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Pahomeanu MR, Ojog D, Nițu DT, Diaconu IȘ, Nayyerani H, Negreanu L. Acute Pancreatitis and Type 2 Diabetes Mellitus: The Chicken-Egg Paradox-A Seven-Year Experience of a Large Tertiary Center. J Clin Med 2024; 13:1213. [PMID: 38592695 PMCID: PMC10931585 DOI: 10.3390/jcm13051213] [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: 02/03/2024] [Revised: 02/10/2024] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Preexisting type 2 diabetes mellitus (T2DM) has been shown in some studies as a risk factor and a severity factor for acute pancreatitis (AP). In this study, we aimed to demonstrate the link between T2DM and AP using data from a large retrospective epidemiological registry in a tertiary center. (2) Methods: We conducted a retrospective, large-cohort study of 1855 cases of AP and recurrent AP drawn from the seven-year consecutive hospitalization electronic health records of the largest acute-care tertiary teaching center in Romania. (3) Results: We observed a significant association between T2DM and a more severe course of the disease, and between T2DM and admission to the intensive care unit (ICU) due to AP, in our cohort using a chi-square test. However, we did not see a meaningful difference in comparing LoS-ICU between T2DM-AP and OAP (other known cause of AP). AP patients with T2DM had a greater probability of a severe course of the disease and were more likely to be admitted to the ICU than to the OAP. (4) Conclusions: The association between T2DM and AP remains a topic very representative of the "chicken-egg paradox". We need further research on DM-related AP and their bidirectional association as our study is limited by its retrospective design.
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Affiliation(s)
- Mihai Radu Pahomeanu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Bucharest Acute Pancreatitis Index (BUC-API) Study Group, 077135 Mogoșoaia, Romania
- Internal Medicine and Gastroenterology Department, University Emergency Hospital of Bucharest, 050098 Bucharest, Romania
| | - Damiana Ojog
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Bucharest Acute Pancreatitis Index (BUC-API) Study Group, 077135 Mogoșoaia, Romania
| | - Diana Teodora Nițu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Bucharest Acute Pancreatitis Index (BUC-API) Study Group, 077135 Mogoșoaia, Romania
| | - Irina Ștefania Diaconu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Bucharest Acute Pancreatitis Index (BUC-API) Study Group, 077135 Mogoșoaia, Romania
| | - Hosein Nayyerani
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Bucharest Acute Pancreatitis Index (BUC-API) Study Group, 077135 Mogoșoaia, Romania
| | - Lucian Negreanu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Bucharest Acute Pancreatitis Index (BUC-API) Study Group, 077135 Mogoșoaia, Romania
- Internal Medicine and Gastroenterology Department, University Emergency Hospital of Bucharest, 050098 Bucharest, Romania
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Czapári D, Váradi A, Farkas N, Nyári G, Márta K, Váncsa S, Nagy R, Teutsch B, Bunduc S, Erőss B, Czakó L, Vincze Á, Izbéki F, Papp M, Merkely B, Szentesi A, Hegyi P. Detailed Characteristics of Post-discharge Mortality in Acute Pancreatitis. Gastroenterology 2023; 165:682-695. [PMID: 37247642 DOI: 10.1053/j.gastro.2023.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 04/25/2023] [Accepted: 05/12/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND & AIMS The in-hospital survival of patients suffering from acute pancreatitis (AP) is 95% to 98%. However, there is growing evidence that patients discharged after AP may be at risk of serious morbidity and mortality. Here, we aimed to investigate the risk, causes, and predictors of the most severe consequence of the post-AP period: mortality. METHODS A total of 2613 well-characterized patients from 25 centers were included and followed by the Hungarian Pancreatic Study Group between 2012 and 2021. A general and a hospital-based population was used as the control group. RESULTS After an AP episode, patients have an approximately threefold higher incidence rate of mortality than the general population (0.0404 vs 0.0130 person-years). First-year mortality after discharge was almost double than in-hospital mortality (5.5% vs 3.5%), with 3.0% occurring in the first 90-day period. Age, comorbidities, and severity were the most significant independent risk factors for death following AP. Furthermore, multivariate analysis identified creatinine, glucose, and pleural fluid on admission as independent risk factors associated with post-discharge mortality. In the first 90-day period, cardiac failure and AP-related sepsis were among the main causes of death following discharge, and cancer-related cachexia and non-AP-related infection were the key causes in the later phase. CONCLUSION Almost as many patients in our cohort died in the first 90-day period after discharge as during their hospital stay. Evaluation of cardiovascular status, follow-up of local complications, and cachexia-preventing oncological care should be an essential part of post-AP patient care. Future study protocols in AP must include at least a 90-day follow-up period after discharge.
