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Lluís N, Asbun H, Besselink MG, Capurso G, Garg PK, Gelrud A, Khannoussi W, Lee HS, Leppäniemi A, Löhr JM, Mahapatra SJ, Mancilla C, van Santvoort HC, Zapater P, Lluís F, de Madaria E, Ramia JM. International multidisciplinary survey on the initial management of acute pancreatitis: Perspective of point-of-care specialists focused on daily practice. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:325-337. [PMID: 35716156 DOI: 10.1002/jhbp.1201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/17/2022] [Accepted: 05/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The initial management of patients with acute pancreatitis impacts both morbidity and mortality. Point-of-care decisions have been reported to differ from clinical guideline recommendations. METHODS An online anonymous questionnaire was distributed through scientific associations and social media using REDCap. Multivariable logistic regression was used to identify the characteristics of participants associated with compliance with the recommendations. RESULTS A total of 1054 participants from 94 countries completed the questionnaire; median age (IQR) was 39 (32-47) years; 30.7% were women. Among the participants, 37% opted for nonmoderate flow of i.v. fluid, 31% for fluid type other than Ringer's lactate; 73.4% were in favor of nil per os to patients who could eat, 75.5% for other than enteral feeding to patients with oral intolerance; 15.5% used prophylactic antibiotic in patients with severe acute pancreatitis, 34.1% in necrotizing acute pancreatitis, and 27.4% in patients with systemic inflammatory response syndrome; 27.8% delayed cholecystectomy after biliary acute pancreatitis. Participants with publications in PubMed on acute pancreatitis showed better compliance (OR, 1.62; 95% CI: 1.15-2.32; P = .007) with recommendations of the clinical guidelines. CONCLUSIONS Feeding and nutrition require the greatest improvement efforts, but also the use of prophylactic antibiotics and timing of cholecystectomy should be improved.
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Affiliation(s)
- Nuria Lluís
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
| | - Horacio Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Andres Gelrud
- Pancreatic Disease Center, Interventional Endoscopy, Miami Cancer Institute, Gastro Health, Miami, Florida, USA
| | - Wafaa Khannoussi
- Hepato-Gastroenterology Department, Mohammed VI University Hospital, Oujda, Morocco.,Laboratoire de Recherche des Maladies Digestives (LARMAD), Mohammed The First University, Oujda, Morocco
| | - Hong Sik Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ari Leppäniemi
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | | | | | - Carla Mancilla
- Gastroenterology Section and Critical Care Unit, University of Chile Clinical Hospital, Santiago, Chile
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Pedro Zapater
- Health and Biomedical Research Institute of Alicante (ISABIAL), Alicante, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Felix Lluís
- Health and Biomedical Research Institute of Alicante (ISABIAL), Alicante, Spain
| | - Enrique de Madaria
- Health and Biomedical Research Institute of Alicante (ISABIAL), Alicante, Spain.,Department of Gastroenterology, General University Hospital of Alicante, Alicante, Spain
| | - José Manuel Ramia
- Health and Biomedical Research Institute of Alicante (ISABIAL), Alicante, Spain.,Department of Surgery, General University Hospital of Alicante, Alicante, Spain
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Lu J, Ding Y, Qu Y, Mei W, Guo Y, Fang Z, Qu C, Gao C, Cao F, Li F, Feng Y. Risk Factors and Outcomes of Multidrug-Resistant Bacteria Infection in Infected Pancreatic Necrosis Patients. Infect Drug Resist 2022; 15:7095-7106. [PMID: 36483142 PMCID: PMC9725918 DOI: 10.2147/idr.s387384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/18/2022] [Indexed: 08/30/2023] Open
Abstract
