Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation

Serum ghrelin, but not obestatin, is a potential predictor of acute pancreatitis severity

The roles of ghrelin and obestatin in AP remain controversial.This study investigates the effects and the predictive value of serum ghrelin and obestatin levels in the early stage of AP.A total of 193 consecutive patients with AP and 24 healthy controls were included. Patients were divided into mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP), and severe acute pancreatitis (SAP) groups. Serum levels of ghrelin and obestatin were measured on the first, third, and fifth days of hospitalization. The predictive value of serum ghrelin and obestatin levels on the first day in AP was examined using receiver-operating characteristic (ROC) curves.On the first day of hospitalization, the mean serum ghrelin level was significantly lower in patients with AP than in controls (P < .01). The serum ghrelin concentration decreased with increasing AP severity and was lower in patients with SAP than in those with MAP and MSAP (P < .05). It increased gradually from the first to the fifth day after treatment. ROC curves demonstrated that the serum ghrelin level on the first day had some predictive value for AP severity (area under the ROC curve = 0.646), with an optimal cut-off value of 87.83 pg/mL. Logistic regression showed that the serum ghrelin level had independent predictive value for non-MAP (odds ratio = 10.94; 95% confidence interval, 5.08-23.55; P < .01). The serum obestatin level did not differ significantly between patients with AP and controls and had the limited predictive value for non-MAP (area under the ROC curve = 0.564). However, the serum obestatin concentration showed a "warning" effect regarding AP etiology; on the first day of treatment, it was significantly lower in patients with AP of hypertriglyceridemic etiology than in those with AP of biliary, alcohol-related, and other etiologies (P = .05, P = .031, and P = .029, respectively).Serum ghrelin and obestatin levels may be related to the progression of AP in the early stage. Only the serum ghrelin level is a potential predictor of AP severity in the early stage. Obestatin may be involved in the pathogenesis of AP caused by hypertriglyceridemia.

Gastrin-Releasing Peptide and Glucose Metabolism Following Pancreatitis

Background

Gastrin-releasing peptide (GRP) is a pluripotent peptide that has been implicated in both gastrointestinal inflammatory states and classical chronic metabolic diseases such as diabetes. Abnormal glucose metabolism (AGM) after pancreatitis, an exemplar inflammatory disease involving the gastrointestinal tract, is associated with persistent low-grade inflammation and altered secretion of pancreatic and gut hormones as well as cytokines. While GRP is involved in secretion of many of them, it is not known whether GRP has a role in AGM. Therefore, we aimed to investigate the association between GRP and AGM following pancreatitis.

Methods

Fasting blood samples were collected to measure GRP, blood glucose, insulin, amylin, glucagon, pancreatic polypeptide (PP), somatostatin, cholecystokinin, gastric-inhibitory peptide (GIP), gastrin, ghrelin, glicentin, glucagon-like peptide-1 and 2, oxyntomodulin, peptide YY (PYY), secretin, vasoactive intestinal peptide, tumor necrosis factor-α (TNF-α), monocyte chemoattractant protein (MCP)-1, and interleukin-6. Modified Poisson regression analysis and linear regression analyses were conducted. Four statistical models were used to adjust for demographic, metabolic, and pancreatitis-related risk factors.

Results

A total of 83 individuals after an episode of pancreatitis were recruited. GRP was significantly associated with AGM, consistently in all four models (P -trend < 0.05), and fasting blood glucose contributed 17% to the variance of GRP. Further, GRP was significantly associated with glucagon (P < 0.003), MCP-1 (P < 0.025), and TNF-α (P < 0.025) - consistently in all four models. GRP was also significantly associated with PP and PYY in three models (P < 0.030 for both), and with GIP and glicentin in one model (P = 0.001 and 0.024, respectively). Associations between GRP and other pancreatic and gut hormones were not significant.

Conclusion

GRP is significantly increased in patients with AGM after pancreatitis and is associated with increased levels of pro-inflammatory cytokines, as well as certain pancreatic and gut hormones. Detailed mechanistic studies are now warranted to investigate the exact role of GRP in derangements of glucose homeostasis following pancreatitis.

Early discharge in Mild Acute Pancreatitis. Is it possible? Observational prospective study in a tertiary-level hospital

BACKGROUND AND AIMS

In acute pancreatitis (AP), first 24 h are crucial as this is the period in which the greatest amount of patients presents an organ failure. This suggests patients with Mild AP (MAP) could be early identified and discharged. This is an observational prospective trial with the aim to demonstrate the safety of early discharge in Mild Acute Pancreatitis (MAP).

METHODS

Observational prospective study in a third level single centre. Consecutive patients with AP from March 2012 to March 2014 were collected.

INCLUSION CRITERIA

MAP, tolerance to oral intake, control of pain, C Reactive Protein <150 mg/dL and blood ureic nitrogen < 5 mg/dL in two samples.

EXCLUSION CRITERIA

pregnant, lack of family support, active comorbidities, temperature and serum bilirubin elevation. Patients with MAP, who met the inclusion criteria, were discharged within the first 48 h. Readmissions within first week and first 30 days were recorded. Adverse effects related to readmissions were also collected.

RESULTS

Three hundred and seventeen episodes were collected of whom 250 patients were diagnosed with MAP. From these, 105 were early discharged. Early discharged patients presented a 30-day readmission rate of 15.2% (16 patients out of 105) corresponding to the readmission rates in Acute Pancreatitis published to date. Any patient presented adverse effects related to readmissions.

CONCLUSION

Early discharge in accurately selected patients with MAP is feasible, safe and efficient and leads to a decrease in median stay with the ensuing savings per process and with no increase in readmissions or inmorbi-mortality.

Accuracy of circulating histones in predicting persistent organ failure and mortality in patients with acute pancreatitis

BACKGROUND

Early prediction of acute pancreatitis severity remains a challenge. Circulating levels of histones are raised early in mouse models and correlate with disease severity. It was hypothesized that circulating histones predict persistent organ failure in patients with acute pancreatitis.

METHODS

Consecutive patients with acute pancreatitis fulfilling inclusion criteria admitted to Royal Liverpool University Hospital were enrolled prospectively between June 2010 and March 2014. Blood samples were obtained within 48 h of abdominal pain onset and relevant clinical data during the hospital stay were collected. Healthy volunteers were enrolled as controls. The primary endpoint was occurrence of persistent organ failure. The predictive values of circulating histones, clinical scores and other biomarkers were determined.

RESULTS

Among 236 patients with acute pancreatitis, there were 156 (66·1 per cent), 57 (24·2 per cent) and 23 (9·7 per cent) with mild, moderate and severe disease respectively, according to the revised Atlanta classification. Forty-seven healthy volunteers were included. The area under the receiver operating characteristic (ROC) curve (AUC) for circulating histones in predicting persistent organ failure and mortality was 0·92 (95 per cent c.i. 0·85 to 0·99) and 0·96 (0·92 to 1·00) respectively; histones were at least as accurate as clinical scores or biochemical markers. For infected pancreatic necrosis and/or sepsis, the AUC was 0·78 (0·62 to 0·94). Histones did not predict or correlate with local pancreatic complications, but correlated negatively with leucocyte cell viability (r = -0·511, P = 0·001).

CONCLUSION

Quantitative assessment of circulating histones in plasma within 48 h of abdominal pain onset can predict persistent organ failure and mortality in patients with acute pancreatitis. Early death of immune cells may contribute to raised circulating histone levels in acute pancreatitis.

Effect of Intravenous Fluids and Analgesia on Dysmotility in Patients With Acute Pancreatitis: A Prospective Cohort Study

OBJECTIVES

Analgesia and intravenous fluid resuscitation are cornerstones of initial patient management in acute pancreatitis (AP). The aim was to investigate the effect of intravenous fluids and analgesia on gastrointestinal motility in the early course of AP.