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Affiliation(s)
- Dóra Czapári
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Center for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Alex Váradi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Department of Metagenomics, University of Debrecen, Debrecen, Hungary; Department of Laboratory Medicine, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Gergely Nyári
- Department of Pathology, University of Szeged, Szeged, Hungary
| | - Katalin Márta
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Szilárd Váncsa
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Rita Nagy
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Brigitta Teutsch
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Center for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Stefania Bunduc
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Fundeni Clinical Institute, Bucharest, Romania
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - László Czakó
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Áron Vincze
- Department of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Ferenc Izbéki
- Szent György Teaching Hospital of County Fejér, Székesfehérvár, Hungary
| | - Mária Papp
- Department of Gastroenterology, Institute of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary; Center for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary; Translational Pancreatology Research Group, Interdisciplinary Center of Excellence for Research Development and Innovation, University of Szeged, Szeged, Hungary.
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Antoniak D, Twohig P, Olson K, Samson K, Mitchell C, Eichele D. Lactated Ringer's or Normal Saline for Initial Resuscitation in Patients Hospitalized With Acute Pancreatitis: A Retrospective Database Analysis. Pancreas 2023; 52:e203-e209. [PMID: 37716004 DOI: 10.1097/mpa.0000000000002237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
OBJECTIVES Fluid resuscitation is required in acute pancreatitis (AP) to prevent hypovolemia and organ hypoperfusion. Lactated Ringer's (LR) is a buffered crystalloid with possible advantages in AP versus normal saline (NS). We aim to assess outcomes in patients hospitalized with AP based on fluid used for resuscitation. METHODS In this retrospective analysis, we identified hospital admissions to Veterans Affairs facilities for AP from 2011 to 2017 and grouped by initial resuscitation fluid: LR versus NS. Outcomes included major complications and mortality at 30 and 365 days. Multivariable models were used to adjust for confounding variables. RESULTS A total of 20,049 admissions were included in the study, of which 10% received LR as initial fluid. After adjustment for all available confounders, resuscitation with LR was associated with lower 1-year mortality compared with NS (adjusted odds ratio, 0.61 [95% confidence interval, 0.50-0.76]). Major complication and early mortality were similar between groups. CONCLUSIONS In this study, we demonstrate an association between use of LR as initial resuscitation fluid and reduced 1-year mortality in a large retrospective sample of veterans hospitalized with AP. These results support the use of LR for resuscitation for most patients hospitalized with AP.
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Affiliation(s)
| | | | | | - Kaeli Samson
- Department of Biostatistics, University of Nebraska College of Public Health, Omaha, NE
| | - Christine Mitchell
- Department of Veterans Affairs, Nebraska-Western Iowa Healthcare System, Omaha, NE
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Patients' Perceptions of Experiences of Recovering From Acute Pancreatitis: An Interview Study. Gastroenterol Nurs 2019; 42:233-241. [PMID: 31145247 DOI: 10.1097/sga.0000000000000375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of registered admissions in inpatient care with a diagnosis of acute pancreatitis was 58 per 100,000 capita in Sweden during the year 2013. Although acute pancreatitis is a well-explored area, there is a demand for research from the patients' perceptions. The aim of this study was to describe patients' perceptions of recovering from acute pancreatitis. Data collection for this phenomenographical study included 16 individual semistructured interviews. Analysis was done according to the 7 steps suggested by . Recovery after acute pancreatitis was perceived within 5 categories; a time of physical suffering, an emotional journey, challenges to the usual life and its good qualities, barriers and need for social support, and healthcare as an important factor. Physical and emotional symptoms influence recovery after acute pancreatitis by challenging the good things and things that are taken for granted in everyday life. Promoting factors toward good recovery was a proper support from the social network as well as healthcare providers.
