in managing acute pancreatitis. Supportive care has long been the standard of treatment for this disease despite extensive, but ultimately unsuccessful, efforts to develop disease-specific pharmacologic therapies. The primary interventions center on aggressive fluid resuscitation, initiation of early enteral nutrition, targeted antibiotic therapy, and the management of complications. In this article, we will detail treatment of acute pancreatitis with a focus on intravenous fluid resuscitation, enteral feeding, and the current evidence behind the use of antibiotics and other pharmacologic therapies.

Acute Pancreatitis-Progress and Challenges: A Report on an International Symposium

An international symposium entitled "Acute pancreatitis: progress and challenges" was held on November 5, 2014 at the Hapuna Beach Hotel, Big Island, Hawaii, as part of the 45th Anniversary Meeting of the American Pancreatic Association and the Japanese Pancreas Society. The course was organized and directed by Drs. Stephen Pandol, Tooru Shimosegawa, Robert Sutton, Bechien Wu, and Santhi Swaroop Vege. The symposium objectives were to: (1) highlight current issues in management of acute pancreatitis, (2) discuss promising treatments, (3) consider development of quality indicators and improved measures of disease activity, and (4) present a framework for international collaboration for development of new therapies. This article represents a compilation and adaptation of brief summaries prepared by speakers at the symposium with the purpose of broadly disseminating information and initiatives.

Management of acute pancreatitis in dogs: a critical appraisal with focus on feeding and analgesia

Knowledge about acute pancreatitis has increased recently in both the medical and veterinary fields. Despite this expansion of knowledge, there are very few studies on treatment interventions in naturally occurring disease in dogs. As a result, treatment recommendations are largely extrapolated from experimental rodent models or general critical care principles. General treatment principles involve replacing fluid losses, maintaining hydrostatic pressure, controlling nausea and providing pain relief. Specific interventions recently advocated in human medicine include the use of neurokinin-1 antagonists for analgesia and early interventional feeding. The premise for early feeding is to improve the health of the intestinal tract, as unhealthy enterocytes are thought to perpetuate systemic inflammation. The evidence for early interventional feeding is not supported by robust clinical trials to date, but in humans there is evidence that it reduces hospitalisation time and in dogs it is well tolerated. This article summarises the major areas of management of acute pancreatitis in dogs and examines the level of evidence for each recommendation.

[Estimation of the role of octreotide in treatment of severe pancreatic necrosis]

It was analyzed the results of treatment of 204 patients with severe course of destructive pancreatitis (severity of organs' dysfunction was 9 and more scores according to APACHE-II scale upon admission to the hospital). Logistic regression and Cox regression were used along with univariant statistical analysis, what permitted to estimate overall effect of octreotide and other potential predictors including severity of condition and medical factors on the mortality rate and extension of necrosis in patients with pancreatic necrosis. It was established that the use of octreotide in case of severe pancreatic necrosis significantly decreases mortality and extension of necrosis.

Serum levels of apolipoprotein A-I and high-density lipoprotein can predict organ failure in acute pancreatitis

Introduction

Predicting severity of pancreatitis is an important goal. Clinicians are still searching for novel and simple biomarkers that can better predict persistent organ failure (OF). Lipoproteins, especially high-density lipoprotein (HDL), and apolipoprotein A-I (APO A-I), have been shown to have anti-inflammation effects in various clinical settings. Severe acute pancreatitis (SAP) is associated with hypo-lipoproteinemia. We studied whether the concentrations of HDL and APO A-I can predict persistent OF in patients with predicted SAP admitted to the ICU.

Methods

In 66 patients with predicted SAP, we prospectively evaluated the relationship between lipid levels, inflammatory cytokines and clinical outcomes, including persistent OF and hospital mortality. Blood samples were obtained within 24 hours of admission to the ICU.