METHODS

Gastrointestinal dysmotility was assessed using the Gastroparesis Cardinal Symptom Index (GCSI). One-way analysis of variance and analysis of covariance were conducted, adjusting for age, sex, body mass index, severity of AP, preexisting diabetes mellitus, and time from first symptom onset to hospital admission.

RESULTS

A total of 108 patients with AP were prospectively enrolled. Opioid analgesia, when compared with nonopioid analgesia, was significantly associated with increase in total GCSI score in both unadjusted and adjusted analyses. There was no significant difference between aggressive and nonaggressive fluid resuscitation in both unadjusted and adjusted analyses. A combination of opioids and any intravenous fluids was associated with a significantly increased total GCSI score compared with opioids and no intravenous fluids in both unadjusted and adjusted analyses. Duration of symptoms was the confounder that significantly affected 6 of 9 studied associations.

CONCLUSIONS

Intravenous fluids and analgesia significantly affect motility independent of severity and other covariates. Guidelines on prudent use of opioids and fluids in AP need to be developed, particularly taking into account duration of symptoms from onset to hospitalization.

Clinical impact of EUS treatment of walled-off pancreatic necrosis with dedicated devices

BACKGROUND AND STUDY AIMS

 Walled-off pancreatic necrosis (WOPN) represents the major risk factor for sepsis-related multiple organ failure. Surgical debridement is an invasive approach associated with high rates of adverse events (AEs) and death. As an alternative, endoscopic ultrasound-guided cysto-gastro-anastomosis has emerged as an effective treatment for WOPNs. Recently a new dedicated-lumen apposing metal stent (LAMS) has been used with satisfactory results in treating peri-pancreatic fluid collections, including WOPNs. The primary outcomes of this study were to evaluate survival and clinical success. Secondary outcomes included: technical success, adverse events and recurrence rate.

PATIENTS AND METHODS

 All consecutive patients with infected WOPN between February 2014 and June 2016 were retrospectively reviewed. Patients underwent placement of a new LAMS incorporated in an electrocautery-enhanced delivery system and direct endoscopic necrosectomy (DEN). DEN was performed immediately after stent deployment and repeated every 3 to 7 days until complete resolution.

RESULTS

 In the study period we treated 20 consecutive patients with infected WOPN using the new LAMS. Technical success was achieved in 95 % of patients. Clinical success was achieved in 73 % and 84.2 % of patients at 1 and 3 months, respectively. Survival rate was 84.2 % and 79 %. Mean length of hospital stay was 19 days (range 3 - 43). No AEs occurred. Patients were followed up after stent retrieval for a mean time of 554,7 days (range 70 - 986) and no recurrence was observed.

CONCLUSIONS

 DEN following "1-step, exchange-free" LAMS positioning recorded excellent results. We believe that simplicity of procedure plays a key role in terms of safety.

Dynamic Measurement of Disease Activity in Acute Pancreatitis: The Pancreatitis Activity Scoring System

OBJECTIVES

Acute pancreatitis has a highly variable course. Currently there is no widely accepted method to measure disease activity in patients hospitalized for acute pancreatitis. We aimed to develop a clinical activity index that incorporates routine clinical parameters to assist in the measurement, study, and management of acute pancreatitis.

METHODS

We used the UCLA/RAND appropriateness method to identify items for inclusion in the disease activity instrument. We conducted a systematic literature review followed by two sets of iterative modified Delphi meetings including a panel of international experts between November 2014 and November 2015. The final instrument was then applied to patient data obtained from five separate study cohorts across Southern California to assess profiles of disease activity.

RESULTS

From a list of 35 items comprising 6 domains, we identified 5 parameters for inclusion in the final weighted clinical activity scoring system: organ failure, systemic inflammatory response syndrome, abdominal pain, requirement for opiates and ability to tolerate oral intake. We applied the weighted scoring system across the 5 study cohorts comprising 3,123 patients. We identified several distinct patterns of disease activity: (i) overall there was an elevated score at baseline relative to discharge across all study cohorts, (ii) there were distinct patterns of disease activity related to duration of illness as well as (iii) early and persistent elevation of disease activity among patients with severe acute pancreatitis defined as persistent organ failure.

CONCLUSIONS

We present the development and initial validation of a clinical activity score for real-time assessment of disease activity in patients with acute pancreatitis.

Recent Advances on Nutrition in Treatment of Acute Pancreatitis

Acute pancreatitis (AP) is a common abdominal acute inflammatory disorder and the leading cause of hospital admission for gastrointestinal disorders in many countries. Clinical manifestations of AP vary from self-limiting local inflammation to devastating systemic pathological conditions causing significant morbidity and mortality. To date, despite extensive efforts in translating promising experimental therapeutic targets in clinical trials, disease-specific effective remedy remains obscure, and supportive care has still been the primary treatment for this disease. Emerging evidence, in light of the current state of pathophysiology of AP, has highlighted that strategic initiation of nutrition with appropriate nutrient supplementation are key to limit local inflammation and to prevent or manage AP-associated complications. The current review focuses on recent advances on nutritional interventions including enteral versus parenteral nutrition strategies, and nutritional supplements such as probiotics, glutamine, omega-3 fatty acids, and vitamins in clinical AP, hoping to advance current knowledge and practice related to nutrition and nutritional supplements in clinical management of AP.

Resveratrol protects against L-arginine-induced acute necrotizing pancreatitis in mice by enhancing SIRT1-mediated deacetylation of p53 and heat shock factor 1

Acute necrotizing pancreatitis (ANP) is a common severe critical illness with a high mortality rate. Resveratrol, a polyphenol compound derived from various plants such as grape skin, peanut, berry and veratrum, exhibits multiple biological activities, especially potent anti‑inflammatory activity, but its effect on ANP has not yet been fully elucidated. The present study aimed to investigate the effects of resveratrol on L-arginine-induced ANP and the possible mechanisms. A mouse model of ANP was established by 2 hourly intraperitoneal injections of 8% L-arginine (4 g/kg). Then the mice were treated by intragastric administration of resveratrol (80 mg/kg) every 12 h immediately after the second injection of L-arginine. Mice with ANP showed increased apoptosis of pancreatic acinar cells, pancreatic myeloperoxidase activity, serum lactate dehydrogenase activity, amylase, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) levels as well as decreased serum IL-10 level, pancreatic expression of heat shock factor 1 (HSF1), sirtuin 1 (SIRT1) and p53, but the ratio of acetylated HSF1 and p53 was markedly increased. Resveratrol enhanced the survival rate of mice with ANP from 47.8 to 71.4% and obviously restored the changes in mice with ANP as mentioned above. Additionally, interactions between SIRT1 and p53 and between SIRT1 and HSF1 in the pancreas of the mice were confirmed by co-immunoprecipitation. These data suggest that resveratrol protects against L-arginine-induced ANP, which may be related to the enhancement of SIRT1-mediated deacetylation of p53 and HSF1.

Effectiveness of contrast-enhanced ultrasound for the diagnosis of acute pancreatitis: A systematic review and meta-analysis

OBJECTIVE

To systematically determine the diagnostic value of contrast-enhanced ultrasound (CEUS) in the assessment of acute pancreatitis.

METHODS

Relevant studies were identified by searching the database up to December 2016. Patient clinical characteristics and diagnostic sensitivity and specificity were extracted. The summary receiver operating characteristic (ROC) curve was used to examine the accuracy of CEUS. A meta-analysis was performed to evaluate the clinical utility in the diagnosis and evaluation of acute pancreatitis.

RESULTS

From 27 citations, seven were included in the meta-analysis, with a total of 421 cases. We detected the heterogeneity of the studies and evidence of publication bias. The methodological quality was moderate. The pooled weighted sensitivity with a corresponding 95% confidence interval (CI) was 0.92 (95% CI: 0.88, 0.95), the specificity was 0.84 (95% CI: 0.78, 0.90), the positive likelihood ratio was 5.38 (95% CI: 3.21, 9.00), the negative likelihood ratio was 0.13 (95% CI: 0.05, 0.36), and the diagnostic odds ratio was 49.37 (95% CI: 14.69, 165.94). The area under the ROC curve was 0.9273 (95% CI: 0.8916, 0.9790).