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Long-term Outcome and Causes of Death for Working-age Patients Hospitalized Due to Acute Pancreatitis With a Median Follow-up of 10 Years. Ann Surg 2019; 269:932-936. [DOI: 10.1097/sla.0000000000002612] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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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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Smeets XJNM, Litjens G, da Costa DW, Kievit W, van Santvoort HC, Besselink MGH, Fockens P, Bruno MJ, Kolkman JJ, Drenth JPH, Bollen TL, van Geenen EJM. The association between portal system vein diameters and outcomes in acute pancreatitis. Pancreatology 2018; 18:494-499. [PMID: 29784597 DOI: 10.1016/j.pan.2018.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/20/2018] [Accepted: 05/14/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Acute pancreatitis (AP) progresses to necrotizing pancreatitis in 15% of cases. An important pathophysiological mechanism in AP is third spacing of fluids, which leads to intravascular volume depletion. This results in a reduced splanchnic circulation and reduced venous return. Non-visualisation of the portal and splenic vein on early computed tomography (CT) scan, which might be the result of smaller vein diameter due to decreased venous flow, is associated with infected necrosis and mortality in AP. This observation led us to hypothesize that smaller diameters of portal system veins (portal, splenic and superior mesenteric) are associated with increased severity of AP. METHODS We conducted a post-hoc analysis of data from two randomized controlled trials that included patients with predicted severe and mild AP. The primary endpoint was AP-related mortality. The secondary endpoints were (infected) necrotizing pancreatitis and (persistent) organ failure. We performed additional CT measurements of portal system vein diameters and calculated their prognostic value through univariate and multivariate Poisson regression. RESULTS Multivariate regression showed a significant inverse association between splenic vein diameter and mortality (RR 0.75 (0.59-0.97)). Furthermore, there was a significant inverse association between splenic and superior mesenteric vein diameter and (infected) necrosis. Diameters of all veins were inversely associated with organ failure and persistent organ failure. CONCLUSIONS We observed an inverse relationship between portal system vein diameter and morbidity and an inverse relationship between splenic vein diameter and mortality in AP. Further research is needed to test whether these results can be implemented in predictive scoring systems.
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Affiliation(s)
- X J N M Smeets
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - G Litjens
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D W da Costa
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - W Kievit
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - P Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - T L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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Reid GP, Williams EW, Francis DK, Lee MG. Acute pancreatitis: A 7 year retrospective cohort study of the epidemiology, aetiology and outcome from a tertiary hospital in Jamaica. Ann Med Surg (Lond) 2017; 20:103-108. [PMID: 28808565 PMCID: PMC5537196 DOI: 10.1016/j.amsu.2017.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is a significant cause of acute abdominal pain, morbidity and hospitalisation. There was previously a dearth of studies exploring the incidence, risk factors and outcome of AP in the Caribbean region. MATERIALS AND METHODS All patients with a diagnosis of AP admitted to the University Hospital of the West Indies (UHWI) between 2006 and 2012 were reviewed. The epidemiological profile, risk factors, clinical presentation and outcomes of patients with AP were retrospectively studied. RESULTS There were 70 females and 21 males with a median age of 44 years (range 2-86). The median age of males was significantly higher than that of females (p = 0.041). The incidence of AP was 74 per 100,000 admissions per year. Vomiting and abdominal tenderness were noted in the majority of patients. The most common aetiology was biliary disease (71.4%), idiopathic (12%), post-ERCP (6.6%) and alcohol (5.5%). Alcoholic pancreatitis was only seen in males whereas idiopathic and post-ERCP pancreatitis only occurred in females. The mean duration of hospitalisation was 9.51 ± 8.28 days. Disease severity was mild in 61.1%, moderately severe in 26.7%, and severe in 12.2% of patients. Factors associated with more severe disease included overweight/obesity, idiopathic aetiology and post-ERCP status. The case fatality rate was 2%. CONCLUSION The incidence of AP was 74/100,000 hospital admissions annually. There was an unusual female preponderance, with biliary pancreatitis being the most common type occurring at an equal frequency among males and females. Only 12.2% of the total cases seen were severe. The case fatality rate was 2%. Local health policy should target timely interventions for biliary pancreatitis and should also address the local factors affecting disease severity.