OBJECTIVE The incidence of acute pancreatitis (AP) is increasing. Twenty percent of AP patients with developing necrotizing pancreatitis (NP), while ~40-70% of NP patients develop potentially fatal infectious complications. When patients are suspected or confirmed infected pancreatic necrosis (IPN), antibiotics should be administered timeously to control the infection, but long-term use of antibiotics can lead to multidrug-resistant bacteria (MDRB) infection and eventually to increased mortality. Our study aimed to determine the incidence of MDRB infection and evaluate the risk factors for MDRB infection in IPN patients. METHODS Clinical data of IPN patients admitted to the general surgery department of Xuanwu Hospital of Capital Medical University between January 1, 2014, and December 31, 2021, were retrospectively analyzed. RESULTS IPN patients (n = 267) were assigned to MDRB infection (n = 124) and non-MDRB infection (n = 143) groups. On admission, patients in the MDRB group had a higher modified computer tomography severity index (CTSI) score (P < 0.05), pancreatic necrosis degree, and PCT level (P < 0.05) than those in the non-MDRB group, and the prognosis of patients in MDRB group was poor. The most common gram-negative bacteria were Acinetobacter baumannii (n = 117), the most common gram-positive bacteria were Enterococcus faecium (n = 98), and the most common fungal infection was Candida albicans (n = 47). Multivariable analysis showed that complications of EPI (OR: 4.116, 95% CI: 1.381-12.271, P = 0.011), procalcitonin (PCT) level at admission (OR: 2.728, 95% CI: 1.502-4.954, P = 0.001), and degree of pancreatic necrosis (OR: 2.741, 95% CI: 1.109-6.775, P = 0.029) were independent risk factors for MDRB infection in IPN patients. CONCLUSION We identified common infectious strains and risk factors for MDRB infection in IPN patients.
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Affiliation(s)
- Jiongdi Lu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yixuan Ding
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yuanxu Qu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wentong Mei
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yulin Guo
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhen Fang
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chang Qu
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chongchong Gao
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Feng Cao
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fei Li
- Clinical Center of Acute Pancreatitis, Capital Medical University, Beijing, People’s Republic of China
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yulu Feng
- Department of Pediatric, Chui Yang Liu Hospital Affiliated Tsinghua University, Beijing, People’s Republic of China
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3
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Adherence to Guidelines Influenced the Mortality, Hospital Stay, and Health Care System Costs in Patients With Acute Pancreatitis. Pancreas 2022; 51:943-949. [PMID: 36607938 DOI: 10.1097/mpa.0000000000002118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The primary end point was the compliance rate with guidelines. The secondaries were mortality, hospital stay, and costs. METHODS This study included 1904 patients with acute pancreatitis (AP): group A, diagnosed before 2013, and group B, after 2013. RESULTS The compliance rate was 0.6%. The compliance rates increased for fluid resuscitation (3.3% vs 13.7%, P < 0.001), for antibiotics use (21.9% vs 28.1%, P = 0.002), for oral feeding (55.0% vs 49.7%, P = 0.007), and for correct use of endoscopic retrograde cholangiopancreatography (ERCP) (83% vs 91.9%, P < 0.001). Compliance to severity assessment with computed tomography (odds ratio [OR], 0.4; P = 0.029), parenteral nutrition recommendations (OR, 0.3; P = 0.009), and early surgery (OR, 0.3; P = 0.010) reduced the mortality. Compliance to antibiotic therapy (OR, 0.6; P < 0.001), correct use of parenteral nutrition (OR, 0.3; P < 0.001), correct use of ERCP (OR, 0.5; P < 0.001), and early surgery (OR, 0.3; P = 0.010) reduced hospital stay. The compliance reduced the costs for parenteral nutrition (P < 0.001), correct use of ERCP (P = 0.011), and surgery (P = 0.010). CONCLUSIONS The adherence to guidelines for AP was low. Compliance could reduce mortality, prolonged hospital stay, and costs.
