[Acute pancreatitis caused by hypertriglyceridemia]

Current Diagnosis and Treatment of Acute Pancreatitis in Korea: A Nationwide Survey

Background/Aims

Acute pancreatitis (AP) is a leading cause of emergency hospitalization. We present the current diagnostic and therapeutic status of AP as revealed by analysis of a large multicenter dataset.

Methods

The medical records of patients diagnosed with AP between 2018 and 2019 in 12 tertiary medical centers in Korea were retrospectively reviewed.

Results

In total, 676 patients were included, of whom 388 (57.4%) were male, and the mean age of all patients was 58.6 years. There were 355 (52.5%), 301 (44.5%), and 20 (3.0%) patients with mild, moderate, and severe AP, respectively, as assessed by the revised Atlanta classification. The most common etiologies of AP were biliary issues (41.6%) and alcohol consumption (24.6%), followed by hypertriglyceridemia (6.8%). The etiology was not identified in 111 (16.4%) patients at the time of initial admission. The overall mortality rate was 3.3%, increasing up to 45.0% among patients with severe AP. Notably, 70.0% (14/20) of patients with severe AP and 81.5% (154/189) of patients with systemic inflammatory response syndrome had received <4 L per day during the initial 24 hours of admission. Only 23.8% (67/281) of acute biliary pancreatitis patients underwent cholecystectomy during their initial admission. In total, 17.8% of patients experienced recurrent attacks during follow-up. However, none of the patients with acute biliary pancreatitis experienced recurrent attacks if they had undergone cholecystectomy during their initial admission.

Conclusions

This study provides insights into the current status of AP in Korea, including its etiology, severity, and management. Results reveal disparities between clinical guidelines and their practical implementation for AP treatment.

Acute Pancreatitis With Normal Amylase and Lipase: A Diagnostic Dilemma

Acute pancreatitis is a common and potentially life-threatening condition. It is characterized by inflammation of the pancreas, most often leading to elevated levels of pancreatic enzymes in the blood. In a subset of patients, however, conventional biomarker levels may remain within the reference range. Such instances have the potential to create a diagnostic challenge for healthcare professionals and can lead to misdiagnosis or delayed treatment. This article presents the intriguing clinical scenario of acute pancreatitis with normal amylase and lipase, discusses factors that may lead to normoenzymatic presentation, and reminds clinicians of the diagnostic criteria for acute pancreatitis, which does not necessarily require elevated pancreatic enzymes.

Hypertriglyceridemia-induced acute pancreatitis in children: A mini-review

Severe hypertriglyceridemia (HTG) is a known metabolic cause of acute pancreatitis (AP) in pediatric patients. The incidence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is less well established in pediatric compared to adult patients. Studies in adults suggest that higher risk of AP occurs when triglyceride levels (TG) are >1,000 mg/dL. Most common etiologies for severe HTG in pediatric patients are either from primary hypertriglyceridemia, underlying genetic disorders of lipid and TG metabolism, or secondary hypertriglyceridemia, separate disease or exposure which affects TG metabolism. Most common theories for the pathophysiology of HTG-AP include hydrolysis of TG by pancreatic lipase to free fatty acids leading to endothelial and acinar cell damage and ischemia, as well as hyperviscosity related to increased chylomicrons. Though there are varying reports of HTG-AP severity compared to other causes of AP, a steadily growing body of evidence suggests that HTG-AP can be associated with more severe course and complications. Therapeutic interventions for HTG-AP typically involve inpatient management with dietary restriction, intravenous fluids, and insulin; select patients may require plasmapheresis. Long term interventions generally include dietary modification, weight management, control of secondary causes, and/or antihyperlipidemic medications. Though some therapeutic approaches and algorithms exist for adult patients, evidence-based management guidelines have not been well established for pediatric patients.

Elevated triglycerides on admission positively correlate with the severity of hypertriglyceridaemic pancreatitis

BACKGROUND

Hypertriglycaeridemia has been positively associated with the risk of acute pancreatitis, but whether increased triglyceride (TG) levels are related to the severity of pancreatitis remains unclear. The aim of this study was to assess the relationship between hyperlipidaemia and disease severity of hypertriglycaeridemic pancreatitis.

METHODS

From 2016 to 2018, patients with hypertriglyceridaemic pancreatitis presented within 24 hours from symptom onset were retrospectively enrolled. The severity was classified by the Atlanta classification 2012. The demographic and clinical characteristics of patients were compared with respect to severity stratification and different TG categories, respectively. The relationships of admission TG levels and disease severity were assessed with Spearman's rank correlation test and Linear-by-Linear Association test.