Results

HDL and APO A-I levels were inversely correlated with various disease severity scores. Patients with persistent OF had lower levels of HDL and APO A-I, while those with transient OF had lower levels of interleukin-6, tumor necrosis factor-α and lower rates of hospital mortality. Meanwhile, hospital non-survivors had lower concentrations of HDL, and APO A-I compared to the survivors. By using the area under the receiver operating characteristic (AUROC) curve, both HDL and APO A-I demonstrated an excellent discriminative power for predicting persistent OF among all patients (AUROC 0.912 and 0.898 respectively) and among those with OF (AUROC 0.904 and 0.895 respectively). Pair-wise comparison of AUROC showed that both HDL and APO A-I had better discriminative power than C-reactive protein to predict persistent OF.

Conclusions

Serum levels of HDL and APO A-I at admission to the ICU are inversely correlated with disease severity in patients with predicted SAP and can predict persistent OF in this clinical setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0832-x) contains supplementary material, which is available to authorized users.

Hepato-pancreato-biliary emergencies for the acute care surgeon: etiology, diagnosis and treatment

Hepatopancreatobiliary (HPB) emergencies include an ample range of conditions with overlapping clinical presentations and diverse therapeutic options. The most common etiologies are related to cholelithiasis (acute cholecystitis, pancreatitis, and cholangitis) and non-traumatic injuries (common bile duct or duodenal). Although the true incidence of HPB emergencies is difficult to determine due to selection and reporting biases, a population-based report showed a decline in the global incidence of all severe complications of cholelithiasis, primarily based on a reduction in acute cholecystitis. Even though patients may present with overlapping symptoms, treatment options can be varied. The treatment of these conditions continues to evolve and patients may require endoscopic, surgical, and/or percutaneous techniques. Thus, it is essential that a multidisciplinary team of HPB surgeons, interventional gastroenterologists and radiologists are available on an as needed basis to the Acute Care Surgeon. This focused manuscript is a contemporary review of the literature surrounding HPB emergencies in the context of the acute care surgeon. The main aim of this review is to offer an update of the diagnosis and management of HPB issues in the acute care setting to improve the care of patients with potential HPB emergencies.

Pharmacologic therapy for acute pancreatitis

While conservative management such as fluid, bowel rest, and antibiotics is the mainstay of current acute pancreatitis management, there is a lot of promise in pharmacologic therapies that target various aspects of the pathogenesis of pancreatitis. Extensive review of preclinical studies, which include assessment of therapies such as anti-secretory agents, protease inhibitors, anti-inflammatory agents, and anti-oxidants are discussed. Many of these studies have shown therapeutic benefit and improved survival in experimental models. Based on available preclinical studies, we discuss potential novel targeted pharmacologic approaches that may offer promise in the treatment of acute pancreatitis. To date a variety of clinical studies have assessed the translational potential of animal model effective experimental therapies and have shown either failure or mixed results in human studies. Despite these discouraging clinical studies, there is a great clinical need and there exist several preclinical effective therapies that await investigation in patients. Better understanding of acute pancreatitis pathophysiology and lessons learned from past clinical studies are likely to offer a great foundation upon which to expand future therapies in acute pancreatitis.

Immune-modulating therapy in acute pancreatitis: Fact or fiction

Acute pancreatitis (AP) is one of the most common diseases of the gastrointestinal tract, bearing significant morbidity and mortality worldwide. Current treatment of AP remains unspecific and supportive and is mainly targeted to aggressively prevent systemic complications and organ failure by intensive care. As acute pancreatitis shares an indistinguishable profile of inflammation with sepsis, therapeutic approaches have turned towards modulating the systemic inflammatory response. Targets, among others, have included pro- and anti-inflammatory modulators, cytokines, chemokines, immune cells, adhesive molecules and platelets. Even though, initial results in experimental models have been encouraging, clinical implementation of immune-regulating therapies in acute pancreatitis has had a slow progress. Main reasons include difficulty in clinical translation of experimental data, poor understanding of inflammatory response time-course, flaws in experimental designs, need for multimodal approaches and commercial drawbacks. Whether immune-modulation in acute pancreatitis remains a fact or just fiction remains to be seen in the future.

