AGA Institute technical review on acute pancreatitis

A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis

BACKGROUND & AIMS

The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies.

METHODS

The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included.

RESULTS

Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis.

CONCLUSION

The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.

Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis

BACKGROUND

The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP).

METHODS

We systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom).

RESULTS

This meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR] = 1.24; 95% confidence interval [CI], 0.78-1.97; p = 0.36), rate of postoperative complications (RR = 1.06; 95% CI, 0.67-1.69; p = 0.80), rate of biliary-related complications (RR = 1.28; 95% CI, 0.42-3.86; p = 0.66), or OT (RR = 1.57; 95% CI, - 1.58-4.72; p = 0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR = - 2.08; 95% CI, - 3.17 to - 0.99; p = 0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR = - 0.40; 95% CI, - 0.80-0.01; p = 0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%).

CONCLUSION

This study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.

Hypertriglyceridemic Pancreatitis Treated with Insulin Therapy: A Comparative Review of 34 Cases

Although the clinical presentation of hypertriglyceridemic pancreatitis is usually similar to other forms of acute pancreatitis, it is frequently associated with increased clinical severity and rate of complications. Therefore, appropriate and timely management is of paramount importance in these patients. We performed a structured literature search of the medical databases PubMed and Google Scholar, using the terms “hypertriglyceridemia,” “acute pancreatitis,” “insulin,” and “treatment.” In this search, we identified 34 cases of hypertriglyceridemia-related pancreatitis available in the full-text form in English. The data on patients’ characteristics, epidemiology, clinical features, comorbid conditions, and diagnostic modalities were collected and summarized. This review illustrates that the use of insulin therapy with close monitoring of blood glucose levels is safe. It can be considered as an important component of management in patients with hypertriglyceridemia-related pancreatitis, especially in a clinical setting without the availability of plasmapheresis. Randomized clinical trials are warranted to outline a generalized and efficient treatment regimen for hypertriglyceridemic pancreatitis.

Incidence and epidemiological features of acute pancreatitis among adult inhabitants in Qatar

BACKGROUND/AIMS

Acute pancreatitis (AP) is one of the most common gastrointestinal causes of hospital admission in Qatar. The aim of the present study was to investigate the epidemiological features and demographic characteristics of patients with AP and to estimate the annual incidence rates of this disease among adult inhabitants in Qatar.

MATERIALS AND METHODS

This retrospective study was conducted using the data collected by reviewing records of patients with AP admitted to the medical and surgical wards of Hamad GeneralHospital and Alkhor Hospital, Qatar from January 2007 to December 2012. Diagnosis of AP was based on abdominal pain suggestive of AP, serum lipase and/or amylase at least three times the upper limit of normal, and/or characteristic findings of AP on abdominal ultrasound or computed tomography.

RESULTS

A total of 382 AP events were reported in 334 patients. There were 250 (75%) males and 84 (25%) females. The mean age (±SD) of the patients was 56.8±18.7 years. Gallstone disease (40.6%) was the highest cause of AP, followed by alcohol consumption (28.5%) and idiopathic AP (20.7%). The mean annual incidence rate of AP was 5 per 100,000 adult inhabitants in Qatar from January 2007 to December 2012. The incidence rate among men was higher than that among women. Mortality rate was low (0.3%), and there were complications in 112 (29.3%) patients.

CONCLUSION

The annual incidence rate of AP is relatively low in Qatar and tends to behave similar to many European countries in etiology, which can be explained by population structure. Gallstone and alcohol consumption are the main causes, and idiopathic AP is responsible for more cases than expected.

Uncomplicated Acute Pancreatitis: Evidenced-Based Management Decisions

Acute pancreatitis is among the most common gastrointestinal disorders requiring hospitalization worldwide. Establishing the cause of acute pancreatitis ensures appropriate management and proper health care resource utilization. Causes of acute pancreatitis include biliary, alcohol use, hypertriglyceridemia, hypercalcemia, drug-induced, autoimmune, hereditary/genetic, and anatomic abnormalities. Fluid therapy remains the cornerstone of managing acute pancreatitis. This article provides a brief summary of current evidence-based practices in the diagnosis and management of uncomplicated acute pancreatitis.

The Role of Endoscopic Ultrasonography and Magnetic Resonance Cholangiopancreatography in Patients With Acute Pancreatitis After Negative Computed Tomography Findings of the Etiology

OBJECTIVES

We aimed to investigate the roles of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in detecting the causes of acute pancreatitis after negative computed tomography (CT) findings.

METHODS

Demographic characteristics, blood test results, the severity of pancreatitis, and definite or possible etiology of pancreatitis by EUS and MRCP were evaluated prospectively in 65 consecutively admitted patients after negative CT findings.

RESULTS

Endoscopic ultrasonography and/or MRCP confirmed the definite causes of pancreatitis in 47.7% (31/65) (choledocholithiasis, 25; pancreatic divisum, 3; pancreatic cancer, 1; and pancreatic intraductal papillary mucinous neoplasm, 1). The possible causes were cholelithiasis in 75.4%, pancreaticobiliary common channel (PBCC) in 70.8%, and both in 89.2%. The diagnostic values of EUS were higher than MRCP for choledocholithiasis (35.4% vs 12.3%, P < 0.05). Cholelithiasis and the common bile duct diameter were independent factors for the definite etiology of acute pancreatitis. Choledocholithiasis was inversely associated with PBCC, and the common bile duct diameter was the only independent factor associated with PBCC.

CONCLUSIONS

Endoscopic ultrasonography is a useful imaging modality for detecting definite or possible causes of acute pancreatitis. A PBCC as well as biliary lithiasis could be not uncommon causes of acute pancreatitis after negative CT findings.

Acute Pancreatitis: Updates for Emergency Clinicians

BACKGROUND

Acute pancreatitis is a frequent reason for patient presentation to the emergency department (ED) and the most common gastrointestinal disease resulting in admission. Emergency clinicians are often responsible for the diagnosis and initial management of acute pancreatitis.

OBJECTIVE

This review article provides emergency clinicians with a focused overview of the diagnosis and management of pancreatitis.

DISCUSSION

Pancreatitis is an inflammatory process within the pancreas. While the disease is often mild, severe forms can have a mortality rate of up to 30%. The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation. The most common etiologies include gallbladder disease and alcohol use. After the diagnosis has been made, it is important to identify underlying etiologies requiring specific intervention, as well as obtain a right upper quadrant ultrasound. The initial management of choice is fluid resuscitation and pain control. Recent data have suggested that more cautious fluid resuscitation in the first 24 h might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously. Appropriate disposition is a multifactorial decision, which can be facilitated by using Ranson criteria or the Bedside Index of Severity in Acute Pancreatitis score. Complications, though rare, can be severe.

CONCLUSIONS

Pancreatitis is a potentially deadly disease that commonly presents to most emergency departments. It is important for clinicians to be aware of the current evidence regarding the diagnosis, treatment, and disposition of these patients.

