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Patel N, Bahirwani J, Bodrya K, Patel D, Schneider Y. Hidden Dangers of Frailty: Higher Mortality, Complications and Costs in Acute Pancreatitis. Dig Dis Sci 2024; 69:3188-3194. [PMID: 38789672 DOI: 10.1007/s10620-024-08480-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Frailty is a clinically recognizable state of increased vulnerability due to age-related decline in reserve and function across multiple physiologic systems that compromises the ability to cope with acute stress. As frailty is being identified as an important risk factor in outcomes of gastrointestinal pathologies, we aimed to assess outcomes in patients with acute pancreatitis within this cohort. METHOD We conducted a retrospective study using the Nationwide Inpatient Sample (NIS) database. ICD-10 codes were used to inquire for patients admitted with acute pancreatitis between September 2015 through 2017. ICD-10 codes corresponding to the Hospital Frailty Risk Score (HFRS) were used to divide the study sample into 2 cohorts: low risk (< 5 points) and intermediate or high risk (> 5 points). To calculate the points, we fitted a logistic regression model that included membership of the frail group as the binary dependent variable (frail vs. non-frail) and the set of ICD-10 codes as binary predictor variables (1 = present, 0 = absent for each code). To simplify the calculation and interpretation, we multiplied regression coefficients by five to create a points system, so that a certain number of points are awarded for each ICD-10 code and added together to create the final frailty risk score. Multivariate regression analysis was performed to find adjusted mortality. RESULTS Out of a total of 1,267,744 patients admitted with acute pancreatitis, 728,953 (57.5%) were identified as intermediate and high risk (> 5 points) (study cohort) and 538,781 (42.5%) as low risk (< 5 points). The mean age in the study cohort was 64.8 ± 12.6 and that in the low-risk group was 58.6 ± 9.5. Most of the patients in both groups were males and Caucasians; Medicare was the predominant insurance provider. A majority of the admissions in both groups were in an urban teaching hospital and were emergency. (Table 1). The primary outcome was in-hospital mortality which was significantly higher in the study cohort as compared to the low-risk group (4.3% vs. 2.5%, p < 0.0001). The age-adjusted Odds ratio of mortality was 1.72(95% CI (Confidence Interval) 1.65-1.80, p < 0.05). When compared between the two groups; median length of stay (6 vs. 4); hospitalization cost ($14,412 vs. $10,193), disposition to a skilled nursing facility (SNF) (17.1% vs. 8.6%) and need for home health care (HHC) was significantly higher in the study cohort. Complications like septicemia, septic shock, and acute kidney injury were also higher in the study group (Table 2). Table 1 Baseline demographics of the cohort Characteristics Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value N = 1,267,744 N = 728,953 (57.5%) N = 538,781 (42.5%) Age Mean years (Mean ± SD) 64.8 ± 12.6 58.6 ± 9.5 < 0.001 Gender < 0.001 Male 59.1% 52.3% Female 40.9% 47.7% *Missing-475 Age groups < 0.001 18-44 3.7% 14.3% 45-64 48% 52.9% 65-84 32.2% 28.7% ≥ 85 16.1% 4.1% Race < 0.001 Caucasians 67.4% 61.9% African Americans 9.6% 16.8% Others 23% 21.3% *Missing-10 Insurance type < 0.001 Medicare 40.9% 36.3% Medicaid 17.2% 24.3% Private 31.8% 27.9% Other 9.9% 11.4% *Missing-75 Active smoking 32.7% 37.9% 0.005 Biliary Stone 36.2% 16.7% < 0.001 Admission Type < 0.001 Emergent 93.7% 94.3% Elective 6.3% 5.7% *Missing-2880 Hospital ownership/control < 0.001 Rural 7.8% 10% Urban nonteaching 26.3% 26.6% Urban teaching 65.9% 63.4% Table 2 Outcomes Outcomes Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value In-hospital mortality *Missing-920 4.3% 2.5% < .0001 1.72(1.65-1.80) < .0001 Length of stay, days (Median,IQR) 6(3-8) 4(2-6) < .0001 Total hospitalization cost, $ (Median,IQR) 14,412(8843-20,216) 10,193(6840-13,842) < .0001 In-Hospital Complications ARDS 0.4% 0.3% 0.08 Ventilator dependence respiratory failure 0.23% 0.29% 0.25 Septicemia 15.2% 9.6% < .0001 Septic Shock 6.1% 2.9% < .0001 AKI 24.8% 14.9% < .0001 Disposition < .0001 Discharge to home 58.9% 74.9% Transfer other: includes Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), and another type of facility 17.1% 8.6% Home health care 11.5% 8.1% Against medical advice (AMA) 1.6% 3.4% *Missing-920 CONCLUSION: Using frailty as a construct to identify those who are at greater risk for adverse outcomes, can help formulate interventions to target individualized reversible factors to improve outcomes in patients with acute pancreatitis. Future large-scale prospective studies are warranted to understand the dynamic and longitudinal relationship between pancreatitis and frailty.
