Management of Severe Acute Pancreatitis

Clinical study of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in hypertriglyceridemia-induced acute pancreatitis and acute biliary pancreatitis with persistent organ failure

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are novel inflammatory indicators that can be used to predict the severity and prognosis of various diseases. We categorize acute pancreatitis by etiology into acute biliary pancreatitis (ABP) and hypertriglyceridemia-induced acute pancreatitis (HTGP).

AIM

To investigate the clinical significance of NLR and PLR in assessing persistent organ failure (POF) in HTGP and ABP.

METHODS

A total of 1450 patients diagnosed with acute pancreatitis (AP) for the first time at Shanxi Bethune Hospital between January 2012 and January 2023 were enrolled. The patients were categorized into two groups according to the etiology of AP: ABP in 530 patients and HTGP in 241 patients. We collected and compared the clinical data of the patients, including NLR, PLR, and AP prognostic scoring systems, within 48 h of hospital admission.

RESULTS

The NLR (9.1 vs 6.9, P < 0.001) and PLR (203.1 vs 160.5, P < 0.001) were significantly higher in the ABP group than in the HTGP group. In the HTGP group, both NLR and PLR were significantly increased in patients with severe AP and those with a SOFA score ≥ 3. Likewise, in the ABP group, NLR and PLR were significantly elevated in patients with severe AP, modified computed tomography severity index score ≥ 4, Japanese Severity Score ≥ 3, and modified Marshall score ≥ 2. Moreover, NLR and PLR showed predictive value for the development of POF in both the ABP and HTGP groups.

CONCLUSION

NLR and PLR vary between ABP and HTGP, are strongly associated with AP prognostic scoring systems, and have predictive potential for the occurrence of POF in both ABP and HTGP.

Acute pancreatitis: A review of diagnosis, severity prediction and prognosis assessment from imaging technology, scoring system and artificial intelligence

Acute pancreatitis (AP) is a potentially life-threatening inflammatory disease of the pancreas, with clinical management determined by the severity of the disease. Diagnosis, severity prediction, and prognosis assessment of AP typically involve the use of imaging technologies, such as computed tomography, magnetic resonance imaging, and ultrasound, and scoring systems, including Ranson, Acute Physiology and Chronic Health Evaluation II, and Bedside Index for Severity in AP scores. Computed tomography is considered the gold standard imaging modality for AP due to its high sensitivity and specificity, while magnetic resonance imaging and ultrasound can provide additional information on biliary obstruction and vascular complications. Scoring systems utilize clinical and laboratory parameters to classify AP patients into mild, moderate, or severe categories, guiding treatment decisions, such as intensive care unit admission, early enteral feeding, and antibiotic use. Despite the central role of imaging technologies and scoring systems in AP management, these methods have limitations in terms of accuracy, reproducibility, practicality and economics. Recent advancements of artificial intelligence (AI) provide new opportunities to enhance their performance by analyzing vast amounts of clinical and imaging data. AI algorithms can analyze large amounts of clinical and imaging data, identify scoring system patterns, and predict the clinical course of disease. AI-based models have shown promising results in predicting the severity and mortality of AP, but further validation and standardization are required before widespread clinical application. In addition, understanding the correlation between these three technologies will aid in developing new methods that can accurately, sensitively, and specifically be used in the diagnosis, severity prediction, and prognosis assessment of AP through complementary advantages.

Enteral Nutrition Versus Parenteral Nutrition on Outcomes in Acute Pancreatitis: Insights From the Nationwide Inpatient Sample

INTRODUCTION

Despite considerable research on the comparison of enteral and parenteral nutrition in patients with acute pancreatitis, there is an ongoing debate about the optimal timing of nutrition initiation, invasiveness of interventions, impact on outcomes, and patient tolerance. Given the gap that still exists in the literature, we investigated the relationship between the mode of nutrition and critical outcomes such as mortality rates, inpatient complications, length of hospitalization, and discharge disposition, using comprehensive national-level data. In addition, we investigated the impact of early enteral nutrition on outcomes in acute pancreatitis.

METHODS

All adult discharges for acute pancreatitis between 2016 and 2018 were analyzed from the National (Nationwide) Inpatient Sample (NIS). Discharges of minors and those involving mixed nutrition were excluded from the analysis. Enteral nutrition and parenteral nutrition subgroups were identified using the International Classification of Diseases, 10th revision (ICD-10) codes. Disease severity was defined using the 2013 revised Atlanta Classification of Acute Pancreatitis, along with the All Patient Refined Diagnosis Related Group (APR-DRG)'s severity of illness and likelihood of mortality variables. Complications were identified using ICD-10 codes from the secondary diagnoses variables within the NIS dataset. Multivariable logistic regression analyses were employed to assess associations between the mode of nutrition and the outcomes of interest.