High-dose versus low-dose octreotide in the treatment of acute pancreatitis: a randomized controlled trial

To evaluate the therapeutic efficacy of high-dose octreotide in patients with predicted severe acute pancreatitis (SAP) or SAP, two hundred and thirty-six patients with predicted SAP and 136 patients with SAP were randomized into control, high-dose octreotide (High-O) and low-dose octreotide (Low-O) groups. In addition to the conventional managements administrated in control group, High-O group received an intravenous infusion of octreotide at 50 μg/h × 3d + 25 μg/h × 4d, and Low-O group received octreotide at 25 μg/h × 7d. The major primary outcomes included the numbers of predicted SAP patients which developed SAP after intervention and the number of patients with SAP amelioration. Secondary outcomes included APACHE II, SIRS scores, plasma levels of somatostatin (SST), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6). There were no significant differences between the control and Low-O groups in terms of prevention and treatment for SAP. The incidence of SAP in patients with predicted SAP who received High-O was significantly lower than the Low-O group: 37.5% vs. 59.8%, p=0.005. Compared with Low-O group, the number of SAP patients in the SAP arm in the High-O group was reduced by 29.8%. Plasma levels of SST in both predicted SAP and the SAP patients were efficiently recovered (from 132.71±31.40 pg/ml to 180.00±23.50 pg/ml, p<0.05) after high-dose octreotide supplementation, which concomitantly reduced TNF-α and IL-6 levels. High-dose octreotide administration within 48h after AP onset may efficiently reduce the risk of SAP developing and partly attenuate SAP through raising plasma SST to a normal level and decreasing IL-6 and TNF-α.

Prevention of severe acute pancreatitis with octreotide in obese patients: a prospective multi-center randomized controlled trial

OBJECTIVES

To evaluate the efficacy of octreotide in preventing severe acute pancreatitis (SAP) in obese patients.

METHODS

A prospective multi-center partly randomized control trial was conducted in patients with mild acute pancreatitis (AP). Nonobese patients received conventional management (nonobese-C, n = 82), whereas obese patients (body mass index ≥ 25 kg/m(2)) were randomized into 2 groups: obese-C (n = 79), who received conventional management, and obese-C+O (n = 82), who received conventional management plus intravenous infusion of octreotide, 50 μg/h for 72 hours.

RESULTS

The risk ratio and relative risk reduction in the development of SAP in the obese-C+O group were 0.27 (95% confidence interval, 0.10-0.69) and 0.73 (95% confidence interval, 0.31-0.90), respectively. The number of cases developing local complications in the obese-C+O group was significantly smaller than that in the obese-C group: 4.9% vs 19%, P = 0.006. The plasma level of somatostatin in the obese-C+O group was significantly higher than that in the obese-C group: 165.5 ± 42.6 vs 112.1 ± 24.86 pg/mL, P < 0.05. Supplement of octreotide also accompanied with reduction in plasma levels of tumor necrosis factor α and IL-6.

CONCLUSIONS

Intravenous administration of octreotide (50 μg/h) for 72 hours in the early stage of AP could prevent the development of SAP effectively in obese patients by raising plasma somatostatin to a normal level and reducing circulating cytokines.

Is there a relationship between beginning time and efficiency of octreotide in the treatment of experimental acute pancreatitis?

Purpose

The efficacy of octreotide in the treatment of acute pancreatitis is controversial. Octreotide treatment for acute pancreatitis often shows poor correlation between results obtained in experimental studies and results of clinical trials. In a clinical setting, there is always a delay between the onset of the disease and initiation of the octreotide treatment. The aim of this study is to investigate the relationship between the beginning of treatment and alteration in effectiveness of octreotide.

Methods

Acute pancreatitis was induced by pancreatic duct ligation in 50 rats. The rats were randomly divided into five groups. Octreotide was not used in group 1 (control group). Only single dose (4 µg/kg) octreotide was administered subcutaneously to rats in group 2, having induced pancreatitis. Octreotide treatment was begun at different times (8th, 24th, 48th hour) in three other groups and continued treatment at a dosage of 4 µg/kg t.i.d. The animals were sacrificed at the end of the 72nd hour and blood and tissue samples were collected.