CONCLUSIONS

CEUS is a reliable, non-invasive imaging modality with no radiation exposure and a high sensitivity and specificity for the assessment of severity of acute pancreatitis. Nonetheless, it should be applied cautiously, and large-scale, well-designed trials are necessary to assess its clinical value.

Role of human lipocalin proteins in abdominal obesity after acute pancreatitis

Lipocalin proteins are small regulatory peptides implicated in metabolism, inflammation, and immunity. Although lipocalin proteins have been linked to various clinical conditions, their role in the acute inflammatory setting, such as acute pancreatitis (AP), has only been sparsely investigated. Two members of the lipocalin family, lipocalin-2 (LCN-2) and retinol binding protein -4 (RBP-4), play an important role in obesity and insulin resistance. In this study, we analysed circulating levels of LCN-2 and RBP-4 in 92 individuals after AP, of whom 41 individuals had abdominal obesity and 51 did not. Binary logistic regression analyses were performed to determine whether abdominal obesity was associated with the two lipocalin proteins. Lipocalin-2 was significantly associated with abdominal obesity in the unadjusted model (Odds ratio (OR)=1.014 [95% confidence interval (CI): 1.000, 1.028], P=0.05) and after adjusting for patient related (age, ethnicity, and diabetes mellitus) and pancreatitis related (aetiology, severity, recurrence, and duration of AP) characteristics (OR=1.018 [95% CI: 1.001, 1.036], p=0.04). Further, the association of LCN-2 with waist circumference was significant in individuals with alcohol aetiology of AP (β=1.082 [95% CI: 1.011, 1.158], p=0.02]. The association between RBP-4 and abdominal obesity was not significant in both unadjusted and adjusted models. These findings indicate that circulating levels of LCN-2 in patients after AP may play a role in chronic low grade inflammation associated with abdominal adiposity and that alcohol consumption may further exacerbate adipose tissue dysfunction.

Chai-Qin-Cheng-Qi Decoction and Carbachol Improve Intestinal Motility by Regulating Protein Kinase C-Mediated Ca2+ Release in Colonic Smooth Muscle Cells in Rats with Acute Necrotising Pancreatitis

Chai-Qin-Cheng-Qi decoction (CQCQD) improves intestinal motility in acute pancreatitis (AP), but the mechanism(s) require elucidation. We investigated the effects of CQCQD and carbachol, a prokinetic agent, on colonic smooth muscle cells (SMCs) in L-arginine-induced necrotising AP model in rats. In treatment groups, intragastric CQCQD (20 g/kg, 2 hourly × 3 doses) or intraperitoneal carbachol (60 μg/kg) was given 24 hours after induction of AP. Both CQCQD and carbachol decreased the severity of pancreatic and colonic histopathology (all P < 0.05). Both CQCQD and carbachol reduced serum intestinal fatty acid binding protein, vasoactive intestinal peptide, and substance P and increased motility levels. CQCQD upregulated SMC phospholipase C-beta 1 (PLC-β1) mRNA and PLC protein (both P < 0.05), while both treatments upregulated protein kinase C-alpha (PKC-α) mRNA and PKC protein and downregulated adenylate cyclase (AC) mRNA and protein compared with no treatment (all P < 0.05). Neither treatment significantly altered L-arginine-induced PKC-β1 and PKC-ε mRNA reduction. Both treatments significantly increased fluorescence intensity of SMC intracellular calcium concentration [Ca²⁺]_i (3563.5 and 3046.9 versus 1086.9, both P < 0.01). These data suggest CQCQD and carbachol improve intestinal motility in AP by increasing [Ca²⁺]_i in colonic SMCs via upregulating PLC, PKC and downregulating AC.

Abdominal paracentesis drainage improves tolerance of enteral nutrition in acute pancreatitis: a randomized controlled trial

OBJECTIVE

The objective of this study is to determine whether abdominal paracentesis drainage (APD) could improve the administration of enteral nutrition (EN) in acute pancreatitis.

METHODS

Between January 2015 and April 2016, a total of 161 acute pancreatitis patients were enrolled and randomly assigned to either the APD group or the non-APD group. Several indexes associated with the administration of EN, including the gastroparesis cardinal symptom index (GCSI), the incidence of gastrointestinal adverse events, and the clinical outcomes, were recorded.

RESULTS

The mean GCSI scores were 13.6 ± 2.1 before randomization and 7.1 ± 2.3 after a week in the APD group. These scores were 13.9 ± 2.4 and 9.7 ± 1.9 in the non-APD group. The incidences of gastrointestinal adverse events in the two groups were similar (p > .05), except for diarrhea. However, the patients in the APD group spent less time achieving the nutrition target (25 per kilogram of body weight per day) and fully tolerated the oral diet (p < .05). Additionally, the clinical outcomes of the APD group were better compared with those of the non-APD group.

CONCLUSION

APD can improve the administration of EN in acute pancreatitis. Given the positive effect of EN on clinical outcomes, this phenomenon possibly explains why APD could improve the clinical outcomes of acute pancreatitis patients in some aspects.

Severe acute pancreatitis: pathogenesis, diagnosis and surgical management

BACKGROUND

Severe acute pancreatitis is a subtype of acute pancreatitis, associated with multiple organ failure and systemic inflammatory response syndrome. In this qualitative review we looked at the principles of pathogenesis, classification and surgical management of severe acute pancreatitis. We also looked at the current shift in paradigm in the management of severe acute pancreatitis since the guideline developed by the British Society of Gastroenterology.

DATA SOURCES

Studies published between 1st January 1991 and 31st December 2015 were identified with PubMed, MEDLINE, EMBASE and Google Scholar online search engines using the following Medical Subject Headings: "acute pancreatitis, necrosis, mortality, pathogenesis, incidence" and the terms "open necrosectomy and minimally invasive necrosectomy". The National Institute of Clinical Excellence (NICE) Guidelines were also included in our study. Inclusion criteria for our clinical review included established guidelines, randomized controlled trials and non-randomized controlled trials with a follow-up duration of more than 6 weeks.

RESULTS

The incidence of severe acute pancreatitis within the UK is significantly rising and pathogenetic theories are still controversial. In developed countries, the most common cause is biliary calculi. The British Society of Gastroenterology, acknowledges the Revised Atlanta criteria for prediction of severity. A newer Determinant-based system has been developed. The principle of surgical management of acute necrotizing pancreatitis requires intensive care management, identifying infection and if indicated, debridement of any infected necrotic area. The current procedures opted for include standard surgical open necrosectomy, endoscopic necrosectomy and minimally invasive necrosectomy. The current paradigm is shifting towards a step-up approach.

CONCLUSIONS

Severe acute pancreatitis is still a subject of grey areas in its surgical management even though new studies have been recorded since the origin of the latest UK guidelines for management of severe acute pancreatitis.

Comparison of the prognostic values of inflammation markers in patients with acute pancreatitis: a retrospective cohort study

OBJECTIVES

Inflammation-based prognostic markers (neutrophil-lymphocyte ratio (NLR), prognostic nutritional index (PNI), red cell distribution width (RDW) and lymphocyte-monocyte ratio (LMR)) are associated with overall survival in some diseases. This study assessed their prognostic value in mortality and severity in acute pancreatitis (AP).

DESIGN

A retrospective cohort study.

SETTING

Patients with AP were recruited from the emergency department at our hospital.

PARTICIPANTS

A total of 359 patients with AP (31 non-survivors) were enrolled.

PRIMARY AND SECONDARY OUTCOME MEASURES

Mortality and severity of AP were the primary and secondary outcome measures, respectively. Biochemistry and haematology results of the first test after admission were collected. Independent relationships between severe AP (SAP) and markers were assessed using multivariate logistic regression models. Mortality prediction ability was evaluated using receiver operating characteristic (ROC) curves. Overall survival was evaluated using the Kaplan-Meier method, with differences compared using the log-rank test. Independent relationships between mortality and each predictor were estimated using the Cox proportional hazard models.