RESULTS

Among 256 patients included, 125 (48.8%) were diagnosed with mild (MAP), 76 (29.7%) with moderate (MSAP) and 55 (21.5%) with severe acute pancreatitis (SAP). The mean TGs (standard derivation) on admission in patients with MAP, MSAP and SAP were 21.6 (15.2) mmol/L (1913 [1346] mg/dL), 34.6 (22.6) mmol/L (3065 [2002] mg/dL) and 41.5 (32.5) mmol/L (3676 [2879] mg/dL), respectively (P < .001). Patients were then categorised based on their TG levels. TG categories had a strong positive correlation with the disease severity (Rho = 0.34, P < .001). Positive trend for the association across increasing TG categories and SAP was observed (P < .001).

CONCLUSIONS

Elevated serum TG levels at the time of admission seem to correlate positively with the severity of hypertriglyceridaemia-induced acute pancreatitis.

Management of Hypertriglyceridemia Induced Acute Pancreatitis

Hypertriglyceridemia is an uncommon but a well-established etiology of acute pancreatitis leading to significant morbidity and mortality. The risk and severity of acute pancreatitis increase with increasing levels of serum triglycerides. It is crucial to identify hypertriglyceridemia as the cause of pancreatitis and initiate appropriate treatment plan. Initial supportive treatment is similar to management of other causes of acute pancreatitis with additional specific therapies tailored to lower serum triglycerides levels. This includes plasmapheresis, insulin, heparin infusion, and hemofiltration. After the acute episode, diet and lifestyle modifications along with hypolipidemic drugs should be initiated to prevent further episodes. Currently, there is paucity of studies directly comparing different modalities. This article provides a comprehensive review of management of hypertriglyceridemia induced acute pancreatitis. We conclude by summarizing our treatment approach to manage hypertriglyceridemia induced acute pancreatitis.

Antithrombin III and D-dimer levels as indicators of disease severity in patients with hyperlipidaemic or biliary acute pancreatitis

Objective To assess changes in anticoagulation and fibrinolytic systems between biliary and hyperlipidaemic acute pancreatitis (AP). Methods Patients with biliary or hyperlipidaemic AP were enrolled. Demographic and clinical data were collected, and antithrombin III (ATIII), protein C, protein S, and D-dimer levels were investigated. Results A total of 45 patients with biliary AP and 50 patients with hyperlipidaemic AP were included (68 with mild AP and 27 with moderately-severe AP). ATIII and protein C levels in the mild AP group were significantly higher, but prothrombin time and D-dimer were significantly lower, versus the moderately-severe AP group. ATIII and D-dimer were found to be risk factors for moderately-severe AP. ATIII could predict AP severity, particularly in patients with biliary AP. D-dimer was a sensitive and specific predictor for disease severity in patients with AP, particularly in patients with hyperlipidaemic AP. Conclusion ATIII and protein C levels decreased as severity of AP increased, particularly in cases of biliary AP. D-dimer levels increased with severity of AP, particularly in hyperlipidaemic AP. ATIII and D-dimer may be useful biomarkers for assessing AP severity in patients with biliary and hyperlipidaemic AP, respectively.

Prospective, Multicentre, Nationwide Clinical Data from 600 Cases of Acute Pancreatitis

Objective

The aim of this study was to analyse the clinical characteristics of acute pancreatitis (AP) in a prospectively collected, large, multicentre cohort and to validate the major recommendations in the IAP/APA evidence-based guidelines for the management of AP.

Design

Eighty-six different clinical parameters were collected using an electronic clinical research form designed by the Hungarian Pancreatic Study Group.

Patients

600 adult patients diagnosed with AP were prospectively enrolled from 17 Hungarian centres over a two-year period from 1 January 2013.

Main Results

With respect to aetiology, biliary and alcoholic pancreatitis represented the two most common forms of AP. The prevalence of biliary AP was higher in women, whereas alcoholic AP was more common in men. Hyperlipidaemia was a risk factor for severity, lack of serum enzyme elevation posed a risk for severe AP, and lack of abdominal pain at admission demonstrated a risk for mortality. Abdominal tenderness developed in all the patients with severe AP, while lack of abdominal tenderness was a favourable sign for mortality. Importantly, lung injury at admission was associated with mortality. With regard to laboratory parameters, white blood cell count and CRP were the two most sensitive indicators for severe AP. The most common local complication was peripancreatic fluid, whereas the most common distant organ failure in severe AP was lung injury. Deviation from the recommendations in the IAP/APA evidence-based guidelines on fluid replacement, enteral nutrition and timing of interventions increased severity and mortality.

Conclusions

Analysis of a large, nationwide, prospective cohort of AP cases allowed for the identification of important determinants of severity and mortality. Evidence-based guidelines should be observed rigorously to improve outcomes in AP.