Results

Leukocyte count and plasma amylase values were less in groups 2 and 3. Hemorrhagic focuses were encountered less at pancreas tissues in group 3. Pancreatic necrosis and alveolar capillary basal membrane damage were lower in groups 3 and 4. No difference was found in fasting blood glucose, calcium and hematocrit.

Conclusion

Octreotide had benefical effects in acute pancreatitis when octreotide treatment was begun in the first 24 hours.

Pancreatic nociception--revisiting the physiology and pathophysiology

BACKGROUND

Pain management of many pancreatic diseases remains a major clinical concern. This problem reflects our poor understanding of pain signaling from the pancreas.

OBJECTIVES

This review provides an overview of our current knowledge, with emphasis on current pain management strategies and recent experimental findings.

METHODS

A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE, and the Cochrane Central Register of Controlled Trials for the years 1965-2011 to obtain access to all publications, especially randomized controlled trials, systematic reviews, and meta-analyses exploring pain and its management in disease states such as acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic cancer (PC).

RESULTS

Over the last decade, numerous molecular mediators such as nerve growth factor and the transient receptor potential (TRP) cation channel family have been implicated in afferent nerve signaling. More recent animal studies have indicated the location of the receptive fields for the afferent nerves in the pancreas and shown that these are activated by agents including cholecystokinin octapeptide, 5-hydroxytryptamine and bradykinin. Studies with PC specimens have shown that neuro-immune interactions occur and numerous agents including TRP cation channel V1, artemin and fractalkine have been implicated. Experimental studies in the clinical setting have demonstrated impairment of inhibitory pain modulation from supraspinal structures and implicated neuropathic pain mechanisms.

CONCLUSIONS

Our knowledge in this area remains incomplete. Characterization of the mediators and receptors/ion channels on the sensory nerve terminals are required in order to facilitate the development of new pharmaceutical treatments for AP and CP.

Continuous regional arterial infusion and laparotomic decompression for severe acute pancreatitis with abdominal compartment syndrome

AIM: To evaluate the therapeutic effects of abdominal decompression plus continuous regional arterial infusion (CRAI) via a drug delivery system (DDS) in severe acute pancreatitis (SAP) patients with abdominal compartment syndrome (ACS).

METHODS: We presented our recent experience in 8 patients with SAP. The patients developed clinical ACS, which required abdominal decompression. During the operation, a DDS was inserted into the peripancreatic artery (the catheter was inserted from the right gastroepiploic artery until it reached the junction between the pancreaticoduodenal and gastroduodenal artery). Through this DDS, a protease inhibitor, antibiotics and octreotide were infused continuously. The duration of the regional artery infusion ranged from 8 to 41 d. The outcomes and the changes in the APACHE II score, computed tomography (CT) severity index and intra-abdominal pressure (IAP) of the patients were retrospectively evaluated.

RESULTS: Eight patients with an initial APACHE IIscore of 18.9 (range, 13-27) and a Balthazar CT severity index of 9.1 (range, 7-10) developed severe local and systemic complications. These patients underwent subsequent surgical decompression and CRAI therapy because of intra-abdominal hypertension (IAH). After a mean interval of 131.9 ± 72.3 d hospitalization, 7 patients recovered with decreased APACHE II scores, CT severity indexes and IAP. The mean APACHE II score was 5.4 (range, 4-8), the CT severity index was 2.3 (range, 1-3), and IAP decreased to 7.7 mmHg (range, 6-11 mmHg) 60 d after operation. One patient died of multiple organ failure 1 wk after surgery.

CONCLUSION: CRAI and laparotomic decompression might be a therapeutic option for SAP patients with ACS.

Octreotide ameliorates intestinal dysmotility by interstitial cells of Cajal protection in a rat acute necrotizing pancreatitis model

OBJECTIVES

Intestinal motility is impaired in acute necrotizing pancreatitis (ANP). The aim of present study was to investigate the effects of octreotide on the small intestinal motor function during experimentally induced ANP.