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Affiliation(s)
- Gail P Reid
- Emergency Medicine Division, Department of Surgery, Radiology, Anaesthesia & Intensive Care, The University Hospital of the West Indies, Mona, Jamaica
| | - Eric W Williams
- Emergency Medicine Division, Department of Surgery, Radiology, Anaesthesia & Intensive Care, The University Hospital of the West Indies, Mona, Jamaica
| | - Damian K Francis
- Epidemiology Research Unit, Caribbean Institute for Health Research, The University of the West Indies, Mona, Jamaica
| | - Michael G Lee
- Department of Medicine, The University Hospital of the West Indies, Mona, Jamaica
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Abstract
OBJECTIVES There is limited knowledge of the prognostic indicators after hospital discharge after acute pancreatitis (AP). The aim was to determine risk factors for mortality after discharge in patients admitted with AP. METHODS A retrospective cohort study was conducted, including consecutive patients with AP admitted to the Cleveland Clinic between 2007 and 2011. Clinical data, mortality status, and the date of death were collected. Univariable and multivariable Cox regression was performed to determine variables significantly associated with mortality within a year of discharge. RESULTS Three hundred thirty-one patients were included in the study, current to July 2012. After a mean follow-up of 20 months, 41 subjects (12.4%) died after discharge from the hospital. Thirty-three (10.0%) died within a year after discharge. In univariable analyses, higher Charlson Comorbidity Index, blood urea nitrogen > 20 on admission, higher Bedside Index of Severity in Acute Pancreatitis scores, longer length of stay, and readmission within 30 days were associated with a higher hazard of mortality. In the multivariable analysis, subjects who were readmitted within 30 days had a 4.5 times higher hazard of dying within a year than those who were not readmitted (hazard ratio, 4.5; 95% confidence interval, 2.2-9.1). CONCLUSION A higher Charlson Comorbidity Index, early readmission, and longer hospitalization predict a higher 1-year mortality after AP.
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Skouras C, Hayes AJ, Williams L, Garden OJ, Parks RW, Mole DJ. Early organ dysfunction affects long-term survival in acute pancreatitis patients. HPB (Oxford) 2014; 16:789-96. [PMID: 24712663 PMCID: PMC4159450 DOI: 10.1111/hpb.12259] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 02/19/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effect of early organ dysfunction on long-term survival in acute pancreatitis (AP) patients is unknown. OBJECTIVE The aim of this study was to ascertain whether early organ dysfunction impacts on long-term survival after an episode of AP. METHODS A retrospective analysis was performed using survival data sourced from a prospectively maintained database of patients with AP admitted to the Royal Infirmary of Edinburgh during a 5-year period commencing January 2000. A multiple organ dysfunction syndrome (MODS) score of ≥ 2 during the first week of admission was used to define early organ dysfunction. After accounting for in-hospital deaths, long-term survival probabilities were estimated using the Kaplan-Meier test. The prognostic significance of patient characteristics was assessed by univariate and multivariate analyses using Cox's proportional hazards methods. RESULTS A total of 694 patients were studied (median follow-up: 8.8 years). Patients with early organ dysfunction (MODS group) were found to have died prematurely [mean survival: 10.0 years, 95% confidence interval (CI) 9.4-10.6 years] in comparison with the non-MODS group (mean survival: 11.6 years, 95% CI 11.2-11.9 years) (log-rank test, P = 0.001) after the exclusion of in-hospital deaths. Multivariate analysis confirmed MODS as an independent predictor of long-term survival [hazard ratio (HR): 1.528, 95% CI 1.72-2.176; P = 0.019] along with age (HR: 1.062; P < 0.001), alcohol-related aetiology (HR: 2.027; P = 0.001) and idiopathic aetiology (HR: 1.548; P = 0.048). CONCLUSIONS Early organ dysfunction in AP is an independent predictor of long-term survival even when in-hospital deaths are accounted for. Negative predictors also include age, and idiopathic and alcohol-related aetiologies.