Relationship between Plasma Triglyceride Level and Severity of Hypertriglyceridemic Pancreatitis

Background

Hypertriglyceridemia is the third most common cause of acute pancreatitis, but whether the level of triglyceride (TG) is related to severity of pancreatitis is unclear.

Aim

To evaluate the effect of TG level on the severity of hypertriglyceridemic pancreatitis (HTGP).

Design

Retrospective cohort study.

Methods

We reviewed the records of 144 patients with HTGP from 1999 to 2013 at Tri-Service General Hospital. Patients with possible etiology of pancreatitis, such as gallstones, those consuming alcohol or drugs, or those with infections were excluded. The classification of severity of pancreatitis was based on the revised Atlanta classification. We allocated the patients into high-TG and low-TG groups based on the optimal cut-off value (2648 mg/dL), which was derived from the receiver operating characteristic (ROC) curve between TG level and severity of HTGP. We then compared the clinical characteristics, pancreatitis severity, and mortality rates of the groups.

Results

There were 66 patients in the low-TG group and 78 patients in the high-TG group. There was no significant difference in the age, sex ratio, body mass index, and comorbidity between the 2 groups. The high-TG group had significantly higher levels of glucose (P = 0.022), total cholesterol (P = 0.002), and blood urea nitrogen (P = 0.037), and lower levels of sodium (P = 0.003) and bicarbonate (P = 0.002) than the low-TG group. The incidences of local complication (P = 0.002) and severe and moderate form of pancreatitis (P = 0.004) were significantly higher in the high-TG group than in the low-TG group. The mortality rate was higher in the high-TG group than in the low-TG group (P = 0.07).

Conclusions

Higher TG level in patients with HTGP may be associated with adverse prognosis, but randomized and prospective studies are needed in the future verify this relationship.

Different Clinical Presentations of Hyperlipidemic Acute Pancreatitis: A Retrospective Study

OBJECTIVES

The goal of this study was to summarize the clinical features of hyperlipidemic acute pancreatitis (HLAP), and help clinicians understand the characteristic presentations of HLAP.

METHODS

From July 2009 to June 2013, 1073 cases of acute pancreatitis were retrospectively assessed. The clinical characteristics of HLAP and non-HLAP were statistically analyzed.

RESULTS

The etiologic ratio of HLAP in acute pancreatitis rose from 13% in 2009 to 25.6% in 2013. Diabetes mellitus, fatty liver, and acute pancreatitis recurrence were positively correlated with HLAP, and female sex, age (>60 years), and alkaline phosphatase level were negatively correlated with HLAP. The diagnostic accuracy of amylase in HLAP was only 40.38%, compared with lipase (91.83%). Different cutoff points of serum triglyceride on day 1 (5.33 mmol/L), day 2 (2.77 mmol/L), and day 3 (2.18 mmol/L) could be used to obtain an accurate diagnosis of HLAP. Higher incidences of acute peripancreatic fluid collection, renal failure, and severe acute pancreatitis were also observed in patients with HLAP.

CONCLUSIONS

Different clinical presentations of HLAP should be applied to be distinguished from non-HLAP in the clinic.

[Plasmapheresis in the treatment of hypertriglyceridemia]

The authors present the case of a 38-year-old woman with severe hypertriglyceridemia-induced acute recurrent pancreatitis (triglyceride 16 761 mg/dl, 189.4 mmol/l). According to the knowledge of the authors, such a high triglyceride has not been previously reported in Hungarian and international scientific literature. The patient received conventional treatment (fluid replacement, analgesic, antibiotics, discontinuation of oral intake) and plasmapheresis too. After two sessions of plasmapheresis with one month interval the clinical and laboratory parameters greatly improved. Severe hypertriglyceridemia (triglyceride level more than 1000 mg/dl, ≈11.3 mmol/l) is an independent risk factor for acute pancreatitis. Plasmapheresis seems to be safe and effective to rapidly decrease triglyceride levels and to remove the causative agent for pancreatitis in a patient with severe hypertriglyceridemia.

Fatty liver in acute pancreatitis: characteristics in magnetic resonance imaging

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.

Recent progress in understanding the pathogenesis of severe acute pancreatitis

Severe acute pancreatitis (SAP) is an acute abdominal disease that is characterized by sudden onset, quick progression, many complications and high mortality. Multiple organ dysfunction syndrome (MODS) is still regarded as the main cause of death in SAP patients. Nowadays, the mortality rate for patients with SAP in developed countries is 22.7%. In the early 21st century, the mortality reached 15.60%-23.77% in mainland China. However, the etiology, pathogenesis and pathophysiology of SAP remains unclear, resulting in puzzle or perplexity in choosing and developing treatment strategies for SAP. This paper reviews recent progress in understanding the pathogenesis of SAP.