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Affiliation(s)
- Nishit Patel
- Department of Gastroenterology, St Luke's University Health Network, 701 ostrum street, Bethlehem, PA, 18015, USA
| | - Janak Bahirwani
- Department of Gastroenterology, St Luke's University Health Network, 701 ostrum street, Bethlehem, PA, 18015, USA.
| | - Krishna Bodrya
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Dhruvanshu Patel
- Department of Medicine, St Luke's University Health Network, Bethlehem, PA, USA
| | - Yecheskel Schneider
- Department of Gastroenterology, St Luke's University Health Network, 701 ostrum street, Bethlehem, PA, 18015, USA
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Metri A, Bush N, Singh VK. Predicting the severity of acute pancreatitis: Current approaches and future directions. Surg Open Sci 2024; 19:109-117. [PMID: 38650599 PMCID: PMC11033200 DOI: 10.1016/j.sopen.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
Acute pancreatitis (AP) is a sudden-onset inflammatory disease of the pancreas. The severity of AP is classified into mild, moderate, and severe categories based on the presence and persistence of organ failure. Severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. It requires early recognition for appropriate timely management. Prognostic scores for predicting SAP incorporating many clinical, laboratory, and radiological parameters have been developed in the past. However, all of these prognostic scores have low positive predictive value for SAP and some of these scores require >24 h for assessment. There is a need to develop biomarkers that can accurately identify patients at risk for SAP early in the course of the presentation. In this review, we aim to provide a summary of the most commonly utilized prognostic scores for AP and discuss future directions.
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Affiliation(s)
- Aida Metri
- Department of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nikhil Bush
- Department of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Vikesh K. Singh
- Department of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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Morelli L, Guadagni S, Palmeri M, Bechini B, Gianardi D, Furbetta N, Di Franco G, Di Candio G. Minimally Invasive Surgery for the Treatment of Moderate to Critical Acute Pancreatitis: A Case-matched Comparison With the Traditional Open Approach Over 10 years. Surg Laparosc Endosc Percutan Tech 2023; 33:191-197. [PMID: 36821700 DOI: 10.1097/sle.0000000000001157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/19/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE The purpose of this study is to compare short-term and midterm outcomes between patients with acute pancreatitis (AP) treated with minimally invasive surgery (MIS) and patients treated with open necrosectomy (ON). MATERIALS AND METHODS We compared data of all patients who had undergone MIS for AP with a similar group of patients with ON patients between January 2012 and June 2021 using a case-matched methodology based on AP severity and patient characteristics. Inhospital and midterm follow-up variables, including quality-of-life assessment, were evaluated. RESULTS Starting from a whole series of 79 patients with moderate to critical AP admitted to our referral center, the final study sample consisted of 24 patients (12 MIS and 12 ON). Postoperative (18.7±10.9 vs. 30.3±21.7 d; P =0.05) and overall hospitalization (56.3±17.4 vs. 76.9±39.4 d; P =0.05) were lower in the MIS group. Moreover, the Short-Form 36 scores in the ON group were statistically significantly lower in role limitations because of emotional problems ( P =0.002) and health changes ( P =0.03) at 3 and 6 months and because of emotional problems ( P =0.05), emotional well-being ( P =0.02), and general health ( P =0.007) at 1 year. CONCLUSIONS MIS for the surgical management of moderate to critical AP seems to be a good option, as it could provide more chances for a better midterm quality of life compared with ON. Further studies are needed to confirm our findings.