Moderate Hypertriglyceridemia Causing Recurrent Pancreatitis: A Case Report and the Literature Review

Recurrent acute pancreatitis secondary to hypertriglyceridemia (HTG) with levels below 1000 mg/dL has been rarely reported in the literature. HTG is the third most common cause of acute pancreatitis and has been established in the literature as a risk factor when levels are greater than 1000 mg/dL. A 43-year-old patient presented to the hospital with severe epigastric abdominal pain. Initial laboratory investigations were significant for a lipase level of 4143 U/L and a triglyceride level of 600 mg/dL. Computed tomography (CT) of the abdomen showed diffuse enlargement of the pancreas consistent with pancreatitis. A diagnosis of severe acute pancreatitis secondary to high triglycerides was made based on the revised Atlanta classification 2012. The patient was initially managed with intravenous boluses of normal saline followed by continuous insulin infusion. Diabetic Ketoacidosis (DKA) was ruled out due to a past medical history of diabetes. Her clinical course was complicated by acute respiratory distress syndrome requiring intubation and mechanical ventilation. During the course, she improved symptomatically and was extubated. She was started on nasogastric feeding initially and subsequently switched to oral diet as tolerated. After initial management of HTG with insulin infusion, oral gemfibrozil was started for long-term treatment of HTG. Emerging literature implicates HTG as an independent indicator of poor prognosis in acute pancreatitis (AP). Despite the paucity of data, the risk of developing AP must be considered even at triglyceride levels lower than 1000 mg/dL.

Pancreatic Involvement in Inflammatory Bowel Disease: A Review

Inflammatory bowel disease (IBD) is a multisystemic disease, and pancreatic manifestations of IBD are not uncommon. The incidence of several pancreatic diseases in Crohn’s disease and ulcerative colitis is more frequent compared to the general population. Pancreatic manifestations in IBD include a wide heterogenic group of disorders and abnormalities of the pancreas and range from mild self-limited diseases to severe disorders. Acute pancreatitis, chronic pancreatitis, autoimmune pancreatitis, pancreatic autoantibodies, exocrine pancreatic insufficiency and asymptomatic imaging and laboratory abnormalities are included in related-IBD pancreatic manifestations. Involvement of the pancreas in IBD may be the result of IBD itself or of medications used.

Cholecystectomy During Index Admission for Acute Biliary Pancreatitis Lowers 30-Day Readmission Rates

OBJECTIVES

Few studies have evaluated national readmission rates after acute pancreatitis (AP) in the United States. We sought to evaluate modifiable factors impacting 30-day readmissions after AP hospitalizations.

METHODS

We used the Nationwide Readmission Database (2013) involving all adults with a primary discharge diagnosis of AP. Multivariable logistic regression models assessed independent predictors for specific outcomes.

RESULTS

Among 180,480 patients with AP index admissions, 41,094 (23%) had biliary AP, of which 10.5% were readmitted within 30 days. The 30-day readmission rate for patients who underwent same-admission cholecystectomy (CCY) was 6.5%, compared with 15.1% in those who did not (P < 0.001). Failure of index admission CCY increased the risk of readmissions (odds ratio [OR], 2.27; 95% confidence interval [CI], 2.04-2.56). Same-admission CCY occurred in 55% (n = 19,274) of patients without severe AP. Severe AP (OR, 0.73; 95% CI, 0.65-0.81), sepsis (OR, 0.63; 95% CI, 0.52-0.75), 3 or more comorbidities (OR, 0.74; 95% CI, 0.68-0.79), and admissions to small (OR, 0.76; 95% CI, 0.64-0.91) or rural (OR, 0.78; 95% CI, 0.65-0.95) hospitals were less likely to undergo same-admission CCY.

CONCLUSIONS

Same-admission CCY should be considered in patients with biliary AP when feasible. This national appraisal recognizes modifiable risk factors to reduce readmission in biliary AP and reinforces adherence to major society guidelines.

A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology

The critical nature of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician/advanced practice provider and the microbiologists who provide enormous value to the healthcare team. This document, developed by experts in laboratory and adult and pediatric clinical medicine, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. This document presents a system-based approach rather than specimen-based approach, and includes bloodstream and cardiovascular system infections, central nervous system infections, ocular infections, soft tissue infections of the head and neck, upper and lower respiratory infections, infections of the gastrointestinal tract, intra-abdominal infections, bone and joint infections, urinary tract infections, genital infections, and other skin and soft tissue infections; or into etiologic agent groups, including arthropod-borne infections, viral syndromes, and blood and tissue parasite infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. In addition, the pediatric needs of specimen management are also emphasized. There is intentional redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a guidance for physicians in choosing tests that will aid them to quickly and accurately diagnose infectious diseases in their patients.

A Clinical Model for the Early Diagnosis of Acute Pancreatitis in the Emergency Department

OBJECTIVE

This study aimed to develop a diagnostic model that predicts acute pancreatitis (AP) risk before imaging.

METHODS

Emergency department patients with serum lipase elevated to 3 times the upper limit of normal or greater were identified retrospectively (September 1, 2013-August 31, 2015). An AP diagnosis was established by expert review of full hospitalization records. Candidate predictors included demographic and clinical characteristics at presentation. Using a derivation set, a multivariable logistic regression model and corresponding point-based scoring system was developed to predict AP. Discrimination accuracy and calibration were assessed in a separate validation set.

RESULTS

In 319 eligible patients, 182 (57%) had AP. The final model (area under curve, 0.92) included 8 predictors: number of prior AP episodes; history of cholelithiasis; no abdominal surgery (prior 2 months); time elapsed from symptom onset; pain localized to epigastrium, of progressively worsening severity, and severity level at presentation; and extent of lipase elevation. At a diagnostic risk threshold of 8 points or higher (≥99%), the model identified AP with a sensitivity of 45%, and a specificity and a positive predictive value of 100%.

CONCLUSIONS

In emergency department patients with lipase elevated to 3 times the upper limit of normal or greater, this model helps identify AP risk before imaging. Prospective validation studies are needed to confirm diagnostic accuracy.

Nationwide Trends in Acute and Chronic Pancreatitis Among Privately Insured Children and Non-Elderly Adults in the United States, 2007-2014

BACKGROUND & AIMS

Epidemiologic analyses of acute pancreatitis (AP) and chronic pancreatitis (CP) provide insight into causes and strategies for prevention and affect allocation of resources to its study and treatment. We sought to determine current and accurate incidences of AP and CP, along with the prevalence of CP, in children and adults in the United States.

METHODS

We collected data from the Truven MarketScan Research Databases of commercial inpatient and outpatient insurance claims in the United States from 2007 through 2014 (patients 0-64 years old). We calculated the incidences of AP and CP and prevalence of CP based on International Classification of Diseases, 9th Revision diagnosis codes. Children were defined as 18 years or younger and adults as 19 to 64 years old.

RESULTS

The incidence of pediatric AP was stable from 2007 through 2014, remaining at 12.3/100,000 persons in 2014. Meanwhile, the incidence for adult AP decreased from 123.7/100,000 persons in 2007 to 111.2/100,000 persons in 2014. The incidence of CP decreased over time in children (2.2/100,000 persons in 2007 to 1.9/100,000 persons in 2014) and adults (31.7/100,000 persons in 2007 to 24.7/100,000 persons in 2014). The prevalences of pediatric and adult CP were 5.8/100,000 persons and 91.9/100,000 persons, respectively, in 2014. Incidences of AP and CP increased with age. We found little change in incidence during the first decade of life but linear increases starting in the second decade.

CONCLUSIONS

We performed a comprehensive epidemiologic analysis of privately insured, non-elderly adults and children with AP and CP in the United States. Changes in gallstone formation, smoking, and alcohol consumption, along with advances in pancreatitis management, may be responsible for the stabilization and even decrease in the incidences of AP and CP.