RESULTS

Compared with survivors of AP, non-survivors had higher RDW (p<0.001), higher NLR (p<0.001), lower LMR (p<0.001) and lower PNI (p<0.001) at baseline. C reactive protein (CRP; OR=8.251, p<0.001), RDW (OR=2.533, p=0.003) and PNI (OR=7.753, p<0.001) were independently associated with the occurrence of SAP. For predicting mortality, NLR had the largest area under the ROC curve (0.804, p<0.001), with a 16.64 cut-off value, 82.4% sensitivity and 75.6% specificity. RDW was a reliable marker for excluding death owing to its lowest negative likelihood ratio (0.11). NLR (HR=4.726, p=0.004), CRP (HR=3.503, p=0.003), RDW (HR=3.139, p=0.013) and PNI (HR=2.641, p=0.011) were independently associated with mortality of AP.

CONCLUSIONS

NLR was the most powerful marker of overall survival in this patient series.

Frequency and prognosis of acute pancreatitis associated with fulminant or non-fulminant acute hepatitis A: A systematic review

BACKGROUND

Acute pancreatitis (AP) in patients with fulminant viral hepatitis is well recognized and its mortality depends on the severity of hepatitis rather than pancreatitis. Acute pancreatitis associated with non-fulminant acute hepatitis A (AHA) has been rarely described, and is considered to have a benign course with good response to conservative management.

OBJECTIVE

To perform a systematic review of the frequency and prognosis of AP associated with fulminant or non-fulminant AHA.

RATIONALE

An increasing number of reports describe AP associated with AHA. Some life-threatening complications related to AP may occur, and death has been reported. In addition, it is possible that early diagnosis of these cases may help in reducing the morbidity and mortality.

DATA SOURCES

Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, Google Scholar, and reference lists of relevant articles.

STUDY SELECTION

All available studies discussing AP associated with fulminant or non-fulminant AHA.

DATA EXTRACTION AND ASSESSMENT

Two blinded independent observers extracted and assessed the frequency of AP associated with AHA based on large studies including all cases of AHA observed during a prolonged period of time, diagnosis of AHA based on anti-HAV IgM, diagnosis of fulminant hepatitis (FH) based on the American Association for the study of Liver Diseases (AASLD) position paper, diagnosis of AP based on the American College of Gastroenterology (ACG) guidelines, diagnosis of AP associated with AHA based on Makharia's association, and diagnosis of AP severity based on the Revision of the Atlanta Classification (RAC). We have developed a tool for risk of bias assessment of case reports and case-series and applied it to the included studies.

RESULTS

The frequency of reported AP associated with AHA is 0-0.1%. Thirty-eight publications with a total of 54 patients meeting the inclusion criteria have been published. Twenty-two studies had a low risk for bias, 10 had moderate risk and 6 had high risk. Patients originated from all continents but most of them were from Asia. The median age at diagnosis was 16 years (range: 2-81) with a male to female ratio of 2. The median interval between the onset of jaundice and onset of AP pain was 4 days (range: 0-30). AP was severe in 9% of patients. The median hospital stay for AP was 8 days (range: 3-35). Most cases occur in patients without FH (94%). Mortality was reported in 2 patients (3.7%).

CONCLUSION

Acute pancreatitis associated with AHA is rare with an estimated frequency of 0-0.1%. Fifty-four documented cases, mostly in Asian patients, have been reported. The median age of patients is 16 years with a M/F ratio of 2. Acute pancreatitis occurs less than one week after the onset of jaundice and mostly in patients without FH. Acute pancreatitis in this setting is severe in 9% of patients with a mortality rate similar to all other causes of AP.

IL-8 gene polymorphism in acute biliary and non biliary pancreatitis: probable cause of high level parameters?

Backgrounds/Aims

Inflammatory mediators of the innate immune response play fundamental roles in the pathogenesis of acute pancreatitis. The correlation between interleukin-8 (IL-8) gene polymorphism with types of acute pancreatitis and severity of pancreatitis, was evaluated in this study.

Methods

According to the diagnostic criteria, 176 patients with acute pancreatitis were grouped into biliary (n=83) and nonbiliary pancreatitis (n=93). Healthy blood donors (n=100) served as controls. Serum alanine transaminase, aspartate transaminase, total and direct bilirubin, amylase, lypase, white blood cell count and c-reactive protein levels were evaluated to correlate with IL-8 rs4073 (-251T/A) polymorphism, which was analyzed using a real-time polymerase chain reaction method with melting point analysis.

Results

The IL-8 AA genotype was detected with a significantly higher frequency among the patients with acute biliary pancreatitis having higher alanine transaminase levels than the median range. Homozygote alleles were significantly higher among patients with acute biliary pancreatitis having amylase levels higher than the median range.

Conclusions

Determination of the frequency of IL-8 polymorphism in acute pancreatitis is informative and provides further evidence concerning the role of IL-8 in laboratory tests.

Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone

OBJECTIVE:

To present our experience in the management of patients with infected pancreatic necrosis without drainage.

METHODS:

The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed.

RESULTS:

We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died.

CONCLUSIONS:

In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.

Multiple interventions with prolonged length of stay are required for treatment of necrotizing pancreatitis

BACKGROUND

A proportion of patients with acute pancreatitis (AP) develop necrosis. Around a third will become infected, and this is associated with a significant requirement for intervention and support. We evaluated the burden of necrotizing pancreatitis (NP) in an Australian tertiary hospital with regards to morbidity, mortality and resource consumption.

METHODS

This is a retrospective case series of patients with AP admitted for at least 5 days to identify those with NP between 2009 and 2014. Data were analysed in groups according to the determinant-based classification of AP severity.

RESULTS

Of 1339 patients with AP, 546 stayed 5 days or longer, and 38 had necrosis. Overall mortality for those with necrosis was 10.5% (4/38). Infection complicated necrosis in 45% (17/38). Organ failure also occurred in 45% (17/38) of patients with necrosis. All patients in the critical category and severe category required admission to the intensive care unit for a median of 21 and 12 days, respectively. A total of 90% of patients with critical category disease developed multi-organ failure, whereas most with severe category disease developed single organ failure only. Overall length of stay increased with increasing severity of disease. Intervention was required in 82% of infected necrosis (median 4 procedures). Those without infection also required multiple radiological investigations (median 7).

CONCLUSION

Necrosis is uncommon in our cohort but is associated with a significant health-care burden. Almost half the patients with necrosis develop organ failure requiring prolonged hospital and intensive care unit stay. Patients require multiple investigations and interventions for infected necrosis. NP remains a costly, morbid disease in our society.

Revised Atlanta classification and determinant-based classification: Which one better at stratifying outcomes of patients with acute pancreatitis?

BACGROUND

Two different severity classifications (revised Atlanta classification [RAC] and determinant-based classification [DBC]) were recently proposed.

METHODS

This was a retrospective analysis of a prospective acute pancreatitis (AP) database. This study aims to compare the ability of three classification systems (RAC, DBC, and original Atlanta classification [OAC]) to stratify outcomes of AP and to determine the association between different severity categories and clinical outcomes.

RESULTS

Overall, as the grade of severity increased, the morbidity and mortality increased accordingly in the three classification systems. The RAC and DBC were comparable, but performed better than OAC in predicting mortality (AUC 0.92 and 0.95 vs. 0.66, p < 0.001), ICU admission (AUC 0.92 and 0.96 vs. 0.68, p < 0.001), ICU LOS (AUC 0.73 and 0.76 vs. 0.50, p < 0.001), and hospital stay (AUC 0.81 and 0.83 vs. 0.70, p < 0.001). The DBC performed better than the RAC and OAC in predicting the need for intervention (AUC 0.87 vs. 0.79 and 0.68, p < 0.05). The mortality rate in patients with critical DBC category was higher than that in those with severe RAC category (42.1% vs. 24.7%; p = 0.008). POF (OR 19.4, p = 0.001) and IN (OR 11.0, p = 0.025) were independent risk factors for mortality.