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Affiliation(s)
- Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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A "tailored" interventional and surgical management for moderate to critical acute pancreatitis in late phase: a cohort study. Langenbecks Arch Surg 2022; 407:2833-2841. [PMID: 35639137 DOI: 10.1007/s00423-022-02557-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Several interventional procedures are available to treat moderate-to-critical acute pancreatitis (AP) in its late phase. The ongoing debate on these options, together with the scarcity of reported quality of life (QoL) information in the Literature, prompted us to conduct a review of our experience. METHODS All the patients treated at our referral Center for moderate-to-critical AP according to Determinant-Based Classification (DBC) were retrospectively reviewed. Patients treated conservatively or operated within 4 weeks were excluded. The included patients were managed following a "tailored" interventional-surgical approach, which did not exclude the possibility to skip one or more steps of the classic "step-up" approach, based on the patient's clinical course, and divided into four groups, according to the first procedure performed: percutaneous drainage (PD), endoscopic approach (END), internal derivation (INT), and necrosectomy (NE). In-hospital and mid-term follow-up variables were analyzed. RESULTS The study sample consisted in 47 patients: 11 patients were treated by PD, 11 by END, 13 by INT, and 12 by NE. A significant distribution of the DBC severity (p = 0.029) was registered among the four groups. Moreover, the NE group had statistically significant reduced SF-36 scores in the domain of social functioning at 3 months (p = 0.011), at 1 year (p = 0.002), and at 2 years (p = 0.001); role limitations due to physical health at 6 months (p = 0.027); and role limitations due to emotional problems at 1 year (p = 0.020). CONCLUSIONS In the "late phase" of moderate to critical AP requiring an invasive management, PD, END, INT, and NE are all effective options, depending on patents' status and necrosis location. A "tailored" interventional-surgical management could be pursued, but up-front more invasive approaches are at higher risk of worse QoL. TRIAL REGISTRATION The manuscript was registered at clinicaltrials.gov in 04/2021 and identified with NCT04870268.
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Abstract
Introduction: Acute pancreatitis (AP) is a common gastrointestinal disease with a wide spectrum of severity and morbidity. Developed in 1974, the Ranson score was the first scoring system to prognosticate AP. Over the past decades, while the Ranson score remains widely used, it was identified to have certain limitations, such as having low predictive power. It has also been criticized for its 48-hour requirement for computation of the final score, which has been argued to potentially delay management. With advancements in our understanding of AP, is the Ranson score still relevant as an effective prognostication system for AP?Areas covered: This review summarizes the available evidence comparing Ranson score with other conventional and novel scoring systems, in terms of prognostic accuracy, benefits, limitations and clinical applicability. It also evaluates the effectiveness of Ranson score with regard to the Revised Atlanta Classification.Expert opinion: The Ranson score consistently exhibits comparable prognostic accuracy to other newer scoring systems, and the 48-hour timeframe for computing the full Ranson score is an inherent strength, not a weakness. These aspects, coupled with relative ease of use, practicality and universality of the score, advocate for the continued relevance of the Ranson score in modern clinical practice.
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Affiliation(s)
- Yuki Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vishal G Shelat
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- FRCS (General Surgery), FEBS (HPB Surgery), Hepato-Pancreatico-BiliarySurgery, Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Li C, Ren Q, Wang Z, Wang G. Early prediction of in-hospital mortality in acute pancreatitis: a retrospective observational cohort study based on a large multicentre critical care database. BMJ Open 2020; 10:e041893. [PMID: 33361165 PMCID: PMC7759962 DOI: 10.1136/bmjopen-2020-041893] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/13/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To develop and validate a prediction model for predicting in-hospital mortality in patients with acute pancreatitis (AP). DESIGN A retrospective observational cohort study based on a large multicentre critical care database. SETTING All subject data were collected from the eICU Collaborative Research Database (eICU-CRD), which covers 200 859 intensive care unit admissions of 139 367 patients in 208 US hospitals between 2014 and 2015. PARTICIPANTS A total of 746 patients with AP were drawn from eICU-CRD. Due to loss to follow-up (four patients) or incomplete data (364 patients), 378 patients were enrolled in the primary cohort to establish a nomogram model and to conduct internal validation. PRIMARY AND SECONDARY OUTCOME MEASURES The outcome of the prediction model was in-hospital mortality. All risk factors found significant in the univariate analysis were considered for multivariate analysis to adjust for confounding factors. Then a nomogram model was established. The performance of the nomogram model was evaluated by the concordance index (C-index) and the calibration plot. The nomogram model was internally validated using the bootstrap resampling method. The predictive accuracy of the nomogram model was compared with that of Acute Physiology, Age, and Chronic Health Evaluation (APACHE) IV. Decision curve analysis (DCA) was performed to evaluate and compare the potential net benefit using of different predictive models. RESULTS The overall in-hospital mortality rate is 4.447%. Age, BUN (blood urea nitrogen) and lactate (ABL) were the independent risk factors determined by multivariate analysis. The C-index of nomogram model ABL (0.896 (95% CI 0.825 to 0.967)) was similar to that of APACHE IV (p=0.086), showing a comparable discriminating power. Calibration plot demonstrated good agreement between the predicted and the actual in-hospital mortality. DCA showed that the nomogram model ABL was clinically useful. CONCLUSIONS Nomogram model ABL, which used readily available data, exhibited high predictive value for predicting in-hospital mortality in AP.