METHODS

L-Ornithine was intraperitoneally injected to induce ANP. Octreotide was administrated subcutaneously every 8 hours. The small intestine migrating myoelectrical complexes and slow waves in vivo were recorded before and after (24, 48, and 72 hours) ANP induction. The morphological alterations of interstitial cells of Cajal (ICCs) in deep muscular plexus were evaluated by immunohistochemistry and Western blots.

RESULTS

Disturbed migrating myoelectrical complex cycle length and decreased dominant frequency of slow waves exacerbated gradually with time. The bolus applications of octreotide per 8 hours attenuated these functional abnormalities. The result of morphological study suggested that octreotide might ameliorate the damage of ICCs at 48 and 72 hours after ANP induction. Decreased expression of c-Kit protein at 72 hours was also attenuated by octreotide.

CONCLUSIONS

The pathogenesis of the ileus in ANP may be related to the sustained deficiencies in ICCs. Octreotide may ameliorate the severity of ileus by minimizing the injury of ICCs.

Multidrug strategies are effective in the treatment of severe experimental pancreatitis

BACKGROUND

Trypsinogen activation, oxygen radicals, cytokines, leukocyte infiltration, and pancreatic ischemia are important steps in the pathogenesis of necrotizing pancreatitis and associated systemic complications. Several drugs that inhibit those pathogenetic steps attenuated biochemical and histologic changes, while survival remained low. The aim of the present study was to evaluate the benefit of multidrug approaches compared to monotherapies on organ injury and survival in acute experimental pancreatitis in the rat model of retrograde bile injection combined with intravenous cerulein.

METHODS

Necrotizing pancreatitis was induced in rats. After a therapy-free interval of 6 hours, 10 treatment regimens were evaluated: multidrug regimen 1, which contained the protease inhibitor gabexate mesilate, oxygen-free radical scavengers, nitric oxide donor L-arginine, a platelet-activating factor antagonist, and antibodies against intracellular adhesion molecule-1 (ICAM-1) dissolved in dextran, was compared to multidrug regimen 2 (dextran, acetylcysteine, L-arginine, and anti-ICAM-1), monotherapies of each of the drugs, and standard intravascular volume replacement.

RESULTS

Both multidrug regimens significantly reduced pancreatic and systemic injury and microcirculatory disturbances compared to any of the monotherapies. Treatment with regimen 1 decreased 24-hour mortality to 0% and increased long-term survival to 85% (standard therapy, 70% and 15%, respectively). Multidrug regimen 2 was as effective as regimen 1.

CONCLUSION

Treatment of acute necrotizing pancreatitis with multidrug regimens significantly decreases short-term mortality compared to monotherapies. Moreover, multidrug strategies are still effective after a wide therapeutic window. Key to this effective therapy is the inhibition of microcirculatory disturbances and of the systemic inflammatory response. The experimental superiority of the multidrug approach should be confirmed in a clinical trial.

Safety and efficacy of vitamin-based antioxidant therapy in patients with severe acute pancreatitis: a randomized controlled trial

BACKGROUND/AIM

Oxidative stress plays a major role in the pathogenesis of pancreatitis. Antioxidant therapy in the form of high-dose vitamin has been used for the treatment of severe acute pancreatitis with equivocal results. We wished to evaluate the efficacy and safety of antioxidant (vitamin A, vitamin C, vitamin E) therapy in patients with severe acute pancreatitis.

SETTING AND DESIGN

This was a single-center, prospective, randomized, open-label with blinded endpoint assessment study of antioxidant therapy, conducted in the emergency department attached to our hospital.

MATERIALS AND METHODS

Thirty-nine patients with severe acute pancreatitis were randomly assigned to antioxidant treatment group (n=19) or a control group (n=20) within 96 hours of developing symptoms. Patients in the antioxidant group received antioxidants (vitamin A, vitamin E, vitamin C) in addition to the standard treatment provided to both the groups for a period of 14 days. The primary outcome variable was presence of organ dysfunction at day 7. The secondary outcome variables were length of hospital stay, multiorgan dysfunction (MODS) at day 7, recovery at the end of 4 weeks, complications, and mortality. The change in markers of oxidative stress from baseline was also measured.