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Siriwardena AK, Jegatheeswaran S, Mason JM, Siriwardena AK, Jegatheeswaran S, Mason JM, Baltatzis M, Sheen AJ, O'Reilly DA, Jamdar S, Deshpande R, De Liguori Carino N, Satyadas T, Qamruddin A, Hayden K, Parker MJ, Butler J, McIntyre B. A procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis (PROCAP): a single-centre, patient-blinded, randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7:913-921. [DOI: 10.1016/s2468-1253(22)00212-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/08/2022] [Accepted: 06/17/2022] [Indexed: 01/18/2023]
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Compliance with evidence-based clinical guidelines in the management of acute biliary pancreatitis: the MANCTRA-1 study protocol. Updates Surg 2021; 73:1757-1765. [PMID: 34142315 PMCID: PMC8211303 DOI: 10.1007/s13304-021-01118-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/14/2021] [Indexed: 12/13/2022]
Abstract
Despite existing evidence-based practice guidelines for the management of biliary acute pancreatitis (AP), the clinical compliance with recommendations is overall poor. Studies in this field have identified significant discrepancies between evidence-based recommendations and daily clinical practice. The most commonly reported gaps between clinical practice and AP guidelines include the indications for CT scan, need and timing of artificial nutritional support, indications for antibiotics, and surgical/endoscopic management of biliary AP. The MANCTRA-1 (coMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis) study is aiming to identify the areas for quality improvement that will require new implementation strategies. The study primary objective is to evaluate which items of the current AP guidelines are commonly disregarded and if they correlate with negative clinical outcomes according to the different clinical presentations of the disease. We attempt to summarize the main areas of sub-optimal care due to the lack of compliance with current guidelines to provide the basis for introducing a number of bundles in AP patients’ management to be implemented during the next years. The MANCTRA-1 study is an international multicenter, retrospective cohort study with the purpose to assess the outcomes of patients admitted to hospital with a diagnosis of biliary AP and the compliance of surgeons worldwide to the most up-to-dated international guidelines on biliary AP. ClinicalTrials.Gov ID Number: NCT04747990, Date: February 23, 2021. Protocol Version V2.2.
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Talukdar R, Tsuji Y, Jagtap N, Pradeep R, Rao GV, Reddy DN. Non-compliance to practice guidelines still exist in the early management of acute pancreatitis: Time for reappraisal? Pancreatology 2021; 21:S1424-3903(21)00471-3. [PMID: 34049823 DOI: 10.1016/j.pan.2021.05.301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Earlier national surveys on the management of acute pancreatitis (AP) had reported non-compliance to practice guidelines. In the past decade, several guidelines were revised based on new evidence. In this multicenter international survey, we aimed to evaluate the practice patterns of early management of AP and compliance to the revised treatment guidelines across different disciplines and practice environments. METHODS A structured questionnaire was sent via email to a target population of 654 that constituted of medical and surgical gastroenterologists, physicians and general surgeons, paediatricians from academic and non-academic centres across 30 countries. Other than demographic variables, the questionnaire contained items pertaining to early management of AP, such as, assessment at admissions and within first 72 h s, details regarding analgesics, IV hydration, oral/enteral feeding and antibiotic use. RESULTS The response rate was 46.2% and after exclusions, a total of 297 participant's responses were analysed. Majority of the participants were from Asia, followed by Europe and the Americas. 181 (60.9%) claimed to follow practice guidelines, out of which 59 (32.6%) followed more than one. On further probing, only 41.9% were actually compliant to feeding and 59.7% to antibiotic guidelines. Even though participants opted for aggressive hydration, early feeding and avoidance of prophylactic antibiotics, there were non-compliance and discrepancies in titration of fluid therapy, indications of feeding and antibiotic use. DISCUSSION Discrepancies and non-compliance still appear to exist in the early management of AP due to lack of strong evidence. We discuss ways that could improve compliance to the existing guidelines until stronger evidence comes to the fore.
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Affiliation(s)
- Rupjyoti Talukdar
- Dept. of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India; Wellcome-DBT Indian Alliance Labs., Institute of Basic and Translational Research, Asian Healthcare Foundation, Hyderabad, India.