RESULTS

 A total of 379,410 hospitalizations were studied. About 2,011 (0.53%) received enteral nutrition, while 4,174 (1.1%) received parenteral nutrition. The mean age of the study was 51.7 years (SD 0.1). About 2,280 mortalities were recorded in the study. After adjustments, enteral nutrition was associated with significantly lower odds of mortality (adjusted OR (aOR): 0.833; 95%CI: 0.497-0.933; P<0.001). Parenteral nutrition was linked with significantly greater odds of mortality (aOR: 6.957; 95%CI: 4.730-10.233; P<0.001). Both enteral nutrition and parenteral nutrition were associated with augmented odds of complications and prolonged hospitalization (P<0.001) compared to normal oral feeding. Initiation of enteral nutrition within 24 hours of admission did not improve the odds of mortality in this study (aOR: 5.619; 95%CI: 1.900-16.615; P=0.002).

CONCLUSION

 Enteral nutrition demonstrates better outcomes in mortality rates and systemic complications compared to parenteral nutrition in patients unable to maintain normal oral feeding.

Effects of nitroglycerin combined with continuous regional arterial infusion on severe acute pancreatitis, triglyceride, inflammatory factors and prognosis

Background: To evaluate the effects of nitroglycerin combined with continuous regional arterial infusion (CRAI) on severe acute pancreatitis (SAP), triglyceride (TG), inflammatory factors and prognosis.

Methods: SAP patients were randomly divided into control and observation groups (n=169). The control group was treated with intravenous infusion of nitroglycerin once daily for 2 d, while the observation group was treated with nitroglycerin combined with CRAI for 7 d. Their hospitalization time, abdominal pain relief time, abdominal distension relief time and intestinal function recovery time were recorded. The levels of inflammatory factors, and TG were measured. Their liver and kidney functions, hemorheological indices, prognosis, and adverse reactions were evaluated.

Results: The observation group had significantly shorter hospitalization time, abdominal pain relief time, abdominal distension relief time, and intestinal function recovery time than those of the control group (P<0.05). After treatment, the levels of interleukin-6, tumor necrosis factor-alpha, endothelin, thromboxane A2 and TG significantly decreased in contrast with those before treatment in both groups, especially in the observation group (P<0.05). The hemorheological indices were significantly improved after treatment compared with those before treatment in both groups, and the observation group had better indices (P<0.05). The Acute Physiology and Chronic Health Evaluation-II score declined significantly in both groups after treatment, and the observation group had a more obvious decrease (P<0.05). During follow-up, similar incidence rates of adverse reactions were observed for both groups (P>0.05).

Conclusion: Nitroglycerin combined with CRAI is prominently effective for treating SAP, which can facilitate the health recovery and reduce the incidence of microcirculation disturbance-induced adverse events such as organ failure.

Comparison of modified Glasgow-Imrie, Ranson, and Apache II scoring systems in predicting the severity of acute pancreatitis

&lt;b&gt;Aim:&lt;/b&gt; The course of acute pancreatitis is variable with patients at risk of poor outcomes. The purpose of this study was to compare Modified Glasgow-Imrie, Ranson, and APACHE II scoring systems in predicting the severity of acute pancreatitis. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Material and Methods: &lt;/b&gt; After a brief history, clinical examination and qualifying inclusion criteria, 70 patients (41 women, 29 men) diagnosed with acute pancreatitis were included in the study. The three scores were calculated for each patient and evaluated for their role in the assessment of specific outcomes. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; 34.3% patients were diagnosed with severe acute pancreatitis, while 65.7% patients had mild acute pancreatitis. A strong positive correlation was found between all the prognostic scores and the severity of disease. In the prediction of the severity of disease according to AUC, it was found that Glasgow-Imrie score had an AUC of 0.864 (0.7560.973), followed very closely by APACHE II score with an AUC of 0.863 (0.7580.968). APACHE II had the highest sensitivity (79.17%) in predicting severity while Glasgow-Imrie score was the most specific (97.83%) of all the scores. Patients with a Glasgow-Imrie score above the cut-off value of 3 had more complications and a longer hospital stay. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion:&lt;/b&gt; The Glasgow-Imrie score was comparable to APACHE II score and better than Ranson score statistically in predicting the severity of acute pancreatitis. Its administration in predicting the severity of acute pancreatitis is recommended.