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Affiliation(s)
- Caifeng Li
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Qian Ren
- Advertising Center, Tianjin Daily, Tianjin, China
| | - Zhiqiang Wang
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Guolin Wang
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, China
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Leppäniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, Ball CG, Parry N, Sartelli M, Wolbrink D, van Goor H, Baiocchi G, Ansaloni L, Biffl W, Coccolini F, Di Saverio S, Kluger Y, Moore E, Catena F. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019; 14:27. [PMID: 31210778 PMCID: PMC6567462 DOI: 10.1186/s13017-019-0247-0] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/27/2019] [Indexed: 02/08/2023] Open
Abstract
Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.
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Affiliation(s)
- Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Emiliano Gamberini
- Anesthesia and Intensive Care Medicine, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Chad G. Ball
- Foothills Medical Centre & the University of Calgary, Calgary, AB Canada
| | - Neil Parry
- London Health Sciences Centre, London, ON Canada
| | | | - Daan Wolbrink
- Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps memorial Hospital, La Jolla, CA USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest Moore
- Trauma Surgery, Denver Health Medical Center, Denver, CO USA
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Avanesov M, Löser A, Smagarynska A, Keller S, Guerreiro H, Tahir E, Karul M, Adam G, Yamamura J. Clinico-radiological comparison and short-term prognosis of single acute pancreatitis and recurrent acute pancreatitis including pancreatic volumetry. PLoS One 2018; 13:e0206062. [PMID: 30359398 PMCID: PMC6201910 DOI: 10.1371/journal.pone.0206062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/06/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The necrosis-fibrosis hypothesis describes a continuum between single attacks of acute pancreatitis (SAP), recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) with endocrine and exocrine pancreatic insufficiency. For prevention purposes we evaluated clinico-radiological parameters and pancreatic volumetry to compare SAP and RAP and provide prognostic relevance on short-term mortality, need for intervention and the hospitalization duration. MATERIALS AND METHODS We retrospectively investigated 225 consecutive patients (150 males, range 19-97years) with acute pancreatitis (74%SAP, 26%RAP) according to the revised Atlanta classification. All patients received an intravenous contrast-enhanced CT after a median time of 5 (IQR 5-7) days after onset of symptoms. Two experienced observers rated the severity of AP by 3 CT scores (CTSI, mCTSI, EPIC). Moreover, total pancreatic volumes and additional parenchymal necrosis volumes were assessed, when appropriate. Clinical parameters were etiology of AP, lipase on admission, CRP 48 hours after admission (CRP48), and the presence of organ dysfunction, assessed by the modified Marshall score. The modified Marshall score included systolic blood pressure, serum creatinine, and the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio) and was assessed on admission and 48 hours after admission to find patients with persistent organ failure. Outcome parameters were total hospitalization duration, short-term mortality and need for intervention. RESULTS Lipase, CRP48, etiology of AP, EPIC, PaO2/FiO2 ratio, and the presence of a pleural effusion differed significantly in both groups (p<0.05). In 109 patients with interstitial edematous AP, the total pancreatic volume was significantly smaller in patients with RAP compared to those with SAP (69±35cm3; (RAP) vs 106±45cm3; (SAP), p<0.001). All outcome parameters including the mortality rates (SAP vs. RAP: 15% vs. 7%) were comparable in both groups (p>0.05). In the necrotizing RAP group, only the necrotic volume correlated significantly with total hospitalization time (r = 0.72, p<0.001), whereas the systolic blood pressure was the only, but weak predictor for short-term mortality (β-coefficient: -0.05, p = 0.03) and the need for intervention (β-coefficient: -0.02, p = 0.048) in the total RAP group. In patients with SAP, the modified Marshall score was the strongest predictor of short-term mortality, followed by the mCTSI on multivariate logistic regression (Marshall score: β-coefficient: 1.79, p<0.001; mCTSI: β-coefficient: 0.40, p<0.001). CTSI was the best predictor for required intervention in necrotizing SAP (β-coefficient: 0.46, p<0.001), followed by the volume of intrapancreatic necrosis (β-coefficient: 0.17, p = 0.03). CONCLUSION Total pancreatic volume differed significantly between interstitial RAP and SAP and intrapancreatic necrosis volume revealed prognostic value for the total hospitalization duration in necrotizing RAP. Although all outcome parameters were comparable between SAP and RAP, only systolic blood pressure and pancreatic volumetry were prognostic in RAP. In SAP, only the modified Marshall score and mCTSI revealed prognostic value for short-term mortality, whereas CTSI was predictive for the need for intervention.