| | - Yoshihisa Tsuji
- Dept. of General Medicine, Sapporo Medical University, Japan
| | - Nitin Jagtap
- Dept. of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - R Pradeep
- Dept. of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - G V Rao
- Dept. of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Dept. of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Abstract
Acute pancreatitis is one of the most common gastrointestinal causes for hospitalization. In 15-20% it evolves into severe necrotizing pancreatitis. Recent studies have shown no association between the initiation of antibiotic therapy in acute pancreatitis and severe outcomes such as organ failure, infection of pancreatic necrosis, extrapancreatic infections or mortality. Specific subgroups with predicted severe acute pancreatitis or both extensive sterile necrosis and persistent organ failure may benefit from prophylactic antibiotics. Local infection develops in 30% of patients with pancreatic necrosis and results in morbidity and mortality. Contrast enhanced computed tomography should be performed in all patients with acute pancreatitis who develop sepsis, organ failure or fail to improve. C-reactive protein is an independent predictor of severe acute pancreatitis. Procalcitonin is the most sensitive laboratory test for detection of pancreatic infection. Antibiotics do however play a large role in patients with suspected or confirmed infected pancreatic necrosis and extrapancreatic infections. In clinical practice most clinicians prescribe antibiotics in the first 3 days of acute pancreatitis which in turns lead to excessive, unjustified use of antibiotics. Deep knowledge of the recent guidelines combined with an individualized management based on right clinical judgment is a rationale approach of patients with acute pancreatitis.
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Affiliation(s)
- Vasiliki Soulountsi
- 1st Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Theodoros Schizodimos
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
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8
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Siriwardena AK, Jegatheeswaran S, Mason JM, Baltatzis M, Chan A, Sheen AJ, O'Reilly D, Jamdar S, Deshpande R, de Liguori Carino N, Satyadas T, Qamruddin A, Hayden K, Parker MJ, Butler J, Rajai A, McIntyre B. PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP): study protocol for a randomised controlled trial. Trials 2019; 20:463. [PMID: 31358032 PMCID: PMC6664733 DOI: 10.1186/s13063-019-3549-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 06/29/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Differentiating infection from inflammation in acute pancreatitis is difficult, leading to overuse of antibiotics. Procalcitonin (PCT) measurement is a means of distinguishing infection from inflammation as levels rise rapidly in response to a pro-inflammatory stimulus of bacterial origin and normally fall after successful treatment. Algorithms based on PCT measurement can differentiate bacterial sepsis from a systemic inflammatory response. The PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP) trial tests the hypothesis that a PCT-based algorithm to guide initiation, continuation and discontinuation of antibiotics will lead to reduced antibiotic use in patients with acute pancreatitis and without an adverse effect on outcome. METHODS This is a single-centre, randomised, controlled, single-blind, two-arm pragmatic clinical and cost-effectiveness trial. Patients with a clinical diagnosis of acute pancreatitis will be allocated on a 1:1 basis to intervention or standard care. Intervention will involve the use of a PCT-based algorithm to guide antibiotic use. The primary outcome measure will be the binary outcome of antibiotic use during index admission. Secondary outcome measures include: safety non-inferiority endpoint all-cause mortality; days of antibiotic use; clinical infections; new isolates of multiresistant bacteria; duration of inpatient stay; episode-related mortality and cause; quality of life (EuroQol EQ-5D); and cost analysis. A 20% absolute change in antibiotic use would be a clinically important difference. A study with 80% power and 5% significance (two-sided) would require 97 patients in each arm (194 patients in total): the study will aim to recruit 200 patients. Analysis will follow intention-to-treat principles. DISCUSSION When complete, PROCAP will be the largest randomised trial of the use of a PCT algorithm to guide initiation, continuation and cessation of antibiotics in acute pancreatitis. PROCAP is the only randomised trial to date to compare standard care of acute pancreatitis as defined by the International Association of Pancreatology/American Pancreatic Association guidelines to patients having standard care but with all antibiotic prescribing decisions based on PCT measurement. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number, ISRCTN50584992. Registered on 7 February 2018.