Integrative effects of transcutaneous electrical acustimulation on abdominal pain, gastrointestinal motility, and inflammation in patients with early-stage acute pancreatitis

BACKGROUND/AIMS

Gastrointestinal (GI) dysmotility in acute pancreatitis (AP) aggravates inflammation and results in severe complications. This study aimed to explore effects and possible mechanisms of transcutaneous electrical acustimulation (TEA) on abdominal pain, GI dysmotility, and inflammation in AP patients.

METHODS

Forty-two AP patients were blindly randomized to receive TEA (n = 21) at acupoints PC6 and ST36 or Sham-TEA (n = 21) at sham points for 2 days. Symptom scores, gastric slow waves, autonomic functions (assessed by spectral analysis of heart rate variability), circulatory levels of motilin, ghrelin, and TNF-α were measured before and after the treatment. Sixteen healthy controls (HCs) were also included without treatment for the assessment of gastric slow waves and biochemistry.

KEY RESULTS

Compared with Sham-TEA, TEA decreased abdominal pain score (2.57 ± 1.78 vs. 1.33 ± 1.02, p < 0.05), bloating score (5.19 ± 1.21 vs. 0.76 ± 0.99, p < 0.001), the first defecation time (65.79 ± 19.51 h vs. 51.38 ± 17.19 h, p < 0.05); TEA, but not Sham-TEA, improved the percentage of normal gastric slow waves by 41.6% (p < 0.05), reduced AP severity score (5.52 ± 2.04 vs. 3.90 ± 1.90, p < 0.05) and serum TNF-α (7.59 ± 4.80 pg/ml vs. 4.68 ± 1.85 pg/ml, p < 0.05), and upregulated plasma ghrelin (0.85 ± 0.96 ng/ml vs. 2.00 ± 1.71 ng/ml, p = 0.001) but not motilin (33.08 ± 22.65 pg/ml vs. 24.12 ± 13.95 pg/ml, p > 0.05); TEA decreased sympathetic activity by 15.0% and increased vagal activity by 18.3% (both p < 0.05).

CONCLUSIONS & INFERENCES

TEA at PC6 and ST36 administrated at early stage of AP reduces abdominal pain, improves GI motility, and inhibits inflammatory cytokine, TNF-α, probably mediated via the autonomic and ghrelin mechanisms.

Efficacy and Safety of Thoracic Epidural Analgesia in Patients With Acute Pancreatitis: A Narrative Review

Patients admitted to the intensive care unit with moderate to severe acute pancreatitis carry significant morbidity and mortality. A few unfortunate patients in whom the initial line of treatment fails to show clinical improvement develop multiorgan dysfunction involving lungs (adult respiratory distress syndrome), renal failure, intra-abdominal infections, sepsis, and septic shock, which ultimately leads to prolonged hospitalization and a substantial cost of treatment. The acute abdominal pain experienced by these patients is excruciating and requires multimodal analgesia. Continuous epidural analgesia has been found to provide good quality, opioid-sparing analgesia in these patients. A few studies have also demonstrated that segmental sympathectomy resulting from epidural blockade could lead to lowering of serum amylase and lipase levels improve paralytic ileus, and thus hastens the process of recovery. The present paper aims to discuss the advantages of continuous epidural analgesia in patients with acute pancreatitis of varying severity and to review the existing literature using specific keywords.

Early prediction of severe acute pancreatitis using machine learning

BACKGROUND

Acute pancreatitis (AP) is one of the most common causes of gastrointestinal-related hospitalizations in the United States. Severe AP (SAP) is associated with a mortality rate of nearly 30% and is distinguished from milder forms of AP. Risk stratification to identify SAP cases needing inpatient treatment is an important aspect of AP diagnosis.

METHODS

We developed machine learning algorithms to predict which patients presenting with AP would require treatment for SAP. Three models were developed using logistic regression, neural networks, and XGBoost. Models were assessed in terms of area under the receiver operating characteristic (AUROC) and compared to the Harmless Acute Pancreatitis Score (HAPS) and Bedside Index for Severity in Acute Pancreatitis (BISAP) scores for AP risk stratification.

RESULTS

61,894 patients were used to train and test the machine learning models. With an AUROC value of 0.921, the model developed using XGBoost outperformed the logistic regression and neural network-based models. The XGBoost model also achieved a higher AUROC than both HAPS and BISAP for identifying patients who would be diagnosed with SAP.

CONCLUSIONS

Machine learning may be able to improve the accuracy of AP risk stratification methods and allow for more timely treatment and initiation of interventions.