CONCLUSIONS

In tertiary referral setting, patients in the critical category are at the greatest risk for death and should be managed in an intensive care unit. Although IN itself may be less influential on mortality than POF, IN as well as POF should be considered as the key determinants for severity stratification.

Relationship between circulating levels of pancreatic proteolytic enzymes and pancreatic hormones

BACKGROUND

While the close morphological relationship between the exocrine and endocrine pancreas is well established, their functional interaction remains poorly understood. The aim of this study was to investigate the associations between circulating levels of pancreatic proteolytic enzymes and insulin, as well as other pancreatic hormones.

METHODS

Fasting venous blood samples were collected and analyzed for trypsin, chymotrypsin, insulin, glucagon, somatostatin, and pancreatic polypeptide. Linear regression analysis was used in unadjusted and two adjusted (accounting for prediabetes/diabetes, body mass index, smoking, and other covariates) statistical models.

RESULTS

A total of 93 individuals with a history of acute pancreatitis were included in this cross-sectional study. Chymotrypsin was significantly associated with insulin in the two adjusted models (p = 0.005; p = 0.003) and just missed statistical significance in the unadjusted model (p = 0.066). Chymotrypsin was significantly associated with glucagon in both unadjusted (p = 0.025) and adjusted models (p = 0.014; p = 0.015); as well as with somatostatin - in both unadjusted (p = 0.001) and adjusted models (p = 0.001; p = 0.002). Trypsin was not significantly associated with insulin in any of the models but was significantly associated with glucagon in both unadjusted (p < 0.001) and adjusted models (p < 0.001), and pancreatic polypeptide in both unadjusted (p < 0.001) and adjusted (p < 0.001) models.

CONCLUSION

The state of hyperinsulinemia is characterized by a dysfunction of the exocrine pancreas. In particular, chymotrypsin is increased in the state of hyperinsulinemia and trypsin is significantly associated with glucagon and pancreatic polypeptide.

Circulating microRNA 216 as a Marker for the Early Identification of Severe Acute Pancreatitis

BACKGROUND

To study the value of circulating microRNA 216 (miR-216) as a marker for the severity of acute pancreatitis (AP) in both murine models and patients.

MATERIALS AND METHODS

Mice with AP were induced by intraperitoneal injection of 50μg/kg/hour cerulean either 7 times, sacrificed at 8, 9, 10, 11 or 12 hours after the first injection, or 12 times, sacrificed at 24 hours after the first injection. Plasma samples and data from patients with AP were obtained from a prospective cohort. Quantitative reverse transcription polymerase chain reaction was used to determine the miR-216a and miR-216b level.

RESULTS

The upregulation of miR-216a and miR-216b in the serum of mice was induced by cerulean injection in both the 7- and 12-injection groups (P < 0.05). The downregulation of miR-216a in pancreatic tissues of mice with AP was detected (P < 0.05), but no difference was observed in pancreatic miR-216b levels among any of the groups (all P > 0.05). The serum miR-216a level was positively correlated with pancreatic histopathology severity scores, and was negatively correlated with pancreatic miR-216a (r = -0.483, P = 0.009). The plasma miR-216a level was significantly upregulated in patients with severe AP (SAP) compared with patients with mild AP (MAP) or moderate severe AP (MSAP) (SAP versus MAP, P = 0.04; SAP versus MSAP, P = 0.00), but no difference was seen between patients with MAP and those with MSAP (P = 0.73).

CONCLUSIONS

Circulating miR-216a might be a potential biomarker for the early identification of SAP.

Endothelial markers are associated with pancreatic necrosis and overall prognosis in acute pancreatitis: A preliminary cohort study

BACKGROUND

Endothelial injury is believed to play an important role in the evolution of pancreatic microcirculatory dysfunction and pancreatic necrosis (PN) in patients with acute pancreatitis (AP). The aim of this study was to investigate the role of three endothelial markers (von Willebrand factor, vWF; E-selectin; endothelial protein C receptor, EPCR) in the early phase of AP, especially the relationship between endothelial markers and PN.

METHODS

From March 2015 to March 2016, 57 AP patients admitted within 72 h of symptom onset in our hospital were included for this study. Blood samples were taken on admission and the clinical characteristics and outcomes of these patients were recorded. The levels of vWF, E-selectin and EPCR were measured using ELISA for analysis and compared with other severity markers of AP.

RESULTS

All the three markers were significantly different in healthy control, mild, moderate and severe AP patients. Moreover, the endothelial markers, especially vWF, also showed significant difference in patients with different extent of PN, as well as those with or without MODS. Additionally, the levels of endothelial markers correlated well with other commonly used markers of AP severity.

CONCLUSION

Elevated endothelium-related mediators (vWF, E-selectin and EPCR) appear to participate in the development of PN and may be a potential indicator of overall prognosis. Our results may help clinicians better understand the pathophysiological process of the development of PN.

Investigation for role of tissue factor and blood coagulation system in severe acute pancreatitis and associated liver injury

This study aims to investigate the molecular mechanisms underlying the pathogenesis of severe acute pancreatitis (SAP) and SAP-associated liver injury, we performed an association analysis of the functions of tissue factor (TF) and blood coagulation system in both SAP patients and mouse SAP model. Our results showed that serum TF and tissue factor-microparticle (TF-MP) levels were highly up-regulated in both SAP patients and SAP mouse model, which was accompanied by the dysfunction of blood coagulation system. Besides, TF expression was also highly up-regulated in the Kupffer cells (KCs) of SAP mouse model. After inhibiting KCs in SAP mouse model, the amelioration of blood coagulation system functions was associated with the decrease in serum TF and TF-MPs levels, and the reduction of SAP-associated liver injury was associated with the decrease of TF expression in KCs. In conclusion, the dis-regulated TF expression and associated dysfunction of blood coagulation system are critical factors for the pathogenesis of SAP and SAP-associated liver injury. TF may serve as a potential and effective target for treating SAP and SAP-associated liver injury.

Acute pancreatitis patient registry to examine novel therapies in clinical experience (APPRENTICE): an international, multicenter consortium for the study of acute pancreatitis

BACKGROUND

We have established a multicenter international consortium to better understand the natural history of acute pancreatitis (AP) worldwide and to develop a platform for future randomized clinical trials.

METHODS

The AP patient registry to examine novel therapies in clinical experience (APPRENTICE) was formed in July 2014. Detailed web-based questionnaires were then developed to prospectively capture information on demographics, etiology, pancreatitis history, comorbidities, risk factors, severity biomarkers, severity indices, health-care utilization, management strategies, and outcomes of AP patients.

RESULTS

Between November 2015 and September 2016, a total of 20 sites (8 in the United States, 5 in Europe, 3 in South America, 2 in Mexico and 2 in India) prospectively enrolled 509 AP patients. All data were entered into the REDCap (Research Electronic Data Capture) database by participating centers and systematically reviewed by the coordinating site (University of Pittsburgh). The approaches and methodology are described in detail, along with an interim report on the demographic results.

CONCLUSION

APPRENTICE, an international collaboration of tertiary AP centers throughout the world, has demonstrated the feasibility of building a large, prospective, multicenter patient registry to study AP. Analysis of the collected data may provide a greater understanding of AP and APPRENTICE will serve as a future platform for randomized clinical trials.