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Affiliation(s)
- Maxim Avanesov
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastassia Löser
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alla Smagarynska
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Keller
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Enver Tahir
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Murat Karul
- Department of Diagnostic and Interventional Radiology, Marienkrankenhaus, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jin Yamamura
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Mesenchymal Stromal Cell Therapy for Pancreatitis: A Systematic Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2018; 2018:3250864. [PMID: 29743979 PMCID: PMC5878867 DOI: 10.1155/2018/3250864] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/31/2017] [Indexed: 12/19/2022]
Abstract
Background Based on animal studies, adult mesenchymal stromal cells (MSCs) are promising for the treatment of pancreatitis. However, the best type of this form of cell therapy and its mechanism of action remain unclear. Methods We searched the PubMed, Web of Science, Scopus, Google Scholar, and Clinical Trials.gov websites for studies using MSCs as a therapy for both acute and chronic pancreatitis published until September 2017. Results We identified 276 publications; of these publications, 18 met our inclusion criteria. In animal studies, stem cell therapy was applied more frequently for acute pancreatitis than for chronic pancreatitis. No clinical trials were identified. MSC therapy ameliorated pancreatic inflammation in acute pancreatitis and pancreatic fibrosis in chronic pancreatitis. Bone marrow and umbilical cord MSCs were the most frequently administered cell types. Due to the substantial heterogeneity among the studies regarding the type, source, and dose of MSCs used, conducting a meta-analysis was not feasible to determine the best type of MSCs. Conclusion The available data were insufficient for determining the best type of MSCs for the treatment of acute or chronic pancreatitis; therefore, clinical trials investigating the use of MSCs as therapy for pancreatitis are not warranted.
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Wang Q, Yan H, Wang G, Qiu Z, Bai B, Wang S, Yu P, Feng Q, Zhao Q, He X, Liu C. RNA sequence analysis of rat acute experimental pancreatitis with and without fatty liver: a gene expression profiling comparative study. Sci Rep 2017; 7:734. [PMID: 28389636 PMCID: PMC5429720 DOI: 10.1038/s41598-017-00821-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/14/2017] [Indexed: 02/07/2023] Open
Abstract
Fatty liver (FL) is one of the risk factors for acute pancreatitis and is also indicative of a worse prognosis as compared to acute pancreatitis without fatty liver (AP). The aim of the present study was to analyze, at the hepatic level, the differentially expressed genes (DEGs) between acute pancreatitis with fatty liver (APFL) rats and AP rats. GO (Gene Ontology) and KEGG (Kyoto Encyclopedia of Genes and Genomes) pathway analyses of these DEGs indicated that PPARα signalling pathway and fatty acid degradation pathway may be involved in the pathological process of APFL, which indicated that fatty liver may aggravate pancreatitis through these pathways. Moreover, the excessive activation of JAK/STAT signaling pathway and toll-like receptor signaling pathway was also found in APFL group as shown in heat map. In conclusion, the inhibition of PPARα signaling pathway and the fatty acid degradation pathway may lead to the further disorder of lipid metabolism, which can aggravate pancreatitis.
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Affiliation(s)
- Qian Wang
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Hongkai Yan
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, 201907, China
| | - Gang Wang
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Zhaoyan Qiu
- Department of General Surgery, The General Hospital of the People's Liberation Army, Beijing, 100039, China
| | - Bin Bai
- Department of Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, 710032, China
| | - Shiqi Wang
- Department of Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, 710032, China
| | - Pengfei Yu
- Department of Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, 710032, China
| | - Quanxin Feng
- Department of Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, 710032, China
| | - Qingchuan Zhao
- Department of Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, 710032, China.
| | - Xianli He
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China.
| | - Chaoxu Liu
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, 201907, China. .,Department of Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, 710032, China.
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Mikolasevic I, Orlic L, Poropat G, Jakopcic I, Stimac D, Klanac A, Carovic F, Milic S. Nonalcoholic fatty liver and the severity of acute pancreatitis. Eur J Intern Med 2017; 38:73-78. [PMID: 27825671 DOI: 10.1016/j.ejim.2016.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 12/11/2022]
Abstract
AIM To explore the effect of nonalcoholic fatty liver as a hepatic manifestation of metabolic syndrome on the severity of acute pancreatitis. We hypothesized that patients with nonalcoholic fatty liver would have a more severe form of acute pancreatitis. PATIENTS AND METHODS We retrospectively analyzed 822 patients hospitalized with acute pancreatitis. We diagnosed acute pancreatitis and determined its severity according the revised Atlanta classification criteria from 2012. We assessed nonalcoholic fatty liver with computed tomography. RESULTS There were 198 (24.1%) patients out of 822 analyzed who had nonalcoholic fatty liver. Patients with nonalcoholic fatty liver had statistically higher incidence of moderately severe (35.4% vs. 14.6%; p=0.02) and severe acute pancreatitis (20.7% vs. 9.6%; p<0.001) compared to patients without nonalcoholic fatty liver. At the admission patients with nonalcoholic fatty liver had higher values of C-reactive protein as well as at day three, higher APACHE II score at admission and significantly higher incidence of organ failure and local complications as well as higher values of computed tomography severity index compared to patients without nonalcoholic fatty liver. We found independent association between the occurrence of moderately severe and severe acute pancreatitis and nonalcoholic fatty liver (OR 2.13, 95%CI 1.236-3.689). Compared to patients without nonalcoholic fatty liver, patients with nonalcoholic fatty liver had a higher death rate, however not statistically significant (5.6% vs. 4.3%; p=NS). CONCLUSION Presence of nonalcoholic fatty liver at admission can indicate a higher risk for developing more severe forms of acute pancreatitis and could be used as an additional prognostic tool.