Pancreatitis

Acute pancreatitis is an inflammation of the glandular parenchyma of the retroperitoneal organ that leads to injury with or without subsequent destruction of the pancreatic acini. This inflammatory process can either result in a self-limited disease or involve life-threatening multiorgan complications. Chronic pancreatitis consists of endocrine and exocrine gland dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the pancreatic acini with permanent structural damage. Recurrent attacks of acute pancreatitis can result in chronic pancreatitis; acute and chronic pancreatitis are different diseases with separate morphologic patterns. Acute pancreatitis has an increasing incidence but a decreasing mortality.

Leptin alleviates intestinal mucosal barrier injury and inflammation in obese mice with acute pancreatitis

BACKGROUND/OBJECTIVES

Obesity is an independent risk factor for severe acute pancreatitis (AP). Leptin plays an important role in energy homeostasis. It has been reported that leptin might also participate in the regulation of the intestinal mucosal barrier and inflammatory response. This study aimed to evaluate the effects of leptin on the intestinal mucosal barrier and inflammatory injury in obese mice with AP.

SUBJECTS/METHODS

AP was induced in leptin-deficient (ob/ob) or wild type (WT) mice by peritoneal injection of caerulein. The animals were divided into 4 groups: WT mice with or without exogenous leptin injection and ob/ob mice with or without leptin treatment. The inflammatory scoring of the pancreas and intestine were evaluated. Intestinal permeability, ileal interleukin (IL)-6 and IL-1β, proliferation, apoptosis and intestinal expression levels of claudin-1 and occludin were measured.

RESULTS

Pancreatic pathologic scores (8.50 ± 0.96 vs. 3.78 ± 1.35, p < 0.001), pancreatic levels of IL-6 (8.34 ± 3.21 ng/mg vs. 4.99 ± 0.53 ng/mg, p = 0.022), intestinal oedema scores (2.25 ± 0.46 vs. 1.14 ± 0.69, p = 0.001) and intestinal permeability to FD4 (0.78 ± 0.06 μg/ml vs. 0.53 ± 0.11 μg/ml, p < 0.001) were significantly higher in ob/ob mice than those in WT mice. Leptin replacement in ob/ob mice greatly improved the intestinal permeability (FD4 0.66 ± 0.03 μg/ml, vs. 0.78 ± 0.06 μg/ml, p = 0.012), increased the ileal expression of claudin-1(1.07 ± 0.08 vs. 0.83 ± 0.07 relative densitometry, p = 0.001) and reduced intestinal IL-6 and IL-1β to levels comparable to those in WT mice. The pancreatic level of IL-6 in ob/ob mice treated with leptin was also significantly decreased relative to that of untreated ob/ob mice (4.45 ± 1.71 ng/mg vs. 8.34 ± 3.21 ng/mg, p = 0.010).

CONCLUSIONS

Obesity may aggravate intestinal inflammation and increase intestinal permeability under the condition of acute pancreatitis. Exogenous leptin supplementation was in favour of anti-inflammation and improvement of intestinal mucosal barrier.

Differences between the outcome of recurrent acute pancreatitis and acute pancreatitis

Background and aim

Overall, a handful of studies are available on the outcomes of recurrent acute pancreatitis (RAP), in comparison to the first episode of acute pancreatitis (AP). We aimed to provide a more complete and updated picture of RAP and how it is different from the initial episode of AP.

Methods

Consecutive patients admitted with an episode of AP over 8 years were divided into two groups on the basis of prior episodes: AP and RAP. Primary outcome measures were for surgical necrosectomy and mortality.

Results

Of the 724 patients (age 39.22 ± 13.25 years, 68% male) with an episode of pancreatitis, 632 (87.3%) had presented with a first episode (AP) and 92 (12.7%) with at least one prior episode (RAP). The incidence of severe pancreatitis was significantly less in RAP patients (10.9%) in comparison to AP patients (48.6%). The requirement of surgical intervention and mortality were less in patients with RAP (1.1 and 2.2%, respectively) compared to patients with AP (9.3 and 18%, respectively). The mean number of episodes per RAP patients was 2.97 ± 1.66 (range 2–10), and 64.1% had only two episodes. Regarding the etiology of RAP patients, biliary etiology (32.6%) and alcohol (30.4%) were the two most frequent factors, and no etiology could be identified in 19.6%.

Conclusion

Patients with RAP had milder disease course and lesser mortality when compared to the initial episode of AP. Appropriate evaluation and dealing with etiological factors at the initial episode of AP can prevent a majority of RAP.

Ringer's lactate versus normal saline in acute pancreatitis: A systematic review and meta-analysis

OBJECTIVE

Aggressive i.v. hydration with crystalloids is the first step in managing acute pancreatitis (AP) and is associated with improved survival. Guidelines about the choice of crystalloids to use are unclear. This systematic review and meta-analysis was aimed to discern whether the choice of fluids in managing pancreatitis was associated with patients' outcomes.

METHODS

A comprehensive literature review was conducted by searching the Embase, MEDLINE, PubMed and Google Scholar databases to December 2017 to identify all studies that compared normal saline (NS) with Ringer's lactate (RL) for managing AP. The characteristics of the participants, outcome measurements (including mortality, the development of systemic inflammatory response syndrome [SIRS] on admission and at 24 h, and pancreatic necrosis) were analyzed.

RESULTS

Five studies (three randomized controlled trials and two retrospective cohort studies) with 428 patients were included in this analysis. Mortality trended lower in the RL group but this was not statistically significant (pooled odds ratio [OR] 0.61, 95% CI 0.28-1.29, P = 0.20). Patients in the RL group had significantly decreased odds of developing SIRS at 24 h (pooled OR 0.38, 95% CI 0.15-0.98, P = 0.05).

CONCLUSIONS

RL has anti-inflammatory effects and is associated with decreased odds of persistent SIRS at 24 h, which is a marker of severe disease in AP patients. Although mortality trended lower in the RL group this did not achieve statistical significance and hence larger randomized controlled trials are needed to evaluate this association.

Predictive biomarkers for acute gallstone pancreatitis in the pediatric population

BACKGROUND

Early biomarkers for diagnosis of gallstone pancreatitis (GP) in pediatrics have not been well studied. Reliably differentiating GP from other causes of acute pancreatitis (AP) would allow for early diagnosis and prompt management. We sought to assess biomarkers and clinical variables for early GP diagnosis from a prospectively-enrolled registry of pediatric patients presenting with first AP episode.

METHODS

Cross-sectional analysis of a prospective acute pancreatitis registry of children enrolled from March 2013 through October 2016 was performed. Fisher's exact test and Wilcoxon rank sum test were used to compare demographic and clinical variables between GP and non-GP groups. A multivariable logistic regression model was derived, and receiver operating characteristic (ROC) curve was built using stepwise selection.

RESULTS

114 subjects were enrolled (21 with GP, 93 as non-GP). Median was statistically higher for GP patients in lipase values X upper limit of normal (ULN) on admission, weight percentile for age, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase. By multivariable analysis, significant predictors were ALT and Lipase xULN. A model built using these two variables for prediction of GP identified an AUROC of 0.85. At a predictive probability of 0.35, the model had an 80% sensitivity, 93% specificity, 76% positive predictive value and 95% negative predictive value.