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Affiliation(s)
- Christos Skouras
- Department of Clinical Surgery, College of Medicine and Veterinary Medicine, University of Edinburgh, Royal Infirmary of EdinburghEdinburgh, UK
| | - Alastair J Hayes
- Department of Clinical Surgery, College of Medicine and Veterinary Medicine, University of Edinburgh, Royal Infirmary of EdinburghEdinburgh, UK
| | - Linda Williams
- Centre for Population Health Sciences, University of Edinburgh Medical SchoolEdinburgh, UK
| | - O James Garden
- Department of Clinical Surgery, College of Medicine and Veterinary Medicine, University of Edinburgh, Royal Infirmary of EdinburghEdinburgh, UK
| | - Rowan W Parks
- Department of Clinical Surgery, College of Medicine and Veterinary Medicine, University of Edinburgh, Royal Infirmary of EdinburghEdinburgh, UK
| | - Damian J Mole
- Department of Clinical Surgery, College of Medicine and Veterinary Medicine, University of Edinburgh, Royal Infirmary of EdinburghEdinburgh, UK,Correspondence, Damian J. Mole, Centre for Inflammation Research (W2.13), Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4SA, UK. Tel: + 44 131 242 3616. Fax: + 44 131 242 3617. E-mail:
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Acharya C, Navina S, Singh VP. Role of pancreatic fat in the outcomes of pancreatitis. Pancreatology 2014; 14:403-8. [PMID: 25278311 PMCID: PMC4185152 DOI: 10.1016/j.pan.2014.06.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 06/19/2014] [Accepted: 06/19/2014] [Indexed: 12/11/2022]
Abstract
The role of obesity in relation to various disease processes is being increasingly studied, with reports over the last several years increasingly mentioning its association with worse outcomes in acute disease. Obesity has also gained recognition as a risk factor for severe acute pancreatitis (SAP).The mortality in SAP may be as high as 30% and is usually attributable to multi system organ failure (MSOF) earlier in the disease, and complications of necrotizing pancreatitis later [9-11]. To date there is no specific treatment for acute pancreatitis (AP) and the management is largely expectant and supportive. Obesity in general has also been associated with poor outcomes in sepsis and other pathological states including trauma and burns. With the role of unsaturated fatty acids (UFA) as propagators in SAP having recently come to light and with the recognition of acute lipotoxicity, there is now an opportunity to explore different strategies to reduce the mortality and morbidity in SAP and potentially other disease states associated with such a pathophysiology. In this review we will discuss the role of fat and implications of the consequent acute lipotoxicity on the outcomes of acute pancreatitis in lean and obese states and during acute on chronic pancreatitis.
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Affiliation(s)
- Chathur Acharya
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Acharya C, Cline RA, Jaligama D, Noel P, Delany JP, Bae K, Furlan A, Baty CJ, Karlsson JM, Rosario BL, Patel K, Mishra V, Durgampudi C, Yadav D, Navina S, Singh VP. Fibrosis reduces severity of acute-on-chronic pancreatitis in humans. Gastroenterology 2013; 145:466-75. [PMID: 23684709 PMCID: PMC3964816 DOI: 10.1053/j.gastro.2013.05.012] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Revised: 04/15/2013] [Accepted: 05/06/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Acute pancreatitis (AP) and chronic pancreatitis (CP) share etiologies, but AP can be more severe and is associated with a higher rate of mortality. We investigated features of CP that protect against severe disease. The amount of intrapancreatic fat (IPF) is increased in obese patients and fibrosis is increased in patients with CP, so we studied whether fibrosis or fat regulate severity of AP attacks in patients with CP. METHODS We reviewed records from the University of Pittsburgh Medical Center/Presbyterian Hospital Autopsy Database (1998-2008) for patients with a diagnosis of AP (n = 23), CP (n = 35), or both (AP-on-CP; n = 15). Pancreatic histology samples from these patients and 50 randomly selected controls (no pancreatic disease) were analyzed, and IPF data were correlated with computed tomography data. An adipocyte and acinar cell Transwell coculture system, with or without collagen type I, was used to study the effects of fibrosis on acinar-adipocyte interactions. We studied the effects of nonesterified fatty acids (NEFAs) and adipokines on acinar cells in culture. RESULTS Levels of IPF were significantly higher in nonobese patients with CP than in nonobese controls. In patients with CP or AP-on-CP, areas of IPF were surrounded by significantly more fibrosis than in controls or patients with AP. Fat necrosis-associated peri-fat acinar necrosis (PFAN, indicated by NEFA spillage) contributed to most of the necrosis observed in samples from patients with AP; however, findings of peri-fat acinar necrosis and total necrosis were significantly lower in samples from patients with CP or AP-on-CP. Fibrosis appeared to wall off the fat necrosis and limit peri-fat acinar necrosis, reducing acinar necrosis. In vitro, collagen I limited the lipolytic flux between acinar cells and adipocytes and prevented increases in adipokines in the acinar compartment. This was associated with reduced acinar cell necrosis. However, NEFAs, but not adipokines, caused acinar cell necrosis. CONCLUSIONS Based on analysis of pancreatic samples from patients with CP, AP, or AP-on-CP and in vitro studies, fibrosis reduces the severity of acute exacerbations of CP by reducing lipolytic flux between adipocytes and acinar cells.