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Affiliation(s)
- Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK. .,Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.
| | | | - James M Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Anthony Chan
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Aali J Sheen
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK.,Centre for Biomedicine, Manchester Metropolitan University, Manchester, UK
| | - Derek O'Reilly
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK.,Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Rahul Deshpande
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Nicola de Liguori Carino
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Thomas Satyadas
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Ahmed Qamruddin
- Department of Microbiology, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Katharine Hayden
- Department of Clinical Biochemistry, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Michael J Parker
- Critical Care Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - John Butler
- Critical Care Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Azita Rajai
- Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Ben McIntyre
- Pharmacy Department, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
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Does Etiology of Pancreatitis Matter? Differences in Outcomes Among Patients With Post-Endoscopic Retrograde Cholangiopancreatography, Acute Biliary, and Alcoholic Pancreatitis. Pancreas 2019; 48:574-578. [PMID: 30946237 DOI: 10.1097/mpa.0000000000001283] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We compared outcomes of acute alcoholic pancreatitis (AAP), acute biliary pancreatitis (ABP), and post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). METHODS This was a retrospective cohort study conducted at a tertiary care center between June 2007 and June 2012. RESULTS A total of 300 (68%) patients were diagnosed with AAP, 88 (20%) with ABP, and 55 (12%) with PEP. Longer length of hospital stay (LOHS) was more common in ABP (23%) as compared with AAP (10%) and PEP (7%, P = 0.025). Pseudocyst (P = 0.048), organ failure (OF) (P = 0.01), need for interventions (P ≤ 0.001), and mortality (P = 0.002) occurred more in ABP as compared with other groups. Systemic inflammatory response syndrome was associated with LOHS of more than 10 days (P = 0.01) and multi-OF (P = 0.05). Chronic pancreatitis was associated more with pseudocyst (P < 0.001) and mortality (P = 0.03). Serum urea nitrogen of greater than 25 g/dL predicted LOHS of more than 10 days (P = 0.02), OF (P < 0.001), multi-OF (P < 0.001), and persistent OF (P < 0.001). CONCLUSIONS Acute biliary pancreatitis is a more severe disease compared with PEP and AAP. Chronic pancreatitis, systemic inflammatory response syndrome, and high serum urea nitrogen are important predictors of morbidity.
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10
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Weiss FU, Laemmerhirt F, Lerch MM. Etiology and Risk Factors of Acute and Chronic Pancreatitis. Visc Med 2019; 35:73-81. [PMID: 31192240 DOI: 10.1159/000499138] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/25/2019] [Indexed: 12/24/2022] Open
Abstract
Based on the recognition of common etiological and genetic risk factors, acute and chronic pancreatitis are increasingly regarded as a continuum of the same disease, with a significant overlap of clinical manifestations and phenotypes but distinct morphological and imaging appearances. Recent population-based and cohort studies have found that tobacco smoke conveys a greater risk than immoderate alcohol consumption for the development of chronic pancreatitis, and hypertriglyceridemia has been identified as a risk factor for acute pancreatitis - even when plasma levels are only mildly elevated. Hereditary pancreatitis, in its autosomal dominant form, is associated with mutations in the cationic trypsinogen gene (PRSS1), whereas a number of germline variations in other genes have been found to represent risk factors for chronic as well as acute pancreatitis. For now, most of these involve the pancreatic digestive protease/antiprotease system. Oftentimes, affected patients are burdened with multiple or accumulating risk factors, and genetic traits when combined with environmental toxins compound the chance of developing the disease. Determining the underlying etiology of pancreatitis is worth the effort since formerly intractable varieties such as autoimmune pancreatitis are now becoming increasingly treatable, and subtype-specific therapeutic modalities may become available.
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Affiliation(s)
- Frank Ulrich Weiss
- Department of Medicine A, Greifswald Medical School, Greifswald, Germany
| | - Felix Laemmerhirt
- Department of Medicine A, Greifswald Medical School, Greifswald, Germany
| | - Markus M Lerch
- Department of Medicine A, Greifswald Medical School, Greifswald, Germany
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11
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Tee YS, Fang HY, Kuo IM, Lin YS, Huang SF, Yu MC. Serial evaluation of the SOFA score is reliable for predicting mortality in acute severe pancreatitis. Medicine (Baltimore) 2018; 97:e9654. [PMID: 29443733 PMCID: PMC5839831 DOI: 10.1097/md.0000000000009654] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute severe pancreatitis caused high mortality, and several scoring systems for predicting mortality are available. We evaluated the effectiveness of serial measurement of several scoring systems in patients with acute severe pancreatitis.We retrospectively obtained serial measurements of Ranson, Acute Physiology and Chronic Health Assessment (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scores of 159 patients with acute severe pancreatitis.The overall mortality rate was 20%, and early mortality (in the first 2 weeks) occurred in 10 (7.4%) patients, while late mortality occurred in 17 (12.6%).All scoring systems were reliable for predicting overall and intensive care unit mortality, while the SOFA score on day 7 presented the largest area under the receiver operator characteristic (ROC) curve (0.858, SE 0.055). Changes in scores over time were evaluated for predicting the progression of organ failure, and the change in SOFA score on hospital day 7 or no interval change in SOFA score was associated with higher mortality rates.APACHE II and SOFA scores are both sensitive for predicting mortality in acute pancreatitis. The serial SOFA scores showed reliable for predicting mortality. Hospital day 7 is a reasonable time for SOFA score reassessment to predict late mortality in acute severe pancreatitis.