CONCLUSIONS

We have developed a model for predicting GP in children that could help guide clinical management of AP patients. Future studies are needed to validate use of laboratory findings and clinical variables in evaluation of gallstone etiology in pediatric AP patients.

Association of Total Fluid Intake and Output with Duration of Hospital Stay in Patients with Acute Pancreatitis

Background/Aims

The aim of this study was to evaluate the association of fluid balance with outcomes in patients hospitalized with acute pancreatitis (AP).

Methods

This was a retrospective study of patients hospitalized between May 2008 and June 2016 with AP and a clinical order for strict recording of intake and output. Data collected included various types of fluid intake and output at 24 and 48 hours after admission. The primary outcome was length of stay (LOS). Analysis was performed using single-variable and multivariable negative binomial regression models.

Results

Of 1256 patients hospitalized for AP during the study period, only 71 patients (5.6%) had a clinical order for strict recording of intake and output. Increased urine output was associated with a decreased LOS at 24 and 48 hours in univariable analysis. An increasingly positive fluid balance (total intake minus urine output) at 24 hours was associated with a longer LOS in multivariable analysis.

Conclusions

Few patients hospitalized for AP had a documented order for strict monitoring of fluid intake and output, despite the importance of monitoring fluid balance in these patients. Our study suggests an association between urine output and fluid balance with LOS in AP.

Severe acute gallstone pancreatitis with diffuse hemorrhagic gastritis

A 67-year-old male presented with acute pancreatitis secondary to gallstones, also known as acute biliary pancreatitis, and subsequently developed gastric outlet obstruction and was transferred to our hospital. A gastro-jejunal feeding tube was placed and an open cholecystectomy was performed. The patient had a pancreatic drain placed for interval increase in pancreatic necrosis and then nearly exsanguinated from gastroduodenal artery pseudoaneurysm bleed. This was managed by coiling the gastroduodenal artery. The patient underwent a pancreatic necrosectomy with malencot drain placement and developed a post-operative upper gastrointestinal bleeding. An EGD showed diffuse gastritis, but no varices. And 18 days later the patient rebled, with the same diffuse gastritis. After further complications the patient elected to receive palliative care at a hospice facility. We are presenting this unusual case of diffuse, hemorrhagic gastritis after acute necrotizing pancreatitis.

The immune imbalance in the second hit of pancreatitis is independent of IL-17A

BACKGROUND

Severe acute pancreatitis (SAP) is characterised by two distinct clinical phases. Organ dysfunction and death is initially as a result of a systemic inflammatory response syndrome (SIRS). Systemic sepsis from infected pancreatic necrosis characterises the second phase, the so called 'second hit' of acute pancreatitis (AP). An immune imbalance during the second hit is postulated to contribute to the formation of the septic complications that occur in these patients. The pro-inflammatory T-helper (Th) 17 pathway has been shown to be an initiator of early SIRS in AP, however to date its role has not been established in the second hit in AP.

METHODS

Thirty-six patients with mild (n = 16), moderate (n = 10) and severe (n = 10) acute pancreatitis were enrolled. Peripheral blood samples were drawn on days 7, 9, 11 and 13 of illness for analysis of routine clinical markers as well as cytokine analysis. Flow cytometry and a IL-17A ELISA was performed to determine cytokine concentrations.

RESULTS

There were no significant differences between days 7, 9, 11 and 13 for either the mild/moderate or SAP groups for IL-17A (CBA assay or ELISA), IFN-γ, TNF-α, IL-2 or IL-4. For each of the study days, the mean IL-6 and IL-10 concentrations were significantly higher in the SAP group compared to the mild/moderate group. WCC, CRP and PCT were all significantly higher in severe acute pancreatitis over the study days.

CONCLUSIONS

An immune imbalance exists in patients with SAP, however secreted IL-17A is not responsible for the second hit in AP.

Early Endoscopic Retrograde Cholangiopancreatography Versus Conservative Treatment in Patients With Acute Biliary Pancreatitis: Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVES

The aim of the study was to evaluate the role of early endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of acute biliary pancreatitis, in comparison with conservative treatment.

METHODS

Systematic review via databases (MEDLINE [PubMed], Latin-American and Caribbean Health Sciences Literature database, Embase, Cochrane Central, and the [Brazilian] Regional Library of Medicine) is conducted. We analyzed 10 randomized controlled trials (1091 patients). Outcomes were the following: local and systemic adverse events; acute cholangitis; death; length of hospital stay; cost; abdominal pain; and time to a reduction in body temperature. For the meta-analysis, we used risk difference (RD) and mean with standard deviation as measures of variability.

RESULTS

There was a statistically significant difference between the patients submitted to ERCP in terms of the following: local adverse events (RD, 0.74; 95% confidence interval [CI], 0.55-0.99), time to pain relief and time to a reduction in axillary temperature (RD, -5.01; 95% CI, -6.98 to -3.04, and RD, -1.70; 95 CI%, -2.33 to -1.08, respectively). Patients undergoing ERCP spent less time in hospital (RD, -11.04; 95% CI, -15.15 to -6.93). Cost was lower in the group treated with ERCP.

CONCLUSIONS

Early ERCP decreases local adverse events, shortening the time to pain relief, to a reduction in axillary temperature, hospital stays, and cost in patients with acute biliary pancreatitis.

Endoscopic versus percutaneous management for symptomatic pancreatic fluid collections: a systematic review and meta-analysis

BACKGROUND

 Symptomatic pancreatic fluid collections (PFCs) are managed by surgical, percutaneous, or endoscopic drainage. Due to morbidity associated with surgical drainage, percutaneous and/or endoscopic options have increasingly been used as initial management.

AIMS

 We conducted a systematic review and meta-analysis comparing the efficacy and safety of endoscopic versus percutaneous drainage for management of PFCs.

METHODS

 We searched several databases from inception through 31 August 2017 to identify comparative studies using endoscopic or percutaneous drainage for PFCs. Our primary outcome was clinical success. Secondary outcomes were technical success, adverse events (AE), rates of recurrence, requirement for subsequent procedures, and length of stay in hospital. Pooled risk ratios (RR) and mean difference (MD) were calculated for categorical and continuous outcomes, respectively.

RESULTS

 Seven studies with 490 patients were included in the final analysis. Pooled RR for clinical success was 0.40 (0.26, 0.61), I²  = 42 % in favor of endoscopic management. On sensitivity analysis, after excluding one study on patients with walled-off necrosis (WON), the clinical success was 0.43 (0.28, 0.66) with no heterogeneity. Pooled RR for technical success was 1.50 (0.52, 4.37) with no heterogeneity. Pooled RR for AE and rate of recurrence were 0.77 (0.46, 1.28) and 0.60 (0.29, 1.24), respectively. Pooled MD for length of stay in hospital and rate of re-intervention were - 8.97 (- 12.88, - 5.07) and - 0.66 (- 0.93, - 0.38), respectively, in favor of endoscopic drainage.

CONCLUSIONS

 Endoscopic drainage should be the preferred therapeutic modality for PFCs compared to percutaneous drainage as it is associated with significantly better clinical success, a lower re-intervention rate, and a shorter hospital length of stay.

Endoscopic Retrograde Cholangiopancreatography Decreases All-Cause and Pancreatitis Readmissions in Patients With Acute Gallstone Pancreatitis Who Do Not Undergo Cholecystectomy: A Nationwide 5-Year Analysis

OBJECTIVES

Cholecystectomy is the definitive management of gallstone pancreatitis (GSP). The benefit of endoscopic retrograde cholangiopancreatography (ERCP) in patients who do not undergo cholecystectomy remains unclear. This study aims to evaluate the effect of ERCP on all-cause and pancreatitis readmissions in GSP.