RESULTS

We demonstrated no significant difference in organ dysfunction (P=1.0), MODS (P=0.8), and length of hospital stay (P=0.29) between the two groups. All the patients survived in the antioxidant-treated group, whereas two patients died in the control group. The change in the levels of malondialdehyde, superoxide dismutase, and reduced glutathione were not significantly different in the two groups at day 7. Univariate analysis showed marginal benefit with antioxidant treatment (P=0.034) in patients with severe acute pancreatitis.

CONCLUSIONS

This randomized study demonstrates that there is no significant benefit from antioxidant therapy in patients with established severe acute pancreatitis.

Chronic pancreatitis: modern surgical management

INTRODUCTION

Chronic pancreatitis (CP) is a disease with enormous social and personal impact. It is most commonly caused by the abuse of alcohol combined with nicotine. CP is usually characterised by an inflammatory mass located in the pancreatic head. Its natural course is characterised by persistent or recurrent painful attacks as well as progressive loss of pancreatic function due to fibrosis of the parenchyma with consecutive endocrine and exocrine insufficiency.

CONCLUSIONS

The only success parameter of any treatment is the effective long-lasting pain relief and improvement in the quality of life. The surgical armamentarium includes simple drainage procedures, resections of different extents or a combination of both. Duodenum-preserving resection of the pancreas offers the best short-term outcome according to trials conducted so far. It has the benefit of combining the highest safety with the highest efficiency. Additionally, the extent of the operation can be adapted to the morphology of the individual patient.

Pharmacotherapy for acute pancreatitis

Our knowledge of acute pancreatitis is still far from complete and there is no unanimous agreement concerning the pathophysiological processes leading to typical alterations during the course of acute pancreatitis. We reviewed the paper published in the last decade on the pathophysiology and treatment of acute pancreatitis. It is difficult to translate the experimental therapeutic results into clinical practice. For example, lexipafant was efficacious in decreasing the severity and mortality of lethal pancreatitis in rats, but seems to have no effect on severe acute pancreatitis in humans. Thus, the main problem in acute pancreatitis, especially in the severe form of the disease, is the difficulty of designing clinical studies capable of giving reliable statistically significant answers regarding the benefits of the various proposed therapeutic agents previously tested in experimental settings. Thus, analgesia, supportive care, and treatment of the pulmonary and renal complications remain the cornerstones of the treatment of acute pancreatitis, especially in the severe form of the disease.

The management of acute and chronic pancreatitis

Pancreatitis, which is most generally described as any inflammation of the pancreas, is a serious condition that manifests in either acute or chronic forms. Chronic pancreatitis results from irreversible scarring of the pancreas, resulting from prolonged inflammation. Six major etiologies for chronic pancreatitis have been identified: toxic/ metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, and obstruction. The most common symptom associated with chronic pancreatitis is pain localized to the upper-to-middle abdomen, along with food malabsorption, and eventual development of diabetes. Treatment strategies for acute pancreatitis include fasting and short-term intravenous feeding, fluid therapy, and pain management with narcotics for severe pain or nonsteroidal anti-inflammatories for milder cases. Patients with chronic disease and symptoms require further care to address digestive issues and the possible development of diabetes. Dietary restrictions are recommended, along with enzyme replacement and vitamin supplementation. More definitive outcomes may be achieved with surgical or endoscopic methods, depending on the role of the pancreatic ducts in the manifestation of disease.

Somatostatin and the gastrointestinal tract

PURPOSE OF REVIEW

Somatostatin influences motility, secretion, and absorption and often has in vivo a modulating, indirect effect on target cells in the gastrointestinal tract. Knowledge on tissue-specific expression of the five somatostatin receptors (SSTRs), their capacities for internalization and downregulation, their subtype-specific intracellular messengers, and the possibility of forming functionally distinct homodimers or heterodimers, has further complicated the actual in-vivo mechanism of action of somatostatin. This review reports recent in-vivo and in-vitro studies on somatostatin effects on the gastrointestinal tract and pancreas, most of them using a new engineered animal model able to define specific roles of somatostatin and/or its receptor subtypes.