Negative pressure irrigation and endoscopic necrosectomy through man-made sinus tract in infected necrotizing pancreatitis: a technical report

BACKGROUND

In recent years, a step-up approach based on minimally invasive techniques was recommended by latest guidelines as initial invasive treatment for infected pancreatic necrosis (IPN). In this study, we aimed to describe a novel step-up approach for treating IPN consisting of four steps including negative pressure irrigation (NPI) and endoscopic necrosectomy (ED) as a bridge between percutaneous catheter drainage (PCD) and open necrosectomy METHODS: A retrospective review of a prospectively collected internal database of patients with a diagnosis of IPN between Jan, 2012 to Dec, 2012 at a single institution was performed. All patients underwent the same drainage strategy including four steps: PCD, NPI, ED and open necrosectomy. The demographic characteristics and clinical outcomes of study patients were analyzed.

RESULTS

A total of 71 consecutive patients (48 males and 23 females) were included in the analysis. No significant procedure-related complication was observed and the overall mortality was +21.1 % (15 of 71 patients). Seven different strategies like PCD+ NPI, PCD+NPI+ED, PCD+open necrosectomy, etcetera, were applied in study patients and a half of them received PCD alone. In general, each patient underwent a median of 2 drainage procedures and the median total drainage duration was 11 days (interquartile range, 6-21days).

CONCLUSIONS

This four-step approach is effective in treating IPN and adds no extra risk to patients when compared with other latest step-up strategies. The two novel techniques (NPI and ED) could offer distinct clinical benefits without posing unanticipated risks inherent to the procedures.

Natural History After Acute Necrotizing Pancreatitis: a Large US Tertiary Care Experience

BACKGROUND

Most studies of acute necrotizing pancreatitis (ANP) focus on short-term outcomes. We evaluated long-term survival and outcomes following ANP.

METHODS

Patients treated for ANP at the University of Pittsburgh Medical Center from 2001 to 2008 were studied. Data on presentation and course during initial hospitalization and follow-up (median 34 months) was extracted.

RESULTS

Mean age of patients (n = 167) was 53 ± 16 years; 70 % were male, 94 % white, 71 % transfers, 52 % biliary etiology, and 78 % had first-attack of acute pancreatitis. Majority had severe disease with high Acute Physiology and Chronic Health Evaluation II (APACHE-II) score (median 11), length of stay (median 26 days), intensive care unit (ICU) admission (87 %), presence of systemic inflammatory response syndrome (SIRS) (90 %), persistent organ failure (60 %), and infected necrosis (50 %). Intervention was needed in 74 %. Eighteen (10.8 %) patients died during index hospitalization, 9 (5.4 %) during the first year, and 13 (7.8 %) after 1 year. Median survival was significantly shorter when compared with age- and sex-matched US general population (9.1 vs. 26.1 years, p < 0.001). Increasing age (HR 1.05), persistent organ failure (HR 4.5), and >50 % necrosis (HR 3.8) were independent predictors of death at 1 year. In eligible patients, new-onset diabetes, oral pancreatic enzyme replacement therapy, and disability were noted in 45, 25, and 53 %, respectively.

CONCLUSION

ANP significantly impacts long-term survival. A high proportion of patients develop functional derangement and disability following ANP.

Accuracy of contrast-enhanced ultrasound compared with conventional ultrasound in acute pancreatitis: Diagnosis and complication monitoring

Contrast-enhanced ultrasound (CEUS) has been used for diagnosing acute pancreatitis (AP), particularly severe acute pancreatitis (SAP). However, the diagnostic difference between CEUS and conventional ultrasonography (CUS) for AP and SAP has not been reported. The aim of the present study was to investigate the diagnostic accuracy of CUS and CEUS for AP. A total of 196 patients clinically diagnosed with AP were selected. All patients underwent CUS, CEUS and contrast-enhanced computed tomography (CECT) within 72 h. CECT was considered the gold standard. Pancreatic size, peripancreatic fluid collection (PPFC) and splenic vessel complications were the variables observed by CUS and CEUS. The differences in the variables among the three methods were analyzed using the χ2 test and statistical analysis software. Significant differences in pancreatic size, PPFC and splenic vessel complications in AP were observed between CEUS and CUS (P<0.05). χ2 test results indicated that CEUS significantly differed from CUS in terms of having a higher diagnostic accuracy for AP and SAP (P<0.05). The results indicate that CEUS is a reliable method for the diagnosis and monitoring of AP and SAP, and may be substituted for CECT.

Management and outcomes of acute pancreatitis patients over the last decade: A US tertiary-center experience

BACKGROUND/OBJECTIVES

Acute pancreatitis (AP) management remains largely supportive and can be challenging in patients with severe disease. This study aims to describe a ten-year US tertiary-center experience in managing AP patients.

METHODS

Clinical management and outcomes of 400 prospectively enrolled AP patients stratified by the Revised Atlanta Classification were analyzed; trends in management between early (2004-2008) and late enrollment phase (2009-2014) were assessed.

RESULTS

Fifty-two% of patients were classified as mild AP (MAP); moderately severe (MoAP) and severe (SAP) grades contained 23.5% and 24.5% of participants. Intravenous fluid administration during the first 24 h (MAP 3.7, MoAP 4.7, and SAP 4.8 L), need for ICU (6%, 23%, 93%), and nutritional support (7%, 51%, 90%) increased significantly with greater AP severity (p < 0.001). One hundred fifty five (39%) patients developed necrotizing AP, of which 41% received prophylactic antibiotics, and 44% underwent pancreatic drainage/debridement. Prophylactic antibiotics (58% vs. 27%) and interventions (63% vs. 27%) were noted more frequently in SAP than MoAP (p < 0.001). Enteral nutrition (18% vs. 30%) and minimally invasive pancreatic interventions (19% vs. 41%) were more commonly used in the late phase (p < 0.05). The overall median length of hospitalization was 7 days reaching 29 days in SAP group. Mortality was 5%; all deaths occurred in SAP group.

CONCLUSIONS

This study provides an extensive report on clinical management of AP and its trends overtime. Pancreatic intervention is required in less than 50% of patients with necrotizing pancreatitis. Utilization of enteral nutrition and minimally invasive pancreatic interventions has been increasing over time.

Predicting the clinical manifestations in necrotizing acute pancreatitis patients with splanchnic vein thrombosis

BACKGROUND

Splanchnic venous thrombosis (SVT) is a relatively rare but important complication of necrotizing acute pancreatitis (NAP). Clinical manifestations and severity of this complication in different patients vary greatly, ranging from mild abdominal discomfort even asymptomatic to lethal gastrorrhagia or hepatic failure. The aim of the present study was to develop a model to predict the clinical manifestations of SVT in NAP patients.

METHODS

This retrospective cohort study was conducted in the surgical intensive care unit (SICU) of Jinling Hospital. Patients with the presence of both pancreatic necrosis and SVT were selected for possible inclusion. Both univariate and multivariate logistic regression analyses were applied using 12 indices including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), CRP(C - reactive protein) levels, etc to assess potential predictors for symptomatic pancreatic splanchnic venous thrombosis (PSVT) in this cohort. A prognostic nomogram was also applied to develop an easy-to-use prediction model.

RESULTS

A total of 104 patients with necrotizing acute pancreatitis (NAP) and splanchnic vein thrombosis (SVT) from January 2012 to December 2013 were enrolled for analysis. A quarter of study subjects (26 of 104, 25%) developed variable symptomatic manifestations including variceal bleeding, persistent ascites and enteral nutrition (EN) intolerance during the disease course. In the multivariable regression model, the following factors were found to be associated with the occurrence of symptomatic SVT: Balthazar's computed tomography (CT) score (OR = 1.818; 95% CI: 1.251-2.641; P = 0.002), intra-abdominal pressure (IAP) (OR = 1.172; 95% CI: 1.001-1.251; P = 0.043 and presence of SMVT (OR = 6.946; 95% CI: 2.290-21.074; P = 0.001). A prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.842.

CONCLUSIONS

Balthazar's CT score, IAP and SMVT are predictors of symptomatic SVT in NAP patients. The nomogram we conducted can be used as an easy-to-use risk stratification tool in either clinical practice or future studies.