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Affiliation(s)
- Yu-San Tee
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kweishan, Taoyuan city, Taiwan
| | - Hsin-Yueh Fang
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kweishan, Taoyuan city, Taiwan
| | - I.-Ming Kuo
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kweishan, Taoyuan city, Taiwan
| | - Yann-Sheng Lin
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kweishan, Taoyuan city, Taiwan
| | - Song-Fong Huang
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kweishan, Taoyuan city, Taiwan
| | - Ming-Chin Yu
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kweishan, Taoyuan city, Taiwan
- Department of Surgery, Xiamen Chang Gung Hospital, Xiamen, Fujian, China
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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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Assessing the severity of acute pancreatitis (ASAP) in Switzerland: A nationwide survey on severity assessment in daily clinical practice. Pancreatology 2017; 17:356-363. [PMID: 28284583 DOI: 10.1016/j.pan.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/21/2017] [Accepted: 02/06/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES We aim to assess which tools for severity stratification in acute pancreatitis are used in today's daily clinical practice and to what extent the new Atlanta classification is being implemented by the medical community in Switzerland. METHODS The heads of surgical, medical and emergency departments of Swiss hospitals (n = 83) that directly treat patients with acute pancreatitis were given access to an online survey and asked to forward the questionnaire to their team. The questionnaire consisted of 16 items, including questions about the specialty background of the participants, the allocation of patients with AP, severity assessment, patient management, the role of imaging procedures, and future perspectives. RESULTS A total of 233 participants from 63 hospitals responded (response rate, 74%). A vast majority of participants [198 (87%)] does assess severity. The most frequently used tools are the Ranson [108 (87%)] and APACHE II scores [28 (23%)]. A majority of the participants were not satisfied with the currently available tools to assess severity [130 (59%)]. A minority [15 (12%)] use the revised Atlanta classification to assess the degree of severity in AP. CONCLUSIONS The Ranson score remains the dominant risk stratification tool in clinical practice in Switzerland, followed by the APACHE II score. Other modern instruments, such as the Atlanta 2012 classification, have not yet earned broad recognition and have not reached daily practice. Further efforts must be made to expand physicians' awareness of their existence and significance.
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Oláh A, Romics Jr L. Enteral nutrition in acute pancreatitis: A review of the current evidence. World J Gastroenterol 2014; 20:16123-16131. [PMID: 25473164 PMCID: PMC4239498 DOI: 10.3748/wjg.v20.i43.16123] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
The use of enteral feeding as part of the management of acute pancreatitis dates back almost two decades. This review describes the indications for and limitations of enteral feeding for the treatment of acute pancreatitis using up-to-date evidence-based data. A systematic review was carried out to analyse current data on the use of enteral nutrition in the management of acute pancreatitis. Relevant literature was analysed from the viewpoints of enteral vs parenteral feeding, early vs delayed enteral nutrition, nasogastric vs nasojejunal feeding, and early oral diet and immunonutrition, particularly glutamine and probiotic supplementation. Finally, current applicable guidelines and the effects of these guidelines on clinical practice are discussed. The latest meta-analyses suggest that enteral nutrition significantly reduces the mortality rate of severe acute pancreatitis compared to parenteral feeding. To maintain gut barrier function and prevent early bacterial translocation, enteral feeding should be commenced within the first 24 h of hospital admission. Also, the safety of nasogastric feeding, which eases the administration of enteral nutrients in the clinical setting, is likely equal to nasojejunal feeding. Furthermore, an early low-fat oral diet is potentially beneficial in patients with mild pancreatitis. Despite the initial encouraging results, the current evidence does not support the use of immunoenhanced nutrients or probiotics in patients with acute pancreatitis.