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Affiliation(s)
- I Mikolasevic
- Department of Gastroenterology, UHC Rijeka, Croatia.
| | - L Orlic
- Department of Nephrology, Dialysis and Kidney Transplantation, UHC Rijeka, Croatia
| | - G Poropat
- Department of Gastroenterology, UHC Rijeka, Croatia
| | | | - D Stimac
- Department of Gastroenterology, UHC Rijeka, Croatia
| | - A Klanac
- School of Medicine, Rijeka, Croatia
| | | | - S Milic
- Department of Gastroenterology, UHC Rijeka, Croatia
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12
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Iranmahboob AK, Kierans AS, Huang C, Ream JM, Rosenkrantz AB. Preliminary investigation of whole-pancreas 3D histogram ADC metrics for predicting progression of acute pancreatitis. Clin Imaging 2017; 42:172-177. [DOI: 10.1016/j.clinimag.2016.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/23/2016] [Accepted: 12/14/2016] [Indexed: 12/24/2022]
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The diffuse reduction in spleen density: an indicator of severe acute pancreatitis? Biosci Rep 2017; 37:BSR20160418. [PMID: 27920277 PMCID: PMC5322749 DOI: 10.1042/bsr20160418] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 11/30/2016] [Accepted: 12/05/2016] [Indexed: 02/07/2023] Open
Abstract
We observed that acute pancreatitis (AP) was associated with diffuse reduction in spleen density (DROSD) in some patients. Furthermore, the condition of these patients was more serious, and the potential relationship between DROSD and structural and functional injury of the spleen remained unclear. Therefore, we performed a preliminary exploration of these factors. We analysed pertinent clinical data for AP patients with normal spleen density (control group) and for those with DROSD (reduction group) at the First Affiliated Hospital of Harbin Medical University (June 2013–June 2015). We measured the immunoglobulin M (IgM) B-cells of the AP patients and examined pancreatic and splenic tissues from AP rats with optical microscopy and TEM. The reduction group had a higher acute physiology and chronic health evaluation II (APACHE II) score, a longer length of stay (LOS) and lower serum calcium than the control group. The levels of triglycerides (TG) and total cholesterol (TC) did not differ significantly between the two groups. The percentage of IgM memory B-cells was significantly lower in the DROSD group than in the control group. TEM revealed that the spleen T-lymphocytes were normal in AP rats, but pyroptotic and necrotic spleen B-cells were observed in the severe AP rats. In AP, DROSD was an independent indicator of more severe conditions. Furthermore, spleen B-lymphocytes showed obvious damage at the cellular level, and the immunological function of the spleen was down-regulated when AP was associated with DROSD.