Comparison Between Revised Atlanta Classification and Determinant-Based Classification for Acute Pancreatitis in Intensive Care Medicine. Why Do Not Use a Modified Determinant-Based Classification?

OBJECTIVE

To compare the classification performance of the Revised Atlanta Classification, the Determinant-Based Classification, and a new modified Determinant-Based Classification according to observed mortality and morbidity.

DESIGN

A prospective multicenter observational study conducted in 1-year period.

SETTING

Forty-six international ICUs (Epidemiology of Acute Pancreatitis in Intensive Care Medicine study).

PATIENTS

Admitted to an ICU with acute pancreatitis and at least one organ failure.

INTERVENTIONS

Modified Determinant-Based Classification included four categories: In group 1, patients with transient organ failure and without local complications; in group 2, patients with transient organ failure and local complications; in group 3, patients with persistent organ failure and without local complications; and in group 4, patients with persistent organ failure and local complications.

MEASUREMENTS AND MAIN RESULTS

A total of 374 patients were included (mortality rate of 28.9%). When modified Determinant-Based Classification was applied, patients in group 1 presented low mortality (2.26%) and morbidity (5.38%), patients in group 2 presented low mortality (6.67%) and high morbidity (60.71%), patients in group 3 presented high mortality (41.46%) and low morbidity (8.33%), and patients in group 4 presented high mortality (59.09%) and morbidity (88.89%). The area under the receiver operator characteristics curve of modified Determinant-Based Classification for mortality was 0.81 (95% CI, 0.77-0.85), with significant differences in comparison to Revised Atlanta Classification (0.77; 95% CI, 0.73-0.81; p < 0.01), and Determinant-Based Classification (0.77; 95% CI, 0.72-0.81; p < 0.01). For morbidity, the area under the curve of modified Determinant-Based Classification was 0.80 (95% CI, 0.73-0.86), with significant differences in comparison to Revised Atlanta Classification (0.63, 95% CI, 0.57-0.70; p < 0.01), but not in comparison to Determinant-Based Classification (0.81, 95% CI, 0.74-0.88; nonsignificant).

CONCLUSION

Modified Determinant-Based Classification identified four groups with different clinical presentation in patients with acute pancreatitis in ICU, with better discriminatory power in comparison to Determinant-Based Classification and Revised Atlanta Classification.

Predictors and outcomes of moderately severe acute pancreatitis - Evidence to reclassify

BACKGROUND/OBJECTIVES

After the creation of the moderately severe acute pancreatitis (MSAP) category in the Revised Atlanta Classification in 2012, predictors to identify these patients early have not been identified. The MSAP category includes patients with (peri)pancreatic necrosis, fluid collections, and transient organ failure in the same category. However, these outcomes have not been studied to determine whether they result in similar outcomes to merit inclusion in the same severity.

METHODS

Retrospective, review of 514 consecutive, direct admissions for acute pancreatitis from 2010 to 2013. Multivariate logistic regression identified predictors of MSAP.

RESULTS

Persistent SIRS was the best prognostic marker of MSAP with AUC 0.72. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for persistent SIRS to predict MSAP are: 55%, 88%, 40%, 93%, and 84%. Patients with necrosis had significantly longer length of stay (LOS) (p = 0.0001) and higher rates of ICU admission (p = 0.02) compared with patients with transient organ failure. Compared to those with acute fluid collections, patients with necrosis had longer LOS (p < 0.0001), higher rates of ICU admission (p = 0.0005), required more interventions (p = 0.001), and demonstrated higher mortality (0.003).

DISCUSSION

Moderately severe pancreatitis can be distinguished from mild pancreatitis on the basis of persistent SIRS but cannot be accurately distinguished from severe pancreatitis in the first 48 h (Peri)pancreatic necrosis demonstrates significantly more morbidity compared to the other components of MSAP of fluid collections and transient organ failure.

Isolated Peripancreatic Necrosis in Acute Pancreatitis Is Infrequent and Leads to Severe Clinical Course Only When Extensive: A Prospective Study From a US Tertiary Center

GOALS

To explore the diagnostic challenges, management, and clinical outcomes of patients with isolated peripancreatic necrosis (PPN), with emphasis on the extent of involvement, and compare them to pancreatic necrosis (PN).

BACKGROUND

PPN, a relatively new term, has been included as a separate entity in the Revised Atlanta Classification.

STUDY

Clinical data of recruited acute pancreatitis patients were recorded prospectively. Contrast-enhanced computed tomographic scans were reviewed by expert radiologists blinded to clinical outcomes.

RESULTS

In total, 271 of the 400 acute pancreatitis patients underwent contrast-enhanced computed tomography, of which 29 (11%) had PPN (14: limited; 15: extensive) and 124 (46%) PN (40: <30%, 16: 30% to 50%, 68: >50% of parenchyma). Patients with PPN were similar to PN in age (56 y), gender (55% male), and body mass index (29 kg/m(2)). Nutritional support was provided in 18 (62%) patients with PPN and 97 (78%) with PN (P=0.12). Drainage/debridement was required in 2 patients (7%) with PPN and 64 (53%) with parenchymal necrosis (P<0.001). Persistent organ failure rates did not differ significantly (34% vs. 51%, P=0.17), but hospital stay was shorter in patients with PPN (15 vs. 20 d, P=0.05). Limited PPN required no intervention and had similar persistent organ failure rates and hospitalization length with interstitial pancreatitis (both P≥0.12). Extensive PPN mainly developed in patients with persistent organ failure (60%) and rarely required drainage (2/15).

CONCLUSIONS

PPN prevalence was lower than PN with a ratio of 1:4. PPN rarely required intervention. Utilizing the extent of involvement has the potential to classify PPN and PN with escalating clinical significance and guide management.

Patients With Sentinel Acute Pancreatitis of Alcoholic Etiology Are at Risk for Organ Failure and Pancreatic Necrosis: A Dual-Center Experience

OBJECTIVES

To assess the relationship between alcoholic etiology, tobacco use, and severe acute pancreatitis (AP).

METHODS

Smoking and alcohol exposure were recorded upon admission in a cohort of patients with AP within the United States. Patients with first, "sentinel" attack of AP were identified for analysis.Associations between alcohol, smoking, and severe AP were validated in an independent cohort of patients from Spain.

RESULTS

US cohort (n = 222): Thirty-five percent developed organ failure (OF), 35% pancreatic necrosis (PNec), and 7% died. OF (54% vs 33%, P = 0.03), PNec (62% vs 31%, P = 0.006), intensive care unit admission (58% vs 36%, P = 0.03), and length of stay (LOS) (20 vs 8 days, P = 0.007) were greater in alcoholic when compared to other etiologies.Spanish cohort (n = 366): Similar differences in outcomes were also found with between alcoholic and nonalcoholic etiologies: OF (24% vs 8%, P = 0.001), PNec (38% vs 14%, P < 0.001), intensive care unit admission (20% vs 3%, P < 0.001), and LOS (17 vs 11 days, P = 0.04).Multivariable analysis confirmed alcoholic etiology to be independently associated with OF and PNec in both cohorts.

CONCLUSIONS

Alcoholic etiology is independently associated with OF and PNec in patients with sentinel AP and is important when evaluating risk for severe disease in AP.

Assessment of D-Dimers for the Early Prediction of Complications in Acute Pancreatitis

OBJECTIVES

Severe acute pancreatitis (AP) is characterized by early microcirculation defects causing hypercoagulability. The purpose of this study was to evaluate the early predictive value of D-dimers in complicated AP.

METHODS

This was a prospective single-center study conducted between September 2010 and April 2012. All patients had AP for less than 48 hours duration at admission. The plasma D-dimer level was determined at admission and every 12 hours over 3 days and compared to other validated severity criteria.

RESULTS

Of 71 patients admitted with AP, 36 (53.1%) developed complicated AP. A threshold D-dimer level greater than 1474 ng/mL at 48 hours after pain onset was predictive of complications with an area under the curve (AUC) of 0.76. Combining D-dimers and C-reactive protein levels at 48 hours increased the prediction of complications (AUC of 0.83). At 36 hours, D-dimers greater than 1474 ng/mL predicted the occurrence of complications with an AUC of 0.75.