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De Waele JJ, Rello J, Anzueto A, Moreno R, Lipman J, Sakr Y, Pickkers P, Leone M, Ferguson A, Oud L, Vincent JL. Infections and use of antibiotics in patients admitted for severe acute pancreatitis: data from the EPIC II study. Surg Infect (Larchmt) 2014; 15:394-8. [PMID: 24819027 DOI: 10.1089/sur.2012.228] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Infectious complications are frequent in severe acute pancreatitis (SAP) but multinational epidemiologic data are lacking. The aim of the study was to analyze the characteristics of the infectious complications and antimicrobial use in this setting. METHODS One-day point prevalence study of infection in critically ill patients (Extended Prevalence of Infection in the ICU-II study), performed in 1,265 ICUs in 75 countries. RESULTS Of the 13,796 patients in the study, 159 were admitted with SAP. One-hundred sixteen (73%) had infections: 31% intra-abdominal, 16% extra-abdominal, and 26% both. Gram-negative bacteria were more prevalent than gram-positive organisms, anaerobes, or fungi. Therapeutically, penicillins and other beta-lactams were used most frequently. Prophylactic antibiotics were administered to 24% of the patients with SAP. CONCLUSIONS Infections are frequent in patients admitted with SAP; most are intra-abdominal infections. Microbiology is diverse with gram-negative micro-organisms most frequently isolated. Most patients admitted to the ICU for SAP receive antibiotics at some point.
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Affiliation(s)
- Jan J De Waele
- 1 Department of Critical Care Medicine, Ghent Medical School and University Hospital , Ghent, Belgium
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Maraví Poma E, Zubia Olascoaga F, Petrov M, Navarro Soto S, Laplaza Santos C, Morales Alava F, Darnell Martin A, Gorraiz López B, Bolado Concejo F, Casi Villarroya M, Aizcorbe Garralda M, Albeniz Arbizu E, Sánchez-Izquierdo Riera J, Tirapu León J, Bordejé Laguna L, López Camps V, Marcos Neira P, Regidor Sanz E, Jiménez Mendioroz F. SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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SEMICYUC 2012. Recommendations for intensive care management of acute pancreatitis. Med Intensiva 2013; 37:163-79. [PMID: 23541063 DOI: 10.1016/j.medin.2013.01.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/17/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Significant changes in the management of acute pancreatitis have taken place since the 2004 Pamplona Consensus Conference. The objective of this conference has been the revision and updating of the Conference recommendations, in order to unify the integral management of potentially severe acute pancreatitis in an ICU. PARTICIPANTS Spanish and international intensive medicine physicians, radiologists, surgeons, gastroenterologists, emergency care physicians and other physicians involved in the treatment of acute pancreatitis. LEVELS OF EVIDENCE AND GRADES OF RECOMMENDATION: The GRADE method has been used for drawing them up. DRAWING UP THE RECOMMENDATIONS: The selection of the committee members was performed by means of a public announcement. The bibliography has been revised from 2004 to the present day and 16 blocks of questions on acute pancreatitis in a ICU have been drawn up. Firstly, all the questions according to groups have been drawn up in order to prepare one document. This document has been debated and agreed upon by computer at the SEMICYUC Congress and lastly at the Consensus Conference which was held with the sole objective of drawing up these recommendations. CONCLUSIONS Eighty two recommendations for acute pancreatitis management in an ICU have been presented. Of these 84 recommendations, we would emphasize the new determinants-based classification of acute pancreatitis severity, new surgical techniques and nutritional recommendations. Note. This summary only lists the 84 recommendations of the 16 questions blocks except blocks greater relevance and impact of its novelty or because they modify the current management.
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