METHODS

Adult hospitalizations for GSP in the 2010-2014 National Readmissions Database were divided into the following 3 groups: (1) no cholecystectomy nor ERCP, (2) no cholecystectomy with ERCP, and (3) cholecystectomy group. A multivariable Cox model was used to compare the 60-day readmission rates controlling for significant confounders.

RESULTS

There were 153,480 GSP admissions, 29.2% did not undergo cholecystectomy or ERCP, 12.0 % underwent ERCP only, and 58.8% had cholecystectomy. In the no cholecystectomy group, ERCP was associated with lower all-cause readmissions (adjusted hazard ratio, 0.80; 95% confidence interval, 0.76-0.83; P < 0.0001) and pancreatitis readmissions rate (adjusted hazard ratio, 0.51; 95% confidence interval, 0.47-0.55; P < 0.0001) compared with no ERCP. The protective effect of ERCP remained significant in severe pancreatitis. Cholecystectomy had the strongest protective effect against readmissions.

CONCLUSIONS

In this large, nationally representative sample, ERCP was associated with reduced readmissions in patients with GSP who did not undergo cholecystectomy. Although cholecystectomy remains the most important intervention to prevent readmissions, these results support performing ERCP in patients unfit for surgery.

Primary and Secondary Organ Failures Cause Mortality Differentially in Acute Pancreatitis and Should be Distinguished

OBJECTIVE

The aim of this study was to study the development of early and late organ failure (OF) and their differential impact on mortality in patients with acute pancreatitis (AP).

METHODS

Consecutive patients (N = 805) with acute pancreatitis were included in an observational study. Organ failure was categorized as primary if it occurred early due to pancreatitis per se and secondary if it occurred late due to infected pancreatic necrosis (IPN). Primary outcome was a relative contribution of primary OF, secondary OF, and IPN to mortality.

RESULTS

Of the 614 patients (mean age, 38.8; standard deviation, 14.6 years; 430 males) in a derivation cohort, 274 (44.6%) developed OF, with 177 having primary OF and 97 secondary OF due to sepsis. Primary OF caused early mortality in 15.8% and was a risk factor for IPN in 76% of patients. Mortality in patients with primary OF and IPN was 49.5% versus 36% in those with IPN and secondary OF (P = 0.06) and 4% in those with IPN but without OF (P < 0.001). The results of the 191 patients in the validation cohort confirmed the relative contribution of primary and secondary OF to mortality.

CONCLUSION

Primary and secondary OF contributed to mortality independently and are distinct in their timing, window of opportunity for intervention, and prognosis.

Acute Pancreatitis Associated with Ixazomib in a Multiple Myeloma Patient

BACKGROUND

Acute pancreatitis is an uncommon complication of anti-myeloma agents. Ixazomib is a first-in-class oral proteasome inhibitor to receive regulatory approval for the treatment of multiple myeloma. This case report describes the first case of ixazomib-associated pancreatitis.

CASE PRESENTATION

An 80-year-old female with relapsed multiple myeloma presented with severe diarrhea, nausea, vomiting, abdominal pain, and acute renal failure 3 weeks after starting ixazomib and dexamethasone for disease progression. An extensive workup revealed acute pancreatitis without a definitive cause. Her condition improved with supportive measures and the discontinutation of ixazomib. The latter was suspected as the probable etiology of the patient's acute pancreatitis, given no clear alternative causes and the temporal relationship between initiating ixazomib and the development of her symptoms.

CONCLUSIONS

Practitioners should include acute pancreatitis as part of their differential diagnosis in patients on ixazomib treatment who present with gastrointestinal symptoms.

Diabetes Mellitus is Associated With Mortality in Acute Pancreatitis

BACKGROUND AND AIM

Predicting severe pancreatitis is important for early aggressive management of patients with acute pancreatitis (AP). Despite the established role of diabetes mellitus (DM) in the risk of AP, the impact of DM on the clinical outcome in AP has not been fully elucidated. The objective of this study was to assess the risk of mortality and severity in AP among patients with type-2 DM.

METHODS

Patients diagnosed with first attacks of AP were enrolled from January 2013 to June 2015.

RESULTS

A total of 201 patients (63.2% male, mean age, 59.4 y) with AP were included. Etiologies included gallstones (51.2%), alcohol (37.3%), hypertriglyceridemia (2%), and idiopathic causes (9.5%). There were 54 AP patients (26.9%) with type-2 DM. Severity indices in AP, such as Atlanta Classification (severe), Ranson score, and Bedside Index of Severity in Acute Pancreatitis, were higher in subjects with DM than those without DM. Prevalence of intensive care unit admission and mortality were higher in AP patients with DM compared with those without DM. The association between DM and increased risk of mortality in AP remained statistically significant even after adjustments for confounding factors and Atlanta Classification (odds ratio, 7.76, 95% confidence interval, 1.26-47.63, P=0.027).

CONCLUSIONS

Type-2 DM was associated with severity and increased mortality in patients with AP. Our findings provide evidence of the potential role of DM in the pathogenesis and management of severe AP.

Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic ultrasound (EUS)-guided transmural drainage has been increasingly utilized as a first-line therapeutic modality for drainage of pancreatic fluid collections (PFC). Recently, lumen-apposing metal stents (LAMS) have been utilized for management of PFCs. We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy and safety of LAMS in the management of PFC (primary outcome). We also compared the efficacy and safety of LAMS with multiple plastic stents (MPS) in the management of PFC (secondary outcome).

METHODS

We searched Medline, Embase and Cochrane databases from inception to November 5, 2016, to identify studies (with ≥ 10 patients) reporting technical success, clinical success, and adverse events (AE) of EUS-guided transmural drainage of PFC using LAMS. Weighted pooled rates (WPR) were calculated for technical success, clinical success and AE. Risk ratios (RR) were calculated and pooled to compare LAMS with MPS in terms of technical success, clinical success, and AE. Pooled mean difference (MD) was calculated to compare the number of endoscopic sessions required by each type of stent to achieve clinical success. All analyses were done using random effects model.

RESULTS

Eleven studies with 688 patients were included in this meta-analysis. WPR for technical success of LAMS in PFC management was 98% (96, 99%), (I ² = 15%). WPR for clinical success was 93% (89, 96%) with moderate heterogeneity (I ² = 50%). There was no difference in clinical success for pseudocysts (PP) versus walled-off pancreatic necrosis (WON) (P = 0.51). WPR for AE was 13% (9, 20%), (I ² = 64%). AE were 10% more in WON as compared to PP (P = 0.009). Most common AE requiring intervention was stent migration (4.2%), followed by infection (3.8%), bleeding (2.4%), and stent occlusion (1.9%). Six studies with 504 patients compared the performance of LAMS with MPS. Pooled RR for technical success was 1.71 (0.38, 7.37). Pooled RR for clinical success was 0.37 (0.20, 0.67) in favor of LAMS. Pooled RR for AE was 0.39 (0.18, 0.84), (I ² = 50%). Pooled MD for number of endoscopic sessions was - 0.84 (- 1.69, 0.01).

CONCLUSIONS

LAMS seem to have excellent efficacy and safety in the management of PFCs. They may be preferred over plastic stents as they are associated with better clinical success and lesser adverse events.