Heparin-binding protein (HBP) worsens the severity of pancreatic necrosis via up-regulated M1 macrophages activation in acute pancreatitis mouse models

Acute pancreatitis (AP) is one of the most widespread clinical emergencies. Macrophages are the most common immune cells in AP pancreatic tissue and are closely associated with pancreatic necrosis and recovery. The level of heparin-binding protein (HBP) is closely linked to inflammation. In this study, we assessed the effect of HBP on AP tissue necrosis severity and whether HBP is associated with M1 macrophages in pancreatic necrosis. We observed the dynamic changes of HBP levels in the pancreas during acute inflammation in the caerulein-induced AP mice model. We used hematoxylin-eosin staining to evaluate pancreatic edema and necrosis, and to detect infiltration of macrophages by immunohistochemistry. Moreover, expressions of the maker and cytokines of macrophages, including inducible nitric oxide synthase (iNOS), and arginase 1 (Arg-1), interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) mRNA, were detected by real-time polymerase-chain reaction (RT-PCR). High levels of HBP in the pancreas were detected at 48 h, and heparin inhibited HBP expression in AP pancreatic tissue. Inhibiting HBP expression by injecting heparin before AP can alleviate pancreatic necrosis and inhibit F4/80 labeled M1 macrophage infiltration and IL-6, TNF-α, and iNOS mRNA expression. Clodronate liposome (CLDL) intraperitoneally treated mice showed no change in pancreatic HBP levels, but pancreatic macrophage-specific antigen F4/80 and TNF-α, IL-1β, and IL-6 mRNA levels decreased after CLDL treatment. HBP is critical for pancreatic necrosis response in acute pancreatitis by increasing the infiltration of M1 macrophages and promoting the secretion of inflammatory factors, such as TNF-α, IL-6, IL-1β, which can be reduced by heparin.

Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis

Objectives

Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency.

Methods

This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected.

Results

Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications.

Conclusions

CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.

The changes of triacylglycerol and inflammatory factors during dialysis treatment of hypertriglyceridemia during pregnancy and analysis of nursing countermeasure

OBJECTIVE

To investigate the changes of triacylglycerol and inflammatory factors after hypertriglyceridemia acute pancreatitis (HTG-AP) dialysis during pregnancy and to analyze the nursing strategies.

METHODS

50 patients treated with HTG-AP dialysis in our hospital from February 2017 to June 2019 were selected. The patient's vital signs, triglyceride (TG), total cholesterol (TC), TG and TC decline rates before treatment, 1, 3, and 5 days after treatment and inflammatory factors [tumor necrosis factor-α (TNF-α), Interleukin-1β (IL-1β), Interleukin-6 (IL-6), Interleukin-10 (IL-10) level changes] were measured, as well as the acute physiological and chronic health evaluation II (APACHEII), multiple organ dysfunction syndromes (MODS), systemic inflammatory response syndrome (SIRS) and maternal treatment outcomes.

RESULTS

There was no significant change in body temperature before and after treatment (P>0.05); The heart rate, WBC, CRP before and after treatment were statistically different (P<0.05); Compared with before treatment, serum levels of TG and TC significantly decreased after treatment, and the rate of decrease was significantly increased (P<0.05); Compared with before treatment, the levels of inflammatory factors (TNF-α, IL-1β, IL-6, IL-10) gradually decreased after treatment, and the serum levels of patient's TNF-α, IL-1β, IL-6, IL-10 after 5 days of treatment were more significant (P<0.05); Compared with before treatment, APACHEll, MODS and SIRS scores significantly decreased after treatment, and APACHEll, MODS and SIRS scores were better after 5 days of treatment (P<0.05); The mortality rate during treatment was 2.00%; the complication rate was 32.00%, including 5 cases of acute respiratory distress syndrome, 4 cases of pleural effusion, 4 cases of lung infection, 2 cases of acute renal insufficiency and 1 case of shock.

CONCLUSION

Dialysis treatment can promote the recovery of HTG-AP patients promptly, improve triglycerides, and reduce inflammation. After the targeted nursing intervention, the treatment efficacy significantly improved.

Effect of early enteral nutrition support for the management of acute severe pancreatitis: A protocol of systematic review

BACKGROUND

This study aims to assess the effect of early enteral nutrition support (EENS) for the management of acute severe pancreatitis (ASP).

METHODS

This study will search Cochrane Library, PUBMED, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, CNKI, and WANGFANG from their inception to the present without language limitations. In addition, this study will also search clinical trial registry and reference lists of included trials. Eligible comparators will be standard care, medications, and any other interventions. Two authors will independently scan all citations, titles/abstracts, and full-text studies. The study methodological quality will be appraised using Cochrane risk of bias tool. If it is possible, we will pool out data and perform meta-analysis. Strength of evidence for each main outcome will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

This study will summarize the most recent evidence to assess the effect of EENS for the management of ASP.

CONCLUSION

The findings of this study will help to determine whether EENS is effective for patients with ASP.

STUDY REGISTRATION

INPLASY202070009.