RECENT FINDINGS

SSTR2 knockout mice showed normal circulating gastrin and unchanged acid output, suggesting a high degree of plasticity behind gastric acid secretion. Intestinal inflammation significantly increased somatostatin mRNA in SSTR2 null compared to wild type suggesting that somatostatin mediates inflammation also in SSTR2 null mice. In pancreatic islets of SSTR1-5 null mice no variations of islet size, cellular organization or glucagon or insulin content was shown when compared with null SSTRs and control mice.

SUMMARY

Although none of the recent findings produced on somatostatin seem ready to be considered for clinical application, recent developments of animal models such as SSTR knockout mice have highlighted promising results to better understand the direct and indirect effects of somatostatin on gastrointestinal tract functions.

Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality

BACKGROUND/AIMS

We evaluated the impact of the initial intravenous fluid resuscitation rate within the first 24 h of presentation to the emergency room on important outcomes in severe acute pancreatitis.

METHODS

Patients presenting directly with a diagnosis of severe acute pancreatitis were identified retrospectively. Patients were divided into two groups - those who received >or=33% ('early resuscitation') and <33% ('late resuscitation') of their cumulative 72-hour intravenous fluid volume within the first 24 h of presentation. The primary clinical outcomes were in-hospital mortality, development of persistent organ failure, and duration of hospitalization.

RESULTS

17 patients were identified in the 'early resuscitation' group and 28 in the 'late resuscitation' group and there were no baseline differences in clinical characteristics between groups. Patients in the 'late resuscitation' group experienced greater mortality than those in the 'early resuscitation' group (18 vs. 0%, p < 0.04) and demonstrated a trend toward greater rates of persistent organ failure (43 vs. 35%, p = 0.31). There was no difference in the total amount of fluid given during the first 72 h.

CONCLUSIONS

Patients with severe acute pancreatitis who do not receive at least one third of their initial 72-hour cumulative intravenous fluid volume during the first 24 h are at risk for greater mortality than those who are initially resuscitated more aggressively.

Treatment of acute pancreatitis: focus on medical care

Acute pancreatitis has an incidence of about 300 per 1 million individuals per year, of which 10-15% of patients develop the severe form of the disease. Novel management options, which have the potential to improve outcome, include initial proper fluid resuscitation, which maintains microcirculation and thereby potentially decreases ischaemia and reperfusion injury. The traditional treatment concept in acute pancreatitis, fasting and parenteral nutrition, has been challenged and early initiation of enteral feeding in severe pancreatitis and oral intake in mild acute pancreatitis is both feasible and provides some benefits. There are at present no data supporting immunonutritional supplements and probiotics should be avoided in patients with acute pancreatitis. There is also no evidence of any benefits provided by prophylactic antibacterials in patients with predicted severe acute pancreatitis. A variety of specific medical interventions have been investigated (e.g. intense blood glucose monitoring by insulin) but none has become clinically useful. Lessons can probably be learned from critical care in general, but studies are needed to verify these interventions in acute pancreatitis.

Acute pancreatitis: a historical perspective

Among the various pancreatic disorders, the pace of scientific discovery in acute pancreatitis has been particularly slow. The objective of this paper was to briefly review the history of scientific discovery of the clinical features, pathophysiology, and treatment of acute pancreatitis. A clinical description of acute pancreatitis was first presented in 1652 by the Dutch anatomist Nicholas Tulp, and despite the nearly 350 years that have passed, there continue to be many unanswered questions. In the late 19th and early 20th century, Reginald Fitz, Nicholas Senn, Eugene Opie, and others made seminal contributions that continue to influence our present understanding of acute pancreatitis. Despite remarkable progress in the past 6 decades, our ability to accurately diagnose and estimate the severity of acute pancreatitis remains limited. History provides multiple examples of empiric remedies and surgical interventions based on the prevailing theories and opinions of the scientific luminaries du jour, and indeed, after 3 centuries of inquiry, the most effective interventions for acute pancreatitis are purely supportive in nature and not specific to the pancreas. However, the perseverance of successive generations of the finest scientific minds provides hope that we will unravel the many mysteries of this enigmatic gland.