Initial Pain Management in Pediatric Acute Pancreatitis: Opioid Versus Non-opioid

Nearly all patients with acute pancreatitis (AP) experience some degree of abdominal pain that is severe enough to prompt medical evaluation and necessitate analgesia. Effective analgesia is a priority in caring for such patients. Despite its importance, strategies for pain management in AP have been poorly studied, particularly in the field of pediatrics. Presently, no published data examine the management of pain because of AP in children at the time of initial presentation. Management approaches are often extrapolated from adult practice and based on anecdotal experience in the absence of objective data. The aim of our study was to examine the initial provision of analgesia to children who presented to a pediatric emergency department with AP.

Cortisol Outperforms Novel Cardiovascular, Inflammatory, and Neurohumoral Biomarkers in the Prediction of Outcome in Acute Pancreatitis

OBJECTIVES

The aims of this study were to assess whether copeptin, pro-atrial natriuretic peptide, proadrenomedullin, and cortisol are associated with disease severity in patients with acute pancreatitis (AP) and to compare their ability in predicting organ failure or death.

METHODS

From April 2011 to January 2015, 142 patients with AP were included in this prospective single-center study and observed for 4 days. Disease severity was rated by the Atlanta 1992 and 2012 criteria and organ failure by the modified Marshall score. The aforementioned laboratory markers, C-reactive protein, and procalcitonin were measured.

RESULTS

Patients with moderate to severe AP showed significantly higher plasma concentrations of all biomarkers than did those with mild AP. Overall, 30 organ failures or deaths occurred. All biomarkers except cortisol had only modest discriminatory ability, with areas under the receiver operating characteristic curve (AUCs) between 0.44 and 0.66. Cortisol showed an AUC of 0.78 compared with the Acute Physiology and Chronic Health Evaluation II score with an AUC of 0.75.

CONCLUSIONS

Cortisol was the best predictor of organ failure or death. All biomarkers were associated with disease severity to a similar degree as C-reactive protein, the criterion-standard marker in AP. Further studies are warranted to define their clinical role.

Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

BACKGROUND

Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed.

METHODS

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation.

RESULTS

The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP.

CONCLUSIONS

This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.

Is MicroRNA-127 a Novel Biomarker for Acute Pancreatitis with Lung Injury?

Background and Aims

The aim of this study was to determine the expression of microRNA-127 (miR-127) in both rat models and patients of acute pancreatitis (AP) with lung injury (LI).

Methods

Rats were administrated with retrograde cholangiopancreatography injection of 0.5% or 3.5% sodium taurocholate to induce AP with mild or severe LI and were sacrificed at 6, 12, and 24 h. Rats from the control group received a laparotomy only. Plasma from a prospective cohort of AP patients was collected. The levels of miR-127 in the tissues and plasma were detected using quantitative reverse transcription-polymerase chain reaction (qRT-PCR).

Results

The upregulation of miR-127 in the lungs of rats was detected in the groups of AP with severe LI at 6 h and 24 h, whereas it was scarcely detectable in plasma. In the pilot study that included 18 AP patients and 5 healthy volunteers, the plasma miR-127 level was significantly downregulated in AP patients with respiratory failure compared with the healthy volunteers (P = 0.014) and those without respiratory failure (P = 0.043).

Conclusion

miR-127 might serve as a potential marker for the identification of AP with LI.

Timing of Laparoscopic Cholecystectomy After Mild Biliary Pancreatitis: A Systematic Review and Meta-Analysis

AIM

To compare the safety of cholecystectomy in early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC).

METHODS

We systematically searched PubMed, EMBASE, and Cochrane Library for studies that were published from January 1992 to March 2017. We included studies on patients with mild biliary pancreatitis and that reported the timing of cholecystectomy and the number of complications, readmissions, and conversion to open cholecystectomy. Moreover, we assessed the quality and bias risks of the included studies.

RESULTS

After screening 4651 studies, we included 3 randomized clinical trials and 10 retrospective studies. The included studies described 2291 patients, of whom 1141 (49.8%) underwent ELC and 1150 (50.2%) underwent DLC. The reported rate of complications for ELC (6.8%) was lower than that for DLC (13.45%). The reported rate of readmission for ELC was lower than that for DLC. The length of hospital stay was longer with DLC than with ELC. ELC and DLC did not have significantly different rates of conversion to open cholecystectomy and duration of surgery.

CONCLUSION

This meta-analysis provides evidence that ELC is better than DLC in many aspects for acute mild pancreatitis patients undergoing laparoscopic cholecystectomy. ELC associated with few complications and readmissions, as well as a short length of hospital stay.

Analysis of Factors Associated with the Severity of Acute Pancreatitis according to Etiology

Background

The objective of this study was to determine the factors associated with severity of acute pancreatitis (AP) according to two major etiologies: alcohol and gallstones.

Methods

We reviewed the medical records of consecutive patients who were admitted with AP between January 2003 and January 2013. A total of 905 patients with AP (660 alcohol-induced, 245 gallstone-induced) were enrolled. Among them, severe AP (SAP) occurred in 72 patients (53 alcohol-induced, 19 gallstone-induced). Contributing factors between patients with and without SAP were analyzed according to the etiology.

Results

Multivariate analysis demonstrated that current smoking, pancreatic necrosis, and bacteremia were associated with AP severity in both alcohol- and gallstone-induced AP. Pancreatic fluid collection was significantly associated with alcohol-induced SAP (p = 0.04), whereas dyslipidemia was significantly associated with gallstone-induced SAP (p = 0.01). Body mass index was significantly correlated with the Bedside Index of Severity in Acute Pancreatitis score in both alcohol- and gallstone-induced AP (p = 0.03 and 0.01, resp.).

Conclusions

Current smoking, pancreatic necrosis, and bacteremia can aggravate the clinical course of AP. Pancreatic fluid collection and dyslipidemia were associated with AP severity according to the different etiologies. Obesity may also be associated with AP severity in both etiologies.

Acute pancreatitis following oesophagogastroduodenoscopy

Acute pancreatitis is a well-recognised complication of endoscopic procedures like endoscopic retrograde cholangiopancreatography but not oesophagogastroduodenoscopy (OGD). I report a case of a 33-year-old woman, admitted with severe epigastric pain and vomiting 2 hours after an elective OGD for evaluation of chronic gastrointestinal symptoms. Pancreatitis was diagnosed on the basis of elevated lipase (40 790 U/L; normal 11-82) and findings on imaging studies. Other common causes of acute pancreatitis such as gallstones, alcohol and medications were ruled out. She had an extended hospital course because of severe disease, characterised by systemic inflammatory response syndrome, pleural effusion and ascites but was successfully managed conservatively with bowel rest, hydration and pain management. Acute pancreatitis should be considered a rare complication of OGD and should be considered in differential diagnosis for abdominal pain post OGD. Pathogenesis is likely from direct trauma to pancreas or gas insufflation.

Which Patients with Mild Acute Pancreatitis Require Prolonged Hospitalization?

Objectives:

In our experience, a subset of mild acute pancreatitis (AP) patients, as defined by the Revised Atlanta Classification, has longer than expected hospitalization. Our aims are to report the prevalence of patients with mild AP who have a prolonged length of stay (LOS), evaluate the etiology, thoroughly phenotype, and finally compare this subset to those with expected LOS.