CONCLUSIONS

D-Dimer levels were predictive of complications of AP as early as 36 hours after the onset of pain. This simple and reproducible marker might be useful in clinical practice to improve the early management of complicated AP.

The oral refeeding trilemma of acute pancreatitis: what, when and who?

Tolerance of oral refeeding is an essential goal of nutritional management of acute pancreatitis. However, oral feeding intolerance remains one of the most common complications in patients with this disease. It often results in longer periods of hospitalization, increased treatment costs, increased risk of readmission, and reduced quality of life. The traditional practice involves keeping patients nil by mouth followed by gradual stepwise reintroduction of food. However, it does not have a solid evidence base and, hence, there is increasing interest in determining alternative strategies that may be beneficial in reducing the occurrence of oral feeding intolerance. This review focuses on the randomized controlled trials that investigated the key questions informing the nutritional management of acute pancreatitis: when to feed, what to feed and who is in charge of the decision-making.

Decision Making in Necrotizing Pancreatitis

The management of acute necrotizing pancreatitis (ANP) has undergone a change of paradigms during the last 2 decades with a decreasing impact of surgical interventions. Modern ANP management is done conservatively as long as possible and therapeutic approaches aim at volume resuscitation, pain management and early enteral nutrition. The diagnostic gold standard of contrast-enhanced CT scan helps to evaluate the extent of necrosis of the pancreas, which correlates with the risk of tissue infection. The crucial point for decision making is the proven existence of infected pancreatic necrosis. This can be achieved by diagnostic needle aspiration of the necrotic material and staining to prove bacterial and/or fungal infection. In case of infected necrosis - besides calculated antimicrobial treatment - an interventional or surgical approach is required to prevent systemic septic progression of the disease. As the first step, percutaneous interventional drainage and spilling of the necrosis are preferable. In case of insufficient clearing of the infectious focus, a step-up approach must be considered, which implies a retroperitoneoscopic or transabdominal minimally invasive necrosectomy and drain placement. Postoperatively, a continuous lavage should be performed using these drains. In case of further deterioration of the patient or development of associated intra-abdominal complications (e.g. bowel perforation or uncontrolled bleeding), an open surgical intervention must always be regarded as a salvage therapy and this offers the possibility to control complications and perform a further necrosectomy and extensive lavage for focus control. However, associated morbidity (e.g. pancreatic fistula, fluid collections, pseudocysts) is about 50-60% and mortality up to 20%. In summary, ANP is managed primarily by a conservative therapy. In case of infected necrosis, interventional and minimally invasive approaches are the therapy of choice. Open surgery should be considered for patients deteriorating despite other measures and should be postponed as long as possible.

Acute Pancreatitis: Landmark Studies, Management Decisions, and the Future

A great deal of progress has been made in the last 50 years in the diagnosis and treatment of acute pancreatitis. Many landmark studies have been published and have focused on the classification of acute pancreatitis, markers of severity, important roles of imaging and endoscopy, and improvements in our treatment. This report will review several landmark studies, describe ongoing controversies in management decisions including standards of early fluid resuscitation and appropriate use of enteral feeding, and outline what will be required in the future to improve the care of patients with acute pancreatitis.

The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes?

OBJECTIVES

To determine which classification is more accurate in stratifying severity.

METHODS

The study used a retrospective analysis of a prospective acute pancreatitis database (June 2005-December 2007). Acute pancreatitis severity was stratified according to the Atlanta classification (AC) 1992, the revised Atlanta classification (RAC) 2012, and the determinant-based classification (DBC) 2012. Receiver operating characteristic analysis (area under the curve) compared the accuracy of each classification. Logistic regression identified predictors of mortality.

RESULTS

338 patients were analyzed: 13% had persistent organ failure (POF) (>48 hours), of whom 37% had multisystem POF, and 11% had pancreatic necrosis, of whom 19% had infected necrosis. Mortality was 4.1%. For predicting mortality (area under the curve), the RAC (0.91) and DBC (0.92) were comparable (P = 0.404); both outperformed the AC (0.81) (P < 0.001). For intensive care unit admission, the RAC (0.85) and DBC (0.85) were comparable (P = 0.949); both outperformed the AC (0.79) (P < 0.05). There were 2 patients in the critical category of the DBC. Multisystem POF was an independent predictor of mortality (odds ratio, 75.0; 95% confidence interval, 13.7-410.6; P < 0.001), whereas single-system POF, sterile necrosis, and infected necrosis were not.

CONCLUSION

The RAC and DBC were generally comparable in stratifying severity. The paucity of patients in the critical category in the DBC limits its utility. Neither classification accounts for the impact of multisystem POF, which was the strongest predictor of mortality.

Gastrointestinal Fistulas in Acute Pancreatitis With Infected Pancreatic or Peripancreatic Necrosis: A 4-Year Single-Center Experience

Gastrointestinal (GI) fistula is a well-recognized complication of acute pancreatitis (AP). However, it has been reported in limited literature. This study aimed to evaluate the incidence and outcome of GI fistulas in AP patients complicated with infected pancreatic or peripancreatic necrosis (IPN).Between 2010 and 2013 AP patients with IPN who diagnosed with GI fistula in our center were analyzed in this retrospective study. And we also conducted a comparison between patients with and without GI fistula regarding the baseline characteristics and outcomes.Over 4 years, a total of 928 AP patients were admitted into our center, of whom 119 patients with IPN were diagnosed with GI fistula and they developed 160 GI fistulas in total. Colonic fistula found in 72 patients was the most common form of GI fistula followed with duodenal fistula. All duodenal fistulas were managed by nonsurgical management. Ileostomy or colostomy was performed for 44 (61.1%) of 72 colonic fistulas. Twenty-one (29.2%) colonic fistulas were successfully treated by percutaneous drainage or continuous negative pressure irrigation. Mortality of patients with GI fistula did not differ significantly from those without GI fistula (28.6% vs 21.9%, P = 0.22). However, a significantly higher mortality (34.7%) was observed in those with colonic fistula.GI fistula is a common finding in patients of AP with IPN. Most of these fistulas can be successfully managed with different procedures depending on their sites of origin. Colonic fistula is related with higher mortality than those without GI fistula.

Admission, management and outcomes of acute pancreatitis in intensive care

BACKGROUND

A review of the management of acute pancreatitis (AP) at a tertiary intensive care unit (ICU) in Auckland, New Zealand, was published in 2004. This paper aims to update this series and identify changes in admission criteria, management and outcomes.

METHODS

A retrospective review of patients admitted to the Department of Critical Care Medicine, Auckland City Hospital, with AP from 2003 to 2014 was undertaken and data compared with the previous study (1988-2001).

RESULTS

Eighty-four patients (male 53, mean ± SD age = 56.9 ± 15 years) with 85 admissions to ICU from 2003 to 2014 were compared with 112 patients in the previous study. Maori were over-represented. Median duration of symptoms prior to admission to ICU decreased from 7 to 3 days. The proportion of total AP patients admitted to ICU halved and the mean Acute Physiology and Chronic Health Evaluation II score on admission decreased from mean 19.9 ± 8.2 SD to 15.4 ± 7.3 (P < 0.001). Two thirds of patients had persistent organ failure. The use of enteral feeding doubled from 46/112 (41%) to 71/85 (84%) (P < 0.001). The use of primary percutaneous drainage increased from 14/112 (13%) to 24/85 (28%) (P = 0.007). Rate of necrosectomy was similar (36/112 (32%) versus 20/85 (24%), P = 0.205), although minimally invasive necrosectomy was introduced. Overall hospital mortality decreased by 29% (P = 0.198).

CONCLUSION

There have been changes to the admission criteria and management in line with evolving guidelines and, overall, outcomes have improved.