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Affiliation(s)
- Chathur Acharya
- Department of Medicine University of Pittsburgh Medical Center
Passavant
| | - Rachel A. Cline
- Department of Medicine, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Deepthi Jaligama
- Department of Medicine University of Pittsburgh Medical Center
Passavant
| | - Pawan Noel
- Department of Medicine, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - James P. Delany
- Department of Medicine, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Kyongtae Bae
- Department of Radiology, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Alessandro Furlan
- Department of Radiology, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Catherine J. Baty
- Department of Cell Biology & Physiology, University of
Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15206
| | - Jenny M. Karlsson
- Department of Cell Biology & Physiology, University of
Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15206
| | - Bedda L Rosario
- Department of Epidemology, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Krutika Patel
- Department of Medicine, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Vivek Mishra
- Department of Medicine, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Chandra Durgampudi
- Department of Medicine University of Pittsburgh Medical Center
Passavant
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Sarah Navina
- Department of Pathology, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
| | - Vijay P. Singh
- Department of Medicine, University of Pittsburgh, 200 Lothrop
Street, Pittsburgh, PA 15206
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Yokoyama A, Mizukami T, Matsui T, Yokoyama T, Kimura M, Matsushita S, Higuchi S, Maruyama K. Genetic polymorphisms of alcohol dehydrogenase-1B and aldehyde dehydrogenase-2 and liver cirrhosis, chronic calcific pancreatitis, diabetes mellitus, and hypertension among Japanese alcoholic men. Alcohol Clin Exp Res 2013; 37:1391-401. [PMID: 23550892 DOI: 10.1111/acer.12108] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/13/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND The presence of the less-active form of alcohol dehydrogenase-1B encoded by ADH1B*1/*1 (vs. *2 allele) and active form of aldehyde dehydrogenase-2 (ALDH2) encoded by ALDH2*1/*1 (vs. *2 allele) increases the risk of alcoholism in East Asians. METHODS The subjects in this cross-sectional survey were 1,902 Japanese alcoholic men (≥40 years) who underwent ADH1B/ALDH2 genotyping. RESULTS Age-adjusted daily alcohol consumption did not differ according to the ADH1B/ALDH2 genotypes. The age-adjusted odds ratios (AORs; 95% confidence interval) for liver cirrhosis (LC; n = 359, 1.58 [1.19 to 2.09]), chronic calcific pancreatitis (CP; n = 80, 2.24 [1.20 to 4.20]), and diabetes mellitus (DM; n = 383, 1.51 [1.15 to 1.99]) were higher in the ADH1B*2 allele carriers than in the ADH1B*1/*1 carriers. The AORs for LC (1.43 [1.01 to 2.02]), CP (1.68 [0.80 to 3.53]), DM (1.63 [1.15 to 2.30]), and hypertension (HT; n = 495, 1.52 [1.11 to 2.07]) were higher in the ALDH2*1/*1 carriers than in the ALDH2*1/*2 carriers. The ADH1B*2-associated AOR for LC was 2.08 (1.46 to 2.94) among those aged 40 to 59 years, but 0.89 (0.56 to 1.43) among those aged 60 years or over, and the interaction between ADH1B genotype and age on the LC risk was significant (p = 0.009). When the group with non-LC and no/mild fibrosis was used as controls, the ADH1B*2-associated AORs increased according to the severity of their liver disease: 1.67 (1.32 to 2.11) for the group with non-LC and serum type IV collagen values ≥200 ng/ml, 1.81 (1.24 to 2.63) for the group of Child-Pugh class A LC, and 3.17 (1.98 to 5.07) for the group with Child-Pugh class B/C LC. Anti-hepatitis C virus (HCV) antibody was positive in 103 patients, and the groups with a high anti-HCV antibody titer and either the ADH1B*2/*2 genotype or the ALDH2*1/*1 genotype had the highest AORs (8.83 and 4.90, respectively). The population attributable fraction (PAF) due to the ADH1B*2 allele was 29% for LC, 47% for CP, and 27% for DM, and the PAF due to the ALDH2*1/*1 genotype was 26% for LC, 34% for DM, and 30% for HT. CONCLUSIONS The ADH1B*2 allele increased the AORs for LC, CP, and DM of the alcoholics, and the ALDH2*1/*1 genotype increased their AORs for LC, DM, and HT. HCV infection and genetic susceptibility had a synergistic effect on the AOR for LC.
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Affiliation(s)
- Akira Yokoyama
- National Hospital Organization Kurihama Medical and Addiction Center, Kanagawa, Japan.
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