Methods:

Patients admitted with AP from 2003 to 2015 were prospectively enrolled into this cohort study. LOS ≥8 days was considered as prolonged LOS. Data on demographics, clinical and laboratory variables, management, and outcomes was both prospectively and retrospectively collected. Continuous variables were compared using the nonparametric t-test (Wilcoxon's test) and categorical variables using the Pearson’s χ² test.

Results:

Among 231 enrolled mild AP patients, 46 (20%) had a prolonged LOS (≥8 days). The main determinants of prolonged LOS included ongoing pancreatitis-related symptoms (n=31, 67.4%) and performance of cholecystectomy (n=11, 23.9%). When compared to patients with expected LOS (<8 days, n=185), patients with prolonged LOS due to ongoing symptoms (n=31) were more likely to have systemic inflammatory response syndrome at 48 h from admission (37% vs. 13.4%, P<0.001), a prolonged fasting period (6.6 vs. 2.8 days, P<0.001), and need for nutritional support (30% vs. 1.6%, P<0.001).

Conclusions:

About 20% of patients with mild AP have a longer than expected hospital stay, mostly attributed to ongoing pancreatitis-related symptoms. An early decision (at 72 h) for enteral nutrition support in these patients needs to be explored so as to shorten hospitalization and reduce cost of care.

Comparison of clinical efficacies and safeties of lumen-apposing metal stent and conventional-type metal stent-assisted EUS-guided pancreatic wall-off necrosis drainage: a real-life experience in a tertiary hospital

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage of pancreatic wall-off necrosis (WON) with transmural stent is regarded as firstline therapy. We aimed at comparing its efficacy and safety with using fully covered self-expandable metal stent (FCSEMS) and lumen-apposing metal stent (LAMS).

METHODS

A retrospective review was performed on all consecutive patients with pancreatic WONs who underwent EUS-guided drainage by either FCSEMS or LAMS.

RESULTS

From 2011 to 2016, 68 patients (66.2% male, median age, 66.5 years) underwent WON drainage (22/68 (32.4%) using FCSEMSs of size 10 × 60 mm (14/22, Hanarostent; 8/22 Wallflex); 46/68 (67.6%) using LAMSs (38/46 and 8/46 with AXIOS of size 15 × 10 mm and 10 × 10 mm, respectively). These two groups were matched for age (66 vs. 70 years, p 0.514), APACHE II (11.5 vs. 10, p 0.693), causes [72.7 vs. 80.4% by gallstone pancreatitis (p 0.472); 9.1 vs. 10.9% by alcoholism (p 0.818)], WON size (8.5 vs. 9 cm, p 0.322), location (36.4 vs. 26.1% at pancreatic head, p 0.384; 54.5 vs. 65.2% at body/tail, p 0.395), and enterostomy site [63.6 vs. 76.1% via transgastric (p 0.285); 31.8 vs. 19.6% via transduodenal (p 0.267)] and their number of necrosectomy (p 0.978). The technical (100 vs. 93.5%, p 0.219) and clinical (95.5 vs. 93.5%, p 0.749) success and adverse event (22.7 vs. 39.1%, p 0.180; 9.1 vs. 19.6% with bleeding, p 0.271; 4.5 vs. 13% with spontaneous stent migration, p 0.28; 9.1 vs. 6.5% with dislodgement during necrosectomy, p 0.704) of the two groups were comparable without significant different. However, the LAMS group associated with early stent revision compared with FCSEMS group (log rank p 0.048).

CONCLUSIONS

EUS-guided drainage of WON using FCSEMSs and LAMSs are comparable in efficacy and safety; however, the latter is associated with early stent revision.

Do lumen-apposing metal stents (LAMS) improve treatment outcomes of walled-off pancreatic necrosis over plastic stents using dual-modality drainage?

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound-guided drainage of symptomatic walled-off pancreatic necrosis (WON) usually has been performed with double pigtail plastic stents (DPS) and more recently, with lumen-apposing metal stents (LAMS). However, LAMS are significantly more expensive and there are no comparative studies with DPS. Accordingly, we compared our experience with combined endoscopic and percutaneous drainage (dual-modality drainage [DMD]) for symptomatic WON using LAMS versus DPS.

PATIENTS AND METHODS

Patients who underwent DMD of WON between July 2011 and June 2016 using LAMS were compared with a matched group treated with DPS. Technical success, clinical success, need for reintervention and adverse events (AE) were recorded.

RESULTS

A total of 50 patients (31 males, 25 patients treated with LAMS and 25 patients treated with DPS) were matched for age, sex, computed tomography severity index, and disconnected pancreatic ducts. Technical success was achieved in all patients. Mean days hospitalized post-intervention (14.5 vs. 13.1, P  = 0.72), time to resolution of WON (77 days vs. 63 days, P  = 0.57) and mean follow-up (207 days vs. 258 days, P  = 0.34) were comparable in both groups. AEs were similar in both groups (6 vs. 8, P  = 0.53). Patients treated with LAMS had significantly more reinterventions per patient (1.5 vs. 0.72, P  = 0.01).

CONCLUSIONS

 In treatment of symptomatic WON using DMD, LAMS did not shorten time to percutaneous drain removal and was not associated with fewer AEs.

Comparison of multifactor scoring systems and single serum markers for the early prediction of the severity of acute pancreatitis

BACKGROUND

The purpose of this study was to clarify whether the current scoring systems and single serum markers used in pancreatitis remain applicable for the early prediction of infected pancreatic necrosis (IPN) and the severity and mortality of acute pancreatitis (AP) in accordance with the revised Atlanta and determinant-based classifications.

METHODS

Demographic, clinical, and laboratory data from 708 consecutive patients with AP were prospectively collected between January 2011 and December 2012. The severity was classified using the revised Atlanta and determinant-based classification systems. The predictive accuracies for moderately severe AP (MSAP), severe AP (SAP), critically severe AP (CAP), IPN, and mortality were measured using area under the receiver operating characteristic curves.

RESULTS

The receiver operating characteristic analysis showed that the multifactor scoring systems and single serum markers had a low predictive accuracy regarding moderately severe AP. The Acute Physiology and Chronic Health Evaluation (APACHE) II score had the highest accuracy in predicting SAP with area under the curve (AUC) values of 0.75 (95% CI = 0.71-0.79) and 0.77 (95% CI = 0.73-0.81) at 24 and 48 h after admission, respectively. Procalcitonin was the most accurate predictor for CAP and IPN, with respective AUCs of 0.86 (95% CI = 0.82-0.89) and 0.83 (95% CI = 0.78-0.87) at 48 h after admission. In predicting mortality, both the APACHE II score and blood urea nitrogen had the highest accuracy.

CONCLUSIONS

The APACHE II score had the highest predictive accuracy for SAP and mortality as defined by the revised Atlanta classification, whereas procalcitonin was the most accurate predictor for CAP and IPN.