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14
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Lusczek ER, Colling K, Muratore S, Conwell D, Freeman M, Beilman G. Stereotypical Metabolic Response to Endoscopic Retrograde Cholangiopancreatography Show Alterations in Pancreatic Function Regardless of Post-Procedure Pancreatitis. Clin Transl Gastroenterol 2016; 7:e169. [PMID: 27148850 PMCID: PMC4893679 DOI: 10.1038/ctg.2016.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/23/2016] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES: Metabolomics-based diagnosis or prediction of risk may improve patient outcomes and improve understanding of the pathogenesis of acute pancreatitis (AP). Endoscopic retrograde cholangiopancreatography (ERCP) is a risk factor for developing AP. This pilot study examined metabolomes of patients before and after ERCP, hypothesizing that metabolomics could differentiate between patients who did and did not develop post-ERCP pancreatitis, and that biomarkers associated with development of AP could be identified. METHODS: Patients at high risk for developing post-ERCP pancreatitis were prospectively enrolled at the University of Minnesota from October 2012 to February 2014. Urine and serum samples were collected before ERCP, 2 h after ERCP, and daily thereafter if patients were admitted to the hospital with AP. Pancreatitis severity was calculated with Bedside Index for Severity in Acute Pancreatitis (BISAP) and Modified Glasgow scores. Patients who developed AP (n=9) were matched to patients who did not develop AP (n=18) by age and gender. Urine and serum metabolites were profiled with nuclear magnetic resonance spectroscopy. Partial least squares discriminant analysis (PLS-DA) was performed to detect changes in metabolic profiles associated with development of pancreatitis. Metabolic networks were constructed to probe functional relationships among metabolites. RESULTS: Of the 113 enrolled patients, 9 developed mild AP according to BISAP and modified Glasglow scores. PLS-DA showed common differences between pre- and post-ERCP metabolic profiles in urine and serum regardless of AP status, characterized by increases in serum and urine ketones and serum glucose. Pre-ERCP lipase levels were somewhat elevated in those who went on to develop AP, though this did not reach statistical significance. Metabolic networks differed between patients with AP and those without after ERCP; however, metabolomics did not identify specific prognostic or diagnostic markers of ERCP-induced AP. Aspartate and asparagine were identified as well-connected hubs in post-ERCP serum networks of cases and were correlated with aspartate transaminase (AST) and white blood cell count levels. These features were not evident in controls. Serum aspartate was elevated in AP patients relative to those without AP after ERCP (P=0.03). CONCLUSIONS: In this pilot study, ERCP was found to induce global changes in urine and serum metabolomes indicative of alterations in pancreatic function and insulin resistance. This should be taken into consideration in future research on this topic. Post-ERCP serum metabolic networks indicate functional differences surrounding aspartate metabolism between patients with AP and those without. Further study must be done in larger patient populations to test elevated lipase as a prognostic biomarker associated with risk of developing AP and to examine active metabolic mechanisms at work.
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Affiliation(s)
| | - Kristen Colling
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sydne Muratore
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Darwin Conwell
- Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA
| | - Martin Freeman
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Greg Beilman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Antioxidant and Anti-Inflammatory Effects of Coenzyme Q10 on L-Arginine-Induced Acute Pancreatitis in Rat. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2016; 2016:5818479. [PMID: 27190575 PMCID: PMC4844882 DOI: 10.1155/2016/5818479] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/10/2016] [Accepted: 03/22/2016] [Indexed: 01/12/2023]
Abstract
This study was aimed at evaluating the protective effect of coenzyme Q10 on L-arginine-induced acute pancreatitis in rats regarding biomarkers and morphologic changes. Thirty-two male Sprague-Dawley rats were divided into 4 equal groups. Control group received intraperitoneal normal saline, while in sham and experimental groups 1 and 2 pancreatitis was induced with L-arginine. E1 and E2 groups were treated with a single dose of 100 and 200 mg/kg Q10, respectively. Serum lipase and amylase, along with pancreas IL-10, IL-1β, and TNF-α, were measured. For evaluation of oxidative stress, pancreatic superoxide dismutase (SOD), glutathione (GSH), malondialdehyde (MDA), and myeloperoxidase (MPO) were assessed. Histopathological examination for morphologic investigation was conducted. Serum amylase and lipase, as well as TNF-α and IL-1β cytokines, reverted with administration of Q10 in consistence with dosage. In contrast, Q10 assisted in boosting of IL-10 with higher dosage (200 mg/kg). A similar pattern for oxidative stress markers was noticed. Both MDA and MPO levels declined with increased dosage, contrary to elevation of SOD and GSH. Histopathology was in favor of protective effects of Q10. Our findings proved the amelioration of pancreatic injury by Q10, which suggest the anti-inflammatory and antioxidant property of Q10 and its potential therapeutic role.
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Popa CC, Badiu DC, Rusu OC, Grigorean VT, Neagu SI, Strugaru CR. Mortality prognostic factors in acute pancreatitis. J Med Life 2016; 9:413-418. [PMID: 27928447 PMCID: PMC5141403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The aim of the study was to present the biological prognostic factors of mortality in patients with acute pancreatitis. Methods: Several usual laboratory values were monitored: glucose, urea, partial pressure of oxygen, WBC count, hemoglobin, total bilirubin, and cholesterol. A statistical analysis was performed by using ROC curves and AUC interpretation. Results: The overall mortality rate was 21.1% and was different depending on the severity of the disease. Only 2.22% of the patients with a mild disease died, as opposed to 45.63% of the patients with a severe form. All the analyses studied were significantly elevated in the deceased patients. A close correlation between blood glucose, urea, partial pressure of oxygen, WBC, hemoglobin, total bilirubin, and cholesterol and mortality was objectified by measuring the AUC, which was of 97.1%, 95.5%, 93.4%, 92.7%, 87.4%, 82.2%, and 79.0%. Conclusions: The usual, easy to use, fast, and cheap tests were useful in predicting mortality in patients with acute pancreatitis. Our study confirmed that the combination of several factors led to an accurate mortality prediction.