Role of endoscopic ultrasound in idiopathic pancreatitis

Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. The initial evaluation fails to detect the cause of RAP in 10%-30% of patients, whose condition is classified as idiopathic RAP (IRAP). Idiopathic acute pancreatitis (IAP) is a diagnostic challenge for gastroenterologists. In view of associated morbidity and mortality, it is important to determine the aetiology of pancreatitis to provide early treatment and prevent recurrence. Endoscopic ultrasound (EUS) is an investigation of choice for imaging of pancreas and biliary tract. In view of high diagnostic accuracy and safety of EUS, a EUS based management strategy appears to be a reasonable approach for evaluation of patients with a single/recurrent idiopathic pancreatitis. The most common diagnoses by EUS in IAP is biliary tract disease. The present review aims to discuss the role of EUS in the clinical management and diagnosis of patients with IAP. It elaborates the diagnostic approach to IAP in relation to EUS and other different modalities. Controversial issues in IAP like when to perform EUS, whether to perform after first episode or recurrent episodes, comparison among different investigations and the latest evidence significance are detailed.

Early Abdominal Imaging Remains Over-Utilized in Acute Pancreatitis

BACKGROUND

Early abdominal computed tomography (CT) or magnetic resonance (MR) imaging is common in acute pancreatitis (AP). Guidelines (2007-2013) indicate routine use is unwarranted.

AIMS

To compare the frequency and evaluate the predictors of early CT/MR utilization for AP between September 2006-2007 (period A) and September 2014-2015 (period B).

METHODS

AP patients presenting directly to a large academic emergency department were prospectively enrolled during each period. Cases requiring imaging to fulfill diagnostic criteria were excluded. Early CT/MR (within 24 h of presentation) utilization rates were compared using Fisher's exact test. Predictors of early imaging usage were assessed with multivariate logistic regression.

RESULTS

The cohort included 96 AP cases in period A and 97 in period B. There were no significant differences in patient demographics, comorbidity scores, or AP severity. Period B cases manifested decreased rates of the systemic inflammatory response syndrome (SIRS) during the first 24 h of hospitalization (67% period A vs. 43% period B, p = 0.001). Independent predictors of early imaging included age >60 and SIRS or organ failure on day 1. No significant decrease in early CT/MR usage was observed from period A to B on both univariate (49% period A vs. 40% period B, p = 0.25) and multivariate (OR 1.0 for period B vs. A, 95% CI 0.5-1.9) analysis.

CONCLUSIONS

In a comparison of imaging practices for AP, there was no significant decrease in early abdominal CT/MR utilization from 2007 to 2015. Quality improvement initiatives specifically targeting early imaging overuse are needed.

Building and verifying a severity prediction model of acute pancreatitis (AP) based on BISAP, MEWS and routine test indexes

PURPOSE

To discuss the value of the Bedside Index for Severity in Acute Pancreatitis (BISAP), Modified Early Warning Score (MEWS), serum Ca2+, similarly hereinafter, and red cell distribution width (RDW) for predicting the severity grade of acute pancreatitis and to develop and verify a more accurate scoring system to predict the severity of AP.

METHODS

In 302 patients with AP, we calculated BISAP and MEWS scores and conducted regression analyses on the relationships of BISAP scoring, RDW, MEWS, and serum Ca2+ with the severity of AP using single-factor logistics. The variables with statistical significance in the single-factor logistic regression were used in a multi-factor logistic regression model; forward stepwise regression was used to screen variables and build a multi-factor prediction model. A receiver operating characteristic curve (ROC curve) was constructed, and the significance of multi- and single-factor prediction models in predicting the severity of AP using the area under the ROC curve (AUC) was evaluated. The internal validity of the model was verified through bootstrapping.

RESULTS

Among 302 patients with AP, 209 had mild acute pancreatitis (MAP) and 93 had severe acute pancreatitis (SAP). According to single-factor logistic regression analysis, we found that BISAP, MEWS and serum Ca2+ are prediction indexes of the severity of AP (P-value<0.001), whereas RDW is not a prediction index of AP severity (P-value>0.05). The multi-factor logistic regression analysis showed that BISAP and serum Ca2+ are independent prediction indexes of AP severity (P-value<0.001), and MEWS is not an independent prediction index of AP severity (P-value>0.05); BISAP is negatively related to serum Ca2+ (r=-0.330, P-value<0.001). The constructed model is as follows: ln()=7.306+1.151*BISAP-4.516*serum Ca2+. The predictive ability of each model for SAP follows the order of the combined BISAP and serum Ca2+ prediction model>Ca2+>BISAP. There is no statistical significance for the predictive ability of BISAP and serum Ca2+ (P-value>0.05); however, there is remarkable statistical significance for the predictive ability using the newly built prediction model as well as BISAP and serum Ca2+ individually (P-value<0.01). Verification of the internal validity of the models by bootstrapping is favorable.

CONCLUSION

BISAP and serum Ca2+ have high predictive value for the severity of AP. However, the model built by combining BISAP and serum Ca2+ is remarkably superior to those of BISAP and serum Ca2+ individually. Furthermore, this model is simple, practical and appropriate for clinical use.

Clinical practice guideline for post-ERCP pancreatitis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERPC) is used for the diagnosis and treatment of pancreatic and biliary diseases. Post-ERCP pancreatitis (PEP) is a complication which needs special care and clinical practice guideline for this morbidity is also needed.

METHODS

The key clinical issues of diagnosis and treatment of PEP were listed and checked, and then the clinical questions were formulated. PubMed (MEDLINE) and Ichushi-web (Japanese medical literature) were used as databases. For the study of diagnostic test accuracy, items similar to QUADAS-2, i.e., random selection from a population to which the diagnostic test is applied, blinding of index tests and reference tests, completeness of reference standard, completeness of test implementations, the same timing of tests, and missing data were assessed as well as the indirectness of the study subjects, index tests, reference standard, and outcomes. Grading of recommendations was determined as strong or weak. In clinical practice, the judgment of attending doctors should be more important than recommendations described in clinical practice guidelines. Gastroenterologists are the target users of this clinical practice guideline. General practitioners or general citizens are not supposed to use this guideline. The guideline committee has decided to include wide clinical issues such as etiological information, techniques of ERCP, the diagnosis, treatments, and monitoring of PEP in this guideline.

RESULTS

In this concise report, we described ten clinical questions, recommendations, and explanations pertaining to risk factors, diagnosis, prognostic factors, treatments, and preventive interventions in the medical practice for PEP.

CONCLUSIONS

We reported here the essence of the clinical practice guideline for PEP.

Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study

OBJECTIVES

Severe acute pancreatitis is associated with peripancreatic morphologic changes as seen on imaging. Uniform communication regarding these morphologic findings is crucial for accurate diagnosis and treatment. For the original 1992 Atlanta classification, interobserver agreement is poor. We hypothesized that for the revised Atlanta classification, interobserver agreement will be better.

METHODS

An international, interobserver agreement study was performed among expert and nonexpert radiologists (n = 14), surgeons (n = 15), and gastroenterologists (n = 8). Representative computed tomographies of all stages of acute pancreatitis were selected from 55 patients and were assessed according to the revised Atlanta classification. The interobserver agreement was calculated among all reviewers and subgroups, that is, expert and nonexpert reviewers; interobserver agreement was defined as poor (≤0.20), fair (0.21-0.40), moderate (0.41-0.60), good (0.61-0.80), or very good (0.81-1.00).

RESULTS

Interobserver agreement among all reviewers was good (0.75 [standard deviation, 0.21]) for describing the type of acute pancreatitis and good (0.62 [standard deviation, 0.19]) for the type of peripancreatic collection. Expert radiologists showed the best and nonexpert clinicians the lowest interobserver agreement.

CONCLUSIONS

Interobserver agreement was good for the revised Atlanta classification, supporting the importance for widespread adaption of this revised classification for clinical and research communications.