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Affiliation(s)
- CC Popa
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
,Department of Surgery, 2nd General Surgery Clinic, University Emergency Hospital, Bucharest, Romania
| | - DC Badiu
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
,Department of Surgery, General Surgery Clinic, “Bagdasar-Arseni” Clinical Emergency Hospital, Bucharest, Romania
| | - OC Rusu
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
,Department of Surgery, 2nd General Surgery Clinic, University Emergency Hospital, Bucharest, Romania
| | - VT Grigorean
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
,Department of Surgery, General Surgery Clinic, “Bagdasar-Arseni” Clinical Emergency Hospital, Bucharest, Romania
| | - SI Neagu
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
,Department of Surgery, General Surgery Clinic, “Bagdasar-Arseni” Clinical Emergency Hospital, Bucharest, Romania
| | - CR Strugaru
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
,Department of Medical Genetics, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
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Xu YH, Yan L, Bian C, Tian ZB, Jing X. Value of procalcitonin in assessing severity of acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2015; 23:4898-4904. [DOI: 10.11569/wcjd.v23.i30.4898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the value of procalcitonin (PCT) in assessing the severity of acute pancreatitis (AP).
METHODS: A total of 154 unrelated patients diagnosed with AP and 41 healthy control subjects were enrolled in this study. The 154 patients with AP were divided into three groups according to the severity of AP: mild acute pancreatitis (MAP) (n = 56), mild-severe acute pancreatitis (MSAP; n = 51), and severe acute pancreatitis (SAP; n = 47). Serological assays of PCT, C-reactive protein, hematocrit, and leukocytes were carried out in accordance with the standard clinical laboratory methods. The score of Bedside Index for Severity in Acute Pancreatitis (BISAP) was determined for all patients. Differences in the serum indexes between two groups, and the association between PCT and AP mortality were evaluated.
RESULTS: The levels of serum PCT were the highest in the SAP group, followed by the MSAP group, the MAP group, and the control group (P = 0.000). The levels of serum PCT were positively associated with BISAP score in patients with AP. The sensitivity and specificity of serum PCT in diagnosis of SAP, similar to those of the score of BISAP, were 77.8% and 87.1%, respectively. AP patients with a PCT level > 2.0 ng/mL had a poor prognosis.
CONCLUSION: Our results indicate that the levels of serum PCT may represent an early sensitive biomarker for evaluating the severity of AP.
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CT severity of post-ERCP pancreatitis: results from a single tertiary medical center. ACTA ACUST UNITED AC 2014; 39:1162-8. [DOI: 10.1007/s00261-014-0147-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fatty liver in acute pancreatitis: characteristics in magnetic resonance imaging. J Comput Assist Tomogr 2012; 36:400-5. [PMID: 22805667 DOI: 10.1097/rct.0b013e31825977c2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this research was to study the characteristics of fatty liver (FL) in acute pancreatitis (AP) in 2-dimensional in-phase (IP)/out-of-phase (OP) magnetic resonance imaging (MRI). METHODS Fifty patients with AP (23 men, 27 women; mean age, 44 [SD, 12] years [range, 16-73 years]) were included in this retrospective study. Patients' informed consent was waived. All of them performed abdominal MRI within 72 hours of symptom onset and MRI follow-up. The severity of the AP was graded according to the magnetic resonance severity index (MRSI). The MRSI cutoff was 7.0 points between the mild and the severe AP. Fatty liver in MRI was determined by the hepatic signal intensity difference between OP and IP images. Correlations between the severity of FL and MRSI or serum triglyceride levels were analyzed. RESULTS Of the 50 patients with AP, FL was found in 66% of patients' MRIs. A close correlation can be seen between the difference of liver signal intensities on IP/OP images and the MRSI (r = 0.83, P < 0.001). Close correlations were found between FL appearance on MRI and serum triglyceride levels in both mild (r = 0.93, P < 0.001) and severe AP (r = 0.95, P < 0.001). During follow-up MRI, the appearance of FL decreased following the decrease in MRSI scores and serum triglyceride levels in both mild and severe AP. CONCLUSIONS Fatty liver in AP is frequently observed in MRI. The appearance of FL in MRI may decrease after subsidence of AP.
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